HESI Case Study: Urinary Patterns

Dsyria: Refers to pain or burning with urination. Frequency: Refers to voiding at more frequent intervals than normal, but it does not specifically refer to voiding more often at night. (Answer) Nocturia: This specifically refers to voiding frequently at night. The incidence of nocturia increases greatly in the older male client who has an enlarged prostate. It may also indicate an inability to concentrate urine because of poor blood flow to the kidneys. Diuresis: This refers to increased urination as would occur when a client is taking diuretic medications, but it does not specifically refer to increased voiding during the night.

Polyuria: Refers to voiding large amounts of urine (Answer) Incontinence: 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. Retention: Refers to the inability to empty the bladder completely. Oliguria: Refers to decreased urinary output.

Restrict oral fluids to 1,000 mL daily in evenly divided amounts. Unless there is a medical necessity to restrict fluids, such as a condition causing fluid volume overload, the elderly client should try to drink 1,200 to 2,000 mL of fluid daily to maintain optimal renal function and prevent problems such as urinary tract infections. Offer warm coffee, cocoa, or tea every 2 hours while awake. Drinks containing caffeine, such as coffee, cocoa, and tea have a diuretic effect, increasing episodes of incontinence. Limit client socialization until voiding patterns are established. Socialization is important for the elderly client and should not be restricted because of incontinence. (Answer) Remind the client to void every 2 hours while awake and to call for assistance to the bathroom. 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 and 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.

- Risk for impaired skin integrity related to urinary incontinence. 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 a Braden Scale assessment should be completed on this client and that every effort should be made to prevent the development of pressure ulcers. - Ineffective coping related to inability to control urine leakage. Mr. Ellis' withdrawn behavior and statements of frustration are evidence that he may be having a difficult time dealing with his incontinence.

(Answer) "Washing the area with mild soap and water followed by ointment can help to protect my husband's skin." Mild soap and warm water should be used to cleanse the skin followed by a protective ointment. These water-repellent ointments help protect the skin from the acidic effects of urine.

- Clean and dry penis. - Apply skin protecting cream and allow it to dry - Wrap adhesive spirally around the shaft of the penis - Place the rolled condom over the glans penis and unroll it gently over the penis - Attach a large leg drainage bag to reduce the frequency of bag emptying while the client is ambulatory.

Gently insert and advance the catheter. Before the catheter is inserted, ask the client to try to void. If the catheter is difficult to insert, it may be because of an enlarged prostate. A smaller catheter or a urology consultation may be necessary in this case. (Answer) Wash perineal area with soap and water. The student nurse should first wash the entire perineal area with soap and water before applying antiseptic or lubricant. Assemble the catheter, lubricant, and drainage receptacle. This is done after the student nurse washes his or her hands, and washes the perineal area. Advance the catheter one more inch (2.5 cm). This step occurs after the urine starts to flow.

(Answer) Prostate gland enlargement. The prostate gland often begins to enlarge after a male client reaches the age of 40, making urethral catheterization more difficult if the gland compresses the urethra. Urethral stricture. Urethral stricture, or narrowing, does not occur as the result of the aging process. Stricture can be caused by trauma due to catheterization or as the result of sexually transmitted infections. Diminished bladder capacity. Diminished bladder capacity often occurs due to aging, but it does not affect catheter insertion. Weakened detrusor muscle. A weakened detrusor muscle may result in incomplete bladder emptying, but it does not affect catheter insertion.

Reassure the client that the pain he is experiencing is only temporary. Inserting a urinary catheter may cause some discomfort, but not pain. Corrective action is needed. Tape the catheter to the client's abdomen to prevent further movement of the Foley. The client's pain is not the result of catheter movement. Remove the catheter from the urethra immediately. There is something else that the student nurse can try first, before removing the catheter. (Answer) Deflate the balloon and insert the catheter farther. The catheter has not been inserted far enough, and the pressure of the inflated balloon in the urethra is painful. Since the student nurse 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.

