koz74686_ch48.

qxd

11/8/06

5:59 PM

Page 1318

1318 UNIT X / Promoting Physiologic Health

Urinary Elimination

CONCEPT MAP

JB
68 y.o. male
BPH

Shopkeeper, c/o urinary

frequency 2 weeks,
nocturia 23 X/night,
difficulty starting stream,
dribbles, c/o not feeling
like bladder is emptied

assess

Height: 185.4 cm (6' 2")

Weight: 85.7 kg (189 lb)
Temperature: 38.1C (100.6F)
Pulse: 88
Respirations: 20/min
BP: 146/86

Catheterization for residual:

300mL amber urine
Foley left in place for 2 days
CBC normal; UA: amber, clear,
ph 6.5, SpGr 1.025, negative for
glucose, protein, ketones, RBCs,
and bacteria; IVP: enlarged
prostate gland

generate nursing diagnosis

Outcomes partially met:
Following removal of
the Foley catheter,
reported continued
difficulty initiating a
urinary stream but less
dribbling and nocturia
Intermittent
catheterization not
indicated
Intake is about
200 mL > output
Selected an acceptable
undergarment and he
reports more confidence

Impaired Urinary Elimination (Retention and Overflow Incontinence) r/t bladder neck
obstruction by enlarged prostate gland (aeb dysuria, frequency, nocturia, dribbling,
hesitancy, and bladder distention)

evaluation

nursing intervention

outcome

outcome

Urinary Continence
aeb
Able to start and
stop stream
Empties bladder
completely

Knowledge:
Treatment
Regimen aeb
substantial
Description
of self-care
responsibilities
for ongoing care
Description of
self-monitoring
techniques

nursing
intervention

Outcomes met:
Able to discuss
the correlation
between enlarged
prostate and
urinary difficulties
TURP scheduled
in 2 weeks

evaluation

nursing intervention

Urinary Incontinence Care

Urinary Retention Care

Teaching: Disease process

activity
activity
activity

Monitor
urinary
elimination,
including
odor,
volume,
and color

Instruct
client to
limit fluids
for 2 to 3
hours
before
bedtime
activity

Help client
select
appropriate
incontinence
garment or
pad for
short-term
management
while more
definitive
treatment is
designed

activity

Limit
ingestion
of bladder
irritants
(e.g., colas,
coffee, tea,
and
chocolate)

Instruct to
drink a
minimum of
1,500 mL
(six 8-ounce
glasses fluids)
per day

Instruct
client or
family
member
to record
urinary
output

activity
activity

activity

Provide enough
time for bladder
emptying
(10 min)

activity

activity
activity

activity

Explain the
pathophysiology
of the disease
and how it
relates to urinary
anatomy and
function

Implement
intermittent
catheterization;
as appropriate

Instruct in ways
to avoid
constipation or
stool impaction

Appraise
current
level of
knowledge
about
benign
prostatic
hypertrophy

Catheterize
for residual
urine, as
appropriate

activity

Describe the
rationale behind
management,
therapy, and
treatment
recommendations

Instruct on
which signs
and
symptoms to
report to the
primary care
provider (e.g.,
burning on
urination,
hematuria,
olliguria)