輸血病人出現畏寒與側腹疼痛，護理師優先評估項目為何？
Which assessment is priority for a client receiving a blood transfusion who develops chills and flank pain?
- AMonitor vital signs監測生命徵象
- BCheck urine output for hemoglobinuria✓ 正解檢查尿液是否有血紅素尿
- CCheck for skin rash檢查皮膚紅疹
- DAssess breath sounds評估呼吸音
畏寒、側腹痛是急性溶血反應的典型徵象。由於紅血球大量破壞導致游離血紅素進入血液，經由腎臟排泄出現血紅素尿，這是評估腎臟損傷之關鍵。雖然 Vital signs 也很重要，但觀察尿液顏色直接顯示溶血的嚴重程度及腎衰竭風險，故為 priority 評估。
Chills and flank pain are classic signs of an acute hemolytic transfusion reaction. Massive destruction of red blood cells releases free hemoglobin into the bloodstream, which is then excreted by the kidneys, producing hemoglobinuria; assessing the urine is therefore the key to identifying renal injury. Although vital signs are also important, observing the urine color directly reflects the severity of hemolysis and the risk of renal failure, making it the priority assessment.
美台皆將輸血反應視為高度危險事件，需立即停止輸血並維持靜脈導管通暢，作業程序高度一致。