NURSING NOTE
Patient: Jane Doe
Age: 60 years
Gender: Female
Medical Diagnosis: Unstable bladder with urinary retention
History:
Jane Doe, a 60-year-old female, has a history of unstable bladder with urinary retention. She was recently admitted to the medical-surgical unit with complaints of urinary frequency and urgency. On physical examination, distended bladder was palpable, and urinalysis revealed significant post-void residual (PVR) urine volume. The patient was diagnosed with urinary retention, and a urinary catheter was inserted to relieve the urinary obstruction.
Assessment:
On initial assessment, vital signs were stable with temperature of 98.6°F, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, and blood pressure of 120/80 mmHg. The patient was conscious, oriented, and reported mild discomfort in the suprapubic area. The urinary catheter was intact, with no signs of leakage or dislodgment. The catheter was connected to a drainage bag, which was hanging below the level of the bladder. The urine in the drainage bag was clear in color and had a normal odor. The patient reported no pain or burning sensation during urination.
Nursing Interventions:
1. Assess and document the volume, color, and consistency of urine output every 2 hours. Notify the healthcare provider if there is any significant change in urine output or appearance.
2. Ensure that the urinary catheter is secured in place and check for any signs of irritation or pressure ulcers. Reposition the catheter if it is causing discomfort to the patient.
3. Maintain a closed urinary catheter system to prevent the risk of infection. Ensure that the drainage bag is securely connected to the catheter and not touching the floor.
4. Encourage the patient to maintain oral fluid intake of at least 2 liters per day, unless contraindicated. Adequate hydration helps prevent urinary tract infections and promotes normal urine production.
5. Perform perineal care at least twice a day and after each bowel movement to maintain cleanliness and prevent urinary tract infections. Use a mild soap and warm water to cleanse the genital area, and pat dry gently.
6. Monitor the patient for signs of urinary tract infection, such as fever, chills, cloudy urine, or foul odor. Notify the healthcare provider if any of these symptoms occur.
7. Encourage the patient to practice bladder training exercises, including Kegel exercises, to help strengthen the pelvic floor muscles and improve bladder control.
8. Provide education to the patient and family about the importance of maintaining good hygiene, avoiding unnecessary manipulation of the catheter, and promptly reporting any signs of infection or catheter-related complications.
9. Collaborate with the healthcare provider to develop a plan for catheter removal and follow-up care. Monitor the patient’s bladder function and urine output after catheter removal.
10. Document all assessments, interventions, and patient responses in the medical record. Maintain accurate and up-to-date records to ensure continuity of care and promote effective communication among the healthcare team.
Documentation:
Date/Time: ___________
Assessment findings: Clear urine output with no signs of infection or catheter-related complications. Catheter secure and patent. Patient reports mild discomfort in the suprapubic area.
Interventions provided: Performed perineal care, ensured proper catheter position, encouraged fluid intake, and educated patient and family about catheter care.
Patient response: No significant changes or complaints reported. Patient cooperative and understanding of recommended care.
