— 降低風險 · MEDIUM · MCQ —
護理師正在照顧一位接受肝素持續靜脈輸注的病人。下列哪項評估發現需要立即處理?
A nurse is caring for a client with a continuous intravenous infusion of heparin. Which assessment finding requires immediate intervention?
- ABruising at the injection site注射部位出現瘀青
- BPlatelet count of 150,000/mm3血小板計數為 150,000/mm3
- CAPTT result of 75 secondsAPTT 結果為 75 秒
- DPresence of hematuria✓ 正解出現血尿
— Explanation · 中文詳解 —
肝素治療的目標是預防栓塞並監控出血風險。出現血尿(hematuria)是明顯的異常出血徵象,可能代表治療劑量過量,應立即暫停藥物並通知醫師進行凝血功能檢查。瘀青或正常的檢測數值雖需持續追蹤,但不屬於緊急干預範疇。
Hematuria is a critical sign of abnormal bleeding that may indicate heparin overdose, requiring immediate intervention such as pausing the infusion and notifying the provider. While minor bruising and normal platelet counts are expected or monitored findings, and therapeutic aPTT levels are desired, active bleeding represents an urgent safety concern.
✦ 台美臨床差異
美台臨床對於抗凝劑監測皆遵循標準protocol,但台灣更強調病人對於抗凝劑藥物教育的確認流程。