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一位術後個案在移除導尿管後尚未排尿。完成護理師以實證為基礎的尿滯留處置。

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The nurse should ::선택::wait until the next shift without assessmentrestrict fluids for 12 hoursinsert an indwelling catheter immediatelyassess voiding, medications, intake and output, mobility, and suprapubic findings, then ::선택::request abdominal radiographymeasure retained volume with bladder ultrasoundgive a loop diureticapply continuous suprapubic pressure. If protocol criteria are met, the nurse should ::선택::encourage repeated strainingleave the bladder distended overnightperform intermittent catheterization according to the nurse-driven protocolinsert a permanent catheter and should ::선택::avoid reflex indwelling recatheterization without a continuing indicationstop reassessment after one drainageignore recurrent retentionkeep the client on bed rest.

護理師應 ::선택::等到下一班再評估限制液體 12 小時立即插入留置導尿管評估排尿、藥物、輸出入量、活動能力及恥骨上發現，然後 ::선택::要求腹部 X 光以膀胱超音波測量殘餘尿量給予環利尿劑持續施加恥骨上壓力。若符合方案標準，護理師應 ::선택::鼓勵反覆用力排尿讓膀胱整夜過度膨脹依護理師主導方案執行間歇性導尿插入永久性導尿管 且應 ::선택::在無持續適應症下避免反射性重新置入留置導尿管一次引流後停止重新評估忽略復發性尿滯留讓個案臥床休息。

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