# 情境 78歲HFrEF個案使用lisinopril與spironolactone，因UTI開立trimethoprim-sulfamethoxazole。基線K 4.6 mEq/L、creatinine 1.4 mg/dL。最適當的護理行為為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375241&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

情境 78歲HFrEF個案使用lisinopril與spironolactone，因UTI開立trimethoprim-sulfamethoxazole。基線K 4.6 mEq/L、creatinine 1.4 mg/dL。最適當的護理行為為何?

## 選項

1. 依照處方給予TMP-SMX，因為鉀離子濃度4.6 mEq/L在正常範圍內且其他檢驗值無需介入處理；持續監測泌尿道感染症狀的緩解並鼓勵液體攝取以預防進一步的腎臟壓力，這是對於患有泌尿道感染的老年個案的標準照護。
2. 聯絡處方者與藥師；高齡並使用ACE抑制劑與醛固酮拮抗劑且腎功能下降，合併TMP-SMX有嚴重高鉀風險(TMP類似amiloride抑制腎臟上皮Na通道)；預期基線與追蹤K與腎功能、必要時改用替代抗生素(CrCl>30用nitrofurantoin、fosfomycin、cephalexin等)、衛教高鉀食物、若K上升做ECG監測。 **✔ 正確答案**
3. 添加鉀補充劑，例如口服氯化鉀20 mEq每日，因為基礎鉀離子4.6 mEq/L可能因抗生素治療和spironolactone（可能導致鉀流失）而下降；這將預防低血鉀並維持此老年心衰竭個案的心臟功能。
4. 增加spironolactone至每日50 mg，以抵消抗生素可能造成的鉀流失並提供額外的心衰竭管理；在治療的最初72小時內每日監測血清鉀離子和肌酸酐濃度，因為已知spironolactone可對抗磺胺類藥物的腎臟影響。

**正確答案: 2**

## 解析

TMP-SMX對UTI廣泛有效，但trimethoprim結構類似amiloride，會抑制遠端腎元上皮Na通道，降低K排泄。與ACEi或ARB(抑醛固酮)、醛固酮拮抗劑(spironolactone、eplerenone)、K補充劑、NSAIDs、β阻斷劑或既有腎功能不全合用，明顯增加嚴重高鉀風險，老年族群已有心律不整、住院與死亡報告。整合護理/協調：(1) 開始前與3~5天追蹤的K、creatinine、BUN；(2) 將風險告知處方者與藥師，若培養許可建議改用替代抗生素 — CrCl>30 mL/min時nitrofurantoin、fosfomycin單次、cephalexin等窄譜；(3) 衛教治療期間限制高鉀食物(香蕉、橘子、番茄、馬鈴薯、含KCl的代鹽)；(4) 回報高鉀症狀(無力、麻木、心悸)，K上升時做ECG並注意peaked T、PR延長、QRS加寬；(5) 同時遵循SJS、光敏感、水分、葉酸等磺胺類常規注意；(6) 記錄過敏並檢視其他升鉀藥物。未確認直接給藥、增加spironolactone、加用K補充劑皆不安全。

## 深入解析

TMP-SMX加上ACEi/spironolactone加上高齡腎功能下降等於高鉀高風險。溝通、監測檢驗、提替代抗生素。

## 重要概念

- **TMP-induced hyperkalemia** — 抑制腎臟上皮Na通道，類似amiloride，降低K排泄，高齡與CKD風險增
- **TMP-SMX alternative for UTI** — nitrofurantoin(CrCl>30)、fosfomycin單次、cephalexin，依培養選擇
- **hyperkalemia ECG** — peaked T、PR延長、QRS加寬、sine wave，可致心臟停止，需立即處置

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