— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師準備皮下注射肝素 (heparin)，下列哪些步驟是正確的？（選所有適合的）
A nurse is preparing to administer heparin subcutaneously. Which actions are appropriate? (Select all that apply.)
- ASelect an area on the abdomen at least 2 inches from the umbilicus✓ 正解選擇距臍部至少 2 吋的腹部區域
- BMassage the injection site thoroughly after administration給藥後徹底按摩注射部位
- CUse a 45-degree angle if the client has limited subcutaneous tissue✓ 正解若病人皮下組織有限，使用 45 度角進針
- DAspirate before injecting the medication注射前進行回抽
- ECheck the PTT result before administration if required by protocol✓ 正解若protocol要求，給藥前檢查 PTT 結果
— Explanation · 中文詳解 —
肝素注射應避開肚臍周圍 2 英吋，避免揉搓以免造成瘀血。若病人皮下脂肪少，可使用 45 度角。aspirate (回抽) 會導致組織受損，現代給藥準則已不建議回抽。監測 PTT 是評估抗凝血療效的標準。
When administering subcutaneous heparin, select an injection site at least 2 inches from the umbilicus and use a 45-degree angle if the client has limited subcutaneous tissue. Do not massage the site to prevent hematoma, avoid aspiration as it is unnecessary and potentially harmful, and monitor PTT levels to ensure therapeutic efficacy.
✦ 台美臨床差異
台灣醫院多使用預充式針劑，且護理紀錄較強調確認給藥時間與部位之交叉核對。