Care Plan- Jessica Caudill

Assessment Data
Objective

-Pt is 58 yr. old female POD #1 (yesterday) of L4-S1 posterior spinal fusion due to a Hx: of Chronic Lower Back
Pain w/controlled pain of 2 on 0-10 pain scale

- Pain managed w/ hydromorphone (Dilaudid, Hydromorph Contin) 0.5-1 mg PO- Q4

- Pt has not voided in 8 hrs. since indwelling urinary Cath d/c

-Pt tolerates PO fluids – total PO intake (875 mL) in past 8 hrs.

- Upon examination of Lower Suprapubic area – area firm & tender upon palpation.

- Bladder scan revealed 765 mL PVR

- V/S prior to straight Cath procedure: T-99.2F’ (oral), P-94, B/P-148/80 (resting in bed)

- V/S after straight Cath: T-99.7F’ (oral), P-81, B/P-136/76 (resting in bed)

Subjective

- 8 hrs. after indwelling Cath d/c, pt puts on call light and states, “having aching Mod pain/pressure above her
pubic bone that she has not had before.” - pt rated pain as 8 on a 0-10 on pain scale.”

- pt states, “This aching Mod pain has been ongoing for the past hr.”

- pt appears restless & uncomfortable w/tense body posture in bed.

Nursing Diagnosis

Problem Focused/Actual Diagnosis

Impaired Urinary Elimination r/t post-op day#1 (L4-S1) posterior spinal fusion, AEB depressant effects of anesthesia’s &
analgesics, bladder scan PVR 765 mL, pt statement, “pressure/ache they’ve never had before,” pain level 8 on 0-10 scale.

Goal/Outcome Statement
Use SMART criteria.

Pt will demonstrate complete bladder emptying as evidenced by urine volume > or = 350 mL with each voiding
& PVR < 100 mL Q4 hours and have pain in suprapubic area of < 6 on 0-10 pain scale.
Nurse will assist and encourage pt to use BSC in sitting position to increase pts voiding success while providing privacy
Q4 to reduce the risk of urinary retention. Nurse will have pt rate their pain Q4 on 0-10 pain scale before and after
voiding attempts. Nurse will inform pts physician of pain > than 6 on 0-10 pain scale.
 Care Plan- Jessica Caudill
Interventions/Implementation

Provide rationales for each in APA format (page numbers from textbook, if applicable).

1. Intervention: Nurse will institute intermittent catheterization if pt has unsuccessful void attempt after
all other non-invasive options have been exhausted and urine volume > or = 300 mL remaining after
each unsuccessful voiding & PVR < 100 mL Q4 hours aeb bladder scan results.
Rationale: Many causes of urinary retention are self-limited, the decision to leave an indwelling
catheter in place should be avoided. This may constitute for chronic retention problems (Gulanick &
Meyers, 2023). Indwelling catheters are the 5th leading cause of CAUTIs.

2. Intervention: Nurse will consult with pts physician with any concerning elimination or medication
adjustments that might be contributing to pts post-op urinary retention. Rationale: QSEN: Teamwork
and collaboration – Urinary retention after surgery could be caused by medications used before or
after spinal fusion that could be causing temporary depressant effects of pts bladder (Gulanick &
Meyers, 2023).

3. Intervention: Nurse will educate pt on importance of adequate fluid intake (e.g., 8-10 glasses of fluids
daily) unless the pt is put on a fluid restriction to allow adequate bladder functioning. Rationale:
Having an increased fluid intake stimulates voiding along with decreasing the risk of developing a UTI
by flushing bacteria from the genitourinary tract (Gulanick & Meyers, 2023).

4. Intervention: Nurse will instruct pt to understand and report the early signs and symptoms of an
overdistended bladder (e.g., decreased or absent urine, frequency, hesitancy, urgency, lower
abdominal distention, or discomfort). Rationale: enable to detect early signs and symptoms of a
distended/full bladder will allow early recognition or treatment before pts condition worsens (Gulanick
& Meyers, 2023).

Evaluation
Goal partially met due to pt not restating pain rating on 0-10 scale and pt unsuccessful attempt to void w/o
use of catheterization.
Objective:
- removal of 800 mL of clear, yellow urine from straight catheterization resolving urinary retention (after
placing pt on BSC w/running water in sink).
- Pts Pulse & B/P has improved (P-81) (B/P – 136/76)
Subjective:
- Pt stated, “Abdominal pain is no longer present.”
 Care Plan- Jessica Caudill
Plan Moving Forward
 To continue to improve pts condition pts vitals & pain rating will be assessed Q4 along with encouragement &
assistance up to BSC using non-invasive natural encouragement techniques to void.
 Pt will be encouraged to notify nurse of any tenderness in suprapubic area prior to pain becoming > 6 on 0-10
pain scale.
 Pt will be encouraged to drink more fluid if not on fluid restrictions.
 Pt will be encouraged to ambulate with assistance to allow natural bladder stimulation from movement by
gravity or urine while ambulating.

Textbook & Other Reference(s)

Cite using APA format.

Gulanick: Nursing Care Plans, 10th Edition, Online Care Planner “Urinary Retention”

Gulanick, M, & Myers ,J.L (2023). Ch 2, Online Care Planner (Urinary Retention). In Nursing Care Plans: Plan of Care For,
(10th ed.), Nursing Diagnosis, Elsevier.

(Gulanick & Meyers, 2023)