Jenna Hensel

Room 458, SS

1/12/15

Med/Surg Nursing Diagnosis: impaired urinary elimination r/t physical injury to bladder AEB bladder leakage
Long-Term Goal: Pt will have proper urinary elimination
Outcome
Criteria
One outcome criteria
for each intervention.
Number each one.

Interventions
Label each as
assess/monitor/independent/
dependent/teaching/collaboration

1. Pt U/O will be
at least 30ml/hr,
clear, and yellow

1. Independent: Monitor
U/O strictly including color,
amount and consistency of
urine qhr

2. Pt will not
have weight gain
of 2lb in 2 days
as monitored
daily

2. Independent: Monitor
weight daily

Rationale
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.

1. This pt had a bladder biopsy done to test for

presence of bladder cancer, which this pt has had in
the past. The biopsy caused a leakage in the pts
bladder which has impaired normal urinary elimination.
A foley catheter has been inserted for this pt so that
urine can expel from the bladder for accurate
measurement of output and so the bladder does not
remain full causing increased leakage into the
peritoneum. It is very important to strictly monitor this
pts urinary output d/t her current medical situation and
her past bladder cancer Dx. If the urine becomes
cloudy, foul smelling, or becomes very dark or
hematuria occurs, then this may be evident of an
infection or an issue that must be addressed by the
health care team to stop further complications. It is
also important that the amount of urine is closely
measured to ensure that the pt is voiding at least
30ml/hr and no urine is being leaked into the
peritoneum, which is wear the bladder is located.
2. This pt has a bladder leakage. If the bladder
contents (urine) is leaking into the peritoneum then the
urine is not being expelled from the body, which would
cause an increase in weight as urine continues to leak.
If the pt has an increase in weight by 2lbs in 2 days or
greater, then there is a possibility that urine is not
being expelled from the body causing impaired urinary
elimination d/t physical injury to bladder. Other

Evaluation
Evaluate the patient
outcome, NOT the
intervention

1. Partially met: Pt had

very small tissue clots
present in foley
drainage bag following
Turbt on 1/8. Urine was
clear and yellow, and
amount in bag was
at ;east 30ml/hr

2. Met

3. Pt abd will be
flat with no
tenderness to
palpation as
assessed qshift

3.Independent: Assess
abdomen for distention and
tenderness qshift

4. Pt will have
pain 0/10
throughout body
as monitored
qshift

4. Independent: Monitor
pain location, duration,
characteristics qshift

5. Pt will be free
of urgency and
frequency
assessed qshift

5. Assess presence of
frequency and urgency with
voiding qshift

6. Pt T96.4100.4, P60-

6. Independent: Monitor VS
q4hr

assessments that may be done include abdominal

assessments, to assess for distention caused by
bladder leakage. WBC should also be monitored
because if urine (foreign agents) enters into the
peritoneum, then WBCs will try to fight the presence of
this foreign substance.
3. The bladder is located in the peritoneum, and this pt
has a bladder leakage. If urine leaks from the bladder it
will enter the peritoneum, causing abdominal
distention from increased fluid. There may also be
tenderness with palpation and pain in the abdominal
area d/t increased pressure the urine is causing in this
cavity. Monitoring this pts abdomen qshift for distention
is a way to promptly catch any changes in urinary
elimination
4. If a bladder leakage is present in this pt, then
increased pressure caused by urine in the peritoneum
may cause pain and tenderness. Pain may also be
present d/t biopsy and turbt that pt had on 1/8. If pain
is present in this area, then that may be evidence of
leakage and pain characteristics must be monitored
closely by the nurse to ensure pain control and assess
the pts impaired urinary elimination. If pain
characteristics correlate with bladder leakage into the
peritoneum, then this should be reported to MD for
further Dx testing and Tx
5. Presence of urinary urgency or frequency is evidence
of impaired urinary elimination. Urgency and frequency
may be symptoms of a urinary tract infection. If the pt
has these symptoms with an indwelling catheter then a
urine specimen may be obtained per MD order. If
infection is present and bladder leakage exists, then
infection may spread into blood stream causing further
complications. Presence of urgency and frequency
cause impaired urinary elimination.
6. This pt has had a physical injury to her bladder
following a bladder biopsy as evidenced by a bladder

3. Met

4. Unmet: Pt had c/o of

pain frequently
ranging from 3-7/10.
Pain meds
(hydrocodone) have
been administered
q4hrs

5. Met

6. Partially met: All VS

WNL except BP 160/80

100bpm, R1220/min,
BP120/80 as
monitored q4hrs

7. Pt will have no
s/s of bladder
leakage into
peritoneum, and
U/O of at least
30ml/hr as
assessed daily
per MD order
8. Pt will
demonstrate and
verbalize
understanding of
Foley care and
how to assess
and report
changes in urine
characteristics
including
<30ml/hr,
changes in urine
color (darker,
blood), and
cloudiness as
taught qshift
9. Pt will
demonstrate and
verbalize
understanding of
kegel exercises
to strengthen
muscles of pelvic

leakage. Physical injury may cause pain which will

increase pulse, BP and respirations d/t stimulation of
SNS. Increased VS may also occur if the pt has an
excess fluid volume caused by leakage of urine from
bladder into peritoneum, which will cause impaired
urinary elimination.
7. Catheterizing this pt is an effective way to obtain
strict urine output following bladder biopsy and bladder
leakage caused by biopsy. This pt has impaired urinary
elimination r/t to a physical injury to her bladder. By
catheterizing the pt, urine is expelled from the bladder
as it appears to decrease possibility of bladder leakage.

d/t underlying HTN.

