Question

Clyde of a Hunter, a 72- Long-term year-old African-American male, is a resident care facility. He has been unable to control the since experiencing a cerebrovascular accident (CVA) The nurse recognizes differing urinary bladder training program for Mr. Hunter patterns and initiates a program is unsuccessful. The nurse includes the diagnosis "Risk for impaired skin integrity" in the plan of care Skin care measures are implemented and a condom cat applied heter is Mr. Hunter is admitted to an acute care unit for surgery nurse indwelling too soon, causi documented. . The supervises a student, who selects equipment to insert an urinary catheter. The student inflates the balloon ng pain. The insertion and urine return are Hunter is confused and pulls on his Following catheter, causing hematuri the nurse obtains a prescription for supervi urinary output surgery, Mr. a. Blood clots obstruct urine flow, So irrigation. The nurse ses a student who irrigates the catheter and measures remains confused. The nurse identifies the need for Mr. Hunter wrist restraints restraints are applied. and monitors the client every 30 minutes while Three days later, the client's urine is cloudy. The nurse performs further assessment, notes the urinalysis results monitors additional lab work, and offers fluids. An antibiotic is prescribed and the nurse monitors the client's creatinine level.

Answer 1

Risk for infection related to urinary cathetarisation

subjective data

client restless

objective data

cloudy urine

urinanalysis report shows infection

goal for the patient

shorterm goal should be control the infection as evidenced by normal urine

longterm goal must be

free from urinary infectuion

the intervention should include

provide plenty of water

catheter care as and when needed

monitor the genital area for any infection

urine analysis for reduction in infection