Medical Surgical Nursing

 Voids at normal

intervals

 Reports absence of

frequency, urgency,

or bladder fullness

 Displays no

palpable suprapubic

distention after

voiding

 Maintains balanced

intake and output

1. Provides a baseline for

comparison and goal to work

toward

2. Voiding 20 to 30 mL

frequently and output less

than intake suggest retention.

3. Determines amount of urine

remaining in bladder after

voiding

4. Promotes voiding

a. Usual position

provides relaxed

conditions conducive

to voiding.

b. Valsalva maneuver

exerts pressure to

force urine out of

bladder.

c. Stimulates bladder

contraction

d. If unsuccessful,

another measure may

be required.

5. Catheterization will relieve

urinary retention until the

specific cause is determined;

it may be an obstruction that

can be corrected only

surgically.

6. Adequate functioning of

catheter is to be ensured to

empty bladder and to prevent

infection.

7. Surgical removal of

obstruction may be

necessary.

1. Determine patient's usual

pattern of urinary function.

2. Assess for signs and

symptoms of urinary

retention: amount and

frequency of urination,

suprapubic distention,

complaints of urgency and

discomfort.

3. Catheterize patient to

determine amount of

residual urine.

4. Initiate measures to treat

retention:

a. Encourage assuming

normal position for

voiding.

b. Recommend using

Valsalva maneuver

preoperatively, if

not contraindicated.

c. Administer

prescribed

cholinergic agent.

d. Monitor effects of

medication.

5. Consult with physician

regarding intermittent or

indwelling catheterization;

assist with procedure as

required.

6. Monitor catheter function;

maintain sterility of closed

system; irrigate as required.

7. Prepare patient for surgery

if indicated.

Nursing Diagnosis: Deficient knowledge related to the diagnosis of: cancer, urinary difficulties, and
treatment modalities
Goal: Understanding of the diagnosis and ability to care for self
 Discusses his
concerns and
problems freely
 Asks questions and
shows interest in his
disorder
 Describes activities
that help or hinder
recovery
 Identifies ways of
attaining/maintainin

1. This is designed to establish

rapport and trust.

2. Orientation to one's anatomy

is basic to understanding its

function.

3. This is based on the

treatment plan; as it varies

with each patient,

individualization is desirable.

4. This is to prevent bleeding;

such precautions are in order

1. Encourage communication

with the patient.

2. Review the anatomy of the

involved area.

3. Be specific in selecting

information that is relevant

to the patient's particular

treatment plan.

4. Identify ways to reduce

pressure on the operative

area after prostatectomy: