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基本照護與舒適 · HARD · MCQ

護理師照護一位經尿道攝護腺切除術(TURP)後進行連續膀胱沖洗(CBI)的病人。下列何種評估結果需立即處理?

A nurse is caring for a client with a continuous bladder irrigation (CBI) post-TURP. Which assessment requires immediate action?

  • AIncreased urine color intensity after ambulation
    步行後尿液顏色加深
  • BPresence of light pink urine in the drainage bag
    引流袋中有淡粉紅色尿液
  • COutput less than intake with bladder distention✓ 正解
    輸出量少於輸入量且膀胱脹滿
  • DPatient reports mild bladder spasms
    病人報告輕微膀胱痙攣
Explanation · 中文詳解

CBI 目的在於沖洗血塊以維持管路通暢。輸出量小於輸入量且膀胱脹大(C)表示管路阻塞,導致尿液滯留,可能引起急性膀胱穿孔或嚴重疼痛,需立即處理。粉紅色尿液(B)術後常見,痙攣(D)為預期症狀,術後適度活動導致顏色變深(A)亦為常見臨床現象。

The purpose of CBI is to flush blood clots and maintain catheter patency. Output less than intake with bladder distention (C) indicates catheter obstruction causing urinary retention, which may lead to acute bladder perforation or severe pain and requires immediate intervention. Pink-tinged urine (B) is common postoperatively, spasms (D) are an expected symptom, and increased urine color intensity after moderate postoperative ambulation (A) is also a common clinical finding.

✦ 台美臨床差異

兩地對 CBI 阻塞的緊急處置標準一致,均需立即執行沖洗或通知醫師。

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