— 基本照護與舒適 · HARD · SATA —
護理師照護一位進行膀胱連續灌洗（CBI）的病人。下列哪些發現應記錄為異常？（選所有適合的）
A nurse is caring for a client with a continuous bladder irrigation (CBI). Which findings should the nurse document as abnormal? (Select all that apply.)
- ADrainage output is less than the irrigation input✓ 正解引流輸出量少於灌洗輸入量
- BDrainage turns bright red with large blood clots✓ 正解引流液變成鮮紅色並伴有大量血塊
- CClient reports abdominal bladder spasms✓ 正解病人報告腹部膀胱痙攣
- DThe fluid in the drainage bag is pinkish-red引流袋中的液體呈現粉紅色
- EThe client complains of an urge to void病人抱怨有解尿慾望
— Explanation · 中文詳解 —
CBI 異常徵兆包括：排出量小於灌入量（代表引流管阻塞）、排出物呈鮮紅色且有大血塊（嚴重出血）、膀胱痙攣（疼痛感）。粉紅色液體是術後常見現象，並非異常。膀胱痙攣時病人常會有想解尿的感覺，雖屬常見但代表膀胱受刺激，需處理。
Abnormal findings in continuous bladder irrigation include drainage output less than input, indicating potential obstruction and bladder distension, and bright red drainage with large clots, suggesting active arterial bleeding. Clients may report abdominal bladder spasms due to irritation or blockage, which requires intervention. Pinkish-red fluid is an expected postoperative finding and does not indicate a complication.
✦ 台美臨床差異
美國醫院對 CBI 的液體平衡監控極為精確，台灣臨床有時受限於操作量大，較難維持每小時精確計算。