— 降低風險 · MEDIUM · SATA —
護理師準備執行輸血，下列哪些措施對確保安全至關重要？（選所有適合的）
A nurse is preparing to hang a blood transfusion. Which actions are necessary to ensure safety? (Select all that apply.)
- AVerify the blood type and crossmatch with a second nurse✓ 正解與第二位護理師共同核對血型與交叉配血試驗
- BObtain the client's baseline vital signs✓ 正解取得個案的基準生命徵象
- CUse a 22-gauge needle or larger for the infusion✓ 正解使用 22 gauge 或較粗的針頭進行輸注
- DEnsure the blood is infused within 4 hours✓ 正解確保血液在 4 小時內完成輸注
- EAdd medication to the blood tubing to speed up administration在輸血管路中添加藥物以加快輸注速度
— Explanation · 中文詳解 —
輸血是高風險醫療行為。必須由兩人核對病人資料、血型與交叉試驗報告。輸血前需測量基準生命徵象以利日後比對。必須使用至少 20-22G 針頭避免破壞紅血球，且須在 4 小時內輸注完畢以防細菌滋生。嚴禁將藥物加入血袋中，以免導致溶血或感染。
Safety measures include verifying blood type and crossmatch with a second nurse, obtaining baseline vital signs, using a large-bore needle (20-22 gauge or larger) to prevent hemolysis, and ensuring the unit is infused within four hours to limit bacterial growth. Medications must never be added to blood products, as this can cause hemolysis or infection.
✦ 台美臨床差異
美台對於輸血核對流程極為相似，皆採雙人確認與嚴格的時間限制管理。