Question

You are caring for Ms. Kowalski, a 65-year-old female who has sustained a brain injury in a MVA. While recovering in the ICU, the medical provider has ordered an indwelling urinary catheter to monitor her fluid balance. You place her indwelling catheter using proper sterile technique.

1. Select a priority nursing diagnosis and an appropriate outcome for Ms. Kowalski.

2. What nursing interventions you will plan to meet this outcome?

3. How will you know when you can remove Ms. Kowalski’s urinary catheter?

Two days later, you remove Mrs. Kowalski’s catheter. Ten hours pass, and Mrs. Kowalski hasn’t voided.

4. What will you, the nurse, do next?

Answer 1

A priority nursing diagnosis for Ms. Kowalski could be 'Risk for infection related to indwelling urinary catheter.' Nursing interventions to meet this outcome include maintaining proper catheter hygiene, monitoring for infection signs, encouraging fluid intake, and reviewing the need for the catheter. If Mrs. Kowalski hasn't voided after catheter removal, the nurse should assess for urinary retention and consult the healthcare provider for further evaluation and intervention.

Step-by-step explanation:

A priority nursing diagnosis for Ms. Kowalski could be 'Risk for infection related to indwelling urinary catheter'. An appropriate outcome for her would be 'The patient will remain free from catheter-associated urinary tract infection (CAUTI) throughout the duration of catheter use.'

To meet this outcome, nursing interventions may include: maintaining proper catheter hygiene by cleaning the catheter and surrounding area regularly, monitoring the patient's temperature and assessing for signs of infection, encouraging fluid intake to flush bacteria out of the urinary tract, and regularly reviewing the need for the catheter and removing it as soon as it is no longer necessary.

The nurse will know when to remove Ms. Kowalski's urinary catheter by assessing her ability to void. If she is able to urinate adequately on her own and does not require continuous monitoring of her fluid balance, the catheter can be safely removed.

If Mrs. Kowalski hasn't voided after the catheter was removed, the nurse should assess her bladder for distention, use bladder scan if necessary, and evaluate for other potential reasons for urinary retention such as medication side effects, anxiety, or neurological issues. The nurse should also consult with the healthcare provider for further evaluation and possible interventions, such as performing a straight catheterization to relieve the retention if necessary.