Interrelated Concepts (In order of emphasis)
Clinical Judgment
Patient Education
NCLEX Client Need Categories Percentage of Items from
... [Show More] Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
This study source was downloaded by 100000852290574 from CourseHero.com on 02-25-2023 06:38:39 GMT -06:00
https://www.coursehero.com/file/70475130/ANSWER-KEY-Urinary-Catheter-SkillsnReasoningpdf/
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
History of Present Problem:
Sheila Dalton is a 52-year-old Caucasian female who has a history of chronic low back pain. She had a posterior spinal
fusion of L4-S1 yesterday and is postoperative day (POD) #1. Her pain is controlled at 2/10 and requires hydromorphone
0.5-1 mg IV every 4 hours. She is able to stand and sit in a chair with assistance. Her indwelling urinary catheter was
discontinued six hours ago and she has not voided since the catheter was removed. Sheila is tolerating oral fluids and has
had an oral intake of 1000 mL in the past eight hours.
Current Complaint:
Two hours later, Sheila puts on her call light and states that she is having moderate pain/pressure above her pubic bone
that she has not had before.
What data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data-Patient Story: Clinical Significance:
Her pain is currently controlled at 2/10 and
requires hydromorphone 0.5-1 mg IV every 4
hours.
Her Foley catheter was discontinued six
hours ago and she has not voided since the
catheter was removed.
Sheila is tolerating oral fluids and has had
1000 mL the last eight hours.
Though hydromorphone is commonly given for postoperative pain, a
urologic side effect of opiates is urinary retention. Clustering additional
clinical data in this scenario will make this problem evident.
You would expect to have a first void within 6 to 8 hours after a catheter
is removed. No void six hours after removal is a clinical RED FLAG that
needs to be recognized by the nurse.
This is an adequate amount of oral intake that should result in urine
formation. Accurate Is and Os would show a + balance, meaning that
Shelia has had more fluid in than out
RELEVANT Data-Current Complaint: Clinical Significance:
Moderate pain/pressure above her pubic bone
that she has not had before.
With any onset of pain that is new and different, the nurse must ask and
determine why. Nurse must investigate the cause by gathering
information about the pain and completing a focused physical exam In
this scenario, new onset of low abdominal pain/pressure sensation is
most likely due to a distended bladder caused by urinary retention.
***Emphasize the importance of pathophysiology and understanding the
mechanism of action of narcotic pain medications and how this can
influence the development of urinary retention.
Nursing Assessment Begins:
Current VS: Most Recent VS: Current WILDA:
T: 99.4 (oral) T: 98.9 (oral) Words: pressure/ache
P: 90 (reg) P: 72 (reg) Intensity: 8/10
R: 20 (reg) R: 18 (reg) Location: lower abdomen/suprapubic
BP: 152/82 BP: 138/80 Duration: ongoing the past hour
O2 sat: 95% room air O2 sat: 96% room air Aggravate: nothing
Alleviate: nothing
This study source was downloaded by 100000852290574 from CourseHero.com on 02-25-2023 06:38:39 GMT -06:00
https://www.coursehero.com/file/70475130/ANSWER-KEY-Urinary-Catheter-SkillsnReasoningpdf/
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
P: 90 (reg)
BP: 152/82
Words: pressure/ache
Intensity: 8/10
Location: lower mid abdomen/pelvic
Duration: ongoing the past hour
Aggravate: nothing
Alleviate: nothing
Though her heart rate is not technically tachycardic, trending clinical data
show the heart rate is elevated and most likely due to physiologic discomfort.
Also, patient is resting in bed and on pain medication so an elevated HR
should be investigated
Though her blood pressure is mildly elevated, when compared to the most
recent reading, it, too, is trending upward. Though blood pressure and heart
rate do not always increase with acute pain, it is commonly seen in clinical
practice and is the most obvious reason for this upward trend.
New onset of moderate to severe pain that is a pressure sensation over the
suprapubic area is consistent with the pain seen with urinary retention. The
nurse needs further data collection and assessment to confirm this potential
problem.
