一位病人因深層靜脈栓塞正接受持續型肝素（Heparin）滴注。目前的 aPTT 值為 110 秒（對照值為 35 秒）。護理師優先採取的行動為何？
A client is receiving a continuous heparin infusion for a deep vein thrombosis. The current activated partial thromboplastin time (aPTT) is 110 seconds (Control: 35 seconds). What is the priority nursing action?
- AContinue the infusion and recheck aPTT in 4 hours繼續滴注並在4小時後重新檢測aPTT
- BAdminister Vitamin K intramuscularly肌肉注射維生素K
- CDecrease the infusion rate by 50%將滴注速率降低50%
- DStop the infusion and notify the provider✓ 正解停止滴注並通知醫師
Heparin 的治療目標通常是將 aPTT 維持在正常對照值的 1.5 到 2.5 倍。在此案例中，對照值為 35 秒，治療範圍應在 52.5 到 87.5 秒之間。病人的 aPTT 為 110 秒，已顯著超過治療上限，具有極高的出血風險。根據安全原則，當檢驗值超出安全範圍且有致命風險時，首要動作是立即停止輸注（Stop the infusion）並通知醫師，以防止內出血或腦出血。調降流速（C）不足以立即降低出血風險；繼續輸注（A）則是嚴重的護理疏失；Vitamin K（B）是 Warfarin 的解毒劑，Heparin 的解毒劑應為 Protamine Sulfate。
The therapeutic goal for heparin is to maintain aPTT at 1.5 to 2.5 times the normal control value. In this scenario, the control is 35 seconds, so the therapeutic range should be 52.5 to 87.5 seconds. The client's aPTT is 110 seconds, which substantially exceeds the upper therapeutic limit and creates a very high risk of bleeding. According to safety principles, when a laboratory value exceeds the safe range and carries a life-threatening risk, the priority action is to stop the infusion immediately and notify the provider, in order to prevent internal bleeding or intracranial hemorrhage. Decreasing the rate (C) is insufficient to rapidly reduce bleeding risk; continuing the infusion (A) constitutes serious nursing negligence; and vitamin K (B) is the antidote for warfarin, while the antidote for heparin is protamine sulfate.
在美國，大型醫院多設有 Heparin Protocol，護理師可根據 aPTT 自動決定停藥時間或調整劑量。台灣則多由醫師看過數值後下達醫囑，但護理師在發現數值危急時，有權利且有義務先暫停滴注再回報。