Question

For a 98 YO male who is admitted to the hospital for hematuria following a cystoscopy with continuous bladder irrigation, devise 3 nursing diagnoses.

Answer 1

Ans) Nursing diagnosis 1) Impaired urinary elimination related to postoperative cystostomy

Goal: No interference elimination urinary elimination pattern

Nursing interventions:

1) Monitoring of urine output and characteristics

Rationale:

- Detecting bladder elimination disorder at an early stage.

2) Maintain a constant bladder irrigation for 24 hours.

Rationale: Prevent blood clots obstruct the flow of urine.

3) Maintain the catheter with irrigation.

Rationale: Prevents blood clots logging the catheter.

4) Persue fluid intake

Rationale: A smooth flow of urine.

5} Once the catheter is removed, continue to monitor the symptoms of impaired bladder elimination pattern

Rationale: Detecting early bladder elimination disorders.

Nursing diagnosis 2:

Impaired sense of comfort: Pain related to post operative cystostomy

Goal: Patients said feeling more comfortable

Nursing interventions:

1) Extension to the patient not to urinate all the around the catheter

Rationale: Reduce the possibility of spasm

2) Monitoring of patient at regular intervals for 24 hours, to recognise early symptoms of bladder spasm

Rationale: Determining the presence of spasm bladder so that medication can be given

3) Providing ordered drugs analgesic, antispasmodic 9

Rationale: Symptoms disappeared

4) Tell the patient that the intensity and frequency will be reduced within 24 hours to 28 hours

Rationale: Inform patient that the discomfort is only temporary

Nursing diagnosis 3

Risk for infection, hemorrhage related to surgery

Goal: No infection, bleeding is minimal

Nursing intervention:

1) Monitoring of vital signs and reported symptoms of shock and fever

Rationale: Prevents before the shock.

2) Monitoring of fresh red blood urine colour, not dark red just a few hours after surgery.

Rationale: The colour changed from fresh red , urine becomes dark red on day 2 and 3 after surgery.

3) Guidance to patients in order to prevent the valsalva maneuver.

Rationale: Can be irritating, prostate bleeding to in early for postoperative period due to the pressure

4) Prevent the use of rectal thermometer , rectal examination at least one week.