Video Case Study - Nursing Care for Urinary Retention
Nurse Tabitha works on an inpatient medical-surgical unit and is caring for Richard, a 61-year-old with a history of benign prostatic hyperplasia, or BPH, who underwent a cholecystectomy three days ago.
In collaboration with the registered nurse, RN Jesse, Nurse Tabitha goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Richard’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.
First, Nurse Tabitha recognizes important cues, including Richard’s vital signs, which are temperature 98.6 F or 37 C, heart rate 100 beats per minute, respirations 20 breaths per minute, and blood pressure 130/80 mmHg.
He also reports his pain as 4 out of 10 in his suprapubic region. Nurse Tabitha notices Richard appears restless, and he states that he has an urge to urinate but can’t.
Next, Nurse Tabitha analyzes these cues. She reviews the electronic health record, or EHR, and sees that Richard received general anesthesia during his surgical procedure.
She realizes that this can lead to urinary retention, due to disruption of the normal neuromuscular processes that control urination.
Nurse Tabitha also realizes that Richard’s enlarged prostate is likely contributing to his urinary retention since it can block the outflow of urine from the lower part of the bladder and urethra.
Nurse Tabitha realizes Richard is likely retaining urine due to a combination of the anesthesia from his surgery and history of BPH, and that he needs effective urinary elimination.
Now, using the information she has gathered, along with Richard’s medical history, Nurse Tabitha reports her findings to RN Jesse, and they choose a priority hypothesis of altered urinary elimination.
Then, they generate solutions to address Richard’s altered urinary elimination that will include nonpharmacologic interventions; and establish the expected outcome that after intervening, Richard will have effective urinary elimination by the end of the shift.
Nurse Tabitha then takes action to implement these solutions. She notifies the health care provider of her findings, and an indwelling urinary catheter is ordered.
While RN Jesse explains the procedure to Richard, Nurse Tabitha gathers the necessary supplies and re-enters Richard’s room.
Nurse Tabitha: Hi, Richard, I’m here to insert a urinary catheter. As RN Jesse explained to you, it’s a small tube that’ll go into your bladder to drain the urine.
Afterwards, you’ll have relief from the pressure in your bladder. Richard: I’m looking forward to that.
Nurse Tabitha then performs the urinary catheter insertion according to the facility policy. Following insertion, clear, yellow urine begins to flow through the tubing into the drainage bag.
At the end of the shift, Nurse Tabitha enters the room to evaluate the outcome of her actions. She takes Richard’s vital signs which are heart rate 72 beats per minute, respirations 16 breaths per minute, blood pressure 130/68 mmHg.
Richard is no longer restless, and he reports his pain is 0 out of 10. Nurse Tabitha notes that his urinary catheter continues to drain clear yellow urine.
Alright, as a quick recap… Nurse Tabitha recognized and analyzed cues related to Richard’s altered urinary elimination, and in collaboration with RN Jesse, prioritized hypotheses and generated solutions to address this problem.
Nurse Tabitha and RN Jesse then implemented measures and evaluated Richard’s outcomes and compared them to the expected outcome.
Since Richard experienced effective urinary elimination by the end of the shift, they determined the plan of care was
- "Foundations of nursing (9th ed.)" Elsevier (2023)
- "Fundamental concepts and skills for nursing (6th ed.)" Elsevier (2022)
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