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Urinary Case Study

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  1. 1. Meet the Client: Clyde Hunter Clyde Hunter, a 72-year-old African-American male, is a resident of a long-term care facility. He has been unable to control the urge to void since experiencing a stroke, formerly called cerebrovascular accident (CVA), 1 month ago. The term brain attack is also used to describe a stroke. Instructions: While taking this case study, all questions must be answered correctly before you will be able to proceed to the next page. For all incorrect answers, select a new response and click the Next button. When all questions have been answered correctly, clicking the Next button will display the next page. • Urinary Patterns Prior to his stroke, Clyde often awakened 5 or 6 times during the night to void but was able to control the urge long enough to make it to the bathroom. • 1. How should the nurse describe the pre-stroke urinary pattern? • Dysuria. This refers to pain or burning with urination. • Frequency. This refers to voiding at more frequent intervals than normal, but it does not specifically refer to voiding during the night. • Nocturia. Correct This refers to voiding frequently at night. The incidence of nocturia increases greatly in the older adult. • Diuresis. This refers to increased urination as would occur when a client is taking diuretic medications, but it does not specifically refer to voiding during the night. • 2. Since Clyde now voids spontaneously without recognizing the need to void, how should the nurse describe his current urinary pattern? • Polyuria. This refers to voiding large amounts of urine.
  2. 2. • Incontinence. Correct 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. This refers to the inability to empty the bladder completely. • Oliguria. This refers to decreased urinary output. • Care of the Incontinent Client The nurse initiates a bladder training program for Clyde. • 3. Which instruction should the nurse provide the unlicensed assistive personnel (UAP) who will be helping care for Clyde? • 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 and contributing to the risk for fluid volume deficit. • Limit client socialization until voiding patterns are established. Socialization is important for the elderly and should not be restricted for a problem that may or may not be correctable. • Remind the client to void every 2 hours while awake. Correct 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 bladder-training program proves unsuccessful, and Clyde's incontinence continues. • 4. When establishing Clyde's plan of care, the nurse includes which nursing diagnosis?
  3. 3. • Fluid volume deficit related to voiding patterns. The incontinent client does not void excessive amounts of urine and will not exhibit fluid volume deficit simply due to the incontinence. The incontinent client may, however, be at risk for fluid volume deficit if caregivers do not ensure adequate fluid intake. • Fluid volume excess related to altered urination. The incontinent client voids normal amounts of urine and will not exhibit fluid volume excess unless another problem exists that reduces the amount of urine voided. • Risk for uremic syndrome related to unresolved incontinence. Uremic syndrome is related to kidney failure and is not a urinary diagnosis. Urinary incontinence does not cause kidney failure. • Risk for impaired skin integrity related to urinary incontinence. Correct 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. • Following an incontinent episode, the nurse observes that the UAP washes the client's perineal area with mild soap and water and applies a water-repellant ointment to the skin exposed to urine. • 5. What action should the nurse implement? • Commend the UAP for the good care being provided to the client. • Advise the UAP to avoid the use of any soap around the perineal area. • Instruct the UAP that the application of lotions and ointments increases the risk of skin breakdown. • Suggest that the UAP continue with the current actions and also massage any reddened areas. Incorrect Massaging reddened areas causes damage to the capillary beds, increasing the risk for skin breakdown. • The nursing staff continues with the bladder-training program, but Clyde's incontinence shows little improvement. Since the bladder training has not been successful, the nurse obtains a prescription to apply a condom catheter. Clyde is ambulatory with assistance. • 6. Which technique(s) should be included when applying the condom catheter? (Select all that apply.) • Clean and dry the penis before applying the condom catheter. Correct Cleaning and drying the penis will help prevent skin irritation and skin breakdown.
