對於接受連續靜脈肝素輸注的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client receiving continuous IV Heparin therapy? (Select all that apply.)
- AMonitor PTT levels as ordered✓ 正解依醫囑監測 PTT 數值
- BAssess for signs of occult bleeding✓ 正解評估是否有隱匿性出血跡象
- CKeep protamine sulfate available at the bedside✓ 正解在床邊準備硫酸魚精蛋白
- DUse soft-bristle toothbrushes for oral care✓ 正解使用軟毛牙刷進行口腔護理
- EMassage injection sites to promote absorption按摩注射部位以促進吸收
肝素為高警訊藥物。治療目標是預防血栓，但也大幅增加出血風險。必須定期追蹤 PTT 或抗 Xa 因子活性，觀察有無牙齦出血、血尿等徵兆。Protamine sulfate 是其拮抗劑，應備妥。牙刷需軟毛以防創傷。禁止按摩注射部位以免產生血腫。
Heparin is a high-alert medication. The therapeutic goal is thrombus prevention, but its use significantly increases the risk of bleeding. Regular monitoring of PTT or anti-Xa activity is required, and the nurse should observe for signs such as gingival bleeding or hematuria. Protamine sulfate is the antidote and should be readily available. A soft-bristle toothbrush is recommended to minimize trauma. Massaging the injection site is prohibited because it may cause hematoma formation.
美國醫院多由護理師根據給藥準則調整輸注速度；台灣多需醫師簽署調整醫囑後由護理師執行。