RELEVANT Assessment Data: Clinical Significance:
GENERAL APPEARANCE:
Appears anxious, uncomfortable, tense
body posture in bed
GI: Lower suprapubic area tender and
firm to palpation, bowel sounds active
and audible per auscultation in all four
quadrants
GU: Has not been able to void since
catheter discontinued six hours ago
This nonverbal body language confirms that she is uncomfortable and is
consistent with the level of pain she reports.
The nurse must understand the influence of anxiety in this scenario. If the
patient is fearful and obsessing over her inability to urinate this can hinder
her ability to void. Help the patient calm down and use relaxation techniques
or distraction to help minimize anxiety that is present.
Performing an assessment and identifying that her lower abdomen/pelvic
area is firm and tender to LIGHT palpation is consistent with urinary
retention as the most likely cause. Abdominal pain can also be caused by an
ileus but active bowel sounds make this unlikely.
Clustering all of the data that has been collected, urinary retention post
discontinuation of an indwelling urinary catheter is the most likely source of
her pain.
1. What additional clinical data do you need to collect to identify the primary problem to guide your plan of care?
(Management of Care)
Current Assessment:
GENERAL
APPEARANCE:
Appears restless and appears uncomfortable, tense body posture in bed
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Lower suprapubic area tender and firm to palpation, bowel sounds active and
audible per auscultation in all four quadrants
GU: No urine output since indwelling urinary catheter discontinued six hours ago
SKIN: Skin integrity intact, 5 cm lateral incision down the lumbar spine with 4 steri-strips
intact, 4 x 4 gauze dressing dry, intact with scant amount of sero-sangineous
drainage, no odor, edges well approximated, surrounding tissue without redness
To definitively determine if urinary retention is present, a bladder ultrasound must be obtained by the nurse to determine
the amount of residual urine currently in the bladder. If the patient is able to void, the residual amount of urine in the
bladder must be ascertained. This study source was downloaded by 100000852290574 from CourseHero.com on 02-25-2023 06:38:39 GMT -06:00
https://www.coursehero.com/file/70475130/ANSWER-KEY-Urinary-Catheter-SkillsnReasoningpdf/
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
1. INTERPRETING relevant clinical data, what is the primary problem? What primary health related concept(s)
does this problem represent? (Management of Care/Physiologic Adaptation)
2. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND?
(Management of Care)
Nursing PRIORITY: Empty the bladder!
Clinical reasoning captures the essence of the current problem. Simply
stating the obvious problem in non-NANDA language concisely captures the
nursing priority!
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Assess location, level of pain and the
number of hours since the last void
Assess for presence of firmness and
distention in the suprapubic area
Give patient opportunity to void. Sit
upright if tolerates and run water in the
sink, provide privacy
If patient does void, measure amount and
then repeat bladder ultrasound.
If the bladder is distended because of
retention, it typically is hours after the last
void. This time frame needs to be
determined.
Firmness and distention in the pelvic area is
consistent with a distended bladder.
Catheterization is a last resort, and the
patient should be given the opportunity to
void. Being upright is more natural and will
facilitate expression of urine if patient is
able to void.
The gold standard to determine if urinary
retention is present post-void if able to do
so. Follow institution policy.
Location and level of pain is
determined.
Firmness is expected if urinary
retention is suspected.
May not be able to void if
retention is present
Bladder ultrasound will
confirm high residual volume
if retention is present.
Problem: Pathophysiology of Problem in OWN Words: Primary Concept(s):
Urinary
retention
When emptying of the bladder is impaired, urine continues to accumulate
and the bladder becomes over distended. Acute urinary retention is the most
common postoperative complication. In addition to the inability to urinate,
they may also experience overflow incontinence and able to urinate 25 to 50
mL of urine at frequent intervals (Berman, Snyder, & Frandsen, 2016)
“Postoperative urinary retention (PUR) is a common complication of
surgery and anesthesia. The risk of retention is especially high after
anorectal surgery, hernia repair, and orthopedic surgery and increases with
advancing age. Certain anesthetic and analgesic modalities, particularly
spinal anesthesia with long-acting local anesthetics and epidural analgesia,
promote the development of urinary retention.” (Darrah, Griebling, &
Silverstein, 2009, p.465). [Show Less]