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基本照護與舒適 · HARD · MCQ

護理師照護一位進行膀胱持續灌洗(CBI)的病人,下列何者為流速需要調整的主要指標?

A nurse is caring for a client with a continuous bladder irrigation (CBI). What is the primary indicator that the flow rate needs adjustment?

  • AThe intake and output totals differ by 50 mL
    灌入量與排出量總計相差 50 mL
  • BThe urine output is bright red with large clots✓ 正解
    尿液呈鮮紅色並有大血塊
  • CThe client reports a feeling of fullness
    病人主訴有脹滿感
  • DThe urine output is clear pink
    尿液呈清澈粉紅色
Explanation · 中文詳解

CBI 的目的是防止血塊阻塞導致尿滯留。若引流液呈現鮮紅色且伴隨大血塊,代表出血速度大於灌洗速度,必須立刻增加流速以沖刷血塊並預防阻塞。粉紅色為預期狀況;感覺脹滿若伴隨引流受阻也需觀察,但血塊是更直接的危險指標。

The purpose of CBI is to prevent clot obstruction and resulting urinary retention. If the drainage is bright red with large clots, this indicates that the rate of bleeding exceeds the rate of irrigation, and the irrigation flow rate must be immediately increased to flush out the clots and prevent obstruction. Pink-tinged drainage is expected; a sensation of fullness may also warrant observation if accompanied by drainage impairment, but clots are a more direct danger indicator.

✦ 台美臨床差異

美國泌尿科術後照顧常由護理師依引流顏色自行滴定(titrate),台灣較偏向遵照醫囑速度執行。

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