護理師照護攝護腺經尿道切除術 (TURP) 後接受持續膀胱沖洗 (CBI) 的病人。護理師發現入量遠大於出量。首要行動為何？
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 intake is much higher than the output. What is the priority action?
- AStop the irrigation and check the catheter for kinks or clots✓ 正解停止沖洗並檢查導尿管是否有扭結或血塊阻塞
- BAdminister a diuretic as ordered依醫囑給予利尿劑
- CNotify the provider immediately立即通知醫師
- DIncrease the irrigation flow rate增加沖洗液流速
攝護腺經尿道切除術 (Transurethral Resection of the Prostate, TURP) 後，持續膀胱沖洗 (Continuous Bladder Irrigation, CBI) 的目的是預防血塊形成並沖洗膀胱內的血凝塊，以維持尿道暢通。護理師需密切監測 CBI 的入量 (intake) 和出量 (output)，以評估引流系統的功能。 當入量遠大於出量時，這是一個危險信號，表示引流系統可能發生了阻塞。阻塞的原因常見為血塊堵塞導尿管或導尿管本身扭結。若不及時處理，膀胱會因持續沖洗液的灌注而過度膨脹，導致病人劇烈疼痛、膀胱痙攣，甚至有膀胱破裂的風險。因此，護理師的首要行動是立即停止沖洗並檢查導尿管的通暢性。這符合「安全」和「降低風險潛能」的原則，優先處理可能導致嚴重併發症的急性問題。 其他選項的行動會延誤處理或加劇問題。
Continuous bladder irrigation (CBI) after TURP keeps the bladder free of clots and maintains catheter patency. When intake far exceeds output, suspect an obstruction—commonly from a clot or kinked catheter. If unrelieved, the bladder distends, causing severe pain, bladder spasms, and potentially rupture. The priority is to stop the irrigation and check the catheter for kinks or clots before notifying the provider; this is an independent nursing intervention to prevent serious complications.