— 照護管理 · HARD · SATA —
護理師照護進行連續膀胱沖洗（CBI）的病人，應回報醫師哪些發現？（選所有適合的）
A nurse is caring for a client with a continuous bladder irrigation (CBI). Which findings should the nurse report to the healthcare provider? (Select all that apply.)
- AOutput is less than input✓ 正解排出量小於輸入量
- BUrine in the drainage bag is bright red引流袋內尿液呈鮮紅色
- CClient reports severe lower abdominal pain✓ 正解客戶主訴嚴重下腹痛
- DThere is a small amount of sediment in the tubing管路內有少量沉澱物
- EThe irrigation fluid is light pink沖洗液呈淡粉紅色
— Explanation · 中文詳解 —
CBI 照護重點在於維持引流順暢。若引流液少於灌注量，表示可能發生血塊阻塞，需立即處理。嚴重下腹痛提示膀胱過度膨脹，有引流不暢的風險。亮紅色尿液（初期）或輕微粉紅色尿液皆為預期內，僅需監測；沉澱物則需視量而定，非絕對急迫回報項目。
The focus of CBI care is maintaining smooth drainage. Output less than input suggests possible clot obstruction and requires immediate intervention. Severe lower abdominal pain points to bladder overdistension and a risk of poor drainage. Bright red urine (early on) or light pink urine is expected and only needs monitoring; small amounts of sediment depend on quantity and are not an absolute reason for urgent reporting.
✦ 台美臨床差異
在美國，這類處置護理師常需依醫囑調整沖洗速度；台灣通常固定速度，調整時需頻繁與醫師確認。