The nurse is caring for a client with a Foley catheter. While rounding on the client, the nurse notices that the client’s urinary output has suddenly stopped over the last 2 hours. The client’s kidney function is within normal limits. Which intervention would the nurse expect to perform? Select all that apply .
check the tubing for any kinks or to see if it is under the client
attempt to gently flush the Foley with 30 cc of sterile saline
perform a bladder scan, record the results, and notify the health care provider
pull back on the catheter about 6 inches, then reinsert it to see if urine flow begins
assess the client for bladder distention and discomfort if the client is alert and oriented
Numbers 1, 2, 3, and 5 are correct.
The first step is to be sure the tubing has not become kinked or lodged under the client. The next step is to gently flush the Foley with 30 cc of sterile saline. Sometimes there may be a blood clot or sediment blocking the flow of urine. Avoid aggressive interventions in order to prevent trauma to the urethra. If the client is alert and oriented, ask the client if he feels pain or pressure or a sense of urinary urgency. The client may not show signs of discomfort, especially if mental function is impaired. A bladder scan is a noninvasive manner in which to determine how much urine is in the bladder. The results should be recorded and the health care provider notified. Joint Commission guidelines encourage minimal use of Foley catheters for the minimum time possible in order to prevent infection. Facility protocols may not allow the nurse to automatically place a new Foley, so the health care provider should be notified to obtain an order for a new Foley. The bulb of the Foley may be lodged against the urethral opening. In this case, the nurse may attempt to reinsert about 2 inches of the catheter after cleaning it with soap and water. This will move the bulb far enough to see if the bulb is blocking urine outflow. However, removing a substantial amount of the tubing and reinserting it increases the risk of infection, even if it has been cleaned.