  4. 4. • Secure the condom with adhesive tape to prevent dislodgement while ambulatory. Adhesive tape will not expand with penis size, so it could potentially act as a tourniquet. • Ensure that the condom fits snugly over the tip of the glans penis. One to two inches of space should be allowed between the tip of the glans penis and the the end of the condom. • Return the foreskin to its normal position after applying skin prep to the penis shaft. Correct After providing perineal care and applying the skin prep provided with the condom catheter, the nurse should return the foreskin to its normal position (if the client is uncircumcised) before smoothly rolling the condom sheath onto the penis. • Attach a large leg drainage bag to reduce the frequency of bag emptying while ambulatory. A full, large drainage bag will place excessive tension on the condom and may pull the catheter off. Large drainage bags may be used at night. • Insertion of an Indwelling Urinary Catheter Clyde is admitted to the acute care facility for minor surgery. His preoperative prescriptions include insertion of an indwelling urinary catheter. A student nurse assigned to care for him obtains a catheter insertion tray that includes a 22 Foley catheter with a 5 ml balloon. Since the student's instructor is busy, the staff nurse preceptor will supervise the student. • 7. What action should the nurse take? • Suggest the use of a smaller diameter catheter. Correct A size 16 or 18 Foley catheter is the size typically inserted in adult males. The catheter diameter size increases with increasing numbers, so a size 22 is a larger size diameter than is typically necessary for the adult male. • Recommend the use of a straight rubber catheter. A straight catheter does not have an inflatable balloon, which is needed to maintain placement of the catheter in the bladder for long-term use. A straight catheter is used for intermittent catheterization. • Advise the student to use a larger balloon. A 5 ml balloon is generally sufficient to ensure that the catheter will not slip out of the bladder. • Affirm that the student has the correct equipment.
  5. 5. The student has not selected the best equipment for this client. • The nurse reviews factors that may impact catheter insertion with the student. • 8. Which physiologic change that commonly occurs in elderly males may affect insertion of the catheter? • Prostate gland enlargement. Correct The prostate gland often begins to enlarge after 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 diseases (STDs). • 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. • Documentation The catheter is successfully placed in the bladder with a return of 200 ml of clear, yellow urine. The catheter is secured, and Clyde is resting comfortably. • 10. In documenting the catheter insertion procedure, which statement should be included? • 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. • 16 Foley catheter inserted with return of clear, yellow urine. Correct 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.
  6. 6. 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. • Clyde returns from the Post Anesthesia Care Unit (PACU). He has an IV of LR infusing at 150 ml/hr, O2 at 2 L/min per nasal prongs, and the indwelling catheter attached to a drainage bag. Clyde 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. • 11. Which recording objectively documents this situation? • Client does not know what he is doing, and he has caused bleeding to occur in the urine. This does not provide the most objective picture of the current situation. • Surgery caused client's confusion, resulting in pulling on the catheter and hemorrhage. This does not provide the most objective picture of the current situation. • Client is confused and pulls on the foley catheter. Urine is pinkish-red with blood clots. Correct 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. Page 6 1. Catheter Obstruction Clyde's 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. 2. 12. What assessment should the nurse complete first? o Palpate for bladder distention. This action should be completed, but it is not the best action to take first.
  7. 7. o 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. o 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. o Observe the urinary drainage tubing. Correct 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. 3. The nurse is unable to resolve the catheter obstruction using noninvasive measures and notifies the healthcare provider, who prescribes bladder irrigation to dislodge any blood clots obstructing the urine flow. 4. 13. The nurse anticipates that the prescription will include the use of which sterile solution to irrigate the catheter? o Normal saline. Correct An isotonic saline is a sterile normal solution that can be used for internal organ irrigations such as the bladder or stomach. o Hydrogen peroxide. Hydrogen peroxide may be diluted and used as an external cleansing agent, but it is not used for urinary catheter irrigation. o Heparinized saline solution. Heparin is an anticoagulant, which would likely increase the client's bleeding problem. o Chlorhexidine antimicrobial solution. This effective antimicrobial solution is used externally to cleanse the skin, but it is not used for urinary catheter irrigation.