No prostate gland enlargement noted during catheter insertion. The nurse should document that the catheter was inserted without difficulty, but prostate gland enlargement or normalcy cannot be assumed. (Answer) 16 French Foley catheter inserted with return of clear, yellow urine. 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. 5 mL balloon inflated in the urethra but client is now comfortable. This statement indicates that the balloon is still inflated in the urethra. Indwelling catheter inserted because the client is incontinent. This is not the most pertinent information to include when documenting this procedure.

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Client does not know what he is doing, and he has caused bleeding to occur in the urine due to pulling on the Foley catheter. This does not provide the most objective picture of the current situation. Surgery caused the client's confusion, resulting in his pulling on the catheter and hemorrhaging. This does not provide the most objective picture of the current situation. (Answer) Client is confused and pulls on the Foley catheter. Urine is pinkish-red with blood clots. This recording is concise but complete, providing objective data that describes the current situation. The client was instructed not to pull on his catheter, and now there is hematuria in the tubing. This does not provide the most objective picture of the current situation.

Palpate for bladder distention. This action should be completed, but it is not the best action to take first. Obtain the blood pressure. Vital sign measurement will provide useful information if the client's restlessness and lack of urine output are related to the onset of hypovolemic shock, but considering the available data, another assessment is more relevant to the client's immediate situation and should be performed first. Measure the oxygen saturation. Oxygen saturation measurement will provide useful information if the client's restlessness and lack of urine output are related to the onset of hypovolemic shock, but considering the available data, another assessment is more relevant to the client's immediate situation and should be performed first. (Answer) Evaluate the urinary drainage tubing. 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 an obstruction. The nurse should also note the presence of any observable blood clots, which can also obstruct urine flow. This simple, noninvasive measure could easily identify and immediately resolve the client's discomfort.

(Answer) Normal saline. An isotonic saline is a sterile normal solution that can be used for internal organ irrigations such as the bladder or stomach. Hydrogen peroxide. Hydrogen peroxide may be diluted and used as an external cleansing agent, but it is not used for urinary catheter irrigation. Heparinized saline solution. Heparin is an anticoagulant, which would likely increase the client's bleeding problem. Chlorhexidine antimicrobial solution. This effective antimicrobial solution is used externally to cleanse the skin, but it is not used for urinary catheter irrigation.

(Answer) Encourage the student nurse to continue, maintaining aseptic technique. The student nurse 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. Instruct the student to instill 30 mL of air, followed by 30 mL of solution. The student should avoid instilling air into the bladder. Advise the student to leave the distal clamp in place for 30 minutes before proceeding. There is no need to keep the distal clamp in place before proceeding with irrigation. The distal clamp should be released after the normal saline is instilled so that the catheter can drain. Remind the student to empty the drainage bag before instilling the solution. This is not a necessary step in this procedure.

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The client is confused. Confusion alone is not sufficient reason for the use of physical restraints. The client just had surgery and is at risk for falls. Postoperative status is not a sufficient reason for the use of physical restraints and there is no evidence that Mr. Ellis is at risk for falling at this time. (Answer) The client is at risk for self-injury. Risk of self-injury is a reasonable rationale for the use of physical restraints. However, all other safety measures should be attempted before physically restraining a client. There is no family member present to stay with the client. Lack of family presence is not sufficient reason for the use of physical restraints.

Skin integrity and pulse volume of the restrained extremities. 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 must be removed at least every 2 hours to allow for range of motion. Pulse rate and volume in the wrists. Assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints must be removed at least every 2 hours to allow for range of motion.

Remove the Foley catheter. The nurse should not remove the Foley catheter unless prescribed by the doctor. There is also no urgent or emergent indication for removing the catheter. Continue the catheter irrigations. If the catheter is draining well and there is no further hematuria, this action is not indicated. (Answer) Obtain a sterile urine specimen. Urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect an infection and identify microorganisms. Palpate the bladder for distention. There is no indication of further urinary retention.

Encourage the intake of high-protein foods. The lack of protein in the client's urine is normal. Offer additional high-carbohydrate snacks. The lack of glucose in the client's urine is normal. Reduce the client's water intake. The specific gravity of the client's urine is normal, with no indication of excessive water intake or altered fluid balance. (Answer) Provide a glass of cranberry juice daily. 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.

