護理師正在照顧一位留置動脈導管(Arterial Line)的病人。為了確保血壓監測的準確性,護理師應採取哪些行動?(選所有適合的)
A nurse is caring for a client with an arterial line. Which actions should the nurse take to ensure the accuracy of the blood pressure readings? (Select all that apply.)
- ALevel the transducer to the phlebostatic axis.✓ 正解將傳感器與靜脈軸心(phlebostatic axis)齊平。
- BZero the system to atmospheric pressure during each shift.✓ 正解每班將系統對大氣壓進行歸零。
- CPerform an Allen test every 4 hours.每 4 小時進行 Allen 試驗。
- DUse a pressure bag maintained at 300 mmHg.✓ 正解使用維持在 300 mmHg 的壓力袋。
- ECheck the waveform for signs of damping.✓ 正解檢查波形是否有衰減跡象。
動脈導管監測的準確性取決於物理壓力傳導系統的正確校正。核心概念包括:1. 定位(Leveling):傳感器必須對準「靜脈軸心(phlebostatic axis)」,即第四肋間與腋中線交點,確保反映心臟壓力。2. 歸零(Zeroing):排除大氣壓干擾。3. 壓力袋:維持在 300 mmHg 以保證持續微量沖洗並防止血液回流。4. 波形觀察:避免波形過度衰減(Damping)導致血壓估計錯誤。Allen test(C)是在置入導管「前」評估尺動脈循環的,導管留置後主要是評估手指末梢血流,而非反覆做 Allen test。整套流程是為了減少因儀器誤差導致的醫療決策錯誤風險。
To ensure accurate arterial line readings, the nurse must level the transducer to the phlebostatic axis, zero the system to atmospheric pressure, use a pressure bag maintained at 300 mmHg, and check the waveform for damping. The Allen test is performed prior to insertion to assess collateral circulation, not as a routine check after placement.
美國 NCLEX 強調靜脈軸心(Phlebostatic axis)的解剖定位與物理校正原則;台灣臨床操作中,護理師同樣重視歸零與定位,但實務上對於壓力袋壓力的監測與波形動力學測試(Square wave test)的描述在美式考題中更為常見。