— 降低風險 · HARD · SATA —
護理師照護一位接受全靜脈營養(TPN)的病人。應執行下列哪些措施?(選所有適合的)
A nurse is providing care to a client receiving total parenteral nutrition (TPN). Which actions should the nurse perform? (Select all that apply.)
- ACheck blood glucose every 6 hours✓ 正解每6小時檢查血糖
- BChange the IV tubing every 24 hours每24小時更換靜脈輸液管路
- CAdminister D10W if the TPN bag runs out✓ 正解若TPN袋用完,給予10%葡萄糖注射液(D10W)
- DUse sterile technique when changing dressings✓ 正解更換敷料時使用無菌技術
- EWeigh the client daily✓ 正解每日稱量病人体重
— Explanation · 中文詳解 —
TPN 含高糖,極易引發高血糖,故需定時監測血糖。TPN 輸液袋若用罄,需掛 D10W 以防低血糖反應(反彈性胰島素分泌)。TPN 管路與接口感染風險極高,更換敷料必須嚴格無菌操作。每日量體重是評估營養吸收與體液平衡之必要手段。TPN 輸液管通常 24-72 小時更換,視醫院政策而定,而非每天。
Because TPN contains high glucose, nurses must monitor blood glucose regularly and administer D10W if the infusion stops to prevent rebound hypoglycemia. Strict sterile technique is required for central line care, and daily weights help track fluid balance and nutritional status.
✦ 台美臨床差異
美國醫院 TP N 管路更換政策通常較嚴謹,多遵循 CDC 指引;台灣各醫院針對 TPN 換管規範差異較大。