Urinary catheters
Catheters are a leading source of health care–associated infection.
| Situation | Nursing action |
|---|---|
| Bag on the bed rail above the bladder | Move it below bladder level to prevent backflow |
| No urine output and a distended bladder | Check for kinks or clamps; reposition; bladder scan; notify |
| Cloudy, foul urine with fever | Report possible infection; culture as ordered |
| After catheter removal | Encourage fluids; expect voiding within about 6–8 hours; report inability to void |
Collect urine specimens from the sampling port with sterile technique, never from the bag.
Urinary retention and incontinence
Retention is common after surgery, anesthesia, and opioids; incontinence threatens skin integrity and dignity.
- Retention cues: suprapubic fullness or discomfort, no void or frequent small voids, restlessness (especially in older adults); confirm with a bladder scanner.
- Interventions: privacy, normal voiding position, running water, and warm water over the perineum; intermittent or indwelling catheterization per order.
- Incontinence care: scheduled toileting (such as every 2 hours), pelvic floor (Kegel) exercises for stress incontinence, prompt cleansing and skin barrier; avoid indwelling catheters for convenience.
Bowel elimination
Constipation is common with opioids, immobility, and low fluid or fiber intake.
- Fecal impaction: no formed stool, liquid seepage, abdominal discomfort; digital removal or enemas per order and policy (watch for vagal bradycardia).
- Cleansing enema: left side-lying, knee bent; warm solution; hold the bag about 12–18 inches above the anus for gravity flow; stop for cramping, then resume slowly.
- Diarrhea: monitor fluids and electrolytes, protect perineal skin, and test for C. difficile when indicated.
Ostomy care
Stoma assessment and pouching are frequent questions.
| Ostomy skill | Key point |
|---|---|
| Stoma assessment | Moist, pink to red is normal; pale, dusky, purple, or black is abnormal |
| Early swelling | Expected after surgery; it shrinks over several weeks, so remeasure |
| Pouch opening | About 1/8 inch (2–3 mm) larger than the stoma |
| Emptying | When one-third to one-half full |
| Skin | Clean with water, dry well, use skin barrier; report breakdown |
| Psychosocial | Body image concerns are common; support and referral to an ostomy nurse |
Clients with an ileostomy should avoid extended-release tablets, which may pass undissolved.
NGN-style case
Spotting an abnormal stoma.
On the day after colostomy surgery, the nurse finds the stoma dark purple and dry. The previous assessment documented a moist, red stoma. What should the nurse do?
- Recognize cues: color change from red to purple, now dry.
- Analyze: impaired blood supply (stomal ischemia or necrosis).
- This is not an expected postoperative change.
- Notify the surgeon immediately and document the assessment.
Answer. Notify the surgeon immediately: a dusky, purple, or black stoma suggests ischemia.