Urinary Retention
NextGen SKINNY Reasoning
Frank Thomas, 62 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
Clinical judgment
NCLEX Client Need Categories
Safe and Effective Care Environment
Management of Care
Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
Covered in
Case Study
NCSBN Clinical
Judgment Model
Covered in
Case Study
Step 1: Recognize Cues
Step 2: Analyze Cues
Step 3: Prioritize Hypotheses
Step 4: Generate Solutions
Step 5: Take Action
Step 6: Evaluate Outcomes
Basic Care and Comfort
Pharmacological and Parenteral
Therapies
Reduction of Risk Potential
Physiological Adaptation
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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
Present Problem:
You are the nurse responsible for the care of Frank Thomas, a 62-year-old male patient who had a knee
replacement yesterday and still has a femoral nerve block in place. He remains on bedrest until later this
afternoon. During your 1200 assessment, you notice that the urinary catheter bag has a small amount of urine in
the tubing and no urine in the collection bag. His urine output for the eight-hour overnight shift was 700 mL.
When you ask Frank how he is feeling, he replies,
as he
points to his lower abdomen.
1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem:
•
There is
no
presents
retention
•
at
in the
problem
•
urinary
•
700mL
unable
which
bag
.
the
urine
+
is
prior shift which
patient feels pressure
us
with
no
1200 hours there was
was
•
a
urine
Clinical Significance:
to urinate
to
urinate
there
normal
but
•
.
urinary retention
post surgery
Patient
to
had
can
can
cause
a nerve
tract
infections (UTI)
urinary retention
"
block creates numbness
"
pain after surgery
of urinary retention
treat
cause
urinary
cause
•
this could
be
a
.
.
Additional Information:
Frank has a past medical history of arthritis and degenerative joint disease and takes aspirin daily. He did not
receive contrast media during this hospitalization. You perform a focused assessment and note that there is
increased pain and tenderness with gentle palpation over the symphasis pubis (low/mid abd) and the abdomen is
firm to touch.
✓
✓
✓
✓
✓
Current VS:
T: 98.5 F/36.9 C (oral)
P: 80 (regular)
R: 16 (regular)
BP: 118/74
O2 sat: 95% room air (RA)
P-Q-R-S-T Pain Assessment:
Provoking/Palliative:
Denies
Quality:
Region/Radiation:
Severity:
Timing:
Lab Results:
Today:
Yesterday:
Today:
Yesterday:
WBC
9.8 v
8.5 ✓
Na
142
144
I
Complete Blood Count (CBC)
HGB
PLTs
13.5
185 ✓
y
12.9
175 ✓
Basic Metabolic Panel (BMP)
K
Gluc.
3.9 ✓
115 3.8 ✓
108 ✓
% Neuts
75
68
Bands
0
0
BUN
10
9
Creat.
0.95
0.89
I
I
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
2. What data from the additional information is RELEVANT and must be NOTICED as clinically significant by the
nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Additional Info:
•
Clinical Significance:
concerns would be :
•
•
•
over the
are
the nurse
should be
Stomach
&
palpating the
find firm distended
stomach to
.
abdomen firm to touch
all lab values
•
tenderness
pain
symphysis pubis
increased
+
,
tender
touch
to
.
.
within
range
•
always check
urinary output especially post op
the nurse should
.
3. Interpreting clinical data collected, what problems are possible? Which problem is priority? Why?
(NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)
Problems:
•
urinary retention
pairs
•
•
Priority Problem:
possible
Rationale:
urinary retention
would be the
risk for UTI
priority
.
urinary retention is fixed the pain
will subside as well as UTI risks eliminated
patient can
If not treated bladder can become stretched
•
once
.
&
•
be at risk
for bladder then possibly kedhey infection
.
4. What nursing priority will guide how the nurse RESPONDS to formulate a plan of care?
(NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)
Urinary Retention
Nursing PRIORITY:
Nursing Interventions:
•
drain
urine
with catheter
have
to
pain risk for UTI
patient do Regal exercises to
receive acute
•
Expected Outcome:
&
restore muscle contractions in
bladder
•
•
have
hot
patient
pack
on
suprapubic
ambutace to
increase
once urine
exercises
.
•
the nerve
is
to
drained
strengthen
block
could be
we can
start
area so
a
patient
patient
on
can
factor in retention
kegae
urinate
&
this
on own
.
can
provide relief
draining the pain will subside
last up to 16 hours so by draining urine it can
•
.
use a
•
area
once
after
pressure from bladder stops
after alleviating urinary retention the paint firm abdomen along
output with possible UTI risk will be eliminated
urine
•
.
5. If the nursing intervention(s) you selected was effective, what will be the assessment data collected that will validate
that the problem has been successfully resolved? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)
PRIORITY
Expected Assessment Data if Successfully Resolved:
Intervention(s):
•
•
catheter plated to
drain urine
16gal exercises taught
method
using teach
•
back
•
no
•
no
•
.
firm abdomen
pain
risk
for
UTI
eliminated
.
ambulate to encourage
urinary output
.
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
.