Serum creatinine and BUN are both elevated above normal. Creatinine relates to renal function, and BUN relates to renal function or hydration status. (Answer) Urine culture shows resistance to the prescribed antibiotic. 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. Partial thromboplastin time (PTT) is excessively prolonged. A prolonged PTT indicates a bleeding problem, which may have contributed to client's earlier hematuria. CBC shows low hemoglobin and hematocrit levels. Low hemoglobin and hematocrit may relate to the previous hematuria that the client experienced, but they do not substantially increase the client's risk for sepsis.

(Answer) Drug toxicity due to reduced drug excretion. 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. Decreased effectiveness due to poor absorption. An elevated creatinine level does not reflect a problem with any of the sites of medication absorption. Altered first-pass effect due to reduced liver function. An elevated creatinine level does not reflect a problem with the liver. Increased free drug molecules due to low albumin levels. An elevated creatinine level is not related to low albumin levels.

Bioavailability. Bioavailablity describes the rate and extent to which a drug enters the systemic circulation. Protein binding. Protein binding describes the reversible (binding and release can occur in milliseconds) interaction of drugs with proteins in plasma. Therapeutic index. Therapeutic index describes the ratio of a drug dose that produces an undesired effect to the dose that causes the desired effects. (Answer) Half-life. Half-life describes the length of time required to reduce a 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.

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Apply firm pressure to the bladder for 2 to 3 minutes. This may be painful to the client, and it is unlikely to stimulate the urge to void. (Answer) Turn on the tap so water is running when the client attempts to void. Running water often stimulates the urge to void, as does placing the client's hands in warm water Place the client's hands in a basin of ice cold water. This action is not useful to stimulate voiding. Place the client in a left lateral Sims' position. This semiprone, side-lying position is not useful to stimulate voiding.Sim's position is a position that is used when an RN is administering an enema or suppository to a client.

Is the capsule scored for ease of opening? Scoring allows a tablet to be safely divided in half. However, a capsule is not scored. Was Mr. Ellis able to swallow the capsules prior to his stroke? Since the dysphagia is a current problem, Mr. Ellis' ability to swallow capsules before the stroke is not pertinent. (Answer) Is the medication in extended-release form? An extended-release medication is formulated for gradual absorption in the body. Opening or crushing the medication will adversely affect this action. Does the medication come in unit dose packaging? Individual, or unit dose, packaging is not information that is needed to determine if a capsule can be opened and mixed with food.

Crush the capsule and mix the medication with applesauce. Crushing the capsule will leave large pieces of the capsule's outer coating, which would be difficult to swallow. (Answer) Open the capsule and mix the medication with pudding. Opening the capsule allows the client to receive the medication enclosed. Pudding is a safe consistency for most clients with dysphagia, who typically have more difficulty swallowing liquids than semi-soft foods. Dissolve the capsule in a glass of warm milk. The client with dysphagia typically has difficulty swallowing liquids. Open the capsule and mix in a glass of fruit juice. The client with dysphagia typically has difficulty swallowing liquids.

Leave Mr. Ellis alone until his crying subsides. Although providing privacy can be a caring intervention, the RN should first implement another action. Assign a UAP to sit with Mr. Ellis. The nurse should first respond to this situation before delegating the care of Mr. Ellis to a UAP. (Answer) Acknowledge to Mr. Ellis the distress that he is experiencing. Acknowledgment of a client's distress is a therapeutic and caring response. This should be the first action implemented by the nurse. Provide a distraction, such as turning on the television. Distraction may be useful, but this is not the best initial action by the nurse.

The room temperature seems excessively warm. Many elderly clients chill easily, but before changing the room temperature the nurse should determine if the client is too warm or feels chilled. A soap opera is playing loudly on the television. This may be at the request of the client, but whatever the case, it does not require the most immediate intervention. A second UAP is watching the television rather than helping. This is inefficient use of personnel, which requires intervention, but it is not the most immediate need. (Answer) Mr. Ellis' room door is open to the hallway. This is disrespectful, demeaning, and an invasion of the client's privacy. It should be corrected immediately.