A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120ml. The drainage system has no obstructions. Which intervention has priority?
A. Give a 500 ml bolus of isotonic saline.
B. Evaluate the patient’s circulation and vital signs.
C. Flush the urinary catheter with sterile water or saline.
D. Place the patient in the shock position and notify the surgeon.
Correct Answer: B. Evaluate the patient’s circulation and vital signs.
A total UO of 120ml is too low. Assess the patient’s circulation and hemodynamic stability for signs of hypovolemia. Normal urine output is 1-2 ml/kg/hr. To determine the urine output of your patient, you need to know their weight, the amount of urine produced, and the amount of time it took them to produce that urine.
Option A: A fluid bolus may be required, but only after further nursing assessment and a doctor’s order. A decrease in output (to less than 400 ml per 24 hours) may indicate acute failure, especially in high-risk patients. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing the risk of fluid overload. Do note that hypervolemia usually occurs in the anuric phase of ARF and may mask the symptoms.
Option C: Accurately record intake and output (I&O) noting to include “hidden” fluids such as IV antibiotic additives, liquid medications, frozen treats, ice chips. Religiously measure gastrointestinal losses and estimate insensible losses (sweating), including wound drainage, nasogastric outputs, and diarrhea.
Option D: Assess skin, face, dependent areas for edema. Evaluate the degree of edema (on a scale of +1–+4). Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). The patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
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