After the insertion of a catheter into the stoma of a continent diversion, a nurse observes that there is no return. The nurse should first:
A. Irrigate the catheter
B. Discontinue the procedure
C. Try moving the catheter in and out slightly
D. Remove the catheter and flush out clots or debris
C
C. If no effluent starts to drain, problem solving is needed. The illustration in the text can be used to help solve the problem of inadequate effluent from pouch. For example, try moving catheter in and out slightly.
A. Moving catheter in and out slightly, have client move side to side, or cough. If these actions do not cause drainage, then gently irrigate the catheter with 30 to 60 ml of sterile saline.
B. Before withdrawing catheter, have client cough three or four times, then slowly remove.
D. Positive pressure inside abdomen clears residual urine or stool from pouch and continence valve; clears mucus from catheter.
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