— 降低風險 · HARD · SATA —
護理師照護一位接受靜脈化療的病人。下列哪些發現暗示可能出現血管外滲？（選所有適合的）
A nurse is caring for a client who is receiving intravenous (IV) chemotherapy. Which of the following findings indicates possible extravasation? (Select all that apply.)
- ASwelling around the insertion site✓ 正解插入部位周圍的腫脹
- BBlood return noted in the tubing在管路中觀察到回血
- CCoolness of the skin around the site✓ 正解部位周圍皮膚的冷感
- DClient complains of burning sensation✓ 正解客戶抱怨有灼熱感
- ELeaking of fluid from the catheter insertion site✓ 正解液體從導管插入部位滲出
— Explanation · 中文詳解 —
化療藥物具強烈腐蝕性，一旦外滲會造成組織壞死。外滲的典型徵象包括穿刺處腫脹、皮膚溫度改變（通常為涼冷）、病人主訴灼熱疼痛，以及導管口滲液。回血（Blood return）通常代表導管位置正確，並非外滲指標。護理師需即刻停止輸注，並根據藥物性質採取特定處置（如冰敷或溫敷）。
Signs of IV extravasation include swelling at the insertion site, coolness of the surrounding skin, client complaints of burning or pain, and leakage of fluid from the catheter site. These indicators suggest that the medication has infiltrated the surrounding tissue rather than remaining in the vein, requiring immediate cessation of the infusion to prevent tissue damage.
✦ 台美臨床差異
美國化療給藥規範（ONS 標準）極其嚴格，護理師需具備專屬證照才能操作，台灣則多為一般護理師依醫囑執行。