Urinary Pattern - HESI Case Study PDF

Preview

Summary

HESI Case Study...

Description

Urinary Pattern Meet the Client: Hunter Ellis Hunter Ellis, a 76-year-old African American male, is a resident in a long-term care facility. He has been unable to control the urge to void since experiencing a stroke 1 month ago. He is alert and oriented and has no verbal deficits since his stroke.

Physiologic Integrity 1. Mr. Ellis states that prior to his stroke, he would get up five or six times during the night to empty his bladder but that he was able to control the urge long enough to make it to the bathroom. How should the nurse describe the urinary pattern that Mr. Ellis is describing? A. Dysuria B. Frequency C. Nocturia D. Diureses Rationale: This refers to frequently voiding at night. The incidence of nocturia increases greatly in the older male client who has an enlarged prostate, or who may possibly indicate an inability to concentrate urine because of poor blood flow to the kidneys. 2. Since Mr. Ellis now voids spontaneously without recognizing the need to void, how should the nurse document his current urinary pattern in the medical chart? A. Polyuria B. Incontinence C. Retention D. Oliguria Rationale: Incontinence is the involuntary loss of urine. In the case of this client, it may be the result of neurologic impairment secondary to the stroke. Safe and Effective Care Environment 3. To help manage Mr. Ellis' incontinence, the nurse initiates a bladder training program. Which instruction should the nurse provide to the unlicensed assistive personnel (UAP) who will be helping care for Mr. Ellis? A. Restrict oral fluids to 1,000 ml daily in evenly divided amounts. B. Offer warm coffee, cocoa, or tea every 2 hours while awake. C. Limit client socialization until voiding patterns are established. D. Remind the client to void every 2 hours while awake. Rationale: A toileting schedule is an effective means to retrain the bladder. Bladder training should start with voiding every 2 hours in the daytime and every 4 hours at

night then be adapted to the individual needs. the call bell should be near the client so that he can ring the bell for assistance to prevent the risk of falling. 4. After several weeks, the bladder training program is unsuccessful in stopping Mr. Ellis' incontinence. Mr. Ellis appears withdrawn and states that he is frustrated at the number of episodes that he is having.Which nursing diagnoses are appropriate for Mr. Ellis? A. Fluid volume deficit related to voiding patterns. B. Fluid volume excess related to altered urination. C. Risk for uremic syndrome related to unresolved incontinence. D. Risk for impaired skin integrity related to urinary incontinence. Ineffective coping related to inability to control urine leakage.

E.

Rationale: The skin of the client with urinary incontinence is frequently exposed to urine, which is irritating to the skin and places the client at risk for impaired skin integrity. The nurse understands that the Braden Scale assessment should be completed on this client and that every effort should be made to prevent the development of pressure ulcers. Rationale: Mr. Ellis’ withdrawn behavior and statements of frustration are evidence that he may be having a difficult time dealing with his incontinence. 6. Following an episode of incontinence, the nurse washes the client's perineal area with mild soap and water and applies a water-repellent ointment to the skin. Mr. Ellis' wife is present and the nurse uses this opportunity to educate her about proper skin care to prevent breakdown. Which of the following statements made by Mrs. Ellis indicates that teaching has been effective? a. "I should not apply lotions and ointments because it could increase the risk of skin breakdown" b. "Washing with mild soap and water followed by ointment can help to protect my husband's skin" c. "I should not use any type of soap on his buttocks or groin." d. "I should massage any reddened areas if I notice them." Rationale: Mild soap and warm water should be used to cleanse the skin followed by a protective ointment. These water-repellant ointments help protect the skin from the acidic effects of urine 7. The nursing staff continues with the bladder-training program, but Mr. Ellis' incontinence shows little improvement. Since the bladder training has not been successful, the nurse obtains a prescription to apply a condom catheter. Mr. Ellis is able to ambulate with assistance. In what order should the prescribed condom catheter be applied to Mr. Ellis? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.)

