— 藥理與非經腸給藥 · HARD · SATA —
護理師準備肝素(Heparin)靜脈輸注,哪些因素對安全給藥至關重要?(選所有適合的)
A nurse is preparing an infusion of heparin. Which factors are crucial for safe administration? (Select all that apply.)
- ACalculating the dose based on weight (kg)✓ 正解根據體重(公斤)計算劑量。
- BObtaining an independent double-check✓ 正解進行獨立雙重核對。
- CMonitoring the aPTT levels✓ 正解監測活化部分凝血活酶時間(aPTT)數值。
- DFlushing the line with heparinized saline以肝素化生理食鹽水沖洗導管。
- EAssessing for signs of bleeding✓ 正解評估是否有出血跡象。
— Explanation · 中文詳解 —
肝素是極高風險的抗凝血劑。劑量計算需精準,通常按體重(kg)計算。給藥必須由雙人核對(Independent double-check)。監測凝血功能指標 aPTT 是調整劑量的標準,同時必須密切觀察臨床是否有出血徵兆。使用肝素液沖洗管路是不建議的,通常使用生理食鹽水即可。
Safe heparin administration requires calculating the dose based on the client's weight and obtaining an independent double-check due to its high-alert status. Nurses must monitor aPTT levels to assess efficacy and closely observe for signs of bleeding, which is the most significant adverse effect.
✦ 台美臨床差異
美國醫院多使用智慧幫浦(Smart Pumps)進行給藥,降低計算錯誤;台灣醫療單位亦普及,但嚴謹度同樣依賴護理人員。