A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?
A.
Irrigate the catheter with sterile water
B.
Clamp the drainage catheter during ambulation
C.
Report viscous drainage with clots to the provider
D.
Remove the catheter if the client feels a strong urge to urinate
The correct answer and Explanation is :
The correct answer is:
C. Report viscous drainage with clots to the provider
Explanation:
Continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP) is a standard procedure to prevent clot formation and ensure proper drainage from the bladder. The purpose of CBI is to keep the bladder continuously flushed, which helps to prevent obstruction of the catheter by blood clots or debris, thus reducing the risk of complications.
Here’s why C is the correct choice:
- Clot Formation and Viscous Drainage: After a TURP, it is common for blood clots to form as the prostate heals. However, the presence of large or viscous clots in the drainage can indicate a problem. If clots are not effectively removed through irrigation, they can block the catheter, leading to urinary retention and increased bladder pressure. This situation requires prompt attention from the healthcare provider to assess and manage potential complications such as significant bleeding or blockage.
- Monitoring and Reporting: It is crucial for the nurse to monitor the drainage for the presence of clots and other abnormalities. Viscous drainage with clots could signify that the irrigation system is not functioning properly or that there may be an issue with excessive bleeding. Reporting this to the provider ensures that appropriate interventions, such as adjusting the irrigation rate or exploring further diagnostic measures, can be undertaken.
Why the Other Options Are Not Correct:
- A. Irrigate the catheter with sterile water: The catheter should not be irrigated with sterile water. The standard practice is to use the prescribed irrigation solution, usually a sterile saline or similar solution, to prevent infection and ensure proper fluid balance.
- B. Clamp the drainage catheter during ambulation: Clamping the catheter during ambulation is not recommended because it can lead to bladder distention, increased discomfort, and potential complications. Continuous drainage is essential to manage the risk of clot formation and bladder pressure.
- D. Remove the catheter if the client feels a strong urge to urinate: The catheter should not be removed based on the client’s urge to urinate. The presence of the catheter is necessary for continuous irrigation and to prevent bladder obstruction post-TURP. Removal should only be done based on the healthcare provider’s orders and typically after careful assessment of the client’s condition.
In summary, reporting viscous drainage with clots ensures that any issues with catheter function or potential complications can be addressed promptly, maintaining patient safety and optimal recovery.