Question

When assessing a client two hours after a transurethral prostatectomy, the nurse notes that the catheter drainage is dark red in color and contains a few clots. Which actions should the nurse take at this time? A. Document the finding and continue to observe the drainage B. Notify the physician immediately and increase the rate of IV fluids C. Place traction on the catheter and tape it to the client's upper thigh D. Request a CBC to determine the amount of blood loss

Short answer

Answer: Notify the physician immediately and increase the rate of IV fluids.

Step-by-step solution

Analyze the situation

To address this question, it is important to understand the context. A transurethral prostatectomy is a surgical procedure to remove part or the entire prostate gland. Dark red colored catheter drainage with clots may indicate a postoperative complication such as bleeding.

Assess each option

We will now analyze each option to determine the most appropriate nursing intervention in this situation. A. Document the finding and continue to observe the drainage: While documentation is important, this option does not provide any active intervention to address the potential bleeding issue. B. Notify the physician immediately and increase the rate of IV fluids: This option involves notifying the physician, which is a relevant step when suspecting postoperative complications. Increasing the rate of IV fluids can help maintain appropriate blood volume and pressure. C. Place traction on the catheter and tape it to the client's upper thigh: This option does not directly address the potential bleeding issue and focuses only on catheter placement. D. Request a CBC to determine the amount of blood loss: While a CBC might provide valuable information about the client's blood levels, it does not directly address the potential bleeding issue or provide an immediate intervention.

Choose the most appropriate option

Based on the analysis of each option, the most appropriate nursing intervention in this situation would be option B. Notify the physician immediately and increase the rate of IV fluids which addresses the potential bleeding issue and provides an active intervention to help maintain the client's blood volume and pressure.

Key concepts

Nursing Interventions

Nursing interventions are actions undertaken by nurses to improve the health outcomes of their patients. These interventions are critical in providing care and ensuring patient safety following procedures such as surgeries.
In the case of a transurethral prostatectomy, there may be a risk of bleeding, noted by observations like dark red catheter drainage containing clots. To address such concerns:

• Immediate notification of a physician is vital, as they can provide further directives or adjustments to the patient's care plan.
• Increasing IV fluid rates helps in maintaining blood volume and preventing potential complications associated with blood loss, like hypotension.
• Decisions on interventions should always consider the potential risks and benefits, ensuring immediate actions contribute positively to the patient's recovery.

Proper nursing interventions not only address present complications but also aid in a smoother recovery trajectory.

Postoperative Care

Postoperative care involves all the care and management given to a patient following a surgical procedure. It's a crucial time for monitoring the patient for any immediate complications and ensuring effective recovery. After a transurethral prostatectomy, careful observation of catheter drainage color and content is essential. Here’s why:

• Dark red urine with clots could indicate bleeding, a potential postoperative complication.
• Being aware of such signs allows for timely intervention, preventing serious outcomes.
• Postoperative care also includes adjusting IV fluid rates, thus supporting the body's blood volume and pressure stabilization during recovery.

Successful postoperative care requires vigilance, prompt identification of abnormalities, and immediate responses to ensure patient safety and comfort.

Clinical Decision-Making

Clinical decision-making in nursing involves selecting the best course of action by evaluating the present situation, patient conditions, and potential outcomes. In complex cases, such as post-surgical observations:

• Nurses must assess symptoms, like changes in catheterized drainage, swiftly to determine the urgency of potential complications.
• Decisions involve notifying the right healthcare team members, implementing immediate responses like adjusting IV fluids, and understanding the possible adverse effects of delayed action.
• Effective clinical decision-making also involves weighing the options and choosing actions that prioritize patient safety and treatment efficacy.

Nurses use critical thinking skills to address complications effectively, ensuring interventions are timely and purposeful.

Patient Assessment

Patient assessment is a foundational practice in nursing which involves observing, measuring, and evaluating the physiological and psychosocial aspects of a patient's status. In the context of postoperative care, like after transurethral prostatectomy:

• Routine assessments include monitoring drainage characteristics, such as color and presence of clots, to identify conditions like bleeding early on.
• Information gathered from patient assessments aids in forming critical responses, such as consulting physicians or modifying treatment plans.
• Regular assessment builds a comprehensive understanding of the patient's ongoing condition, guiding effective and informed care decisions.

A thorough patient assessment leads to more accurate diagnoses, timely interventions, and improved patient outcomes.