1. clean and dry penis 2. apply skin cream 3. wrap adhesive spiral 4. place the rolled condom 5. attach a large leg drainage bag Rationale: Right order Safety and Infection Control 7. Mr. Ellis is admitted to the acute care facility for minor surgery. His preoperative prescriptions include the insertion of an indwelling urinary catheter. A student nurse is assigned to care for Mr. Ellis. The nursing instructor asks the student nurse to prepare to insert the indwelling catheter under supervision. What is the first step in the proper placement of an indwelling urinary catheter for a male client? a. Assemble the catheter, lubricant, and drainage receptacle b. advance the catheter on more inch (2.5cm) c. Gently insert and advance the catheter d. Wash the perineal area with soap and water. Rationale: To prevent the introduction of bacteria into the bladder, the student nurse should first the entire perineal area with soap and water before applying antiseptic or lubricant. 8. The nurse reviews factors that may impact catheter insertion with the student nurse. Which physiologic change that commonly occurs in elderly males may affect insertion of the catheter? A. Prostate gland enlargement. B. Urethral stricture. C. Diminished bladder capacity. D. Weakened detrusor muscle. Rationale: The prostate gland often begins to enlarge after the age of 40, making urethral catheterization more difficult if the gland compresses the urethra. 9. The student obtains a 16 French Foley catheter from the supply room. The student nurse explains the procedure to Mr. Ellis, who gives permission to begin. After cleansing the urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4 inches. While inflating the balloon, Mr. Ellis cries out in obvious pain. What action should the student nurse take? A. Reassure the client that the pain he is experiencing is only temporary. B. Tape the catheter to the client's abdomen to prevent further movement.

C. Remove the catheter from the urethra immediately. D. Deflate the balloon, and insert the catheter farther. Rationale: The catheter has not been inserted far enough, and the pressure of the inflated balloon in the urethra is painful. Since the student has maintained aseptic technique, the balloon can be deflated and the catheter inserted farther. Typically, the catheter should be inserted 6 to 9 inches to ensure proper placement in the adult male. Documentation 10. The catheter is successfully placed in the bladder with a return of 200 mL of clear, yellow urine. The catheter is secured and Mr. Ellis is resting comfortably. In documenting the catheter insertion procedure, which statement should be included? A. No prostate gland enlargement noted during catheter insertion. B. 16 Foley catheter inserted with return of clear, yellow urine. C. 5 ml balloon inflated in the urethra but client is now comfortable. D. Indwelling catheter inserted because the client is incontinent. Rationale: This statement includes the best objective data, including the size of the catheter and the outcome of the procedure. In addition, the nurse should also document how the client tolerated the procedure and the client's condition following completion of the procedure. 11. Mr. Ellis returns from the Post Anesthesia Care Unit (PACU) after his surgical procedure. He has an IV of LR infusing at 125 mL/hr, O2 at 2 L/min per nasal cannula, and an indwelling catheter attached to a drainage bag. Four hours later, the nurse documents Mr. Ellis' intake/output. The LR solution has been running for 4 hours, and the nurse administers and IV antibiotic that runs in 150 mL of normal saline. Mr. Ellis is still NPO after the procedure. How does the nurse document Mr. Ellis' intake in mL? (Enter numerical value only. If rounding is necessary, round to the whole number?) 650 mL Rationale: 150 mL x 4 = 500 mL of LR. 500 mL + 150 mL (antibiotic) = 650 mL 12. Mr. Ellis is responsive but confused and frequently pulls on the urinary catheter. The nurse observes obvious hematuria in the drainage bag and notes the presence of several blood clots in the tubing. How should the nurse document this situation? A. Client does not know what he is doing, and he has caused bleeding to occur in the urine. B. Surgery caused client's confusion, resulting in pulling on the catheter and hemorrhage.

