護理師為一位前列腺經尿道切除術(TURP)後進行持續膀胱灌洗(CBI)的病人規劃護理,應包含哪些內容?(選所有適合的)
A nurse is planning care for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which actions should the nurse include? (Select all that apply.)
- AIncrease the irrigation rate if the urine output appears bright red with clots✓ 正解若尿液呈現鮮紅色並伴有血塊,請增加灌洗速率
- BMonitor for symptoms of transurethral resection syndrome✓ 正解監測經尿道攝護腺切除症候群的症狀
- CEncourage the client to void around the catheter to reduce bladder spasms鼓勵病患繞著導尿管排尿以減輕膀胱痙攣
- DEnsure the irrigation output is less than the input確保灌洗流出量小於流入量
- EMaintain sterile technique when manipulating the irrigation system✓ 正解在操作灌洗系統時維持無菌技術
CBI 護理重點在於保持引流管暢通,透過調整流速解決出血問題,並預防灌洗液吸收造成的低血鈉(TUR 症候群)。術後應絕對避免病人嘗試解尿,因為會刺激膀胱肌肉痙攣。同時,必須嚴守無菌操作原則以降低感染風險。
The nursing priorities for continuous bladder irrigation (CBI) are to maintain catheter patency, adjust the irrigation rate to address bleeding, and prevent hyponatremia from absorption of irrigation fluid (TUR syndrome). After surgery, the client must be strictly prevented from attempting to void, as this can trigger bladder muscle spasms. At the same time, strict aseptic technique must be maintained to reduce the risk of infection.
台灣醫院中,此類沖洗護理常由專業護理師嚴格監控流速,美國則更強調病人對轉移症狀的自我監測衛教。