— 降低風險 · EASY · MCQ —
護理師照護一位接受經尿道前列腺切除術後進行連續膀胱沖洗的病人。下列哪項評估結果需要立即處置？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which assessment finding requires immediate intervention?
- APatient reports sensation of needing to void病人報告有想排尿的感覺
- BLight pink urine in the drainage tubing引流管中有淺粉紅色尿液
- COutput is less than irrigation input✓ 正解排出量少於沖洗輸入量
- DPresence of small blood clots in the drainage bag引流袋中有少量血塊
— Explanation · 中文詳解 —
經尿道前列腺切除術（TURP）後進行連續膀胱沖洗（CBI）旨在預防血塊形成導致的管路阻塞。若引流量小於沖洗液輸入量，意味著液體滯留在膀胱內，這可能導致膀胱過度膨脹、劇烈痙攣，甚至引發出血或膀胱穿孔。此情況屬於臨床急症，必須立即評估管路是否扭曲、有無大量血塊堵塞，並依醫囑進行手動沖洗（Manual irrigation）。
If continuous bladder irrigation output is less than the input, it indicates potential obstruction and bladder distension, requiring immediate intervention to prevent complications such as hemorrhage or perforation.
✦ 台美臨床差異
在美國臨床，護理師依醫囑執行手動沖洗（Irrigate with 30-50mL sterile saline）的頻率較高，且若發生阻塞，護理師應具備立即執行手動沖洗排除血塊的自主執行權（Scope of Practice），無需等待醫師前來。