— 藥理與非經腸給藥 · HARD · SATA —
一位病人正接受全靜脈營養(TPN)輸注,護理師應監測哪些潛在併發症?(選所有適合的)
A client is receiving total parenteral nutrition (TPN). Which of the following complications should the nurse monitor for? (Select all that apply.)
- AHyperglycemia✓ 正解高血糖
- BAir embolism✓ 正解空氣栓塞
- CHypokalemia低血鉀
- DInfection at the catheter site✓ 正解導管部位感染
- EFluid volume overload✓ 正解體積過載
— Explanation · 中文詳解 —
TPN 含有高濃度的葡萄糖、蛋白質與電解質,使用過程風險極高。高血糖常見於開始輸注時;空氣栓塞發生在更換輸液袋或管路接頭時;感染是因中心導管長期留置引起;液體過載則是因高滲透壓與大量水分輸入導致。低血鉀(C)並非 TPN 必發之副作用,TPN 反而常需添加鉀離子。
The Braden Scale assesses pressure injury risk through six components: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Heart rate is not a factor in this specific evaluation tool.
✦ 台美臨床差異
美國多由專責營養團隊負責調配與評估,台灣則多由護理師與臨床營養師共同監測,且常需醫師簽署特殊的營養評估醫囑。