— 降低風險 · MEDIUM · SATA —
下列哪些護理評估對於識別輸血病人的潛在併發症至關重要？（選所有適合的）
Which of the following nursing assessments are critical for identifying potential complications in a client receiving a blood transfusion? (Select all that apply.)
- AMonitor for chills and fever✓ 正解監測是否有畏寒和發燒
- BAssess for itching or rash✓ 正解評估是否有搔癢或皮疹
- CCheck for flank or back pain✓ 正解檢查是否有側腹或背痛
- DMonitor for changes in urine color✓ 正解監測尿液顏色變化
- EAssess blood pressure every 4 hours每4小時評估血壓
— Explanation · 中文詳解 —
輸血反應可能包括溶血、過敏或發熱反應。寒顫發燒（發熱反應）、皮膚紅疹癢（過敏反應）、背痛與尿液變色（急性溶血反應）皆為嚴重併發症徵兆。輸血期間應密切監測生理變化，每 4 小時量血壓太長，通常應在開始輸血後的最初 15 分鐘及輸血期間頻繁監測。
Transfusion reactions such as febrile, allergic, and hemolytic responses require vigilant assessment for signs like chills, fever, itching, rash, flank pain, and dark urine. Blood pressure must be monitored frequently, especially during the initial 15 minutes of the transfusion, rather than every 4 hours, to ensure early detection of complications.
✦ 台美臨床差異
台灣輸血紀錄單要求比美國更詳細，通常需紀錄輸血全程的生命徵象變異。