一位病人在接受經尿道攝護腺切除術 (TURP) 後進行持續膀胱沖洗 (CBI)。護理師發現引流停止，且病人主訴嚴重的膀胱痙攣。護理師應優先採取哪項措施？
A nurse is caring for a client with a continuous bladder irrigation (CBI) after a transurethral resection of the prostate (TURP). The nurse notes that the drainage has stopped and the client reports severe bladder spasms. Which action should the nurse take first?
- AIncrease the rate of the irrigation fluid增加沖洗液的滴速
- BNotify the healthcare provider immediately立即通知醫療提供者
- CCheck the catheter tubing for kinks or blood clots✓ 正解檢查導尿管管路是否有扭曲或血塊
- DAdminister an antispasmodic medication as prescribed依處方給予抗痙攣藥物
TURP 術後的 CBI 是為了移除膀胱內的血塊並防止尿道阻塞。當引流停止且病人出現痙攣時，最可能的生理原因是引流管路被血塊（Clots）或扭曲（Kinks）阻塞，導致沖洗液在膀胱內蓄積，撐大膀胱引發劇烈收縮疼痛。根據護理程序（Nursing Process），應先進行評估與排除簡單障礙（C）。如果增加沖洗速度（A），只會讓更多水進入已阻塞的膀胱，加劇疼痛甚至導致膀胱破裂。只有在確認管路無扭曲但仍不通暢時，才考慮依醫囑手動沖洗（Manual irrigation）或通知醫師。給予止痛藥（D）無法解決物理性阻塞問題。
Continuous bladder irrigation (CBI) after TURP is used to remove blood clots from the bladder and prevent urethral obstruction. When drainage stops and the client experiences spasms, the most likely physiological cause is obstruction of the drainage tubing by clots or kinks, allowing irrigation fluid to accumulate in the bladder and overdistend it, producing severe contractile pain. According to the nursing process, the nurse should first assess and rule out simple obstructions (C). Increasing the irrigation rate (A) would only allow more fluid to enter an obstructed bladder, worsening the pain and even risking bladder rupture. Only after confirming that the tubing is not kinked but still not draining should manual irrigation be considered per physician's orders, or the physician notified. Administering analgesics (D) cannot resolve a physical obstruction.
美國護理師在 CBI 管理上有較大的自主權，可根據機構 protocol 自行決定何時進行手動沖洗抽吸血塊；台灣則較多要求先回報醫師，由醫師評估是否需要親自沖洗或由護理師執行。