— 藥理與非經腸給藥 · MEDIUM · MCQ —
接受肝素（Heparin）治療的病人 aPTT 為 110 秒。護理師應採取之首要行動為何？
A client receiving heparin therapy has an aPTT result of 110 seconds. What is the nurse's priority action?
- ANotify the physician通知醫師
- BStop the heparin infusion✓ 正解停止肝素輸注
- CAssess the client for signs of bleeding評估病人是否有出血徵象
- DAdminister protamine sulfate給予硫酸魚精蛋白
— Explanation · 中文詳解 —
治療性 aPTT 通常為對照值的 1.5-2.5 倍，110 秒已明顯超出治療範圍，有極高出血風險。護理師應先停止給藥（Stop），隨後評估病人（Assess），最後才通知醫師（Notify）。Protamine sulfate 僅在嚴重出血時使用，非處置第一步驟。
An aPTT of 110 seconds indicates supratherapeutic anticoagulation with a high risk of bleeding, making it the nurse's priority to stop the heparin infusion immediately. After halting the medication, the nurse should assess for signs of bleeding and notify the provider, as protamine sulfate is reserved for severe hemorrhage rather than elevated lab values alone.
✦ 台美臨床差異
台美對於肝素抗凝血過高的處置原則一致，皆以先停藥為主，護理師對調整速率的決策權視醫院協定而定。