Case study - Urinary retention: Nursing

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.

Next, she notes that Richard has a PRN order for bladder scans. Nurse Tabitha then performs a bladder scan, which reveals 900 milliliters of urine in Richard’s bladder.

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.