In: Nursing
Randy Thiessen is a 74-year-old resident in Shady Pines Long-Term Care Facility. Randy has a hx of BPH and frequent episodes of urinary retention. In the past, his physician has recommended intermittent catheterization, but due to the increasing number of episodes with little time in between, the physician has ordered an indwelling foley catheter.
Randy has a hx of rheumatoid arthritis and is now quite dependent on others for his personal care.
For this case scenario, add data to support the need for an indwelling foley catheter.
The charting due for this case scenario is your nursing notes recording your assessments, the insertion of the catheter, and a follow up assessment 2 hours after insertion. There are no orders for intake and output.
You are working an 8-hour day shift. The order for the catheter was received at 1100.
NURSING ASSESMENT
1)DECREASED URINARY OUTPUT RELATED TO URINARY RETENTION SECONDRY TO BPH
2)DECREASED PHYSICAL ACTIVITY SECONDRY TO RHEUMATOID ARTHRITIS
3)SELF CARE DEFECIT SECONDRY TO DECREASED PHYSICAL ACTIVITY
4)RISK FOR URINARY TRACT AND ASCENDING INFFECTION SECONDRY TO URINARY RETENTION
5)RISK FOR UTI RELATED TO INTERMITTENT CATHETERISATION
11am
ASSESING THE ABOVE NURSING PROBLEMS AN INDWELLING FOLYS CATHETER WAS INSERTED UNDER STERILE TECHNIQUE
1PM
CLEAR URINE DRAINED .NO SIGNS OF HAEMMORHAGE OR CLOTS