here are my answers:
Assessment : i will do abdominal assessment, assess for bowel sounds for possible constipation and assess the bladder for possible urinary retention. Check vitals if stable or not. Why, because resident has history of diabetes, renal failure and chronic UTI.
Nursing Diagnosis: urinary retention and incontinence
Dx will be urinary retention secondary to renal failure and chronic UTI
Planning: monitor for urine output and also monitor for bowel movement
Implementation: if there is a bladder scan available, use bladder scan to see, measure and confirm the urinary retention, and or if decreased urine output or no voiding at all, call doctor ask for an order of in and out catheter or maybe indwelling catheter.
Why - to confirm the nursing diagnosis of urinary retention and to provide relief to resident from the retention and from abdominal pain.
Resident was evaluated for having urinary retention, so documentation will be about the abdominal assessment, bowel sounds, bladder condition , pain assessment, calling doctor for orders, if in and out was done then document and document how much urine output was drained and how did the resident tolerated procedure, how resident was feeling after the the catheterization and if the pain has been relieved and overall effect of the nursing measures done.
To all who have seen this post of mine, I did not mean anything here, I just dont want to create a bad impression and thank you for your comments and advices. I was just hoping for a good discussion, a support from a colleague, support from co nurses.
If i was wrong i do apologize now and in advance. Please if you have opinions and advices for this case study, I am very much open to it, I maybe wrong with my assessments so I am fine with some constructive criticism, this is just a healthy and friendly discussion.