— 降低風險 · MEDIUM · MCQ —
護理師照護一位持續靜脈輸注肝素的病人。下列何項發現應優先處理？
A nurse is caring for a client with a continuous intravenous infusion of heparin. Which finding should the nurse prioritize?
- AThe client has visible hematuria✓ 正解病人出現肉眼可見的血尿
- BThe client reports mild itching at the infusion site病人報告輸注部位有輕微搔癢
- CThe client has a small ecchymosis at the IV site病人靜脈注射部位有小面積瘀青
- DThe client's PTT is 1.5 times the control病人的部分凝血活酶時間（PTT）為對照值的1.5倍
— Explanation · 中文詳解 —
肝素（Heparin）為抗凝血劑，嚴重副作用為出血。血尿（hematuria）顯示可能有系統性出血跡象，屬於危險徵兆，必須立即停止輸注並通知醫師檢查凝血功能。輕微瘀青或輕度癢感通常不需立即中斷治療，而 1.5 倍 PTT 屬治療範圍內。
Visible hematuria indicates potential systemic bleeding, which is a serious adverse effect of heparin requiring immediate intervention such as stopping the infusion and notifying the provider. While minor itching or small ecchymoses may be localized reactions, and a PTT 1.5 times the control is within the therapeutic range, active bleeding poses the highest priority risk.
✦ 台美臨床差異
台美皆嚴格監測肝素值；台灣臨床多由護理師根據 Nomogram 自動調整輸注速率，無需次次請示。