# 一名產後病人於30分鐘內浸濕2片會陰墊。子宮底軟而上移。使用4 Ts架構之適當護理行動為何？請選擇所有適用項目。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374930&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

一名產後病人於30分鐘內浸濕2片會陰墊。子宮底軟而上移。使用4 Ts架構之適當護理行動為何？請選擇所有適用項目。

1

延遲30分鐘進行子宮底按摩及膀胱評估，以觀察子宮是否能自行變硬，因為過度操作可能導致進一步出血。

2

Thrombin(凝血異常)：於子癇前症、胎盤剝離、敗血性休克時評估DIC徵象；採血做凝血面板。

3

Trauma(裂傷或血腫)：檢查會陰、陰道、子宮頸有無裂傷或可見血腫；子宮底硬但仍鮮紅出血提示創傷。

4

Tissue(胎盤殘留)：分娩後檢查胎盤完整性；若子宮已收縮但PPH持續即懷疑殘留物。

5

Tone(子宮張力低下 — 最常見原因)：立即執行子宮底按摩並協助排空膀胱，因為脹滿膀胱會使子宮移位並惡化張力低下。

## 解析

產後出血4 Ts：TONE(子宮張力低下 — 占PPH 70-80%；按摩、oxytocin、methylergonovine、carboprost、misoprostol；確認膀胱)、TISSUE(胎盤殘留)、TRAUMA(裂傷、血腫)、THROMBIN(凝血異常 — DIC)。選項5危險 — PPH為母體死亡主因；需立即行動並通報醫師，不可等待。

## 深入解析

Tone為首要評估之T，因子宮張力低下占PPH 70-80%。位置上移之軟子宮底常見於膀胱脹滿造成之典型張力低下。記住子宮收縮藥階梯：oxytocin → methylergonovine(避用於HTN) → carboprost(避用於氣喘) → misoprostol → tranexamic acid。PPH中「等等看」陷阱是致命的。

## 臨床情境

**產後病人30分鐘內浸濕2片會陰墊**且**子宮底軟並上移**。護理師使用**4 Ts架構**(Tone、Tissue、Trauma、Thrombin)評估產後出血原因。

## 重要概念

- **PPH之4 Ts** — Tone、Tissue、Trauma、Thrombin — 產後出血原因之系統性評估架構。
- **子宮張力低下** — 子宮無法收縮呈軟狀；占PPH 70-80%；以按摩、排空膀胱、oxytocin、methylergonovine、carboprost治療。
- **Methylergonovine/carboprost注意** — Methylergonovine禁用於HTN/子癇前症；carboprost(Hemabate)禁用於氣喘。

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