C. Client is confused and pulls on the foley catheter. Urine is pinkish-red with blood clots. D. The client was instructed not to pull on his catheter, and now there is hematuria in the tubing. Rationale: This recording is concise but complete, providing objective data that describes the current situation. Reduction of Risk Potential 13. Mr. Ellis' hematuria continues. Two hours later, he becomes restless and appears to be in pain. The nurse observes that there has been no urinary output during the last 2 hours. Which assessment should the nurse complete first? A. Palpate for bladder distention. B. Obtain the blood pressure. C. Measure the oxygen saturation. D. Evaluate urinary drainage tubing Rationale: The client has had no urine output in 2 hours, he has been experiencing blood clots in his urine, and he is in obvious discomfort. The nurse should first consider that the catheter tubing is obstructed and assess for kinks or pressure on the tubing that might cause the obstruction. The nurse should also not the presence of any observable blood clots, which can also obstruct the urine flow. This simple noninvasive measure could easily identify and immediately resolve the client's discomfort. 14. The nurse is unable to resolve the catheter obstruction using noninvasive measures and notifies the healthcare provider (HCP), who prescribes bladder irrigation to dislodge any blood clots obstructing the urine flow. The nurse anticipates that the prescription will include the use of which sterile solution to irrigate the catheter? A. Normal saline. B. Hydrogen peroxide. C. Heparinized saline solution. D. Chlorhexidine antimicrobial solution. Rationale: An isotonic saline is a sterile normal solution that can be used for internal organ irrigations such as the bladder or stomach 15. The RN encourages the student nurse to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing. What action should the nurse take? A. Encourage the student to continue, maintain aseptic technique. B. Instruct the student to instill 30 ml of air, followed by 30 ml of solution. C. Advise the student to leave the distal clamp in place for 30 minutes. D. Remind the student to empty the drainage bag before instilling the solution.

Rationale: The student is performing the procedure correctly. Irrigation may also be performed by opening the connection between the catheter and the drainage tubing, but opening that connection increases the risk of contamination. 16. The student nurse instills a total of 60 mL of the correct solution and withdraws 40 mL of fluid containing several small blood clots. The student nurse then empties 200 mL from the urinary drainage bag. What urinary output should be recorded? (Enter the numerical value only. If rounding is required, round to the whole number.) 180 mL Rationale: The student instilled 20 ml more than was withdrawn, so that amount must be subtracted from the volume emptied from the drainage bag. 200 mL-20 mL=180mL The nurse may instill the irrigant without withdrawing any fluid. In that circumstance the entire amount of the irrigant must be subtracted from the amount of fluid emptied from the drainage bag to obtain an accurate measurement of the client's output. Safe and Effective Care Environment 17. During the catheter irrigation, the nurse observes that Mr. Ellis is still confused and attempts to pull at his urinary catheter, his IV, and his nasal cannula. The nurse considers the use of wrist restraints on the basis of which rationale? A. The client is confused. B. The client just had surgery. C. The client is at risk for self-injury. D. There is no family member present to stay with the client. Rationale: Risk of self-injury is a reasonable rationale for the use of physical restraints. However, all other safety measure should be attempted before physically restraining a client. 18. The nurse notifies the HCP and obtains a prescription for wrist restraints. The nurse applies the restraints and plans to monitor the client every 30 minutes. Which assessments are most important for the nurse to perform at each of these times? A. Skin integrity and pulse volume of the restrained extremities B. Auscultation of bilateral breath sounds and heart sounds. C. Vital signs and oxygen saturation via pulse oximetry. D. The presence and integrity of all invasive tubes. Pulse rate and volume in the wrists

E.

Rationale: Wrist restraints can impede circulation, causing tissue damage under the restraint and distal to the restraint. Skin integrity and assessment of distal circulation

(including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints removed at least every 2 hours to allow for ROM. Rationale: Assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints removed at least every 2 hours to allow for range of motion. Physiologic Adaptation 19. Mr. Ellis' confusion decreases, and 12 hours later the nurse is able to remove the wrist restraints. By the third postoperative day, no further hematuria or blood clots are observed in Mr. Ellis' urine. However, the nurse does observe that the urine has developed a cloudy appearance. Which action should the nurse implement? 18. Which should the nurse implement? A. Assess the client's skin turgor. B. Continue the catheter irrigations. C. Obtain a sterile urine specimen. D. Palpate the bladder for distention. Rationale: Urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect and ID microorganisms. 20. Urinalysis results are: pH 8.5 Specific gravity 1.015 Protein none Glucose none WBCs 8 RBCs 2 Bacteria present Based on the urinalysis results, the HCP prescribes a broad-spectrum antibiotic. After 24 hours of receiving the antibiotic, Mr. Ellis’ condition has not improved. What additional nursing intervention will the nurse implement? A. Encourage the intake of high-protein foods. B. Offer additional high-carbohydrate snacks. C. Reduce the client's water intake. D. Provide a glass of cranberry juice daily. Rationale: The pH of the client's urine is elevated, indicating alkaline urine. Cranberry juice is believed to increase the acidity of urine, providing a less desirable environment for bacterial growth. 21. Which diagnostic test result would make the nurse concerned that the client is at risk for sepsis?

