# 一名照護敗血症性休克個案的護理師發現左前臂的周邊IV正在輸注norepinephrine 8 mcg/分鐘的部位冰冷、蒼白、腫脹、壓痛,且IV pump響起阻塞警報。護理師最適當的行動順序為何? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: PA ## 題目 一名照護敗血症性休克個案的護理師發現左前臂的周邊IV正在輸注norepinephrine 8 mcg/分鐘的部位冰冷、蒼白、腫脹、壓痛,且IV pump響起阻塞警報。護理師最適當的行動順序為何? ## 選項 1. 立即將norepinephrine輸液速率增加2 mcg/min以維持腦和腎灌注，然後暫停輸液並用10 mL生理食鹽水沖洗周邊靜脈導管，以稀釋和分散外滲的藥物；之後移除導管，記錄處置，並在腫脹消退後於新部位重新嘗試輸液。 2. 立即停止norepinephrine輸注,先保留導管以抽吸殘留藥物,抬高肢體·標記部位,通報醫師,準備phentolamine 5~10 mg於NS 10 mL以皮下分次注入漏出部位周圍,並建立新的中心靜脈或大號近端IV以恢復vasopressor。 **✔ 正確答案** 3. 維持原速率繼續輸液，在部位使用冰敷20分鐘以減輕水腫，然後嘗試用含肝素的生理食鹽水沖洗導管；若持續有阻力，記錄事件並要求在相同肢體原部位遠端重新放置周邊靜脈導管。 4. 停止輸液並移除周邊靜脈導管，在部位直接加壓10分鐘，然後放置溫敷以促進吸收；15分鐘後，透過右前臂的新靜脈注射部位以原速率重新開始norepinephrine輸液，並確保監視器警報靜音以減輕病人焦慮。 **正確答案: 2** ## 解析 Vasopressor漏出 — vesicant緊急 Norepinephrine等強力vasopressor為vesicant。皮下漏出引起強局部血管收縮·缺血·組織壞死。冰冷·蒼白·腫脹·壓痛+occlusion警報=extravasation高度懷疑。標準步驟:立即停止·導管保留·吸抽殘留·肢體抬高·標記·通報醫師·phentolamine 5~10 mg於NS 10 mL周圍SC分次注入(α阻斷反轉血管收縮)·建立新中心靜脈/大近端IV·文件化。冰敷避免(catecholamine會加重血管收縮)。同路徑重試·提速·單純拔針皆不當。 ## 深入解析 為何選2 Norepinephrine等強力vasopressor為vesicant。皮下漏出引起強烈局部血管收縮·缺血·組織壞死。冰冷·蒼白·腫脹·壓痛+pump occlusion警報強烈提示extravasation。 標準護理順序 (1)立即停止輸注。(2)先保留導管 — 抽吸殘留藥物(依機構政策)。(3)抬高肢體·標記受影響範圍。(4)立即通報醫師。(5)phentolamine 5~10 mg於NS 10 mL,於漏出部位周圍SC分次注入 — catecholamine extravasation標準解毒劑。競爭性α阻斷反轉局部血管收縮。替代:topical nitroglycerin paste·terbutaline。(6)建立新IV — 中心靜脈或大號近端靜脈。Vasopressor建議走中心路徑。(7)記錄時間·藥物·劑量·IV部位·標記·處置·個案反應。 禁忌 Catecholamine extravasation避免冰敷(加重血管收縮)。同路徑重啟·提速·無phentolamine/通報就單純拔除皆錯誤。 誤答分析 1:同部位敷冰·同路徑重試會加重組織損傷。3:立即拔除+壓迫失去清除殘藥機會·遺漏phentolamine與通報。4:提速會加速漏出+加重組織壞死+違反通報義務。 ## 重要概念 - **Norepinephrine** — 內生性catecholamine·α1·β1作用。敗血症性休克及其他vasodilatory shock第一線vasopressor。起始0.05 mcg/kg/分鐘·MAP ≥65 titration。建議中心靜脈。Extravasation = phentolamine。突然停藥會低血壓。 - **Phentolamine** — 非選擇性α阻斷劑。Norepinephrine·dopamine·epinephrine extravasation標準解毒劑。5~10 mg於NS 10 mL — 漏出部位周圍SC分次注入。漏出後12小時內有效。 - **Vesicant** — 漏出時引起組織壞死的藥物。Catecholamine(norepinephrine·dopamine·epinephrine)·部分化療藥·高滲透壓液(KCl·hypertonic saline)·CaCl2·diazepam·phenytoin。建議中心靜脈。 ## 相同主題題目 - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_