— 藥理與非經腸給藥 · MEDIUM · SATA —
病人正在接受靜脈輸注肝素（Heparin）。護理師應監測哪些潛在中毒徵象？（選所有適合的）
A client is receiving an intravenous infusion of heparin. Which signs of potential toxicity should the nurse monitor for? (Select all that apply.)
- AEpistaxis✓ 正解鼻出血
- BMelena✓ 正解黑便
- CHematuria✓ 正解血尿
- DPetechiae on the extremities✓ 正解肢體瘀點
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
肝素主要抗凝血機制會增加出血風險。當出現藥物效應過強時，體表與體內皆會出現異常出血徵兆。鼻出血、黑便、血尿、皮下瘀點皆是典型凝血功能異常表現。若大量內出血導致血壓下降，則顯示病情已進入失代償危險狀態。
When monitoring a client receiving intravenous heparin, the nurse should assess for signs of bleeding such as epistaxis, melena, hematuria, petechiae, and hypotension. These symptoms indicate potential toxicity or excessive anticoagulation, ranging from minor mucosal bleeding to severe internal hemorrhage causing hemodynamic instability.
✦ 台美臨床差異
台灣與美國在 Heparin 監測上皆重視出血徵象，但美國護理師常依據 Nomogram 自行調整給藥速度，台灣則多需嚴格遵循醫師醫囑調整。