A 20-year-old man is receiving rehabilitation after surgery for a T12 spinal cord injury. He has an indwelling urinary catheter connected to a closed drainage system, with the bag below bladder level. Over two hours, urine output falls from 45 to 5 mL/hour, blood pressure falls from 122/78 to 96/56 mm Hg, and heart rate rises from 84 to 118/min. Which action should the LPN/VN take first?
- Record the trends without notifying the RN or provider, then reassess at the next scheduled observation round.
- Irrigate the catheter before checking the tubing or requesting further assessment.
- Immediately alert the RN or provider to the deterioration and obtain urgent assessment while checking drainage tubing for obstruction.
- Collect urine from the drainage bag for culture before reporting the changes.