Care Case Study (1)-Urinary Patterns
Pt is 72 yo, African American male, resident of long-term care facility. He has been unable to control urge to void since experiencing a brain attack 1month ago. The RN understands that the term brain attack, is now used to alert people to the need for immediate treatment at the first sign of a stroke. Pt states that prior to brain attack he got up five or six times during the night to empty his bladder but that he was able to control the urge long enough to make it to the bathroom. How should the RN describe the urinary pattern that pt is describing?
Nocturia-refers to frequently voiding at night
Since pt now voids spontaneously w/o recognizing the need to void, how should the RN documents his current urinary pattern?
Incontinence-involuntary loss of urine (could be result of neurologic impairment secondary to the stroke)
RN initiates a bladder training program for pt. Which instruction should the RN provide to the unlicensed assistive personnel (UAP) who will be helping care for pt?
Remind pt to void every 2hrs while awake and to call for assistance to the bathroom-scheduling effective means to retrain bladder, every 2hrs during the day, every 4hrs at night
The bladder-training program proves unsuccessful, and pt’s incontinence continues. When establishing pt’s plan of care, RN includes which nursing diagnosis?
Risk for impaired skin integrity r/t urinary incontinence
Which of the following statements made by pt’s wife indicates that teaching has been effective?
-“washing with mild soap and water followed by ointment can help to protect my husband’s skin”
Nursing staff continues with the bladder-training program, but pt’s incontinence shows little improvement. Since the bladder training has not been successful, the RN obtains a prescription to apply a condom catheter. Pt is ambulatory with assistance. Which technique(s) should be included when applying the condom catheter?
-clean and dry the penis before applying condom catheter
-return the foreskin to its normal position after applying skin prep to the penis shaft- while providing perineal care and applying skin prep provided with condom catheter, the RN should return the foreskin to normal position before smoothly rolling the condom sheath onto the penis
Pt is admitted to acute care facility for minor surgery. His preop prescriptions include insertion of an indwelling urinary catheter. A student nurse is assigned to care for pt. The nursing instructor asks the student nurse to prepare to insert indwelling catheter under supervision. What is the 1st step in proper placement of an indwelling urinary catheter for a male client?
Wash your hands, provide privacy, and explain the procedure
RN reviews factors that may impact catheter insertion w/the student. Which physiologic change that commonly occurs in elderly males may affect insertion of the catheter?
Prostate gland enlargement
The student obtains a 16 foley catheter from the supply room. She explains the procedure to pt, who gives her permission to begin. After cleansing urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4″ and inflating the balloon. Pt cries out in obvious pain. RN should advise student to take which action?
Deflate the balloon and insert the catheter farther- catheter is not far enough. Since student maintained aseptic technique, balloon can be deflated and catheter inserted farther. 6-9″ to ensure proper placement in adult male
The catheter is successfully placed in the bladder w/ a return of 200mL of clear, yellow urine. The catheter is secured, and pt is resting comfortably. In documenting the catheter insertion procedure, which statement should be included?
16 Foley catheter inserted w/return of clear, yellow urine.
Pt returns from the PACU. He has an IV of LR infusing at 150mL/hr, O2 at 2L/min per nasal prongs, and the indwelling catheter attached to a drainage bag. Pt is responsive but confused and frequently pulls on the urinary catheter. The RN observes obvious hematuria in drainage bag and notes the presence of several blood clots in the tubing. Which recording objectively documents this situation?
Client is confused and pulls on Foley catheter. Urine is pinkish-red w/ blood clots
Pt’s hematuria continues. 2 hrs later, pt becomes restless and appears to be in pain. RN observes that there has been no UO during the past 2 hrs. What assessment should RN complete first?
Observe the urinary drainage tubing for UO and color
RN is unable to resolve the catheter obstruction using noninvasive measures and notifies the HCP, who prescribes bladder irrigation to dislodge any blood clots obstructing the urine flow. RN anticipates that the prescription will include the use of which sterile solution to irrigate the catheter
NS-isotonic saline is a sterile normal solution that can be used for internal organ irrigations such as bladder and stomach
The RN encourages the nursing student to perform irrigation. The student prepares the sol’n, applies gloves, calmps the distal tubing, and begins to clean the specimen port on drainage tubing. What action should RN take.
