# TURP術後第0日病人具三向尿管並進行持續膀胱沖洗(CBI)中。哪些護理介入適當？請選擇所有適用項目。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374201&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

TURP術後第0日病人具三向尿管並進行持續膀胱沖洗(CBI)中。哪些護理介入適當？請選擇所有適用項目。

1

評估膀胱膨脹、突發劇烈痙攣或無引流 — 可能為血塊阻塞，依流程執行手動沖洗。

2

以總引流量減去注入沖洗量計算真實尿量。

3

常規每2小時手動以50 mL無菌生理鹽水灌洗導管，以維持通暢及預防血塊形成。

4

預期對嚴重膀胱痙攣，必要時將依醫囑使用抗膽鹼藥（如oxybutynin）或belladonna-and-opium栓劑。

5

調整CBI速率使尿色維持淡粉紅至清；變深紅或出現血塊時提高速率。

## 解析

經尿道前列腺切除術後持續膀胱灌洗之護理：調整流速使排出液呈淺粉色至清澈（若排出液顏色變深或有血塊形成，則加快流速），計算真實尿量為總引流量減去灌入量，評估血塊阻塞徵象（腹脹、痙攣、無引流液）並依規範以手動灌洗處理，預期使用抗蕈毒鹼藥物或B&O栓劑以緩解痙攣。選項3不正確——每2小時例行手動灌洗並非必要；僅於出現血塊阻塞徵象時方執行手動灌洗，因不必要之灌洗會增加感染與尿道創傷之風險。

## 深入解析

TURP/CBI最常考兩原則：(1)尿量減法每NCLEX循環必考 — 總引流減注入沖洗等於真實尿量；(2)血塊阻塞(突發膨脹、劇烈痙攣、無引流)需依流程立即手動沖洗，不可等待。鮮紅色排出或血塊增加 = 可能前列腺床出血，立即通知泌尿科。

## 臨床情境

**TURP術後第0日，三向尿管，正以生理食鹽水進行CBI**。目前尿色偏粉紅且無血塊。病人意識清楚，主訴輕度膀胱壓力感但無劇痛。

## 重要概念

- **持續膀胱沖洗(CBI)** — TURP術後經三向尿管之持續食鹽水沖洗以清除血塊並預防阻塞。
- **真實尿量計算** — 總引流量減注入沖洗量等於真實尿量。
- **血塊阻塞徵象** — 膀胱膨脹、突發劇烈痙攣、無引流；依流程執行手動沖洗並通報醫師。

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