— 降低風險 · MEDIUM · SATA —
一位放置周邊置入中心靜脈導管（PICC）的病人，下列哪項發現需護理師立即介入？（選所有適合的）
A nurse is caring for a client with a new peripherally inserted central catheter (PICC). Which of the following findings requires immediate intervention? (Select all that apply.)
- AArm circumference measurement increase of 3 cm above the insertion site✓ 正解插入點上方手臂周徑增加 3 公分
- BInability to aspirate blood return from the catheter無法從導管抽吸回血
- CClient reports chest pain and shortness of breath✓ 正解病人主訴胸痛和呼吸困難
- DSmall amount of clear serous drainage on the dressing敷料上有少量清澈血清樣滲出液
- EResistance noted during the flushing process✓ 正解沖洗過程中感到阻力
— Explanation · 中文詳解 —
PICC 導管監測重點在於栓塞與導管位置。手臂圍增加顯示可能發生血栓，需立即評估。胸痛與呼吸急促暗示可能發生導管相關栓塞或氣胸，屬於緊急狀況。沖管時遇到阻力暗示導管阻塞，強行沖洗可能導致血管損傷或栓塞脫落。Serous 分泌物若極少量屬術後正常反應。
An increase in arm circumference suggests venous thrombosis, while chest pain and dyspnea indicate a potential pulmonary embolism or pneumothorax, both requiring immediate intervention. Resistance during flushing signals a catheter occlusion, where forceful flushing could dislodge a clot. These findings prioritize patient safety over routine assessments.
✦ 台美臨床差異
美方護理師對 PICC 管理權限較高，台灣常需會診血管通路團隊或醫師處理導管阻塞問題。