🛏️ 基础护理与舒适 · 第6课，共6课 · 6 min
导管、造口和造口颜色图表
Catheters, Ostomies and the Stoma Color Chart
🟣 健康的造口颜色和你的脸颊内侧一样。紫色的造口正在坏死。苍白的造口可能提示贫血。考试会展示一种颜色，让你判断是记录下来还是打电话报告。
🟣 A healthy stoma is the color of the inside of your cheek. A purple one is dying. A pale one can signal anemia. The exam shows you a color and asks whether to chart it or call.
💡 核心要点
导管引流袋位于膀胱以下，保持密闭系统，尽快拔除导管。造口粉红且湿润是健康的；暗沉或紫色是紧急情况；造口袋装满三分之一时将其排空。
Catheter bag below the bladder, closed system, out as soon as possible. Stoma pink and moist is healthy; dusky or purple is an emergency; empty the pouch at one-third full.
🧠 为什么重要
留置导尿管只能在真正有指征时用无菌技术插入，并尽快拔除以预防CAUTI；要将引流袋保持在膀胱水平以下且不接触地面，保持管路无扭结和垂悬环路，将导管固定在大腿上，进行常规会阴护理，保持密闭系统，并至少每8小时排空引流袋。不要为了取样而断开连接；要使用采样口。拔除后，要监测患者是否在6到8小时内排尿。造口护理方面，健康的造口呈粉红色到红色、湿润且略微隆起；暗沉、紫色或黑色提示缺血，要立即报告；苍白提示贫血。回肠造口的排出物预计为液体且频繁，液体和电解质丢失较多，而乙状结肠造口的排出物则已成形。当造口袋装满三分之一到二分之一时将其排空，将底盘剪得比造口大约1/8 inch（3 mm）以保护皮肤，并告知最初几周的轻度肿胀是正常的。可限制会产生气体或气味的食物（豆类、卷心菜、洋葱、鸡蛋）；酸奶和欧芹可能有助于减轻气味。
INDWELLING URINARY CATHETERS: insert with sterile technique only when truly indicated and remove as soon as possible to prevent CAUTI; keep the bag BELOW bladder level and off the floor, keep the tubing free of kinks and dependent loops, secure the catheter to the thigh, perform routine perineal care, maintain a closed system, and empty the bag at least every 8 hours. Do not disconnect for samples; use the sampling port. After removal, monitor for voiding within 6 to 8 hours. OSTOMY care: a healthy STOMA is pink to red, moist and slightly raised; dusky, purple or black indicates ischemia and is reported immediately; pale suggests anemia. Expect ileostomy output to be liquid and frequent, with high fluid and electrolyte losses, while sigmoid colostomy output is formed. Empty the pouch when it is one-third to one-half full, cut the wafer about 1/8 inch (3 mm) larger than the stoma to protect the skin, and teach that mild swelling in the first weeks is normal. Foods that cause gas or odor (beans, cabbage, onions, eggs) can be limited; yogurt and parsley may reduce odor.
🏥 真实场景
🧴 术后首日，一个新的回肠造口看起来肿胀且鲜红；患者感到惊慌。护士解释说，早期出现水肿和鲜牛肉样的红色是预期现象。两小时后，造口边缘变成深紫色。这时护士给外科医生打电话：血液供应受损是外科急症，而两次情况之间的区别仅仅在于颜色。
🧴 On the first post-op day a new ileostomy stoma looks swollen and bright red; the client is alarmed. The nurse explains that edema and a beefy red color are expected early. Two hours later the stoma turns a deep purple at the edge. Now the nurse calls the surgeon: compromised blood supply is a surgical emergency, and the difference between the two calls is nothing but color.
📌 要点总结
- 导管：位于膀胱以下，密闭系统，已固定，尽早拔除Catheter: below bladder, closed system, secured, removed early
- 造口：粉红色或红色且湿润是正常的；暗沉、紫色或黑色表示缺血Stoma: pink or red and moist is normal; dusky, purple or black means ischemia
- 回肠造口排出物是液体；要注意液体和电解质Ileostomy output is liquid; watch fluids and electrolytes
📖 本课术语
造口 (Stoma): 造瘘手术形成的开口，健康时呈粉红色且湿润，发暗或紫色时是急症。
CAUTI: 导管相关性尿路感染，通过无菌插入、封闭系统和尽早拔管来预防。
✅ 自我测试
无执照辅助人员在护理留置导管患者时的哪种行为需要纠正？Which action by unlicensed assistive personnel caring for a client with an indwelling catheter requires correction?
- 将导管管路固定在大腿上Securing the catheter tubing to the thigh
- 将引流袋挂在膀胱水平以上Hanging the drainage bag above bladder level
- 将引流袋保持在膀胱水平以下Keeping the drainage bag below the level of the bladder
- 每8小时排空引流袋Emptying the bag every 8 hours
答案: B · 将引流袋挂在膀胱水平以上
引流袋位于膀胱以上会让尿液回流到膀胱，增加感染风险。它必须保持在膀胱水平以下。每8小时排空引流袋是常规做法，无需纠正。
A bag above the bladder allows urine to flow back into the bladder, increasing infection risk. It must stay below bladder level. Emptying the bag every 8 hours is routine practice and needs no correction.
护士评估一个新结肠造口，发现造口呈深紫色。优先行动是什么？The nurse assesses a new colostomy stoma that is dark purple. What is the priority action?
- 将该发现记录为预期现象Document the finding as expected
- 进行热敷Apply a warm compress
- 立即通知外科医生Notify the surgeon immediately
- 更换造口袋系统Change the pouch system
答案: C · 立即通知外科医生
暗沉或紫色的造口提示血液循环受损和可能坏死，需要立即进行外科评估。将其记录为预期现象是错误的，因为健康的新造口虽然肿胀，但呈鲜牛肉样的红色或粉红色，绝不会是紫色。
A dusky or purple stoma indicates compromised circulation and possible necrosis, which requires immediate surgical evaluation. Documenting it as expected would be wrong, since a healthy new stoma is swollen but beefy red or pink, never purple.
一名新做回肠造口的患者询问何时排空造口袋。正确的指导是什么？A client with a new ileostomy asks when to empty the pouch. What is the correct teaching?
- 当它完全装满时When it is completely full
- 每天睡前一次Once a day at bedtime
- 只有在它漏出时Only when it leaks
- 当它装满三分之一到二分之一时When it is one-third to one-half full
答案: D · 当它装满三分之一到二分之一时
在装满三分之一到二分之一时排空，可防止重量破坏密封并导致漏出。等到造口袋完全装满，其重量会拉扯密封处，使漏出更可能发生。
Emptying at one-third to one-half full prevents the weight from breaking the seal and causing leaks. Waiting until the pouch is completely full lets its weight pull on the seal and makes leakage more likely.
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