8. Teaching: teach pt proper

Foley Care and how to
assess U/O qshift

8. This pt has an indwelling catheter that she is being

discharged home with, and therefor must be aware of
how to wash around catheter and keep as clean as
possible to prevent infection. This pt must also know
how to monitor her U/O for changes that occur caused
by impaired urinary elimination. She must be taught s/s
of bladder leakage prior to d/c so that they can be
reported to correct her impaired urinary elimination.

8. Met

9. Teaching: Teach kegel

exercises qshift

9. This pt has impaired urinary elimination r/t physical

injury to bladder following a tissue biopsy. She also has
an indwelling catheter so she does not have to
physically void on her own. To achieve proper urinary
elimination, kegel exercises are important because
they strengthen the muscles of the pelvic floor.
Repetitious tightening and relaxation of these muscles

9. Met

7. Dependent: catheterize
pt to prevent accident,
urine leakage and measure
accurate U/O daily per MD
order

7. Met

floor as taught
qshift
10. Pt WBC will
be 5,000-10,000
as monitored
daily

10. Independent: Monitor

WBC lab values daily

11. Pt will have

no c/o of pain in
bladder area and
bladder spasms
as administered
daily per MD
order.

11. Dependent: Administer

Vesicare 10 mg tab orally
daily per MD order

12. Pt CT scan
will be free of
evidence of
bladder leakage
into the
peritoneum as
assessed qshift
per MD order
13. Pt urine
culture will be
negative for
bacteria (UTI) as
obtained per MD
order

12. Dependent: Assess

results of CT scan for
evidence of bladder leak
qshift per MD order

13. Dependent: Obtain

specimen for urine culture
per MD order

will allow this pt to remain continent once catheter is

removed and leakage is resolved, allowing her to have
proper urinary elimination.
10. This pt has impaired urinary elimination r/t a
bladder leakage caused by a bladder biopsy done on
1/8. Monitoring WBC count is important because if
urine leaks into the peritoneum, WBCs will attempt to
attack and destroy these foreign organisms, reflecting
an increase in WBC. Trending WBC count daily is a way
to catch the bodys natural immune defense
mechanism and prevent further impaired urinary
elimination.
11. This pt has a Hx of bladder cancer and has
undergone a bladder biopsy on 1/8. To prevent bladder
spasms and pain in bladder, the MD has prescribed
10mg of Vesicare daily. Vesicare is an anticholinergic
that acts as a muscarinic receptor antagonist , which
antagonizes bladder smooth muscle contractions.
Bladder spasms and pain associated with voiding will
further increase the pts Dx of impaired urinary
elimination, therefore the daily administration of this
medication is an important part of this pts care.
12. This pt had a bladder biopsy on 1/8 to detect
bladder cancer. The biopsy caused a bladder leakage
which has caused impaired urinary elimination for this
pt. If urine is leaking into the peritoneum then it should
be detected on a CT scan. The CT scan should be
assessed, monitored, and discussed with MD so that
interventions can be made to correct the problem and
allow this pt to have proper urinary elimination.
13. This pt has an indwelling foley catheter inserted
following her bladder biopsy, which increases the risk
for infection in her urinary tract/bladder. By obtaining a
urine specimen, the pts urine can be tested for
presence of organisms and bacteria which would
contribute to her impaired urinary elimination.
Catching a UTI and treating it quickly is important for

10. Met

11. Met

12. Met

13. Unmet: Pt urine

culture was positive
for >100,000 cfu/ml
staph.

14. Pt will have

pain 0/10
following
administration of
Lortab per MD
order.
15. pt biopsy will
be negative for
presence of
cancer cells as
assessed by MD
and health care
team

14. Dependent: Administer

Lortab 5-325mg 1 tab orally
q4h prn for moderate pain
per MD order

15. Collaboration:
Collaborate with MD for
biopsy results regarding Dx
of bladder cancer qshift

this pt and her current condition to prevent spread of

infection through body.
14. This pts impaired urinary elimination may cause
moderate pain d/t bladder biopsy and turbt performed
on 1/8. Pain control is an important part of this pts
recovery because pain increases stimulation of the SNS
and will take away from healing the bladder leakage
that is present.
15. This pt was admitted to the hospital for a bladder
biopsy to detect regrowth of bladder cancer cells. If the
biopsy results are positive for presence of cancer cells,
then the pts urinary elimination will continue to be
impaired regardless of bladder leakage. S/S of bladder
cancer include hematuria, urgency, frequency and
bladder irritability. These symptoms correlate with
impaired urinary elimination, and the pt must be
instructed to report these s/s to the MD as they occur.

14. Unmet: Following

administration of
Lortab, pt pain level
went from 7/10 to
3/10.
15. Unmet: Results of
biopsy are pending.