— 降低風險 · EASY · MCQ —
一位病人的靜脈注射部位出現冰冷、蒼白且腫脹的情形，下列哪項護理措施最適當？
A client presents with an IV infiltration site that is cool, pale, and swollen. Which nursing intervention is appropriate?
- ADiscontinue the infusion and remove the catheter✓ 正解停止輸注並拔除導管
- BContinue the infusion to flush the line繼續輸注以沖洗管路
- CApply a warm compress to the area在患處施加熱敷
- DElevate the extremity and notify the physician immediately抬高患肢並立即通知醫師
— Explanation · 中文詳解 —
靜脈注射部位出現上述症狀，代表發生了靜脈滲漏（Infiltration）。當務之急是立刻終止注射，防止藥液繼續進入皮下組織造成損傷。後續步驟包括移除針頭、抬高肢體以促進回流，並評估是否需施加溫或冷敷，但終止給藥為優先。
Cool, pale, and swollen IV sites indicate infiltration, requiring immediate discontinuation of the infusion and removal of the catheter to prevent further tissue damage. Continuing the infusion or flushing the line would force more fluid into the subcutaneous space, exacerbating the injury.
✦ 台美臨床差異
美台護理對於靜脈輸液照護準則高度一致，皆強調即刻評估並移除管路。