Nursing Care Plan Help-Impaired Urinary Elimination

Esme12, ASN, BSN, RN · Oct 9, 2013

What semester are you? This patient with this extensive surgery has more issues than impaired urinary function.

Forget tht you have a care plan.....tell me the assessment of your patient. What do they say? Why was this procedure done? Are they in pain? What other risks are involved with this surgery? What about body image issues....what teaching does he need....tell me bout the patient not about what i=diagnosis he may need.

This XY year old patient was admitted with.....patient c/o.......and had xyz surgery on Blah Blah....patient is alert and oriented....color is ......lungs sounds.....blah blah.....SP tube noted draining....blah...and foley with...balh....patient complains of....blah....

Tell me about the patient.

Chiquitabonita1982 · Oct 9, 2013

I am a 2nd semester student.

He is a XY yr old male admitted with bladder cancer and a radical cystectomy, prostatectomy, and bilateral lymphadenctomy and ileal neobladder reconstruction. He has the placement of the following catheters, drains, and tubes. Subrapubic catheter, Foley catheter, urostomy pouch, NG tube at intermittent suction, Jackson Pratt Drain, peripheral IV line with NaCl 0.45%, continuous TPN (PPN since it is peripheral), and a spinal epidural with Dilaudid and Bupivacaine. He is alert and oriented and fairly knowledgeable about his condition and procedure. He appears tired and mildly annoyed (it was his 2nd day of having students also). He does not complain of pain except for mild incisional pain upon movement. He makes no comments as to the issue of appearance or presence of stoma. and is shocked that he has bladder cancer after no signs/symptoms of the cancer until a few weeks ago, and no family history of cancer. Vital signs normal, temperature normal, patient complains of being mildly chilled at intervals. He has Type II diabetes but is not being treated for it in the hospital despite his blood sugar being as high as 206. He has a history of hypertension, but is not receieving anti hypertensives in the hospital due to his blood pressures being either normal or low. Pt did have one episode of standing up and feeling faint. He has some labs that are off including low prealbumin,high chloride, low calcium, low RBC, low hematocrit, high neutrophils, low lymphocytes.

Is that helpful? I did write a second care plan that I may use as my primary one on Risk for Infection r/t surgical midline abdominal incision, presence of foley catheter, suprapubic catheter, urostomy, and JP drain.

I need to write 2 care plans, so other diagnoses that I am considering using are: Deficient knowledge r/t care of stoma, Ineffective Self Health management r/t new care of the urostomy and stoma, and self, and Body Image Disturbance r/t presence of stoma (however, I'm not sure if the last one would work because pt made no mention of feeling offended or disturbed by the stoma yet.

Esme12, ASN, BSN, RN · Oct 9, 2013

In this early stage...you could do pain. He does have an epidural....what are the possible issues with am epidural? What would you look for?

You could do deficient knowledge.......he clearly will need teaching on care of the stoma.....his avoidance in discussing it is telling me that he isn't ok with it.

He is at BIG risk for infection especially with all the invasive tubes.

He has an NGT.....how does this effect his nutrition? How does the nutrition effect his healing? What does the albumin indicate?

\

Most TPN has insulin in it.....with orders for coverage. Are they not checking his fingerstick glucose? How would an unstable glucose affect his healing?

Esme12, ASN, BSN, RN · Oct 9, 2013

My question is....do you really have Impaired Urinary Elimination?

Impaired Urinary Elimination is defined by NANDA as....Dysfunction in urine elimination.

Related to......Dysuria; frequency; hesitancy; incontinence; nocturia; retention, urgency

as evidenced by......Anatomic obstruction; multiple causality; sensory motor impairment; urinary tract infection

Is the surgery the impairment? or did the surgery resolve the impairment?

If it resolved it....is this still a patient problem?

your care plan is good but it is more for deficient knowledge related to the care of stoma from surgery.

Chiquitabonita1982 · Oct 10, 2013

Thank you so much for your replies! It definitely helped me out quite a bit. After I wrote the Impaired Urinary Elimination, I know that something was not quite right with it and it didn't really seem to be fitting with the definition. I have wrote 2 care plan (we have to write 2 for the assignment) now: Deficient Knowledge and Risk for Infection

Deficient knowledge

R/T: New diagnosis, new condition, recent procedure with new placement of urostomy pouch and stoma.

AEB: Inability to perform required self-cares with instruction.

Long Term Goal: Patient will demonstrate proper ability to care for the stoma by being free from infection.

Short Term Outcome: Patient will accurately verbalize how to care for the stoma prior to discharge from the hospital.

