Nursing Care Plan - Download Now DOC by l62idC8


									                                                                 Nursing Care Plan
                                                                   Second Year
        Pt. initials: BS                                                                           Date: 3/12/07
        Student: Dave Porter                                                                       Systems Key:
        Medical Diagnosis: Bladder Cancer                                                          WC: Wholly Compensatory
        Ref.’s> Nursing Care Plans (Mosby)[NCP]/Med Surge RN Car (Mosby)[MSNC]                     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     N/S    Expected outcome
defining characteristics            (Short-term           Nursing Interventions                 Rationale for Action                 Evaluation
         (ASB)                       objectives)                                                                                   (Criteria met?)
                                  with criteria and
                                                      The nurse will;
At risk for urinary        PC    1. Patient will      1. Visually inspect and        1. The bladder lies below the umbilicus      1. Yes. Patient
retention related to             empty bladder        palpate lower abdomen for      and distension can be seen or palpated       voided approx
blood clots in bladder           completely via       distention and use bladder     for firmness. The bladder scanner            1800 ml during
over the next 7 days.            Foley catheter by    scanner to check for urinary   detects residual urine in the bladder via    my shift
                                 discharge.           retention.                     ultrasound. Geriatric male patients often    without
                                                                                     have an enlarged prostate gland which        displaying
                                                                                     decreases force or urinary flow and/or       signs or
                                                                                     leading to tendency for bladder              symptoms of
                                                                                     retention.. [NCP pg 181]                     retention.

                                                      2. Use an indwelling Foley     2. Retention of urine in the bladder
                                                      or straight catheter and       predisposes the geriatric patient to UTI's
                                                      measure residual urine if      and may indicate the need for an
                                                      incomplete emptying is         intermittent catheterization program.
                                                      suspected.                     [NCP pg 181]

                                                      3. Monitor BUN and CR lab      3. Geriatric patients may have impaired
                                                      values.                        renal function. However, this will
                                                                                     differentiate between urinary retention
                                                                                     and urinary failure. [NCP pg 181]
PC   2. Patient will keep   1. Insert the indwelling          1. This prevents the catheter from           2. Yes. Foley
     the irrigation Foley   irrigation catheter as ordered;   dislodging or inadvertent displacement,      maintained a
     catheter in place,     secure catheter tube access       which may contribute to urinary              consistent flow
     secured, attached to   using a catheter tape and         retention. The bag acts as a reservoir to    and catheter
     the leg bag, and       Velcro retaining device and       hold urinary drainage. Kinks in the          was secured
     kept patient by        attach a leg bag to the           tubing may restrict proper drainage.         and draining
     discharge.             catheter system.                  [NCP pg 182]                                 properly.

                            2. Encourage intake of fluids     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]

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