Encourage student to continue, maintaining aseptic technique-opening connection between catheter and drainage tubing increases risk of contamination
The student instills a total of 60mL of the correct sol’n and withdraws 40mL of fluid containing several small blood clots. The student then empties 200ml from urinary drainage bag. What UO should be recorded?
180…Since the student nurse only withdrew 40 mL of the 60 mL put into the catheter, the patient may be considered to have taken in 20 mL of the fluid. This has to be subtracted from the output.
During catheter irrigation, RN observes pt is still confused and attempts to pull at his catheter, IV and nasal cannula. RN considers the use of wrist restraints, on the basis of which rationale?
The client is at risk for self-injury (reasonable rationale for the use of physical restraints. However, all other safety measures should be attempted before physically restraining a client)
After obtaining a prescription for wrist restraints, RN applies restraints and plans to monitor client ever 30min. Which assessment is most important for the RN to perform at each of the times
Skin integrity and pulse volume of restrained extremities (wrist restraints could impede circulation, causing tissue damage under the restraint. Skin integrity and assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be removed at least every 2hrs to allow for ROM)
Pt’s confusion decreases, and 12hrs later nurse is able to remove the wrist restraints. By the 3rd postop day, no further hematuria or blood clots are observed in pt’s urine. However, the nurse does observe that the urine has developed a cloudy appearance. Which action should the RN implement?
Obtain a sterile urine specimen-urine is cloudy when a UTI has developed. A sterile specimen is needed to detect and ID microorganisms
Urinalysis (pH 8.5, specific gravity 1.015, protein none, glucose none, WBCs 8, RBCs 2, bacteria present) Based on these results, the HCP prescribes a broad-spectrum abx. After 24hrs of receiving the abx, pt’s condition has not improved. What add’l nursing intervention of RN implement?
Provide a glass of cranberry juice daily-pH of urine is elevated, indicating alkaline urine. the juice is believed to increase acidity of urine, providing a less desirable environment for bacterial growth
Which diagnostic test result ID the client as being at risk for sepsis?
Urine culture shows resistance to the prescribed abx
After reviewing the diagnostic tests, RN consults HCP and receives prescription for new abx. Since pt’s creatinine levels are elevated, the RN is concerned abuot which problem in the administering the med?
Drug toxicity due to reduced drug excretion (elevated creatinine level reflects problem in kidney. The kidneys are unable to excrete drug efficiently, the drug will remain in the body for a prolonged period of time, which may result in drug toxicity.”
RN notes that the med dosage is in the safe range for elderly clients. The med is to be administered by IV every 12 hrs. The RN recognizes that the frequency of drug administration is based on which characteristics of medication?
Pt’s indwelling catheter is removed by RN on the morning of pt’s anticipated discharge. The RN instructs the UAP to report if Mr. Hunter has not voided w/in what time period?
8hrs-if pt hasn’t voided w/in 6-8hrs of removal, further action should be taken.
Pt voids 4hrs after the catheter is removed. He is discharged to long-term care facility. To encourage voiding, the RN instructs the UAP to perform what intervention?
Turn on the tap so water is running when pt attempts to void (running water stimulates urge to void, as does placing pt’s hand in warm water)
Pt is discharged from acute care facility and is transferred to the long-term facility. Since he no longer has an IV, the prescription for his abx is now an oral medication. Pt has difficulty swallowing, and RN is considering the best technique to help pt swallow medication. Before deciding to open capsule and mix with food, what will RN need to determine?
Is the medication in extended-release form? (an formulated for gradual absorption in the body. Opening or crushing the medication will adversely affect this action)
RN determines that the capsule can be opened and mixed w/ a food the client likes. Which technique will RN use?
Open the capsule and mix the medication w/pudding
Pt’s incontinence continues. Use of condom catheter is resumed until pt develops localized dermatitis. The condom catheter is removed temporarily to promote healing, and although the nursing staff takes pt to bathroom every 2hrs, he occasionally wets his clothing. RN enters pt’s room and finds him crying. What is the best intial response by the RN to this behavior?
Acknowledge pt the distress he is experiencing
When pt is calm, RN assigns UAP to help him into dry clothing. Minutes later, RN walks down hall and sees UAP in room changing pt’s clothes. RN enters the room and assesses the situation. Which aspect of situation requires the RN’s most immediate intervention
Pt’s room door is open to hallway