一位病人正接受 20 mEq 氯化鉀加入 100 mL 生理食鹽水靜脈輸注,護理師觀察到輸注部位紅腫、發熱且觸感冰涼。護理師的首要行動為何?
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the infusion site is erythematous, edematous, and cool to the touch. What is the nurse's priority action?
- ASlow the infusion rate減慢輸注速率
- BStop the infusion and remove the catheter✓ 正解停止輸注並拔除導管
- CApply a warm compress to the site在患處敷熱敷包
- DAspirate the IV line to verify placement抽吸靜脈通路以確認位置
氯化鉀(KCl)屬於高警訊藥物(High-Alert Medication),具有強烈的血管刺激性。臨床上,若靜脈輸注部位出現紅腫、水腫及冰涼,顯示發生了「滲漏(Infiltration)」。若鉀離子滲漏至皮下組織,極易引起化學性靜脈炎甚至組織壞死。護理師的首要行動是立即停止輸注,以防止更多藥物進入組織,並移除導管以減輕刺激。
The nurse must immediately stop the infusion and remove the catheter because potassium chloride is a vesicant that causes severe tissue damage upon infiltration. Continuing the infusion would exacerbate chemical phlebitis and potential necrosis at the site.
美國醫院對於高警訊藥物(如鉀離子)的外滲處理極為嚴謹,通常會有明確的 Protocol(如是否需使用特定解毒劑或熱敷/冷敷),護理師應熟悉單位內的 Policy,特別是在處理 Vesicant(發泡劑)時。