A nurse is caring for a 70-year-old male client who underwent transurethral resection of the prostate (TURP) 24 hours ago. The client has a three-way urinary catheter with continuous bladder irrigation (CBI). Which nursing intervention should the nurse prioritize?
1Monitor the color and consistency of urine output and adjust irrigation flow rate appropriately✓ 정답
2Encourage the client to perform Kegel exercises every hour while awake to strengthen pelvic floor muscles
3Administer prescribed pain medication only when the client reports severe pain to prevent dependency
4Remove the urinary catheter within 12 hours to prevent urinary tract infection
해설
Monitoring urine output and adjusting irrigation flow to maintain light pink or clear drainage is the priority to prevent clot formation and bladder obstruction. Other options are less immediate or contraindicated in early post-TURP care.
Core Nursing ExplanationKey Concept Analysis: This question assesses priority nursing care for a patient with a Three-way urinary catheter and Continuous Bladder Irrigation (CBI) following a Transurethral Resection of the Prostate (TURP). The primary goal of CBI post-TURP is to flush out blood clots and tissue debris from the bladder to prevent Catheter obstruction, which can lead to painful bladder distension, increased bleeding, and potential damage to the surgical site. The nurse's priority is to ensure the system is functioning correctly to achieve this goal.
Answer Rationale: Key Point! The correct answer is to Monitor the color and consistency of urine output and adjust irrigation flow rate appropriately. This is a continuous, active intervention directly tied to patient safety. The irrigation rate is titrated to keep the effluent (drainage) a light pink or clear color. If the drainage becomes bright red or contains many clots, the flow rate is increased. If it becomes completely clear, the rate may be decreased to conserve irrigation fluid. This dynamic assessment and intervention prevent life-threatening complications like Bladder tamponade (clot retention).
Distractor Analysis:
Watch out for confusion! Option ② (Kegel exercises) is important for long-term urinary continence recovery but is not a priority in the immediate 24-hour postoperative period. Initiating these exercises too early could potentially increase discomfort or bleeding at the surgical site.
Option ③ represents an outdated and unsafe approach to pain management. Preventing pain is easier than treating severe pain. Postoperative pain should be managed proactively with prescribed analgesics (often on a scheduled basis) to promote comfort, mobility, and effective coughing/deep breathing.
Option ④ is contraindicated. The three-way catheter with CBI is typically left in place for 24-48 hours or longer post-TURP. Removing it prematurely (within 12 hours) would halt the crucial irrigation process, almost certainly lead to clot retention, and drastically increase the risk of infection from re-catheterization.
Related Concepts: Understanding the mechanics of a three-way catheter is essential. One lumen inflates the balloon to hold the catheter in the bladder, a second lumen allows for continuous inflow of sterile irrigation solution (often normal saline), and a third, larger lumen allows for continuous drainage of fluid and clots. The nurse must ensure the drainage bag is never raised above the level of the bladder to maintain gravity flow and prevent backflow, which can cause infection.
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, a 70-year-old who had a TURP yesterday for benign prostatic hyperplasia (BPH). He has a three-way Foley catheter connected to a bag of sterile normal saline for continuous irrigation and a large drainage bag. He reports a constant feeling of "needing to urinate" and some bladder spasms.
Nursing Intervention Strategy:
1AssessmentEvery 15-30 minutes initially, assess the CBI system. Check the Irrigation fluid inflow rate (as ordered, e.g., "to keep drainage light pink") and the Urine output (drainage) color, clarity, and presence of clots. Compare the volume of irrigation fluid hung with the volume of drainage collected to estimate true urine output (Output - Input = Approximate Urine Output). Assess for signs of obstruction: decreased or absent drainage, bladder distension, suprapubic pain, and increased irrigation fluid leaking around the catheter.
2Interventions & Patient Education* Maintaining Patency: If drainage slows or stops, first check for kinks in the tubing. If clots are suspected, you may gently irrigate the catheter manually with a piston syringe and sterile solution per protocol—never use force.
* Pain Management: Administer antispasmodic medications (e.g., oxybutynin) and analgesics as scheduled to manage bladder spasms and incisional pain. Explain to the patient that the urge to void is normal due to the catheter balloon.
* Mobility & Hygiene: Ensure the drainage bag is secured below bladder level when ambulating. Provide meticulous perineal care to reduce infection risk.
3EvaluationThe system is working effectively if drainage is continuous, light pink to clear, and the patient is comfortable without signs of bladder distension.
Patient Safety and Precautions: The greatest immediate risk is Catheter obstruction leading to bladder distension and hemorrhage. If the bladder becomes overdistended, it can disrupt the freshly cauterized blood vessels on the prostate, causing significant bleeding. Always ensure the drainage bag is never lifted above the level of the bladder. Use strict aseptic technique when handling the catheter or irrigation system.
Nursing Procedure & Medication FlowManaging Continuous Bladder Irrigation (CBI):
1. Verify the physician's order for the type of solution (e.g., Normal Saline) and the irrigation parameters (e.g., "titrate to keep drainage light pink").
2. Hang the irrigation solution on an IV pole. Connect the irrigation tubing to the designated port on the three-way catheter using sterile technique.
3. Set the initial flow rate as ordered. The drainage tubing should be connected to a large-volume urinary drainage bag.4. Calculate True Urine Output: Record the total volume of drainage from the bag. Subtract the total volume of irrigation fluid infused from this amount over a given period (e.g., every 8 hours). This difference is the patient's approximate urine output. Report a urine output of less than 30 mL/hr.
5. If manual irrigation is needed for a clot, use a large piston syringe (e.g., 60 mL) and sterile irrigation solution. Gently instill and withdraw fluid; never instill more than 30-60 mL at once in the immediate post-op period to avoid pressure on the surgical site.
A Word from Your Senior Nurse
"Post-TURP with CBI is a classic 'hands-on' nursing scenario. Your eyes and your assessment skills are the primary monitor for this patient's safety. That drainage bag is your window into what's happening in the bladder. Bright red drainage? Speed up the irrigation. No drainage? Your patient is headed for a painful emergency. This isn't just about following an order to 'run the irrigation'; it's about critically thinking and adjusting your care based on what you see. Mastering this will make you an invaluable asset on a urology floor and give you rock-solid confidence for those priority-setting NCLEX questions."
Transurethral Resection of the Prostate — A surgical procedure to remove part of an enlarged prostate gland through the urethra. It is the most common surgery for Benign Prostatic Hyperplasia (BPH).
Continuous Bladder Irrigation — The continuous instillation of a sterile solution (e.g., normal saline) into the bladder via a three-way catheter to flush out blood clots and debris, preventing catheter obstruction after procedures like TURP.
Three-Way (Triple-Lumen) Urinary Catheter — A catheter with three separate channels: one to inflate the retention balloon, one for continuous inflow of irrigation fluid, and one for continuous outflow of drainage.
Bladder Tamponade / Clot Retention — A complication where blood clots obstruct the urinary catheter or bladder neck, preventing drainage. This causes painful bladder distension and can lead to increased bleeding and infection.
Bladder Spasm — Painful, involuntary contractions of the bladder muscle often experienced after urological procedures or with an indwelling catheter. Managed with antispasmodic medications.