照護留置尿管病人,下列哪些護理措施適當?(選所有適合的)
A nurse is caring for a client with an indwelling urinary catheter. Which nursing actions are appropriate? (Select all that apply.)
- AKeep the drainage bag below the level of the bladder✓ 正解將引流袋保持在膀胱水平以下
- BClean the meatus daily with soap and water✓ 正解每日用肥皂和水清潔尿道口
- CEmpty the bag when it is completely full當引流袋完全充滿時再排空
- DSecure the catheter to the client's thigh✓ 正解將導尿管固定在病人的大腿上
- ELoop the tubing to ensure drainage將管路盤繞以確保引流
導尿管照護原則:袋子需低於膀胱高度(A)防止逆流;每日清潔尿道口(B);固定管路(D)防止拉扯。C 錯誤:袋子應在 1/2 至 2/3 滿時即清空,以免過重污染或阻塞;E 錯誤:管路不得彎曲或打結,防止阻塞,需保持平直引流。
Indwelling urinary catheter care principles: the bag should be kept below bladder level (A) to prevent backflow; the urethral meatus should be cleansed daily (B); the tubing should be secured (D) to prevent traction. C is incorrect: the bag should be emptied when 1/2 to 2/3 full to avoid contamination or obstruction from excessive weight; E is incorrect: tubing must not be kinked or knotted, must remain straight to prevent obstruction and maintain drainage.
美台對導尿管照護的規範一致,均強調導管照護包(Catheter Care Bundle)與 CAUTI 監測。