— 藥理與非經腸給藥 · MEDIUM · SATA —
病人持續接受靜脈肝素治療，出現血尿與皮下瘀斑。護理師應採取哪些處置？（選所有適合的）
A nurse is caring for a client receiving IV heparin. The client develops hematuria and ecchymosis. Which interventions should the nurse perform? (Select all that apply.)
- AStop the heparin infusion immediately✓ 正解立即停止肝素輸注
- BNotify the physician of the signs of bleeding✓ 正解通知醫師出血徵象
- CPrepare to administer protamine sulfate✓ 正解準備施用硫酸魚精蛋白
- DObtain a prothrombin time (PT/INR) test取得凝血酶原時間 (PT/INR) 檢驗
- EAssess vital signs to detect internal bleeding✓ 正解評估生命徵象以偵測內出血
— Explanation · 中文詳解 —
此為肝素導致的出血反應。處理流程：立即停藥（停止持續暴露）、告知醫師（調整醫囑）、監測生命徵象（評估失血程度）、備妥拮抗劑 Protamine sulfate。PT/INR 用於監測 Warfarin，肝素應監測 aPTT。
This represents a heparin-induced bleeding reaction. The management sequence is: immediately stop the medication (halt continued exposure), notify the provider (to adjust orders), monitor vital signs (assess the extent of blood loss), and prepare the antidote protamine sulfate. PT/INR is used to monitor warfarin therapy; heparin should be monitored with aPTT.
✦ 台美臨床差異
在美國護理師常依據醫院出血評估表主動停藥；台灣護理師通常會先通知醫師確認後再停藥，較為謹慎。