一位腹部手術後 24 小時的病人尚未排氣。護理師注意到腸音消失。護理師的下一步行動是什麼？
A client is 24 hours post-abdominal surgery and has not yet passed flatus. The nurse notes absent bowel sounds. What is the nurse's next action?
- ANotify the surgeon immediately of a suspected paralytic ileus立即通知外科醫師懷疑有麻痹性腸阻塞
- BAdminister a prescribed laxative給予處方瀉劑
- CInsert a nasogastric tube to decompress the stomach插入鼻胃管以減壓胃部
- DEncourage the client to ambulate in the hallway✓ 正解鼓勵病人到走廊散步
腹部手術後，病人常見的併發症之一是術後腸阻塞 (postoperative ileus)，表現為腸道蠕動暫時性減弱或停止，導致腸音消失和無法排氣。術後 24 小時內出現腸音減弱或消失，且尚未排氣，通常被視為正常的生理性反應，而非立即需要醫療介入的緊急狀況。在這種情況下，護理師的優先行動是鼓勵病人早期下床活動 (ambulation)。早期活動能促進腸道蠕動的恢復，減少腸阻塞的發生和持續時間，同時還有助於預防其他術後併發症，如深部靜脈栓塞 (deep vein thrombosis, DVT) 和肺炎。因此，在排除了其他緊急狀況後，鼓勵病人活動是促進腸道功能恢復最有效且安全的護理措施。
After abdominal surgery, postoperative ileus is a common complication, manifesting as transient decreased or absent bowel motility with absent bowel sounds and inability to pass flatus. Absent bowel sounds and no passage of flatus within the first 24 hours postoperatively are usually considered a normal physiologic response rather than an immediate emergency. In this situation, the nurse's priority action is to encourage early ambulation. Early ambulation promotes the return of peristalsis and reduces the incidence and duration of postoperative ileus, and also helps prevent other postoperative complications such as deep vein thrombosis (DVT) and pneumonia. Therefore, once other urgent conditions are ruled out, encouraging ambulation is the most effective and safe nursing intervention to promote return of bowel function.
美國醫院非常強調「ERAS」（術後加速康復）協議，下床活動是強制性的；台灣也推行 ERAS，但病人下床意願常受文化（需多休息）影響。