A practical nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). The client suddenly reports severe lower abdominal cramping and a feeling of extreme bladder fullness. The nurse observes that irrigation fluid is infusing into the bladder, but there is no output in the catheter drainage bag. In what order should the practical nurse perform the following actions? Arrange the actions from first to last.
- 1Inspect the catheter drainage tubing for any kinks or external compression
- 2Stop the continuous bladder irrigation (CBI) infusion
- 3Manually irrigate the urinary catheter with sterile normal saline per facility protocol
- 4Notify the registered nurse (RN) or healthcare provider
- 5Administer a prescribed antispasmodic medication
Answer
1. Inspect the catheter drainage tubing for kinks, 2. Stop the continuous bladder irrigation, 3. Manually irrigate the urinary catheter, 4. Notify the registered nurse, 5. Administer a prescribed antispasmodic medication
When a client receiving continuous bladder irrigation (CBI) develops severe cramping and a lack of urinary output, it strongly indicates a catheter obstruction, most likely due to a blood clot. The first nursing action is to assess for simple mechanical issues like kinked tubing. If none are found, the CBI must be stopped immediately to prevent further fluid from infusing into an obstructed bladder, which could cause serious trauma or rupture. Next, the nurse should manually irrigate the catheter to clear the clot. Once the immediate danger is addressed and flow is restored (or if irrigation fails), the RN or provider is notified. Finally, an antispasmodic can be administered, as it is only safe to treat a bladder spasm after confirming the bladder is draining properly.
Step-by-Step Solution
Key Concept
Prioritization of care and safety interventions for a postoperative TURP client experiencing continuous bladder irrigation obstruction.