— 藥理與非經腸給藥 · HARD · SATA —
護理師照護靜脈輸注肝素(Heparin)的病人。應優先監測哪些發現以預防嚴重損傷?(選所有適合的)
A nurse is caring for a client receiving intravenous Heparin. Which findings should the nurse prioritize to prevent serious injury? (Select all that apply.)
- APlatelet count✓ 正解血小板計數
- BPresence of hematuria✓ 正解血尿的存在
- CaPTT levels✓ 正解活化部分凝血活酶時間(aPTT)
- DSpontaneous epistaxis✓ 正解自發性鼻出血
- ESerum creatinine血清肌酸酐
— Explanation · 中文詳解 —
肝素治療需嚴謹監測出血徵兆。血小板計數(A)用於偵測 HIT(肝素誘發血小板減少症),這是致命併發症。血尿(B)與鼻出血(D)為顯著出血徵兆。aPTT(C)則是用於調整輸注速度的核心數據。肌酸酐(E)雖與排泄有關,但非肝素輸注期間優先監測的出血或血栓指標。
Monitoring platelet counts is critical to detect heparin-induced thrombocytopenia (HIT), while aPTT levels guide dosage adjustments. Signs of bleeding such as hematuria and spontaneous epistaxis must also be prioritized to prevent serious injury.
✦ 台美臨床差異
美國護理師常依據特定醫療機構的 Heparin Nomogram 自行調整點滴速度,台灣多需依賴醫師下醫囑調整。