Question

Mrs. Jones is a 72 year old female, who was admitted to the hospital for after having a small stroke. She is widowed and lives independently, with the assistance of her 7 children. 

She has a history of HTN and type two diabetes. Medications include a She takes a diuretic. A complication of her stroke is extreme constipation. 

Mrs. Jones had a Foley catheter inserted in the ED at the time of her stroke and it was removed yesterday.    

Mrs. Jones has been incontinent of urine since her catheter was removed last night. Her daughters talked to you this morning and are very upset their mother is wearing a diaper. 

Identify three assessment/data, three nursing interventions, and three patient education.

Answer 1

Assessment :

• Assess for pain and discomfort at the site
• Assess whether there is bleeding or blood tinged while micturation
• Collect information on patient vital signs especially rise of temperature or fever to know any infection
• Assess for skin peel

Nursing intervention

Some of the nursing intervention for managing are

• Monitor output level
• Provide skin care or back care (Perianal area) to avoid skin irritation and ulcer by keeping big moisture free
• Encourage to pass urine
• Increase fluid intake

Patient education:

• Health educate that the symptoms like burning, stinging will last for 24-48 hours
• Inform any thing like blood in urine,discomfort lasting more than 48 hours, incomplete bladder emptying,bloated abdomen,leaking urine
• Encourage to take plenty of liquids
• Inform about the effect of diuretics as it will increase urine output