一位患有深層靜脈栓塞的病人正在接受肝素（Heparin）連續靜脈滴注。病人的活化部分凝血活酶時間（aPTT）為 110 秒。護理師應首先採取哪項行動？
A client is receiving a continuous intravenous infusion of heparin for the treatment of a deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 110 seconds. Which action should the nurse take first?
- AIncrease the infusion rate as per the heparin protocol.根據肝素協議增加輸注速率。
- BAdminister protamine sulfate immediately.立即給予硫酸魚精蛋白。
- CContinue the infusion and recheck the aPTT in 4 hours.繼續輸注並在 4 小時後重新檢查 aPTT。
- DStop the infusion and notify the healthcare provider.✓ 正解停止輸注並通知醫療提供者。
本題的核心概念在於肝素（Heparin）治療的監控與安全性管理。Heparin 的治療目標通常是將 aPTT 維持在正常對照值的 1.5 到 2.5 倍之間。正常的 aPTT 大約在 30-40 秒，因此治療範圍約在 60-80 秒。當 aPTT 達到 110 秒時，表示抗凝血作用過強，出血風險極高。根據臨床安全原則，首要動作是停止輸注以防止進一步的藥物進入循環，並立即通知醫師（D）。增加流量（A）會加劇出血風險；繼續輸注（C）是不負責任的，因為病人已處於危險區間；雖然 Protamine sulfate（B）是解毒劑，但在沒有醫師醫囑或病人尚未出現嚴重活動性出血前，通常先停藥觀察半衰期（Heparin 半衰期短），不應由護理師自行決定立即施打。護理師應優先確保病人安全，停藥是控制損害的最快方式。
The central concepts in this question are the monitoring and safety management of heparin therapy. The therapeutic goal for heparin is generally to maintain the aPTT at 1.5 to 2.5 times the normal control value. Normal aPTT is approximately 30-40 seconds, so the therapeutic range is about 60-80 seconds. An aPTT of 110 seconds indicates excessive anticoagulation and a very high risk of bleeding. Based on clinical safety principles, the priority action is to stop the infusion to prevent more drug from entering the circulation and to immediately notify the physician (D). Increasing the rate (A) would worsen the bleeding risk; continuing the infusion (C) is irresponsible because the client is already in a dangerous range; although protamine sulfate (B) is the antidote, in the absence of a physician's order or major active bleeding the medication is usually held first to allow the heparin to clear (heparin has a short half-life), and the nurse should not initiate protamine independently. The nurse must prioritize client safety; stopping the infusion is the fastest way to limit harm.
在美國，許多醫院設有護理師驅動的 Heparin Protocol，護理師可根據 aPTT 數值自行調整劑量或停藥（Stop/Hold）；在台灣，雖然也有類似規範，但臨床護理師在停藥後通常需立即致電醫師補開立醫囑，自主權限範圍在不同等級醫院差異較大。