Nursing Care Plan Second Year

Pt. initials: BS Student: Dave Porter Medical Diagnosis: Bladder Cancer Ref.s> Nursing Care Plans (Mosby)[NCP]/Med Surge RN Car (Mosby)[MSNC] Date: 3/12/07 Systems Key: WC: Wholly Compensatory PC: Partially Compensatory N/S Nursing system Key: Long-Term Goal (with deadline) SE: Supportive-Educative Patient will be free or urinary retention by means of indwelling catheter for next 7 days and will follow up with MD at that time.
Nursing Diagnosis with defining characteristics (ASB) N/S Expected outcome (Short-term objectives) with criteria and deadline Nursing Interventions Rationale for Action Evaluation (Criteria met?)

At risk for urinary retention related to blood clots in bladder over the next 7 days.

PC

1. Patient will empty bladder completely via Foley catheter by discharge.

The nurse will; 1. Visually inspect and palpate lower abdomen for distention and use bladder scanner to check for urinary retention.

1. The bladder lies below the umbilicus and distension can be seen or palpated for firmness. The bladder scanner detects residual urine in the bladder via ultrasound. Geriatric male patients often have an enlarged prostate gland which decreases force or urinary flow and/or leading to tendency for bladder retention.. [NCP pg 181] 2. Retention of urine in the bladder predisposes the geriatric patient to UTI's and may indicate the need for an intermittent catheterization program. [NCP pg 181] 3. Geriatric patients may have impaired renal function. However, this will differentiate between urinary retention and urinary failure. [NCP pg 181]

1. Yes. Patient voided approx 1800 ml during my shift without displaying signs or symptoms of retention.

2. Use an indwelling Foley or straight catheter and measure residual urine if incomplete emptying is suspected. 3. Monitor BUN and CR lab values.

PC

2. Patient will keep the irrigation Foley catheter in place, secured, attached to the leg bag, and kept patient by discharge.

1. Insert the indwelling irrigation catheter as ordered; secure catheter tube access using a catheter tape and Velcro retaining device and attach a leg bag to the catheter system. 2. Encourage intake of fluids

1. This prevents the catheter from dislodging or inadvertent displacement, which may contribute to urinary retention. The bag acts as a reservoir to hold urinary drainage. Kinks in the tubing may restrict proper drainage. [NCP pg 182] 2. Geriatric patients are typically dehydrated. Unless medically contraindicated, fluid intake should be at least 1500ml/24 hours. This stimulates urine production and keeps a min of 30ml/hr output rate. The continued flow rate helps to prevent blockage at the tip. [NCP pg 182]

2. Yes. Foley maintained a consistent flow and catheter was secured and draining properly.