Question

Patient Frank T. 62 y. old male had a knee replacement yesterday and still had a femoral nerve block. He is on bedrest until later this afternoon.During assessment at 12:00, nurse 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 8 hr overnight shift was 700 ml. When asking Frank how he is feeling, ge sais "I feel a lot of pressure, almost like I need to urinate " as he points to his lower abdomen.
1.WHAT IS RELEVANT DATA from present problem and what CLINICAL SIGNIFICANCE must be noticed by the nurse?

Additional Info:
Frank has a past medical history of arthritis and degenerative joint disease and takes aspirin daily . He did not receive contrast during hospitalization. By performing a focused assessment the nurse note that thereis increased pain and tenderness with gentle palpitation over the symphasis pubis and abdomen is firm to touch.
T: 98.5 oral
P: 80
R: 16
BP: 118/74
O2: 95% room air
LABS: TODAY YESTERDAY
WBC: 9.8. 8.5
HGB: 13.5. 12.9
PLTs: 185 175
% Neuts: 75 68
Bands: 0 0
Na: 142 144
K: 3.9 3.8
Gluc:
115 108
BUN: 10 9
Creat: 0.95 9.89

2. From these additional info what is RELEVANT DATA and CLINICAL SIGNIFICANCE?

3. From clinical data colected, what problems are possible and which problem is priority? Rationale?
4. What nursing priority will guide nursing intervention and what's expected outcome?
5. If the selected nursing intervention was effective, what will be the assessment data collected that will validate that the problem has been resolved?

p.s This study is Urinary Retention

have someone else who know look at it

Answer 1

1.The relevant data noted by the nurse should be lack of adequate urine output(700 ml) and the description of the symptoms presented by the patient,that is the feeling of pressure in the abdomen and the urge to urinate.

Clinical significance:Acute urinary retention can be defined as a new onset inability to pass urine, which then leads to pain and discomfort, with significant residual volumes.This condition is most prevalent during immobility,with a medical condition such as BPH, surgeries or a person who is experiencing the side effects of medications, including anesthetic agents, antihypertensives, antispasmodics, antihistamines, and anticholinergics etc.

2.The relevant data to be noted from the additional investigation is the elevated creatinine level in blood.It was reported to be 0.95 today and 9.89 the previous day.The hematology as well as electrolyte levels were found to be in the normal range.

Clinical significance:Creatinine is a waste product that is produced by the muscle and is typically removed through the kidneys. Healthy kidneys filter creatinine out of your blood, and it leaves the body through urine.Hence,in the case of urinary retention,creatinine levels may rise.

Normal levels of creatinine in the blood are approximately 0.6 to 1.2 milligrams (mg) per deciliter (dL) in adult males

3.The clinical data indicates a previous diagnosis of arthritis and degenerative joint disease for which the patient was taking aspirin.The present symptoms as well as laboratory value of creatinine is indicative of acute urinary retention,which must be given priority right now.

Rationale:This condition,if neglected can increase the pressure within the affect urinary tract and affect the kidneys, which in turn can lead to high blood pressure, leg swelling, and further kidney damage.Moreover,the patient had complaints of discomfort associated with the condition,which must be taken care of by the nurse.

4.The nursing priority would be to ensure that:

• Patient empties bladder completely.
• Patient voids in sufficient quantity with no palpable bladder distension.
• Patient has adequate urine volume and normal creatinine levels.

Expected outcomes:

• Complete and regular elimination of urine from the bladder
• Correction or relief from obstructive symptoms like pain and feeling of pressure in abdomen
• Normalisation of lab values
• Reducing the risk of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)

5.Assesment data:

• Information from the patient or caretaker, regarding the character and duration urine output,symptom relief etc.
• A focused physical assessment or review of the results of a recent physical examination including perineal skin integrity; neurological examination, inspection, percussion, and palpation of the lower abdomen for obvious bladder distension; look for laboratory values like creatinine and BUN.
• A catheter log, including patterns of urine elimination, patterns of urine loss (if present), nocturia, and volume and type of fluids consumed for a period of 3 to 7 days.
• Physician reports, concerning eliminating or altering medications suspected of producing or exacerbating urinary retention.