A 68-year-old male had a radical prostatectomy

A 68-year-old male had a radical prostatectomy with a perineal resection due to a stage III cancerous tumor this morning. He is receiving continuous bladder irrigation (CBI) via a triple-lumen catheter with sterile normal saline; the orders are to infuse at a rate to keep the drainage light pink without clots. Twelve hours after the surgery, he reports having occasional bladder spasms, and currently his pain level is a “7” out of 10. The urine in the tubing is mostly clear, pink-tinged, with a rare clot noted. The perineal incision is dry and intact, with no drainage noted. 1) Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient’s care at this time. Nursing Action Indicated Contraindicated Nonessential Medicate for pain as needed. Encourage patient to urinate every 2 to 3 hours. Keep the collection bag level with the bladder. Encourage fluids. Instill 50 mL of normal saline into the catheter every 4 hours. Measure the inflow and outflow amounts. Disconnect catheter to assist with putting on clothes. Test urine for the presence of blood every shift. Administer an enema as needed for constipation. Teach patient to avoid activities that increase abdominal pressure, such as sitting or walking for prolonged periods. SCIENCE HEALTH SCIENCE NURSING NSG 435

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