一名因深層靜脈栓塞接受持續肝素（heparin）輸注的病人，最新的活化部分凝血活酶時間（aPTT）為 105 秒。對照值為 35 秒。護理師應首先採取哪項行動？
A client is receiving a continuous heparin infusion for a deep vein thrombosis. The most recent activated partial thromboplastin time (aPTT) is 105 seconds. The control value is 35 seconds. Which action should the nurse take first?
- AIncrease the infusion rate增加輸注速率
- BNotify the healthcare provider after stopping the drip停止滴注後通知醫療提供者
- CStop the heparin infusion✓ 正解停止肝素輸注
- DAdminister Vitamin K intramuscularly肌肉注射維生素K
核心概念在於監測肝素治療的安全性。肝素的治療目標通常是 aPTT 為對照值的 1.5 到 2.5 倍。在此案例中，對照值為 35 秒，治療區間應為 52.5 至 87.5 秒。病人的 105 秒遠超過治療上限，增加了嚴重出血的風險。根據安全優先原則，護理師的首要行動是立即停止肝素輸注（C），以防止凝血功能進一步受損。維生素 K（D）是華法林（Warfarin）的解毒劑，肝素的解毒劑是魚精蛋白（Protamine sulfate），且給藥前需先停藥。通知醫師（B）是必要的，但必須在執行停藥這一保護病人的緊急動作之後。臨床思路上，處理藥物毒性或過量時，『移除致病源』永遠是第一步。
The core concept here is the safety monitoring of heparin therapy. The therapeutic target for heparin is generally an aPTT 1.5 to 2.5 times the control value. In this case, with a control of 35 seconds, the therapeutic range is approximately 52.5 to 87.5 seconds. The patient's value of 105 seconds is far above the therapeutic upper limit, posing a significant bleeding risk. Based on the safety-first principle, the nurse's first action is to stop the heparin infusion immediately (C) to prevent further impairment of coagulation. Vitamin K (D) is the antidote for warfarin; the antidote for heparin is protamine sulfate, and the medication must be stopped before its administration. Notifying the provider (B) is necessary but must follow the urgent action of stopping the medication to protect the patient. Clinically, when managing medication toxicity or overdose, removing the offending agent is always the first step.
在美國，許多醫院設有「Heparin Protocol」，護理師可根據 aPTT 結果獨立決定停藥或調整流速，不需每次詢問醫師；台灣則通常需要依據醫囑執行，但面對此種危急值，護理師仍應先停藥並同步尋求授權。