護理師對於接受中央靜脈全靜脈營養(TPN)的病人,應執行哪些護理措施?(選所有適合的)
Which of the following interventions should the nurse perform for a client receiving parenteral nutrition via a central line? (Select all that apply.)
- AChange the TPN tubing every 24 hours✓ 正解每24小時更換TPN輸液管路
- BMonitor blood glucose levels every 6 hours✓ 正解每6小時監測血糖
- CUse an infusion pump for administration✓ 正解使用輸注幫浦進行給藥
- DChange the central line dressing every 7 days每7天更換中心靜脈導管敷料
- EWeigh the client daily✓ 正解每日稱量病人体重
全靜脈營養液高糖高脂,是細菌培養基,必須每 24 小時更換輸液管路。因其高滲透壓易致高血糖,需每 6 小時監測血糖。為確保給藥精確,必須使用輸液幫浦。每日測量體重可評估營養療效與液體平衡。更換敷料則依機構規定,通常透明敷料每 7 天,紗布敷料每 48 小時,此題 D 項非固定選項。
TPN solutions are high in dextrose and lipids, providing a medium for bacterial growth—tubing must be changed every 24 hours. The high osmolarity causes hyperglycemia, so blood glucose is checked every 6 hours. An infusion pump ensures a precise constant rate. Daily weights track nutritional adequacy and fluid status. Central line dressing change frequency varies by dressing type and institutional policy and is not strictly every 7 days for all dressings.
美國醫院多由專科護理師或營養團隊監控,台灣則由臨床護理師配合營養師醫囑執行。