Page 1301 - Saunders Comprehensive Review For NCLEX-RN

Monitor urinary output closely following bladder surgery. Irrigate the ureteral

catheter (if present and if prescribed) gently to prevent obstruction. Follow the surgeon’s
prescriptions and agency policy regarding irrigation.
1. Monitor vital signs.
2. Assess incision site.
3. Assess stoma (should be red and moist) every hour for
the first 24 hours.
4. Monitor for edema in the stoma, which may be present
in the immediate postoperative period.
5. Notify the surgeon if the stoma appears dark and
dusky (indicates necrosis).
6. Monitor for prolapse or retraction of the stoma.
7. Assess bowel function; monitor for expected return of
peristalsis in 3 to 4 days.
8. Maintain NPO status as prescribed until bowel sounds
return.
9. Monitor for continuous urine flow (30 to 60 mL/hr).
10. Notify the surgeon if the urine output is less than
30 mL/hr or if no urine output occurs for more than 15
minutes.
11. Ureteral stents or catheters, if present, may be in place
for 2 to 3 weeks or until healing occurs; maintain
stability with catheters to prevent dislodgment.
12. Monitor for hematuria.
13. Monitor for signs of peritonitis.
14. Monitor for bladder distention following a partial
cystectomy.
15. Monitor for shock, hemorrhage, thrombophlebitis, and
lower extremity lymphedema after a radical
cystectomy.
16. Monitor the urinary drainage pouch for leaks, and
check skin integrity (see Box 44-18).
17. Monitor the pH of the urine (do not place the dipstick
in the stoma), because highly alkaline or acidic urine
can cause skin irritation and facilitate crystal
formation.
18. Instruct the client regarding the potential for urinary
tract infection or the development of calculi.
19. Instruct the client to assess the skin for irritation,
monitor the urinary drainage pouch, and report any
leakage.
20. Encourage the client to express feelings about changes
in body image, embarrassment, and sexual
dysfunction.

XXV. Oncological Emergencies

A. Sepsis and disseminated intravascular coagulation (DIC)

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