Bladder Cancer

A nurse is caring for a client who underwent a radical cystectomy with urinary diversion 2 days ago. Which nursing intervention is most important to prevent complications?

1 Encourage the client to drink at least 3000 mL of fluid daily to prevent urinary tract infections
2 Change the urostomy appliance every 24 hours to maintain skin integrity
3 Monitor urine output and assess stoma color and viability every 4 hours ✓ 정답
4 Teach the client to empty the urostomy bag when it is completely full

해설

Regular monitoring of urine output and stoma assessment is critical postoperatively to detect early complications like obstruction or necrosis. Other interventions are important but less urgent in the immediate postoperative period.

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Understanding the Priority Postoperative Assessment

Following a radical cystectomy with urinary diversion, the immediate postoperative period carries the highest risk for complications related to tissue perfusion and surgical site integrity. The newly constructed urinary diversion relies on a segment of bowel that has been surgically altered to form a stoma. The most critical nursing intervention in the first few days is the frequent monitoring of urine output and stoma viability.

Why Stoma and Urine Output Assessment is the Priority

The stoma is essentially a piece of intestinal tissue that now functions as a conduit for urine. Its viability depends entirely on adequate blood supply. A radical cystectomy is a procedure with "considerable morbidity," as noted in the context of postoperative care trajectories for older adults . Compromised blood flow to the stoma is a surgical emergency that can lead to ischemia and necrosis. By assessing the stoma every 4 hours, you are evaluating its color (it should be a healthy, rosy pink) and moisture. A dusky, pale, or cyanotic stoma indicates impaired perfusion and requires immediate escalation to the surgical team.

Simultaneously, monitoring urine output is the most direct and essential indicator of renal function and fluid balance after a major surgery involving the urinary tract. A sudden decrease or cessation of output could signal a mechanical obstruction, such as mucus plugging (common with bowel segments), or a more serious condition like acute kidney injury from hypovolemia. This continuous, focused assessment allows for the earliest possible detection of these life-altering complications, making it the most important intervention to prevent irreversible damage.

Analyzing the Other Options

The other options contain critical errors in timing or accuracy that make them lower priorities or even harmful in the immediate postoperative phase.

- Option 1 (Fluid Intake): While maintaining hydration is an important long-term goal to prevent urinary tract infections, a patient 2 days post-cystectomy is likely still advancing their diet and may not tolerate such a high oral fluid volume. Aggressive oral intake this early is not the immediate priority over direct assessment of surgical site viability and renal output.
- Option 2 (Appliance Change): Changing the urostomy appliance every 24 hours is not standard practice and would be detrimental. Frequent, unnecessary changes disrupt the protective skin barrier, leading to skin breakdown and impaired peristomal skin integrity. A well-sealed appliance is typically left in place for several days. The priority is to protect the skin, not to change the appliance on a rigid schedule.
- Option 4 (Emptying Schedule): Teaching a patient to empty the urostomy bag only when it is completely full is incorrect. A bag that is completely full becomes heavy, which can pull on the appliance, break the seal, and cause leakage onto the skin. The standard teaching is to empty the bag when it is one-third to one-half full to prevent this tension and maintain the integrity of the pouching system. This patient education, while important, is not the most critical intervention at the bedside 2 days postoperatively. The immediate, hands-on assessment of the stoma and urine output takes precedence for preventing acute, serious complications.

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A nurse is caring for a client who underwent a radical cystectomy with urinary diversion 2 days ago. Which nursing intervention is most important to prevent complications?

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