  8. 8. 5. The nurse encourages the nursing student 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. 6. 14. What action should the nurse take? Encourage the student to continue, maintaining aseptic technique. Correct o 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. Instruct the student to instill 30 ml of air, followed by 30 ml of solution. o The student should avoid instilling air into the bladder. Advise the student to leave the distal clamp in place for 30 minutes. o The distal clamp should be released after the NS is instilled so the catheter can drain. Remind the student to empty the drainage bag before instilling the solution. o This is not a necessary step in this procedure. 7. The student instills a total of 60 ml of the correct solution and withdraws 40 ml of fluid containing several small blood clots. The student then empties 200 ml from the urinary drainage bag. 8. 15. What output should be recorded? (Enter the numerical value only. If rounding is required, round to the whole number.) Correct Correct Responses 1. 180 Congratulations! You have mastered this section. You may now proceed to the next page. Page 7 1. Legal Considerations: Use of Restraints During the catheter irrigation, the nurse observes that Clyde is still confused and attempts to pull at his catheter, his IV, and his nasal cannula.
  9. 9. 2. 16. The nurse considers the use of wrist restraints, based on which rationale? o The client is confused. Confusion alone is not sufficient reason for the use of physical restraints. o The client just had surgery. Postoperative status is not sufficient reason for the use of physical restraints. o The client is at risk for self-injury. Correct 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. o 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. 3. After obtaining a prescription for wrist restraints, the nurse applies the restraints and plans to monitor the client every 30 minutes. 4. 17. Which assessment is most important for the nurse to perform at each of these times? o Skin integrity and pulse volume of the restrained extremities. Correct 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. o Auscultation of bilateral breath sounds and heart sounds. The nurse will continue to perform this assessment if previously determined by the client's condition, but performing this assessment every 30 minutes based on the application of wrist restraints is not necessary. o Vital signs and oxygen saturation via pulse oximetry. The nurse will continue to perform this assessment if previously determined by the client's condition, but performing this assessment every 30 minutes based on the application of wrist restraints is not necessary. o The presence and integrity of all invasive tubes.
  10. 10. The nurse will continue to perform this assessment as previously determined by the client's condition, but performing this assessment every 30 minutes based on the application Which action should the nurse implement? • Assess the client's skin turgor. This action should be taken if the nurse suspects a change in fluid volume. However, that would be suggested by a change in the color of the urine, rather than a cloudy appearance. • Continue the catheter irrigations. If the catheter is draining well and there is no further hematuria, this action is not indicated. • Obtain a sterile urine specimen. Correct Urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect and identify microorganisms. • Palpate the bladder for distention. There is no indication of further urinary retention. Page 9 1. After 24 hours of receiving the antibiotic, Clyde's condition has not improved. 2. Urinalysis results are: o pH 8.5 o Specific gravity 1.015 o Protein none o Glucose none o WBCs 8 o RBCs 2 o Bacteria present Based on the urinalysis results, the healthcare provider prescribes a broad-spectrum antibiotic. 3. 19. What additional nursing intervention will the nurse implement? o Encourage the intake of high-protein foods. The lack of protein in the client's urine is normal. o Offer additional high-carbohydrate snacks.
  11. 11. The lack of glucose in the client's urine is normal. o 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. o Provide a glass of cranberry juice daily. Correct 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. 4. 20. Which diagnostic test result identifies the client as being at risk for sepsis? o Serum creatinine and BUN are both elevated above normal. Creatinine relates to renal function, and BUN relates to renal function or hydration status. o Urine culture shows resistance to the prescribed antibiotic. Correct 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. o Partial thromboplastin time (PTT) is excessively prolonged. A prolonged PTT indicates a bleeding problem, which may have contributed to client's earlier hematuria. o 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 in Page 10 1. Pharmacodynamics After reviewing Clyde's diagnostic test results, the nurse consults with the healthcare provider and receives a prescription for a new antibiotic. 2. 21.
