# 一位68歲男性接受全膝關節置換術後8小時。他接受了脊髓內嗎啡注射和需要時靜脈嗎啡給藥。他自手術後尚未排尿，主訴下腹部脹滿感和壓迫感，觸診時下腹部有壓痛且隆起。他否認劇烈疼痛。優先的護理行動是什麼？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375151&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位68歲男性接受全膝關節置換術後8小時。他接受了脊髓內嗎啡注射和需要時靜脈嗎啡給藥。他自手術後尚未排尿，主訴下腹部脹滿感和壓迫感，觸診時下腹部有壓痛且隆起。他否認劇烈疼痛。優先的護理行動是什麼？

## 選項

1. 不再評估直接放置留置型Foley導尿管。
2. 進行bladder scan，若殘尿超過400 mL則先試非藥物方式(隱私、流水聲、熱敷、若允許下床走動)；若無效則依流程做straight (in-and-out) catheterization；若反覆或持續通知處方者並考慮鴉片rotation或PAMORA。 **✔ 正確答案**
3. 安撫病人，鴉片類會降低感覺，會自然解決。
4. 為緩解腹部不適再給IV morphine。

**正確答案: 2**

## 解析

鴉片類藥物引起的尿滯留很常見，尤其是年長男性有攝護腺肥大，以及接受脊髓內或硬脊膜外鴉片類藥物後。機轉：mu受體活化增加膀胱括約肌張力，並減少逼尿肌收縮。未處理的尿滯留會導致膀胱過度膨脹、逼尿肌恢復能力下降、泌尿道感染和急性腎損傷。標準護理流程：(1) 評估排尿型態（上次排尿時間、尿量）、腹部檢查和個案主訴——膀胱脹滿、骨盆壓迫感、躁動不安；(2) 膀胱掃描是非侵入性的標準——餘尿超過400毫升或無排尿即為有意義；(3) 先嘗試非侵入性措施——提供隱私、聽流水聲、置溫水袋於恥骨上區域、會陰護理、若允許則下床走動、手泡溫水；(4) 單次導尿（間歇性導尿）優於留置導尿管，以避免導尿管相關泌尿道感染並讓膀胱恢復；(5) 若反覆發生或持續，通知醫師進行診斷評估、將鴉片類藥物更換為較不易引起滯留的藥物（如芬太尼）、加上週邊作用性mu受體拮抗劑，或短期留置導尿配合膀胱訓練。常規安撫、給予額外鴉片類藥物（會加劇滯留）或未經掃描即置入導尿管，都違反了非侵入性優先的標準流程。

## 深入解析

Bladder scan先做、再非侵入、再straight導尿、再通知處方者。CAUTI風險使Foley限必要時。

## 重要概念

- **opioid-induced urinary retention** — μ受體、括約肌張力增加加上逼尿肌收縮減少，高齡男、脊髓內後常見，採in-and-out導尿
- **bladder scan** — 非侵入測量殘尿，超過400 mL為介入閾值
- **straight catheterization** — in-and-out導尿，降CAUTI風險，協助膀胱恢復

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