護理師準備對低血鉀病人靜脈給予氯化鉀(KCl)。下列哪些護理措施是正確的?(選所有適合的)
A nurse is preparing to administer potassium chloride (KCl) IV to a client with hypokalemia. Which of the following nursing actions are appropriate? (Select all that apply.)
- AEnsure the concentration does not exceed 10 mEq/100 mL for peripheral lines✓ 正解確保周邊靜脈輸液的濃度不超過10 mEq/100 mL
- BAdminister as an IV bolus to quickly correct the deficit作為靜脈推注以快速糾正缺乏
- CUse an infusion pump to regulate the flow rate✓ 正解使用輸液幫浦調節流速
- DAssess the IV site for signs of phlebitis or infiltration✓ 正解評估靜脈穿刺部位是否有靜脈炎或滲漏跡象
- EInstruct the client to report any burning sensations✓ 正解指示病人報告任何灼熱感
鉀離子對靜脈具有高度刺激性。給藥時必須使用輸液泵精確控制速率(不可快速推注,以免造成心律不整甚至心跳停止),並嚴格限制周邊靜脈濃度。護理師需密切監測輸注部位,若出現疼痛或灼熱感,應懷疑外滲並立即停止輸注。
Potassium chloride is highly irritating to veins and must be administered via an infusion pump to ensure precise control of the flow rate, preventing rapid infusion that could cause cardiac arrhythmias. For peripheral lines, the concentration should not exceed 10 mEq/100 mL to avoid vein damage. Nurses must assess the IV site for phlebitis or infiltration and instruct the client to report burning sensations, as potassium causes severe tissue necrosis if it leaks into surrounding tissues.
台美臨床皆嚴格禁止 KCl 推注,但美國針對高濃度 KCl 輸注通常需由中央靜脈導管(CVL)給予,台灣則有時在緊急下對濃度限制較靈活。