NURSING CARE IN Mr.

X WITH URINARY RETENTION

Disusun Oleh :

MEGA MEILISA MANARA 2014901072

POLITEKNIK KESEHATAN TANJUNGKARANG

JURUSAN KEPERAWATAN
PRODI PROFESI NERS
TAHUN AKADEMIK 2020/ 2021
 Nursing Care
A. Assessment data
1. Personal Data
Name : Mr.X
Age : 75 years old
Date of Birth : 01 january 1945
Religion : Islam
Address : Bandar Lampung
Education : Senior High School
Medical record number : 101011
Diagnosis : BPH (Beningn Prostatic Hyperplasia)

2. Chief Complaint
Mr. X is a 75 years old was admitted to the hospital with urinary retention. He said that feels hot when urinating. Mr. X
said that he doestn’t feel emptied his bladder after urinating. He also has to get up two times during the night to urinate.
During the past few days, he said difficulty starting urination.

3. History of Present Illness

Please circle the appropriate response

Do you get up at night to urine? Yes No

Does your urine come out freely? Yes No

 When you get the urge to urinate, can you hold it? Yes No

Do you have burning with urination? Yes No

Have you noticed blood in your urine? Yes No

Have you had a urinary tract infection? Yes No

Have you had a kidney stone? Yes No

4. Past Medical History

Please circle the appropriate response

Do you have or have ever had :

Diabetes Yes No

High blood pressure Yes No

Heart problems Yes No

Any other medical problems Yes No

If yes, please list them all :-
List any surgeries you have had :-
Are you on any medications ? Yes No
If yes, please list all of them :-
Do you have any allergies to any medications ? Yes No

5. History of Family Illness

 Do you have family history of ?
Diabetes Yes No
High Blood pressure Yes No
Heart disease Yes No
Cancer Yes No

6. Social History
Married Yes No Children Yes No
Do you currently smoke Yes No if yes how much? 2 childrens
Have you smoked in the past Yes No Stopped when ? 5 years ago
Do you drink alcohol Yes No if yes, how much ? -
What type of work do you do ? Yes No
If not currently working, what type of work did you do in the past ? farmer

7. Physical Examination
Height : 172 cm
Weight : 60 kg
Temperature : 37,9 C
Pulse : 89 BPM
Respiration : 19/ minute
Blood pressure : 140/80 mmHg
 Assessment Nursing diagnosis Objectives Nursing interventions Rationale

Urinary retention related to Goal : Independent:

Subjective cues:
proliferation of the prostate
After of holistic nursing 1.) Monitor urinary output 1.)To provide base
- Mr. X said that feels gland as evidenced by
intervention, the patient line data for
hot when urinating bladder distention 2.) monitor input
will be able to : comparison of

- Mr. X said that he 3.) assist client to sit records

-Patient empties bladder
doestn’t feel emptied upright on bedpan or
completely 2.)To prevent
his bladder after commode, or stand
worsening of the
-patient voids in
urinating condition
sufficient quantity with 4.) use techniques like
Objectives cues: no palpable bladder running water in the sink or 3.)To provide

distention warm water over perineum functional position

T : 37,9 C
of voiding
5.) encouraged client to
PR : 89 BPM
report problems 4.)To stimulate
RR : 19/ minute immediately urination

BP : 140/80 Dependent: 5.) To institute

treatment promptly
-Urinary output of 6.) catheterize with
15ml/hr intermittent or indwelling
catheter as ordered by the 6.)To resolve acute
-Bladder distention retention
physician
-Weak and pale in 7.)To improves the
7.) administer medications
appearance patient’s prognosis
as prescribe by the
and status
-Difficulty of urination physician