— 生理適應 · HARD · MCQ —
病患正接受全靜脈營養（TPN）。下列哪項發現需要立即回報？
A client is receiving total parenteral nutrition (TPN). Which finding requires immediate reporting?
- ABlood glucose of 210 mg/dL血糖值 210 mg/dL
- BA slight increase in thirst口渴感輕微增加
- CInfiltration of the IV site✓ 正解靜脈注射部位滲出
- DWeight gain of 0.5 kg in a day一天內體重增加 0.5 kg
— Explanation · 中文詳解 —
TPN 溶液濃度極高，若發生滲漏 (Infiltration) 或外滲，會導致組織損傷、化學性灼傷甚至壞死。A 選項血糖升高為 TPN 常見副作用，需監控但通常不會立即造成組織危害。B 需評估是否為液體負荷，非立即性損害。D 的外滲風險在 TPN 中極為嚴重，需優先處理。
Total parenteral nutrition (TPN) is highly hypertonic, so infiltration into surrounding tissues can cause severe chemical burns and tissue necrosis, requiring immediate reporting and intervention. While hyperglycemia and mild thirst are expected side effects managed with monitoring and insulin, they do not pose the same immediate risk of local tissue destruction as an infiltrated IV site.
✦ 台美臨床差異
美國護理師常負責護理 PICC 或 CVC 線路，台灣多依院內感控政策進行，但對滲漏的處置皆為最高警報。