A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.
The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?

Choice A rationale:

Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.

Here is a detailed explanation of how anemia can lead to cellular hypoxia:

Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.

Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.

Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.

Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.

Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.

Common signs and symptoms of cellular hypoxia:

Fatigue Weakness

Shortness of breath Pale skin

Dizziness Headache Chest pain

Tachycardia (rapid heart rate) Cognitive impairment

Choice A rationale:

Pallor, or paleness, is not a typical sign of phlebitis. It can be associated with other conditions such as anemia, decreased blood flow, or shock. In the context of IV therapy, pallor at the insertion site might suggest a problem with blood flow, such as infiltration or a clot, but it's not a direct indication of inflammation.

Choice B rationale:

Coolness at the IV site is also not a characteristic sign of phlebitis. It could potentially suggest infiltration of the IV fluids into the surrounding tissues, but it's not a primary indicator of inflammation. Phlebitis typically involves warmth and redness due to the inflammatory response.

Choice C rationale:

Erythema, or redness, is the hallmark sign of phlebitis. It's caused by the dilation of blood vessels in the area as part of the inflammatory response. The redness is often accompanied by warmth, swelling, and tenderness along the vein.

Mechanism of erythema in phlebitis:

When the inner lining of the vein (endothelium) is irritated or damaged by the IV catheter, it releases inflammatory mediators. These mediators cause the blood vessels to dilate, leading to increased blood flow and redness in the area.

The redness is often more pronounced along the path of the vein, rather than just at the insertion site.

Choice D rationale:

Drainage from the IV site can be a sign of infection, but it's not a primary feature of phlebitis. If drainage is present, it's important to assess for other signs of infection, such as pus, fever, or increased pain.