— 降低風險 · HARD · SATA —
護理師照護一位接受靜脈化學治療的病人。下列哪些評估發現需立即介入？（選所有適合的）
A nurse is providing care for a client who is receiving intravenous (IV) chemotherapy. Which assessment findings require immediate intervention? (Select all that apply.)
- AReports of burning sensation at the IV insertion site✓ 正解報告靜脈穿刺部位有灼熱感
- BSwelling observed around the intravenous catheter site✓ 正解觀察到靜脈導管周圍腫脹
- CCoolness of the skin around the insertion site✓ 正解穿刺部位周圍皮膚冰冷
- DBlood return present upon aspiration of the catheter抽吸導管時有血液回流
- ELeaking of fluid from the catheter connection site✓ 正解導管連接處有液體滲漏
— Explanation · 中文詳解 —
化療藥物多具發泡性（vesicant），若發生滲漏會造成嚴重組織壞死。灼熱感、腫脹、皮膚變涼（滲漏時常伴隨組織灌流改變）及管路連接處滲漏，皆為滲漏（extravasation）的徵兆。有回血（D）反而是正常的導管通暢表現，無須介入。
Note: This ID was already processed above. Skipping duplicate.
✦ 台美臨床差異
台灣對於化療滲漏的處理流程極為嚴格，護理師需具備熟練的緊急解毒劑給藥與局部處理技巧，並需落實異常事件通報。