A. Serum creatinine and BUN are both elevated above normal. B. Urine culture shows resistance to the prescribed antibiotic. C. Partial thromboplastin time (PTT) is excessively prolonged. D. CBC shows low hemoglobin and hematocrit levels. Rationale: If the microorganisms causing the urinary tract infection are resistant to the prescribed antibiotic, the antibiotic is ineffective, and the client is at risk for sepsis, or generalized infection. Pharmacological and Parenteral 22. After reviewing Mr. Ellis' diagnostic test results, the nurse consults with the HCP and receives a prescription for a new antibiotic. Since Mr. Ellis' creatinine level is elevated, the nurse is concerned about which problem in administering the medication? A. Drug toxicity due to reduced drug excretion. B. Decreased effectiveness due to poor absorption. C. Altered first-pass effect due to reduced liver function. D. Increased free drug molecules due to low albumin levels. Rationale: An elevated creatinine level reflects a problem with the kidneys. If the kidneys are unable to excrete drug molecules efficiently, the drug will remain in the body for a prolonged period of time, which may result in drug toxicity. 23. The nurse notes that the medication dosage is in the safe range for elderly clients, which is to be administered by IV every 12 hours. The nurse recognizes that the frequency of drug administration is based on which characteristic of the medication? A. Bioavailability. B. Protein binding. C. Therapeutic index. D. Half-life. Rationale: Half-life describes the length of time required to reduce the drug level to one half of its initial value. Drugs with shorter half-lives will have to be given more frequently than those with longer half-lives Base Care and Comfort 24. Mr. Ellis' indwelling catheter is removed by the nurse on the morning of Mr. Ellis' anticipated discharge. The nurse instructs the UAP to report if Mr. Ellis has not voided within how many hours? (Enter numerical value only. If rounding is necessary, round to the whole number.) 8 hours Rationale: Generally, if the client has not voided within 6 to 8 hours of catheter removal, further action should be taken. That may include reinserting a catheter.

25. To encourage voiding, the RN instructs the UAP to perform what intervention? A. Apply firm pressure to the bladder for 2-3 minutes. B. Turn on the tap so water is running when the client attempts to void. C. Place the client's hands in a basin of ice cold water. D. Place the client in a left lateral Sim's position. Rationale: Running water often stimulates the urge to void, as does placing the client's hands in warm water. Pharmacological and Parenteral Therapies 26. Mr. Ellis voids after the catheter is removed and he is discharged from the acute care facility and transferred to the long-term care facility. Since he no longer has an IV, the prescription for his antibiotic is changed to an oral medication. Mr. Ellis has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help Mr. Ellis swallow the medication. Before deciding to open the capsule and mix it with food, what will the nurse need to determine? A. Is the capsule scored for ease of opening? B. Was Mr. Ellis able to swallow the capsules prior to his stroke? C. Is the medication in extended-release form? D. Does the medication come in unit dose packaging? Rationale: An extended-release medication if formulated for gradual absorption in the body. Opening or crushing the medication will adversely affect this action 27. The nurse consults with the pharmacist, who determines that the capsule can be opened and mixed with a food that the client likes. Which technique should the nurse use? A. Crush the capsule and mix with applesauce. B. Open the capsule and mix the medication with pudding. C. Dissolve the capsule in a glass of warm milk. D. Open the capsule and mix in a glass of fruit juice. Rationale: Opening the capsule allows the client who receive the medication enclosed. Pudding is safe consistency for most clients with dysphagia, who typically have more difficulty swallowing liquids than semi-soft foods Psychosocial Care 28. Mr. Ellis' incontinence continues. Use of the condom catheter is resumed until Mr. Ellis develops localized dermatitis. The condom catheter is removed temporarily to promote healing, and although the nursing staff takes Mr. Ellis to the bathroom every 2 hours, he occasionally wets his clothing. The nurse enters Mr. Ellis' room and finds him crying.

What is the best initial response by the nurse to this behavior? A. Leave Mr. Ellis alone until his crying subsides. B. Assign a UAP to sit with Mr. Ellis. C. Acknowledge to Mr. Ellis the distress that he is experiencing. D. Provide a...