  12. 12. Since Clyde's creatinine level is elevated, the nurse is concerned about which problem in administering the medication? o Drug toxicity due to reduced drug excretion. Correct 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. o Decreased effectiveness due to poor absorption. An elevated creatinine level does not reflect a problem with any of the sites of medication absorption. o Altered first-pass effect due to reduced liver function. An elevated creatinine level does not reflect a problem with the liver. o Increased free drug molecules due to low albumin levels. An elevated creatinine level is not related to low albumin levels. 3. The nurse notes that the medication dosage is in the safe range for elderly clients. The medication is to be administered by IV every 12 hours. 4. 22. The nurse recognizes that the frequency of drug administration is based on which characteristic of the medication? o Bioavailability. Bioavailablity describes the rate and extent to which a drug enters the systemic circulation. o Protein binding. Protein binding describes the reversible (binding and release can occur in milliseconds) interaction of drugs with proteins in plasma. o Therapeutic index. Therapeutic index describes the ratio of a drug dose that produces an undesired effect to the dose that causes the desired effects. o Half-life. Correct 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 frequ
  13. 13. Page 11 1. Urinary Retention Clyde's indwelling catheter is removed by the nurse on the morning of Clyde's anticipated discharge. 2. 23. The nurse instructs the UAP to report if Clyde has not voided within what time period? o 2 hours. More time is generally allowed before further action is required. o 4 hours. More time is generally allowed before further action is required. o 8 hours. Correct 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. o 12 hours. This length of time is too long to wait before taking action. Page 12 1. 24. To encourage voiding, the nurse instructs the UAP to perform what intervention? o 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. o Turn on the tap so water is running when the client attempts to void. Correct Running water often stimulates the urge to void, as does placing the client’s hands in warm water. o Place the client's hands in a basin of ice cold water. This action is not useful to stimulate voiding.
  14. 14. o Place the client in a left lateral Sims' position. This semiprone, side-lying position is not useful to stimulate vo • Medication Administration: Dysphagia Clyde is discharged from the acute care facility and is 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. Clyde has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help Clyde swallow the medication. • 25. Before deciding to open the capsule and mix it with food, what will the nurse need to determine? • 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 Clyde able to swallow the capsules prior to his stroke? Since the dysphagia is a current problem, Clyde's ability to swallow capsules pre-stroke is not pertinent. • Is the medication in extended-release form? Correct 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. • The nurse determines that the capsule can be opened and mixed with a food that the client likes. • 26. Which technique will the nurse use? • Crush the capsule and mix with applesauce. Crushing the capsule will leave large pieces of the capsule’s outer coating, which would be difficult to swallow. • Open the capsule and mix the medication with pudding. Correct 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.
  15. 15. • 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 li Page 14 1. Psychosocial Care Clyde's incontinence continues. Use of the condom catheter is resumed until Clyde develops localized dermatitis. The condom catheter is removed temporarily to promote healing, and although the nursing staff takes Clyde to the bathroom every 2 hours, he occasionally wets his clothing. The nurse enters Clyde's room and finds him crying. 2. 27. What is the best initial response by the nurse to this behavior? o Leave Clyde alone until his crying subsides. Although providing privacy can be a caring intervention, the nurse should first implement another action. o Assign a UAP to sit with Clyde. The nurse should first respond to this situation before delegating his care to a UAP. o Acknowledge to Clyde the distress that he is experiencing. Correct Acknowledgment of a client's distress is a therapeutic and caring response. This should be the first action implemented by the nurse. o Provide a distraction, such as turning on the television. Distraction may be useful, but this is not the best initial action by the nurse. 3. When Clyde is calm, the nurse assigns the UAP to help him into dry clothing. Several minutes later, the nurse walks down the hall and sees the UAP in the room changing Clyde's clothes. The nurse enters the room and assesses the situation. 4. 28. Which aspect of the situation requires the nurse's most immediate intervention?
  16. 16. o 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. o 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. o 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. o Clyde's room door is open to the hallway. Correct This is disrespectful, demeaning, and an invasion of the client's privacy. It should be corrected immediately. The nurse closes the door, reassures Clyde, and tells the UAPs that she would like to talk with both of them after Clyde's care is completed.