The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the assessment data, which of the following nursing interventions would be most appropriate at this time?
A. Change the appliance bag.
B. Notify the physician.
C. Obtain a urine specimen for culture.
D. Encourage a high fluid intake.
Correct Answer: D. Encourage a high fluid intake.
Mucus is secreted by the intestinal segment used to create the conduit and is a normal occurrence. The client should be encouraged to maintain a large fluid intake to help flush the mucus out of the conduit. Monitor intake and output (I&O) carefully, measure liquid stool. Weigh regularly. Provides direct indicators of fluid balance. Greatest fluid losses occur with an ileostomy, but they generally do not exceed 500–800 mL/day.
Option A: Because mucus in the urine is expected, it is not necessary to change the appliance bag or notify the physician. Inspect stoma and peristomal skin area with each pouch change. Note irritation, bruises (dark, bluish color), rashes. Monitors the healing process and effectiveness of appliances and identifies areas of concern, need for further evaluation and intervention.
Option B: It is unnecessary to inform the physician. Verify that the opening on the adhesive backing of the pouch is at least 1?16 to 1?8 in (2–3 mm) larger than the base of the stoma, with adequate adhesiveness left to apply pouch. Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area prevents the skin barrier wafer from being too tight. Note: Too tight a fit may cause stomal edema or stenosis.
Option C: The mucus is not an indication of an infection, so a urine culture is not necessary. Monitor vital signs, noting postural hypotension, tachycardia. Evaluate skin turgor, capillary refill, and mucous membranes. Reflects hydration status and/or the possible need for increased fluid replacement.
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