— 照護管理 · MEDIUM · SATA —
護理師照護一位診斷為深層靜脈血栓（DVT）並接受 heparin 治療的病人，哪些護理措施對監測治療效果與安全性是必要的？（選所有適合的）
A nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT) who is receiving heparin therapy. Which nursing interventions are essential for monitoring therapeutic effectiveness and safety? (Select all that apply.)
- ACheck the client's platelet count✓ 正解檢查病人的血小板計數
- BUse the INR as the primary test for titrating the heparin dose以 INR 作為調整 heparin 劑量的主要檢驗
- CAssess the client for signs of bleeding✓ 正解評估病人是否有出血跡象
- DMonitor activated partial thromboplastin time (aPTT)✓ 正解監測活化部分凝血活酶時間 (aPTT)
- EUse the serum potassium level to determine whether the heparin dose is therapeutic以血清鉀濃度判斷 heparin 劑量是否達治療效果
— Explanation · 中文詳解 —
未分段 heparin 治療需同時監測抗凝效果與不良反應。依 protocol 追蹤 aPTT、評估臨床出血表徵並監測血小板變化，可分別判斷劑量是否合宜、及早發現出血，以及辨識 heparin 誘發血小板減少症。INR 主要監測 warfarin，血清鉀則不能用來判斷 heparin 的治療效果。
Effective and safe heparin therapy requires comprehensive monitoring, including aPTT to assess anticoagulant efficacy, platelet counts to detect heparin-induced thrombocytopenia, and assessment for signs of bleeding. These parameters collectively ensure therapeutic effectiveness while minimizing the risk of hemorrhage and other complications.