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
Assessment data
Name : Mr.X
Age : 75 years old
Religion : Islam
Address : Bandar Lampung
Education : high school
medical record number : 101011
diagnosis : BPH (Beningn Prostatic Hyperplasia)

Nusing assesment
Mr. X is a 75 year old was admitted to the hospital with urinary retention and feels hot when urinating. Mr.x states he has
noticed urinary frequency during the day for the past 1 weeks and that he doestn’t feel he has emptied his bladder after urinating. He
also has to get up two times during the night to urinate. During the past few days, he had difficulty starting urination.

Physical Examination
Height : 172 cm
Weight : 60 kg
Temperature : 37,9 C
Pulse : 89 BPM
Respiration : 19/ minute
Blood pressure : 140/80 mmHg
 Goal and
Nursing expected Nursing
Assessment Nursing analysis Rationale Evaluation
diagnosis outcomes interventions

Urinary retention The over production The patient Independent: Goal partially
Subjective:
related to of the testosterone will be able met:
1.) Monitor 1.)To
- admitted to the proliferation of causes the prostate to void in
urinary output provide base The patient was
hospital with the prostate gland to increase in sufficient
line data for able to void in
urinary retention gland as its size. The amounts 2.) monitor input
comparison sufficient amounts
evidenced by enlarged prostate within 8
- feels hot when 3.) assist client of records after 8 hours of
bladder gland blocks the hours of
urinating to sit upright on rendering nursing
distention and urethra that alters rendering 2.)To
bedpan or care.
reduced urinary the normal nursing care. prevent
- Mr.x states he
commode, or
stream elimination pattern worsening of
has noticed
stand
of urine which leads the condition
urinary frequency  Urine
it to urinary 4.) use
during the day for 3.)To output of 25
retention. techniques like
the past 1 weeks provide ml/hr with
and that he running water in functional IFC
doestn’t feel he the sink or warm position of connected
has emptied his water over voiding
bladder after perineum
4.)To
 stimulate
urinating 6.) encouraged
urination
client to report
Objectives:
problems 6.) To

T : 37,9 C immediately institute

treatment
PR : 89 BPM Dependent:
promptly
RR : 19/ minute 7.) catheterize
with intermittent 7.)To resolve
BP : 140/80
or indwelling acute
-Urinary output catheter as retention
of 15ml/hr ordered by the
8.)To
physician
-Bladder
improves the
distention 8.) administer patient’s
-Reduced urinary medications as prognosis
stream prescribe by the and status
physician
-Weak and pale
in appearance

-Difficulty of
urination