— 降低風險 · MEDIUM · SATA —
護理師照顧一位帶有中心靜脈導管(CVC)的病人,下列哪些護理行動是適當的?(選所有適合的)
A nurse is caring for a client with a central venous catheter (CVC). Which of the following are appropriate nursing actions? (Select all that apply.)
- AUse aseptic technique for dressing changes✓ 正解更換敷料時使用無菌技術
- BFlush each lumen with heparinized saline as ordered✓ 正解依醫囑以肝素化生理食鹽水沖洗每個管腔
- CChange the transparent dressing every 7 days or if soiled每 7 天或當敷料汙損時更換透明敷料
- DUse a 10 mL syringe for flushing to prevent catheter rupture✓ 正解使用 10 mL 針筒進行沖洗,以防止導管破裂
- EClamp the catheter only when not in use僅在不使用時夾住導管
— Explanation · 中文詳解 —
中心靜脈導管(CVC)護理的核心在於嚴格執行無菌技術(Aseptic technique)以預防導管相關血流感染(CRBSI)。操作時需維護管路壓力平衡,使用 10mL 以上針筒可避免過大壓力導致導管破裂或栓子脫落。定期沖洗(Flushing)則能保持導管通暢。護理師必須熟悉這些標準操作規範以確保病人的安全與導管壽命。
CVC care centers on strict aseptic technique to prevent CRBSI. Maintain pressure balance — using a 10 mL or larger syringe avoids excessive pressure that could rupture the catheter or dislodge emboli. Regular flushing preserves patency. Nurses must follow these standards to ensure patient safety and catheter longevity.
✦ 台美臨床差異
美國醫院對於 CVC 敷料更換頻率非常嚴格,通常依照各院 Policy 執行,若為透明敷料(Tegaderm)多為 7 天,但若為紗布敷料則為 48 小時。