— 降低風險 · MEDIUM · MCQ —
一位經尿道前列腺切除術（TURP）後的病人正在進行膀胱沖洗（CBI）。下列何種徵象需要護理師立即通知醫師？
A nurse is caring for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which finding requires the nurse to immediately notify the provider?
- AThe output is light pink with small clots排出液呈淡粉紅色並伴有少量血塊
- BThe client experiences intermittent bladder spasms病人經歷間歇性膀胱痙攣
- CThe client reports a feeling of bladder fullness病人報告有膀胱飽脹感
- DThe output has stopped despite the inflow being patent✓ 正解儘管流入管路暢通，但排出液已停止
— Explanation · 中文詳解 —
CBI 的目標是保持引流管暢通，若沖洗液持續進入但尿袋無引流，代表導尿管阻塞，易導致膀胱過度膨脹甚至破裂。輕微粉紅色與血塊、膀胱痙攣及飽脹感在術後常見，可先檢查管路有無扭曲或手動沖洗管路，但若完全無引流則屬急迫狀況。
If irrigation fluid enters but no output is drained, it indicates catheter obstruction, which can cause bladder distension and potential rupture. This requires immediate notification of the provider, whereas mild hematuria or spasms are expected postoperative findings.
✦ 台美臨床差異
台美皆重視 CBI 管路維護，美國護理師多依醫囑執行 manual irrigation，台灣亦同，但若阻塞嚴重需醫師介入重置。