Key Concepts for NCLEX

This document provides essential nursing care notes on Continuous Bladder Irrigation (CBI) post-TURP, including expected outcomes, troubleshooting, complications, and patient instructions.

Alice Edwards

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1IMPORTANT NOTESBladderIrrigation"Continuous Bladder irrigation done mostly in TURF"Thisis a three waycatheter that keeps blood from accumulating•This is done with normal saline•Color of the urine should slowly progress to an amber coloroThe initial voiding following removal may be uncomfortable,, red in color and contain dots. Thecolor of the urine should progress toward amberin2 to 3 days.oOn the fourth day the urine should be clear - 4thday if you see blood this is NOT a good thingoIf bright-red or ketchup-appearing (arterial) bleeding with clots is observed, the nurse shouldincrease the rate"Ifthe catheter becomes obstructed (bladder spasmsrreduced irrigation outflow), turn offthe CBI andirrigate with 50 mL of irrigation solution using a large piston syringe.oContact the primary care provider if unable to dislodge the clot.•Record the amount of irrigating solution instilled (generally very large volumes) and the amount ofreturn. The difference equals urine output"Instruct the client to not try t o push peeoThe catheter has a large balloon (30 to 45 mL) that is taped tightly to the leg, creating tractionso that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. Thismakes the client feel a continuous need to urinate.oTell patient not to push (muscle spasms) can cause more bleeding§Once an obstruction is ruled out administer an antispasmodic to stop spasms•Expected output 150-200ml q2-3hr (normal is 30ml/hr)oInstruct the client that expectedoutputis 150 to 200mLevery 3 to 4hr. The client shouldcontact the provider if unable to void.•Need to watch out for blockage•Sodium can be absorbed through bladder irrigation•Avoid kinks in the tubing.•Complications:Urethraltrauma,urinary retention, bleeding, and infection are complicationsassociated with TURF. Other complications include re-growth of prostate tissue and reoccurrence ofbladder neck obstruction.Crutches■With crutches elbows should be flexed30degrees."Do not alter crutches after proper fit has been determined. Follow the prescribed crutch gait.•Support body weight at the hand grip with the elbows flexed at 30:.•Position the crutches on theunaffected side when sittingor risingfrom a chair.Climbingthe Stairs with Crutches■Upstairs - Good foot (good up to heaven)"Downstairs-Bad (bad go down hell)

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National Council Licensure Examination

Key Concepts for NCLEX

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