護理師正在照顧一位接受經尿道攝護腺切除術 (TURP) 後進行持續膀胱沖洗 (CBI) 的病人。下列哪項評估發現顯示應增加沖洗速率？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which assessment finding indicates the irrigation rate should be increased?
- AThe urine output is greater than the amount of irrigant infused.尿液排出量大於灌洗液注入量
- BThe drainage is bright red with small clots.✓ 正解引流液呈鮮紅色並伴有小血塊
- CThe client reports a feeling of bladder fullness.病人主訴有膀胱飽脹感
- DThe drainage is pale pink and clear.引流液呈淡粉紅色且清澈
TURP 術後 CBI 的主要目的是防止血液凝固成塊阻塞尿道或導尿管。核心概念是「根據排出液的顏色調整流速」。理想的排出液應該是淡粉紅色（Pale pink）。如果排出液呈現鮮紅色（Bright red）或含有血塊（B），表示手術部位仍有活動性出血或沖洗不足，此時必須加快流速以沖淡血液並防止阻塞。感到膀胱脹（C）通常是導管阻塞的徵兆，應先評估管路是否通暢而非單純加流速。尿量大於沖洗量（A）是正常的，表示有包含病人的尿液。掌握 CBI 的動態調整是骨盆腔手術後減少阻塞與出血風險的關鍵護理技能。
Bright red drainage with clots during continuous bladder irrigation indicates active bleeding and insufficient flushing, necessitating an increase in the irrigation rate to prevent catheter obstruction. The goal is to maintain pale pink drainage; therefore, bright red output signals the need for faster flow to dilute blood. If the client reports bladder fullness, the nurse should first assess for tube kinks or blockages before adjusting the rate.
在美國護理實務中，CBI 的調整通常屬於護理師的專業裁量範圍（Nursing judgment），不需每次都請示醫囑；台灣護理師通常也會主動調整，但更強調精確計算總入量與出量的差值（True urine）。