護理師監測一位接受連續靜脈硝酸甘油輸液的心臟衰竭病人。哪項發現需要護理師立即通知醫療提供者？
A nurse is monitoring a client with heart failure who is receiving a continuous infusion of intravenous nitroglycerin. Which finding requires the nurse to notify the healthcare provider immediately?
- AHeart rate 75 bpm心率75次/分
- BSignificant drop in blood pressure after repositioning✓ 正解重新安置體位後血壓顯著下降
- CHeadache頭痛
- DBlood pressure 110/70 mmHg血壓110/70 mmHg
靜脈注射硝酸甘油（Intravenous Nitroglycerin）是一種強效血管擴張劑，主要作用於靜脈系統以減少心臟前負荷（Preload），進而降低心肌耗氧量。在給藥過程中，血壓的變動是監測重點。當病人因姿勢改變出現顯著血壓下降（體位性低血壓），代表身體無法有效透過交感神經代償來維持灌流，這通常是血管擴張效果過強或體液容積不足的徵兆。護理師必須立即評估病人的意識狀態，並通知醫療提供者（HCP）以調整劑量，防止發生暈厥或重要器官灌流不足。
Intravenous nitroglycerin is a potent vasodilator that reduces preload; therefore, significant drops in blood pressure, especially upon repositioning, require immediate notification of the healthcare provider. This finding suggests orthostatic hypotension or excessive vasodilation, which can lead to syncope or inadequate organ perfusion. While headaches are a common side effect, hemodynamic instability takes precedence.
在美國臨床，硝酸甘油輸液通常使用專屬的無 PVC（Non-PVC）管路，因硝酸甘油會吸附在標準 PVC 管路上，導致藥效不穩定。台灣臨床亦逐漸普及此做法，但在藥物儲存與準備上應特別確認。