— 生理適應 · MEDIUM · SATA —
護理師正為一位新裝設人工肛門（結腸造口）的病人進行衛教，下列哪些項目應包含在教學計畫中？（選所有適合的）
A nurse is caring for a client with a new colostomy. Which actions should the nurse include in the teaching plan? (Select all that apply.)
- AEmpty the bag when it is 1/3 to 1/2 full✓ 正解當袋子裝至1/3到1/2滿時排空
- BClean the skin around the stoma with warm water✓ 正解用溫水清潔造口周圍的皮膚
- CApply an oil-based ointment to the stoma to prevent irritation在造口上塗抹油性軟膏以預防刺激
- DCut the skin barrier 1/8 inch larger than the stoma✓ 正解將皮膚屏障切口比造口大1/8英吋
- EAvoid high-fiber foods for the first few weeks✓ 正解在前幾週避免高纖維食物
— Explanation · 中文詳解 —
結腸造口（Colostomy）照護的核心在於保護造口周圍皮膚完整性及維持造口功能。護理師應指導病人採取預防性措施，包括適時清空造口袋以防重量過重導致底盤脫落、以溫和方式清潔皮膚、精確裁剪底盤以避免皮膚受損，以及透過飲食調整控制糞便性質。術後初期腸道腫脹尚未消退，低纖飲食有助於減少腸道蠕動負擔，避免阻塞。
Care includes emptying the pouch when one-third to one-half full to prevent skin breakdown from excessive weight, cleaning the peristomal skin with warm water, and cutting the barrier slightly larger than the stoma to avoid constriction. Additionally, avoiding high-fiber foods initially helps prevent obstruction while the bowel heals.
✦ 台美臨床差異
台灣臨床常見使用「人工肛門袋」稱呼，美國則稱為 Colostomy appliance 或 pouching system。美國護理教學強調造口護理師（WOCN）的角色，若病人出院前有造口照護困難，必須轉介造口專科護理師協助。