Diagnostic Label: Risk for Infection

R/T: Surgical midline abdominal incision, presence of Foley catheter, suprapubic catheter, urostomy, and JP drain.

AEB: (no defining characteristics because this is a risk diagnosis)

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[TD]Planning

Long Term Goal: Patient will remain free of infection as evidenced by normal temperature and vital signs, normal WBC count, and absence of purulent drainage from wound, drains, and tubes (catheter and IV).

Short Term Outcome: Patient will inform staff of any signs of fever, chills, pus, or drainage from the wound, drain, or catheter, or IV exit sites immediately after he notices any signs or symptoms.

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Do you think I am at least on the right track?

nurseprnRN, BSN, RN · Oct 10, 2013

Chiquitabonita1982 said:
Diagnostic Label: Risk for Infection
R/T: Surgical midline abdominal incision, presence of Foley catheter, suprapubic catheter, urostomy, and JP drain.
AEB: (no defining characteristics because this is a risk diagnosis)
[TABLE]
[TR]
[TD]Planning
Long Term Goal: Patient will remain free of infection as evidenced by normal temperature and vital signs, normal WBC count, and absence of purulent drainage from wound, drains, and tubes (catheter and IV).
Short Term Outcome: Patient will inform staff of any signs of fever, chills, pus, or drainage from the wound, drain, or catheter, or IV exit sites immediately after he notices any signs or symptoms.[/TD]
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Do you think I am at least on the right track?

Sort of. You have Goals under Planning, but there are no nursing actions. (Your patient informing you (or anyone) does not decrease his risk for infection. It can be a short term goal, though.)

I don't see anything in planning about what you plan to do to decrease his risk of infection yet. What's your plan?

Chiquitabonita1982 · Oct 10, 2013

That's how our sheet to follow from our instructors is set up. It says:

Planning:

Outcome

Long-term Goal:

Short Term Outcome:

So If I change the short term outcome to say that nursing staff will monitor for signs of fever, chills, pus, or drainage from the wound, drain, or catheter, or IV exit sites does that change it?

But then I'm not writing a short term outcome that the patient can meet right?

Chiquitabonita1982 · Oct 10, 2013

And to answer the questions about what I plan to do to decrease his chance of infection. Here is what I have listed under Interventions with the Evidence/Rationale

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[TR]

[TD]Interventions & Evidence:

(Independent)

1. Wash hands before contact with this patient and between procedures with this patient.

Evidence/Rationale: Warm soapy water when hands are visibly soiled or the use of hand sanitizing foam upon entering and leaving patients room, and washing hands between procedures reduces the risk of transmitting pathogens from one area of the body to another. Hand washing is the number one way to prevent infection from occurring.

(Potter and Perry, 2013)

(Education)

2. Teach patient the signs and symptoms including fever, chills, or pain as these may be a possible sign of infection.

Evidence/Rationale: Patient should be involved in his care and educated on the signs of infection proper treatment can begin.

(Gulanick & Myers).

(Assessment)

3. Monitor for signs of infection. Including monitoring temperature. Monitor for redness, swelling, increased pain, or purulent drainage at incisions, exit sites of tubes, drains, or catheters, and monitor the appearance of urine.

Evidence/Rationale: Temperature above 101.3 after POD #3 may indicate infection. Any suspicious drainage should be cultured and if positive antibiotic therapy is determined by pathogens identified at culture.

(Gulanick & Myers, 2007).

(Independent)

4. Maintain closed drainage systems of the all urinary catheters and drains to maintain adequate flow of urine and to prevent the accumulation of pathogens.

Evidence: Correct placement of the catheters and catheter bags allows for the correct downhill flow of urine.

(Lewis, 2011)

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nurseprnRN, BSN, RN · Oct 10, 2013

Chiquitabonita1982 said:
That's how our sheet to follow from our instructors is set up. It says:
Planning:
Outcome
Long-term Goal:
Short Term Outcome:
So If I change the short term outcome to say that nursing staff will monitor for signs of fever, chills, pus, or drainage from the wound, drain, or catheter, or IV exit sites does that change it?
But then I'm not writing a short term outcome that the patient can meet right?

Precisely. I think your instructor's format doesn't lend itself to thinking about the nursing process, but as my friend Esme often says, you have to do what your faculty wants. By definition, the words "outcome" and "goal" are the same thing in care planning, so I guess your short and longterm goals have to be patient goals, not nurse/nurse delegated goals. I just wish your faculty included a spot for what the nurse is supposed to do to accomplish the patient goals, is all.