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Objective ◈ c IVF of D5LR 1L @ 30 gtts/min ◈ pale in appearance ◈ weak looking ◈ on NPO ◈ c abdominal dressing, dry & intact ◈ (+) anesthetic effect on pelvic & lower extremities
Reference: Understanding Pathophysiology, Huether
Short Term Goal ◈ Impaired Urinary Elimination r/t oral fluid/solid restriction & sensory motor impairment Oral fluid/solid restriction ◈ After 4 hours of nursing intervention, normal urine elimination and output will be maintained.
Independent ◈ Assessed patency of foley catheter. ◈ Provides basis for further assessment & action. ◈ Prevents or reduces risk of contamination of foley catheter. ◈After 4 hours of nursing intervention, the goal is met through exhibition of adequate urinary output and patent drainage system.
Less urinary output
◈ Used asepsis and hand hygiene in providing care and manipulating the urinary drainage system. ◈ Assessed color, volume, odor and components of urine.
◈ Provides information about adequacy of urine output, condition and patency of foley catheter and debris in urine.
Dependent ◈ c foley catheter draining to yellowish urine, > 30 mL/hr ◈ Administered IV fluids such as PNSS on fast drip as prescribed. ◈ By regulating the amount of sodium, the kidney can regulate the volume of body fluids.