護理師照護一位經尿道前列腺切除術(TURP)後進行持續性膀胱沖洗(CBI)的病人,哪些發現需通知醫師?(選所有適合的)
A nurse is providing care for a client with a continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). Which findings should the nurse report to the provider? (Select all that apply.)
- ABright red drainage with clots✓ 正解引流液呈鮮紅色並伴有血塊
- BDecreased outflow compared to irrigation intake✓ 正解流出量少於沖洗輸入量
- CBladder spasms and pain膀胱痙攣與疼痛
- DDrainage appearing reddish-pink引流液呈現紅粉色
- EClient reports abdominal distension✓ 正解病人主訴腹部脹滿
經尿道前列腺切除術(TURP)後,持續性膀胱沖洗(CBI)的目的是防止血液凝塊阻塞尿道。護理師需密切監測引流液的量與顏色。鮮紅色引流液合併血塊(A)代表有活動性出血;引流液減少或消失(B)則顯示沖洗液未順利排出,可能導致膀胱充盈、痙攣與破裂風險;腹脹(E)也是膀胱過度充盈的臨床徵象,均為緊急狀況,須立即通知醫師處理。
Nurses must report bright red drainage with clots, decreased outflow compared to intake, and abdominal distension to the provider immediately. Bright red drainage with clots indicates active arterial bleeding, while decreased outflow suggests an obstruction that could lead to bladder perforation. Abdominal distension is a sign of bladder overdistention due to poor drainage.