一位加護病房護理師發現，一位因肺栓塞而接受持續肝素滴注的病患發生了急性鼻出血，且血壓突然下降至 88/50 mmHg。目前的 aPTT 檢驗結果回報為 140 秒。護理師的首要行動為何？
An intensive care nurse discovers that a client with a continuous heparin infusion for a pulmonary embolism has experienced an acute nosebleed and has a sudden drop in blood pressure to 88/50 mmHg. The current aPTT result comes back at 140 seconds. What is the priority nursing action?
- ASlow the continuous heparin infusion rate by half according to the standard hospital protocol.根據醫院標準協議，將持續肝素滴注速率減半。
- BBolus the client with 500 mL of normal saline to correct the sudden hypotension.對病人進行 500 mL 生理食鹽水快速靜脈注射，以糾正突發的低血壓。
- CImmediately stop the heparin infusion and prepare to administer intravenous protamine sulfate.✓ 正解立即停止肝素輸注，並準備給予靜脈注射硫酸魚精蛋白。
- DApply firm direct pressure to the client's nose for 10 minutes and page the physician.對病人的鼻子施加持續直接壓力 10 分鐘，並呼叫醫師。
本題測驗危險藥物的管理與優先順序 (Management of Care: Medical Emergencies / Prioritization)。病患正在接受肝素 (Heparin) 治療。肝素的治療目標是讓 aPTT 維持在正常值 (25-35秒) 的 1.5 到 2.5 倍（大約 46-70 秒）。這名病患的 aPTT 高達 140 秒，代表血液極度無法凝固，處於嚴重的毒性狀態。合併出現鼻出血與突發低血壓，這是『全身性大出血 (systemic hemorrhage)』伴隨抗凝血劑過量的絕對危急徵象 (急性低血容休克)。對於任何正在引發致命毒性反應的點滴，護理學永遠的第一步介入是：『立刻停止點滴 (Stop the infusion)』以切斷毒性源頭。隨後準備肝素的專屬解毒劑『魚精蛋白 (Protamine sulfate)』給予急救（選 C 正確）。選項 D 的加壓止血與選項 B 的給水都是必要的後續急救動作，但如果不關掉肝素，病患會繼續出血致死。選項 A 減慢滴注是針對輕微超標的作法，對於已在出血休克的個案是嚴重的醫療疏失。
This item tests management of high-alert medications and prioritization (Management of Care: Medical Emergencies / Prioritization). The client is receiving heparin therapy. The therapeutic goal of heparin is to maintain aPTT at 1.5 to 2.5 times the normal value (25-35 seconds), approximately 46-70 seconds. This client's aPTT is as high as 140 seconds, indicating that the blood is severely uncoagulable and the client is in a serious toxic state. The combination of epistaxis and sudden hypotension represents the absolute critical signs of systemic hemorrhage with anticoagulant overdose (acute hypovolemic shock). For any IV infusion causing a life-threatening toxic reaction, the nurse's eternal first intervention is: stop the infusion immediately to cut off the source of toxicity. Subsequently, prepare the heparin-specific antidote, protamine sulfate, for emergency administration (option C is correct). Option D (applying pressure for hemostasis) and option B (administering fluids) are necessary subsequent emergency actions, but if the heparin is not stopped, the client will continue to bleed to death. Option A, slowing the infusion rate, is appropriate for mild over-anticoagulation, but is a serious medical error for a client already in hemorrhagic shock.
世界急救標準鐵律。正在打某種藥物，病人出現該藥物的毒性或過敏反應，第一件事永遠是「關掉這包點滴 (Stop the infusion)」。不要先去通報醫生或先給解藥，先切斷毒源。