# A nurse is caring for a 72-year-old client who underwent a radical cystectomy with bilateral ureterostomy 2 days ago. The client has two ureteral stents in place and is receiving continuous bladder irrigation through a three-way catheter. Which nursing intervention is the priority for this client?

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## 문제

A nurse is caring for a 72-year-old client who underwent a radical cystectomy with bilateral ureterostomy 2 days ago. The client has two ureteral stents in place and is receiving continuous bladder irrigation through a three-way catheter. Which nursing intervention is the priority for this client?

## 보기

1. Encourage the client to perform deep breathing exercises every 2 hours
2. Monitor urine output and characteristics from both ureteral stents hourly **✔ 정답**
3. Assist the client with early ambulation to prevent complications
4. Provide emotional support regarding body image changes

**정답: 2**

## 해설

Monitoring urine output and characteristics from both ureteral stents hourly is the priority to assess kidney function and surgical site integrity, preventing complications like obstruction. Other interventions are important but secondary in the immediate post-operative period.

## 심화 해설

Understanding the Postoperative Context

After a radical cystectomy with bilateral ureterostomy, the client's urinary system has been surgically reconstructed. The ureters are now diverted directly to the abdominal surface, and ureteral stents are placed to maintain patency of these newly created, narrow openings. In the immediate postoperative period (48 hours), the stents are critical lifelines for renal function. The priority nursing intervention is to ensure urine is flowing freely from both kidneys.

Why Monitoring Stent Output is the Priority

The bilateral ureteral stents are prone to obstruction from mucus, blood clots, or edema. A blockage in even one stent can rapidly lead to hydronephrosis, increased intrapelvic pressure, and acute kidney injury. This directly threatens the client's physiological integrity. The evidence on indwelling catheter management emphasizes that maintaining a closed, unobstructed drainage system is a cornerstone of safe care and infection prevention [1]. While that evidence focuses on urethral catheters, the principle is magnified with ureteral stents, where the lumen is much smaller and the consequence of obstruction is direct kidney damage. Failure mode analysis in catheterization processes identifies inadequate monitoring of output and failure to recognize obstruction as high-risk potential failures that can lead to severe patient harm [2]. Hourly monitoring allows the nurse to detect a sudden decrease or cessation of output from one side, which is an early and critical sign of stent occlusion.

Analyzing the Other Options

The other interventions are important but do not take precedence over ensuring renal function in this specific, early postoperative window.

- **Deep breathing exercises:** These prevent atelectasis and pneumonia, a common postoperative risk. However, respiratory complications typically develop over days, whereas a blocked ureteral stent can cause irreversible kidney damage within hours.

- **Early ambulation:** This is vital for preventing venous thromboembolism and ileus. However, for a client with two newly created ureterostomies, stents, and a three-way bladder irrigation catheter, safe ambulation requires careful planning and stabilization of all tubes. It is a secondary priority to first establishing that the urinary diversion is functioning.

- **Emotional support regarding body image:** A radical cystectomy with a permanent urinary diversion is a life-altering surgery. Psychosocial support is a critical component of holistic care, but it does not take priority over a life-threatening physiological risk. The acute physiological need for renal perfusion and urine flow must be stabilized first.

Connecting the Evidence to Clinical Judgment

The systematic evidence on catheter care highlights that the primary goal is to prevent complications through meticulous monitoring and maintenance of the drainage system [1]. A proactive risk analysis of catheterization processes identifies failure to monitor and assess drainage as a key failure mode with potentially catastrophic consequences [2]. Applying this to the client with bilateral ureterostomy, the nurse uses clinical judgment to recognize that the most immediate, preventable threat is the loss of renal function due to an obstructed stent. The assessment of urine output from each stent—comparing volume, color, and clarity hourly—is the direct application of this evidence, making it the absolute priority nursing intervention.

References (research sources)

- [1]Best Evidence for Preventing Urinary Tract Infections and Optimizing Care in Adults with Indwelling Urinary Catheters.Research articleTang J, Fan Y, Lu J, Zhang Y. (2025) · DOI: 10.2147/rmhp.s557548

- [2]Failure mode and effect analysis in the indwelling urinary catheterization process.Research articleGiacomini CZP, Silva AEBC, Urbanetto JS, Sousa P, Magnago TSBS. (2026) · DOI: 10.1590/1518-8345.7589.4795

## 임상 시나리오

Post-Cystectomy Ureteral Stent MonitoringPreventing Acute Kidney Injury in Urinary Diversion
After a radical cystectomy with bilateral ureterostomy, the ureteral stents are the only pathway for urine from the kidneys. The narrow lumen is highly susceptible to obstruction from mucus plugs, blood clots, or edema in the first 48 hours.

The priority nursing action is to monitor urine output from each stent individually at least every hour. A sudden decrease or cessation of output from one side signals a unilateral obstruction, which can rapidly progress to hydronephrosis and acute kidney injury (AKI).

CautionNever irrigate a ureteral stent without a specific provider order. If an obstruction is suspected based on decreased output, immediately notify the surgeon. Document output from the left and right stents separately to localize the problem.

## 핵심 개념

- **Radical Cystectomy** — Surgical removal of the urinary bladder, often requiring urinary diversion for urine elimination.
- **Bilateral Ureterostomy** — A surgical procedure where both ureters are diverted to the abdominal surface to create a stoma for urine drainage.
- **Ureteral Stent** — A thin, flexible tube placed in the ureter to maintain patency and ensure urine flow from the kidney to the collection device.
- **Hydronephrosis** — Swelling of a kidney due to a buildup of urine, caused by an obstruction in the urinary tract preventing normal drainage.
- **Acute Kidney Injury (AKI)** — A sudden episode of kidney failure or damage that happens within a few hours or days, causing waste products to build up in the blood.

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