Question

Sandy is a 47 year old female 2 days post operative abdominal surgery. She has a foley to gravity drainage. While assessing P.M.'s VS at noon, you note that there is no urine in the tubing and there is little in the bag. The patient tells you "I am in pain and I feel like I need to urinate."

What could be the problem?

What should you assess and do for this patient?

Write 3 possible NANDA nursing diagnoses for this patient according to priority of this patient.

Answer 1

There is no urine in the tubing and the patient is in pain.

The should be a block on the urinary catheter, which leads to urinary retention and causing severe pain. It is a common problem after abdominal surgery.

To confirm we should palpate the lower abdomen just above the urinary bladder area to fell the content of the urinary bladder. An ultrasound can be done to confirm bladder content. It is an emergency condition, we should act as fast as possible to prevent bladder rupture.

After confirmation performs a catheter flush by Tommy syringe with normal saline. If still problem persist then change the urinary catheter.

1. Severe pain and discomfort related to Urinary retention as evidenced by patient verbalization and irritability.

2. The risk for infection related to post-operative surgery.

3. Anxiety related to symptoms of health status as evidenced by irritability.