— 降低風險 · EASY · MCQ —
護理師照護一位持續靜脈輸液的病人，哪項發現顯示輸液滲漏（Infiltration）？
A nurse is caring for a client who is receiving a continuous intravenous infusion. Which finding indicates the client is experiencing infiltration?
- AThe site is warm and red穿刺部位溫熱且發紅
- BThe client complains of intense burning pain病人抱怨劇烈灼痛
- CThe site is cool to the touch✓ 正解穿刺部位觸感冰冷
- DThere is a streak of red along the vein靜脈沿線出現紅色條紋
— Explanation · 中文詳解 —
輸液滲漏是指藥液進入皮下組織，臨床表現為局部皮膚溫度降低（因液體在皮下散熱）、腫脹、緊繃感及流量降低。選項A與D為靜脈炎（Phlebitis）的特徵，主要表現為發紅、溫熱及觸痛；選項B常見於刺激性藥物，雖可能與滲漏有關，但低溫腫脹是滲漏的典型定義。
Infiltration occurs when IV fluid enters the surrounding tissue, typically causing the site to feel cool to the touch due to the temperature of the infused solution. This distinguishes it from phlebitis, which presents with warmth, redness, and pain. Therefore, coolness at the insertion site is a primary indicator of infiltration.
✦ 台美臨床差異
台美針對靜脈治療皆需遵循INS標準，對於滲漏的處置流程及分級標準高度相似。