hello im new here, hehe and i need help

EricJRN, MSN, RN · Sep 7, 2006

hello everybody, its my first time posting here in allnurses.com, i hope you guys can help me on my Nursing Care Analysis Record about a 62-yr old male who has Urinary Retention..
i just have a question that's bugging me.. The patient is on foley cath and one of the doctor's order was to check how many cc of urine there is every hour. the thing is, i do not get what's the relation of getting the cc of urine per hour to my patient's situation.. his tentative diagnosis is: Urinary retention secondary to urethral structure. there is no final diagnosis yet..
and could you give me suggestions of possible nursing diagnoses for this, hehe. thanks..
i hope u guys can help me, this is already due out tomorrow.. -_-'

Does your school use NANDA?

beatot · Sep 7, 2006

yea it does.. :)

Daytonite, BSN, RN · Sep 7, 2006

the patient has a urethral stricture which means there is blockage to the urine flowing out of the bladder. the relation between watching how many cc of urine per hour coming out of the bladder and your patient's situation is most important. can you see it now? the doctor is wanting to make sure that the patient is producing urine. look in your textbooks or physiology book for the normal amount of urine that the body should be producing hourly. the reasoning here is that depending on how long the patient has had this condition it is possible that the obstruction of urine over time (before the patient sought medical attention) has caused something called reflux where urine was forced back up into the kidneys causing possible kidney damage. where else was the urine to go? monitoring hourly urine output is one way the physician knows if the kidneys are working properly to produce urine. it also tells the physician if the patient is sufficiently hydrated.

any nursing diagnosis you decide to chose is going to be based on the symptoms your patient is having. there are only two possibilities based on the information you have included in your post:

urinary retention r/t urethral stricture aeb (the symptoms would include things like urinary residuals greater than 150ml, patient stating his bladder feels full, stopping and starting of urinary stream, dribbling of urine, patient feeling that bladder in not empty after voiding, urgency and frequency of voiding)
risk for infection r/t invasive procedure [the foley catheter]

one final note. in your post you mention "there is no final diagnosis yet.." i just want to point out that when you are working on a careplan, or nursing care analysis record, the physician's medical diagnosis of the patient's condition is important to nursing insofar as providing us with clues about the symptoms the patient is having as well as the possible tests and treatments that might be ordered that nursing will need to prepare the patient for. most of the nursing care we nurses provide has two components (1) the things we do for the patient by doctor's order, and (2) those things we do as independent nursing professionals that have nothing to do with what the doctor has ordered for the patient. the things we do for patients as independent nursing professionals are based on the symptoms and problems we nurses see in the patients with our "nursing eyes". we find these symptoms and problems during our own physical assessment of the patient and they are not necessarily related to the medical diagnosis.

beatot · Sep 7, 2006

hello sir, thank you for the advice, youv'e helped me that much, thanks again :)

i hope i can pull this off..

cebutops · Sep 12, 2006

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