— 降低風險 · MEDIUM · SATA —
病人接受輸血時，出現哪些評估發現應提醒護理師注意可能發生溶血反應？（選所有適合的）
Which assessment findings in a client receiving a blood transfusion should alert the nurse to a potential hemolytic reaction? (Select all that apply.)
- ALow back pain✓ 正解腰背痛
- BFever and chills✓ 正解發燒與畏寒
- CHypotension✓ 正解低血壓
- DWheezing喘鳴
- EHemoglobinuria✓ 正解血紅素尿
— Explanation · 中文詳解 —
急性溶血反應是嚴重的輸血併發症，典型症狀包括腰背痛（由腎臟血管收縮與血紅素沉積引起）、發燒、寒顫、低血壓及血紅素尿。喘鳴（Wheezing）通常與過敏性反應或輸血相關性急性肺損傷（TRALI）較為相關，非溶血反應典型徵兆。
Acute hemolytic transfusion reaction is a severe complication. Classic findings include flank/low back pain (from renal vasoconstriction and hemoglobin deposition), fever and chills, hypotension, and hemoglobinuria. Wheezing is more typical of anaphylactic reactions or TRALI, not hemolysis.
✦ 台美臨床差異
美國醫院輸血需兩人雙簽且需輸血護理紀錄單；台灣亦採雙簽制度，並針對輸血反應有明確的異常事件通報流程。