— 降低風險 · MEDIUM · MCQ —
病人接受前列腺切除術後進行連續膀胱沖洗，發現尿袋尿液呈鮮紅色。護理師應採取的第一個行動為何？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a TURP. The urine in the drainage bag appears bright red. What is the nurse's first action?
- AAdminister a prescribed analgesic給予處方止痛藥
- BStop the irrigation停止沖洗
- CNotify the surgeon immediately立即通知外科醫師
- DIncrease the flow rate of the irrigation✓ 正解增加沖洗液的流速
— Explanation · 中文詳解 —
經尿道前列腺切除術（TURP）術後，連續膀胱沖洗（CBI）的主要目的是防止血塊形成並保持導尿管通暢。當尿液變為鮮紅色時，通常表示靜脈出血或血塊阻塞，若不處理，血塊堆積會導致膀胱痙攣（bladder spasms）及尿路阻塞。護理師應優先增加沖洗速度，以利用壓力沖刷血塊。若增加流速後尿液仍持續呈現深紅色或血塊過多，才考慮通知醫師。停止沖洗會導致血塊迅速累積，增加阻塞風險，絕非首選。
Bright red urine after TURP indicates active bleeding or clot formation that may obstruct the catheter. The nurse's first action is to increase the irrigation flow rate to flush out clots and maintain patency, rather than stopping the irrigation which could lead to retention.
✦ 台美臨床差異
在美國臨床實務中，護理師通常依據醫囑（Standing orders）即可自行調整 CBI 流速以維持尿液顏色為淡粉紅色（light pink），無需每次調整都請示醫師，這體現了護理師的自主決策權。