Question

Create a scenario for a patient in which you are documenting a urinary assessment. Then, document a nurse's note about that urinary assessment. In the assessment, be sure to include urine volume, a method for voiding, characteristics of the urine (color, odor, particulate matter, blood, clarity, etc.), and any difficulties with voiding

Answer 1

A nurse documents a patient's urinary assessment, noting decreased urine volume, dark amber color, and discomfort during voiding. The nurse recommends increased fluid intake and follow-up tests.

Step-by-step explanation:

Documenting a Urinary Assessment:

A patient presents with a complaint of difficulty voiding. During the urinary assessment, the nurse notes that the patient's urine volume is below the expected 300-400 mL per void. The patient voids using the natural method without the aid of catheterization. Urine characteristics are noted as follows: the color is a dark amber, suggesting possible dehydration; the odor is pungent; there is no visible particulate matter; clarity is slightly cloudy; and importantly, there is no blood present, which would need further investigation, unless due to known menstrual contamination. The patient reports some discomfort while voiding, which may indicate a urinary tract infection or other urinary pathology.

Nurses' notes:
Patient exhibits decreased urine volume with dark amber color and strong odor. Voiding is unassisted but accompanied by discomfort. Advised to increase fluid intake and scheduled for a follow-up urinalysis. No blood detected in urine. Will monitor for changes in urine characteristics and volume, as well as any persistent or worsening symptoms.