— 藥理與非經腸給藥 · HARD · SATA —
護理師照護一位因深層靜脈栓塞而接受肝素輸注的病人。下列哪些現象提示潛在的肝素相關併發症？（選所有適合的）
A nurse is caring for a client receiving heparin infusion for deep vein thrombosis. Which signs indicate potential heparin-induced complications? (Select all that apply.)
- APlatelet count drop from 250,000/mm³ to 100,000/mm³✓ 正解血小板計數從 250,000/mm³ 降至 100,000/mm³
- BDark, tarry stools noted in the bedpan✓ 正解便盆中發現黑色焦油樣糞便
- CGum bleeding during oral hygiene✓ 正解口腔護理期間牙齦出血
- DPersistent headache and blurred vision✓ 正解持續性頭痛與視力模糊
- EDevelopment of a new skin rash at the injection site注射部位出現新發皮膚紅疹
— Explanation · 中文詳解 —
肝素治療常見併發症為出血（黑便、牙齦出血、顱內出血引發頭痛）及肝素誘發血小板減少症（HIT）。HIT 定義為血小板數值下降超過 50% 或跌破 150,000/mm³。此類情況必須立即停藥並通知醫師，評估是否更換抗凝血劑。
Common complications of heparin therapy include bleeding (melena, gum bleeding, intracranial hemorrhage causing headache) and heparin-induced thrombocytopenia (HIT). HIT is defined as a drop in platelet count of more than 50% or below 150,000/mm3. In these situations, heparin must be discontinued immediately and the physician notified to evaluate switching to an alternative anticoagulant.
✦ 台美臨床差異
在美國，HIT 的監測與護理師權限密切相關，台灣較傾向由醫師下令檢測血小板，護理師角色為觀察並及時回報。