— 降低風險 · MEDIUM · SATA —
護理師正在照護一位放置周邊靜脈留置針的病人。出現哪些跡象顯示病人已發生靜脈炎？（選所有適合的）
A nurse is caring for a client with a peripheral IV line. Which signs indicate the client has developed phlebitis? (Select all that apply.)
- AThe area around the site is red and warm✓ 正解穿刺點周圍區域紅腫且發熱
- BThe area around the site is cool and edematous穿刺點周圍區域冰冷且水腫
- CA palpable cord-like vein is present✓ 正解可觸摸到條索狀硬化的靜脈
- DThe client reports pain and tenderness along the vein✓ 正解病人報告沿靜脈路徑有疼痛和壓痛
- EThe infusion rate has significantly slowed✓ 正解輸注速率顯著減慢
— Explanation · 中文詳解 —
靜脈炎的典型徵象包括發紅（redness）、溫熱感（warmth）、沿著靜脈走向的疼痛與壓痛，且嚴重時可摸到條索狀（cord-like）血管。由於血管壁受損發炎，輸液速度亦會變慢。選項B則是滲漏（infiltration）的特徵，而非靜脈炎。
Phlebitis is indicated by redness, warmth, pain, tenderness along the vein, and a palpable cord-like structure due to vascular inflammation. These signs distinguish it from infiltration, which typically presents with coolness and edema, and phlebitis can also slow the infusion rate by restricting the vessel lumen.
✦ 台美臨床差異
美國護理界對於靜脈炎分級有嚴格標準（如 Visual Infusion Phlebitis scale）；台灣臨床評估多依賴醫護經驗，較少系統化記錄分級。