# 一位病人正透過中心靜脈導管接受靜脈營養。請標示出需要立即進行導管感染追蹤的發現。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522665&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

一位病人正透過中心靜脈導管接受靜脈營養。請標示出需要立即進行導管感染追蹤的發現。

| 領域 | 發現 |
| --- | --- |
| 全身性 | 輸注期間出現新發燒伴寒顫 |
| 置入部位 | 導管置入部位有膿性引流液 |
| 置入部位 | 導管路徑出現新壓痛 |
| 敷料 | 透明敷料潮濕且兩邊翹起 |
| 敷料 | 敷料清潔、乾燥、有日期且完整 |
| 管腔 | 專用管腔在不使用時保持封蓋 |
| 技術 | 消毒液在操作前已允許乾燥 |
| 監測 | 體溫保持在記錄的基準值 |

## 解析

發燒伴寒顫、引流液、置入部位壓痛以及潮濕或鬆脫的敷料，都需要立即進行中心靜脈導管評估和依據規範的追蹤。清潔乾燥的敷料和完整的專用管腔是保護性發現。

## 深入解析

快速解答
升高 全身性感染跡象以及敷料或置入部位完整性受損。

為何這是正確的
中心靜脈通路可將病原體直接送入血流。敷料完整性、無菌接頭操作、皮膚消毒以及對感染跡象的及時反應是核心保護措施。

簡單類比或心像
將每次輸注視為受控的臨床系統：核實產品和通路、識別變化的跡象、停止可預防的暴露、穩定病人並確認反應。

記憶點
產品、通路、相容性、輸注跡象、保護措施和再評估。

NCLEX 決策規則
選擇能預防最直接輸注相關傷害的措施，同時保留血管通路和醫囑診斷證據。

為何其他選項是錯誤的
重新啟動可疑產品、繞過安全裝置、強行疏通阻塞導管或延遲再評估的選項，可能將可逆的警訊轉變為嚴重傷害。References
1CDC Guidelines for Prevention of Intravascular Catheter-Related InfectionsChlorhexidine-alcohol skin preparation, drying, sterile barrier practice, dressing integrity, and infection assessment
2ASPEN Parenteral Nutrition Safety Consensus RecommendationsDedicated access, compatibility, admixture protection, infection prevention, laboratory surveillance, and safe administration

## 臨床情境

血液製品、營養和靜脈輸液安全審查
核實產品、處方、途徑、通路裝置、過濾器或管路、相容性、基準發現、新出現的不良跡象、應對計畫和可衡量的追蹤。

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