LAST TEST NURSING ARTS EXAM| 18 QUESTIONS AND ANSWERS

Equipment needed for CBI Irrigating solution (2000 mL sterile normal saline) as prescribed IV tubing with roller clamp IV pole Antiseptic swabs Clean gloves what to document for CBI Type and amount of solution administered for irrigation • Rate of administration of irrigating solution • Description of urinary output. including color and presence of clots or debris • Any statements of discomfort or cramping • Medication given for pain • Amount of actual urine output (total urine output minus amount of irrigant instilled) CBI expected outcomes Continuous bladder irrigation is maintained to prevent clot formation and catheter obstruction. • Client does not experience discomfort. CBI Unexpected outcomes Irrigation flow is not infusing at prescribed rate. Irrigation outflow is less than expected. Painful bladder spasms Dark pink urine with blood clots What would the nurse do if they suspected an obstruction in CBI? a. Check tubing for kinks. b. Have client change position. c. Maintaining sterile technique, disconnect catheter outflow port and gently aspirate solution from catheter to remove clots. d. Instill 30-50 mL irrigating solution to free clots. e. Reconnect drainage system and observe for 30 minutes; bladder spasms may block outflow of urine. f. Notify physician if problem is not resolved or client develops nausea, hypertension, bradycardia (client may develop TU RP syndrome due to absorption of hypotonic irrigating solution). • Increase irrigation inflow rate; monitor vital signs. • Do not allow client to cough. keep catheter taped leg staight try chanaging positions notify dr and ask for anti spasmodics if needed How high does the nurse hang the CBI irrigationg bags Hang irrigating solution on IV pole at height of 24-36 inches above ! bladder. what is bladder irrgiation Irrigation: washing or flushing out with ordered solution. Bladder irrigation usually done on physicians order, may require added medication. Closed method done for continuous irrigation. Use three-way or triple lumen cath. Flows in through irrigation port and out through urine drain port What is the purpose of Bladder irrigation? Maintain patency of catheter and tubing Rinses clots and debris from bladder Prevents bladder spasms and excess bleeding Why CBI? BPH: benign prostatic hyperplasia (or hypertrophy); nonmalignant non-inflammatory enlargement of prostate. Over 50 Y/O most common. Can lead to urethral obstruction and interference with urine flow, frequency, nocturia, dysuria, and UTI. Bladder surgery TUR/ TURP : transurethral resection prostate. Used for removal of prostatic tissue. Optical instrument introduced through urethra to prostate. Gland removed in small chips with electrical cutting loop. shaving down an enlarged prostate from a tennis ball to a walnut what to know before starting to irrigate Check order and reason for irrigation Type of sterile solution, amount and strength, and rate normal saline Check that proper type of catheter in place solution used for CBI SOLUTION: Normal Saline in 3000 cc bags How is the Rate of flow decided? Titrated to type of output flow Is sanguinous drainage in the drainage tubing/bag considered normal? 40- 60 drops per minute Toleration: no pain, no distention and urine = good signs Sangionous draingage increase drainage If its bright red increas flow rate over 60 stay with pt and reassess Light pink is what we want to see Sanginous in drainage bag = bad cuz of clotting If drainage is too light decrease rate Assessments for CBI Vs, pain, check fr distention, loc, bladder spasms?, meds (rectal suppositories B & O (bella donna and opium) ) assess drainage Tubing should only sit 24 hours before being changed CBI nursing implementation Prepare the solution (must maintain sterility). Close clamp on tubing and spike the bag with the tubing. Place bag on an IV pole. Fill the drip chamber one-half full by squeezing the chamber. Open the clamp to completely fill tubing and remove air. Close the clamp and maintain sterility.NURSE ALERT Change solution and tubing every 24 hours to maintain sterility. Wipe off irrigation port of triple-lumen catheter with antiseptic swab and connect to irrigation tubing aseptically. Remove gloves. Adjust rate at roller clamp (according to physician's orders or agency protocol). If urine is bright red or has clots, increase irrigation rate until clears. Run increased intil light pink Change irrigation solution as needed. Using gloves, empty catheter bag as needed (may need to be hourly). Not right don't empty until whole 3 liters is infused Compare urine output with irrigation solution's infusion every hour.NURSE ALERT: Expect bright red-tinged urine for first 24 hours, gradually turning to light pink. Use Policy & Protocol. ACCURATE I&0's While documenting subtract bag 3 liters to amount in drainage bag and record Any time you hang a bag you need to empty and measure the drainage bag CBI Evaluation Measure urine output by subtracting total irrigation solution from total drainage in bag. Kelly out - solution = input Evaluate the characteristics and amount of urine output. Determine the client's comfort level and the presence of signs and symptoms of an infection.