一位病人進行經尿道攝護腺切除術(TURP)後,正在進行連續膀胱沖洗(CBI)。護理師應採取哪項措施以降低阻塞風險?
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which nursing action is essential to reduce the risk of obstruction?
- ATitrate the irrigation rate based on the color of the urine✓ 正解根據尿液顏色調整沖洗速率
- BChange the catheter bag every shift每班更換導尿管集尿袋
- CEncourage the client to strain to evacuate clots鼓勵病人用力以排出血塊
- DKeep the drainage tubing clamped for 2 hours將引流管夾住2小時
經尿道攝護腺切除術(TURP)後,膀胱內容易形成血塊,若不及時排出將導致尿管阻塞,進而引起膀胱痙攣及繼發性出血。CBI 的核心護理目標是維持引流管通暢,防止血塊滯留。護理師必須根據引流液的顏色動態調整沖洗速度:當引流液顏色變深(如鮮紅色或深紅色)或出現血塊時,應加快沖洗速度以加速血塊排除;若尿液顏色變淺(如粉紅色或澄清),則可減慢速度,以避免過度沖洗對膀胱黏膜產生不必要的刺激。
After transurethral resection of the prostate (TURP), clots can readily form within the bladder; if they are not promptly evacuated, they will obstruct the urinary catheter, causing bladder spasms and secondary hemorrhage. The core nursing goal of continuous bladder irrigation (CBI) is to maintain patency of the drainage tubing and prevent clot retention. The nurse must dynamically adjust the irrigation rate based on the color of the outflow: when the drainage appears darker (e.g., bright red or dark red) or contains clots, the irrigation rate should be increased to accelerate clot removal; when the urine becomes lighter (e.g., pink or clear), the rate may be slowed to avoid unnecessary irritation of the bladder mucosa from over-irrigation.