A client is receiving continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The client suddenly reports severe lower abdominal cramping, and the nurse observes that the outflow drainage has significantly decreased. Arrange the following nursing actions in the correct priority sequence to manage this complication.
- 1Assess the catheter tubing for any kinks or external compression.
- 2Stop the inflow of the continuous bladder irrigation fluid.
- 3Manually irrigate the catheter with sterile normal saline.
- 4Administer the prescribed antispasmodic medication.
- 5Reassess the client's pain level and the characteristics of the drainage.
Answer
The correct sequence is to first assess the tubing for kinks, then stop the irrigation fluid, manually irrigate the catheter to clear clots, administer antispasmodic medication, and finally reassess the client's response.
When managing a client with decreased CBI outflow and severe cramping, the nurse must follow a sequence prioritizing bladder safety. First, a non-invasive assessment of the tubing checks for easily fixable kinks. If the tubing is patent, the inflow must be stopped immediately to prevent further distension. Next, manual irrigation clears the likely cause, which is typically blood clots. Once the obstruction is cleared, pharmacological management of spasms is appropriate, followed by final evaluation of the interventions.
Step-by-Step Solution
Key Concept
Continuous Bladder Irrigation (CBI) Complication Management