Question

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) a. Increase the rate of the CBI. b. Assess the patency of the drainage system. c. Measure urine output. d. Assess vital signs. e. Administer ordered pain medication.

Short answer

The nurse's initial interventions should include assessing the patency of the drainage system (b), measuring urine output (c), and assessing vital signs (d). Only after ensuring that the catheter and drainage system are functioning correctly and there are no other complications should pain medication be administered (e), if ordered.

Step-by-step solution

Assess Complaints and Patient Condition

Listen to the patient's complaints and assess their condition. Lower abdominal pain and distention in a patient with an indwelling urinary catheter could suggest a blockage in the catheter or inadequate drainage.

Assess the Patency of the Drainage System

Examine the catheter, tubing, and drainage bag for kinks, clots, or anything that might obstruct urine flow. Ensuring the drainage system is patent is essential for patient comfort and to prevent complications like bladder distention.

Measure Urine Output

Check the output in the drainage bag for any abnormalities in volume or appearance. Accurate measurement of urine output is vital for monitoring the patient's fluid balance and catheter function.

Assess Vital Signs

Monitor the patient's vital signs to evaluate for signs of infection or other complications, as pain and abdominal distention could be symptoms of a larger issue.

Administer Ordered Pain Medication

If the patient's pain persists after ensuring the catheter system is functioning correctly, and there are no signs of a more serious underlying problem, administer any pain medication that has been prescribed by the physician.

Key concepts

Assessing Patient Condition

When a patient with continuous bladder irrigation (CBI) reports lower abdominal pain and distention, it's crucial to first carefully listen and evaluate their condition. As a nurse, this means considering the potential causes like a blockage or inadequate drainage which could escalate to more serious complications. A thorough assessment includes observing their overall appearance, discomfort levels, and any visible signs that may indicate a problem with the CBI system. Consider factors such as recent fluid intake, the position of the patient, and any other symptoms they may report. A systematic and compassionate approach to assessing the patient condition can help ensure their safety and comfort.

Patency of Urinary Drainage System

Ensuring the urinary drainage system is functioning correctly is a paramount concern. Start by examining the CBI system: check the catheter itself, the connecting tubing, and the drainage bag. Look for kinks or bends in the tubing that might be obstructing the flow of urine. Check for clots or sediment that could be preventing urine from draining properly. An unobstructed, or 'patent', drainage system is critical to prevent painful bladder distention and potential damage to the urinary tract. Be vigilant in identifying even minor signs of blockage, as early detection can prevent significant complications.

Measuring Urine Output

Urine output measurement is an essential factor in patient care for those with CBI. This is not only an indicator of kidney function but also of the effectiveness of bladder irrigation. To measure urine output, observe the volume collected in the drainage bag, making note of any changes in coloration or consistency that could signal complications. Accurate, consistent, and frequent measurement can give valuable insights into the patient's fluid balance and the functioning of the catheter. Tracking these measurements over time is also essential for evaluating the patient's progress and response to treatment.

Monitoring Vital Signs

Monitoring the patient's vital signs can provide critical information about their overall condition and help identify potential complications early. Regular checks of temperature, pulse, respiration, and blood pressure offer clues to possible infections, pain response, or other systemic issues. Particularly, in the context of abdominal pain and distention in a patient with a CBI, changes in vital signs may be indicative of severe complications like sepsis or kidney failure. Timely and accurate monitoring of vital signs, therefore, remains an integral part of nursing care for CBI patients.