Question: Urinary Retention NextGen SKINNY Reasoning Frank Thomas, 62 Years Old . Primary Concept Elimination Interrelated Concepts (In Order Of Emphasis) Clinical Judgment NCLEX Client Need Categories Covered In NCSBN Clinical Case Study Judgment Model Safe And Effective Care Environment Step 1: Recognize Cues Management Of Care Step 2: Analyze Cues Safety And …

Urinary Retention NextGen SKINNY Reasoning Frank Thomas, 62 years old . Primary Concept Elimination Interrelated Concepts (In order of emphasis) Clinical judgment NCLEX Client Need Categories Covered in NCSBN Clinical Case Study Judgment Model Safe and Effective Care Environment Step 1: Recognize Cues Management of Care Step 2: Analyze Cues Safety and Infection Control Step 3: Prioritize Hypotheses Health Promotion and Maintenance Step 4: Generate Solutions Psychosocial Integrity Step 5: Take Action Physiological Integrity Step 6: Evaluate Outcomes Covered in Case Study ✓ • . Basic Care and Comfort . Pharmacological and Parenteral Therapies Reduction of Risk Potential Physiological Adaptation . © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN Present Problem: You are the nurse responsible for the care of Frank Thomas, a 62-year-old male patient who had a knee replacement yesterday and still has a femoral nerve block in place. He remains on bedrest until later this afternoon. During your 1200 assessment, you notice that the urinary catheter bag has a small amount of urine in the tubing and no urine in the collection bag. His urine output for the eight-hour overnight shift was 700 mL. When you ask Frank how he is feeling, he replies, “I feel a lot of pressure, almost like I need to urinate” as he points to his lower abdomen. 1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Additional Information: Frank has a past medical history of arthritis and degenerative joint disease and takes aspirin daily. He did not receive contrast media during this hospitalization. You perform a focused assessment and note that there is increased pain and tenderness with gentle palpation over the symphasis pubis (low/mid abd) and the abdomen is firm to touch. Current VS: T: 98.5 F/36.9 C (oral) P: 80 (regular) R: 16 (regular) BP: 118/74 02 sat: 95% room air (RA) P-Q-R-S-T Pain Assessment: Provoking/Palliative: Quality: Denies Region/Radiation: Severity: Timing: Lab Results: Today: Yesterday: WBC 9.8 8.5 % Neuts 75 68 Bands 0 0 Complete Blood Count (CBC) HGB PLTS 13.5 185 12.9 175 Basic Metabolic Panel (BMP) K 3.9 115 3.8 108 Gluc. Today: Yesterday: Na 142 144 BUN 10 9 Creat 0.95 0.89 © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN 2. What data from the additional information is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Additional Info: Clinical Significance: 3. Interpreting clinical data collected, what problems are possible? Which problem is priority? Why? (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care) Problems: Priority Problem: Rationale: 4. What nursing priority will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care) Nursing PRIORITY: Nursing Interventions: Expected Outcome: 5. If the nursing intervention(s) you selected was effective, what will be the assessment data collected that will validate that the problem has been successfully resolved? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) PRIORITY Expected Assessment Data if Successfully Resolved: Intervention(s): 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any ..ARN form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permis 3/3