After transurethral resection of the prostate, the nurse notices that the client’s urine is bright red, has numerous clots, and is viscous. Which nursing action is most appropriate?
Irrigate the catheter to remove clots.Milk the catheter tube vigorously.Increase the client’s fluid intake.Assess vital signs and notify the surgeon.
The Correct Answer and Explanation is:
Correct Answer: Increase the rate of continuous bladder irrigation (CBI).
Explanation:
After a transurethral resection of the prostate (TURP), continuous bladder irrigation (CBI) is commonly used to flush out blood and prevent clot formation in the bladder. CBI helps maintain catheter patency and ensures that the bladder remains free of clots that could lead to urinary retention or obstruction.
The presence of bright red urine with numerous clots and viscous consistency suggests active bleeding and ineffective irrigation, leading to the accumulation of blood and clots in the bladder. This is a significant finding and indicates that the bladder is not being adequately cleared.
The most appropriate initial nursing intervention is to increase the rate of continuous bladder irrigation. Increasing the flow rate helps to dilute the blood, remove clots, and restore free flow through the catheter. This step can reduce the risk of catheter blockage and prevent the bladder from becoming distended, which could worsen bleeding.
If increasing the irrigation rate does not resolve the issue, the nurse may need to:
Other options such as clamping the catheter or stopping the irrigation are inappropriate and dangerous in this context. Clamping the catheter can increase bladder pressure, worsen bleeding, and lead to clot retention. Simply observing the client without taking action may allow the condition to worsen.
In summary, after TURP, bright red urine with clots signals a complication that requires prompt nursing action. By increasing the CBI rate, the nurse can promote clot removal, reduce bladder pressure, and help stabilize the client, which is essential in the post-operative phase to prevent further complications.