A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?
A.
Perform a bladder scan.
B.
Cleanse the meatus.
C.
Provide perineal care.
D.
Lubricate the catheter.
The Correct answer and Explanation is:
The correct answer is A. Perform a bladder scan.
Explanation
When planning to perform intermittent urinary catheterization for a client who is unable to urinate, the first action the nurse should take is to perform a bladder scan. Here’s why:
- Determine the Need for Catheterization: Performing a bladder scan is essential to assess whether there is indeed urinary retention that requires catheterization. A bladder scan, which uses ultrasound technology, allows the nurse to measure the volume of urine in the bladder. This assessment helps to confirm whether the client has urinary retention or if other interventions might be more appropriate. If the bladder scan shows that the bladder is not significantly full, catheterization may not be necessary.
- Guide Catheterization Decisions: If the bladder scan reveals significant urine retention, the nurse can proceed with catheterization with a clear understanding of the extent of retention. This also helps in selecting the appropriate catheter size and avoiding unnecessary discomfort or complications.
- Prevent Unnecessary Procedures: Performing a bladder scan first helps to prevent unnecessary catheterizations. If the bladder scan indicates that the client can urinate adequately or that the issue may be related to other factors, the nurse can explore alternative interventions, such as bladder training or medications, before resorting to catheterization.
- Establish a Baseline: By conducting a bladder scan, the nurse establishes a baseline measurement of urine volume, which is useful for future assessments and for evaluating the effectiveness of the catheterization.
After the bladder scan, if the decision is made to proceed with catheterization, the nurse should then:
- Cleanse the meatus (B) to reduce the risk of infection.
- Provide perineal care (C) if needed, to ensure hygiene and comfort.
- Lubricate the catheter (D) to facilitate insertion and minimize discomfort.
In summary, performing a bladder scan is the initial step in the process as it confirms the need for catheterization and informs subsequent actions.