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

NURSING ASSESSMENT OF PATIENT:

1. Cincinnati prehospital stroke scale(cpss):used to notify emergency services (FAST) facial drop,arm drit,speech, time to call
2. National institutes of health stroke scale (NIHSS)- to identify the severity of ischemic stroke by assessing 11 areas score<4 -indicates a high likelihood of functional independence, high score >22 - indicates the patient may experience severe debilitation.
3. Miami emergency neurologic deficit (MEND) - incorporates cpss and 8 components of nihss including LOC, eye gaze,orientation, commands ,visual field, leg motor strength, ataxia, and sensation.
4. physical examination

• inspect head and extremities for signs of trauma
• auscultate heart for irregular rhythm and abnormal rate and murmurs
• auscultate lungs for adventitious breath
• insoect skin for echymosess and evidence of surgery
• saturation levels
• serum glucose , cbc , abg,electroencephalogram
• ecg
• assess standards for prompted voiding , timed voiding, habit training
• bladder stress test
• voiding dairys
• urine culture renal function test
• planned process including screening procedures, including screening procedure
• assessment profile of incontinence

Urinary incontinence affects up to 60% of patients following stroke.

SUBJECTIVE    :

• defer in urinary patterns
• pain while catheterization
• patient feels confusion
• cloudy urine

OBJECTIVES

hematuria

creatine levels

blood tests