— 藥理與非經腸給藥 · MEDIUM · MCQ —
一位接受肝素輸注治療深層靜脈栓塞的病人，PTT 值為 120 秒。護理師的首要行動為何？
A client receiving heparin infusion for deep vein thrombosis shows a PTT of 120 seconds. What is the nurse's priority action?
- AAdminister protamine sulfate immediately立即給予硫酸魚精蛋白
- BAssess the client for signs of active bleeding✓ 正解評估病人是否有活動性出血的徵象
- CObtain a repeat PTT in 6 hours6小時後重複檢測PTT
- DContinue the infusion at the current rate以目前速率繼續輸注
— Explanation · 中文詳解 —
正常 PTT 範圍約 25-35 秒，治療目標通常為對照值的 1.5-2.5 倍。120 秒已遠超治療範圍，顯示出血風險極高。護理評估應優先於醫囑執行，先檢查是否有皮下出血、牙齦出血或血尿，確保病人臨床狀態穩定。
A PTT of 120 seconds indicates excessive anticoagulation and a high risk for bleeding, requiring immediate assessment for signs of hemorrhage such as bruising or hematuria. While protamine sulfate is the antidote, it is typically reserved for severe or uncontrolled bleeding; the nurse must first evaluate the client's clinical status before notifying the provider or adjusting the infusion.
✦ 台美臨床差異
美國護理師常依據醫院制定的抗凝血藥物滴定表（Nomogram）自動調整劑量，台灣則多需醫師調整醫囑。