MB 72-Year-Old Acute Urinary Retention Case Study
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
You are working in the emergency department (ED) when M.B., a 72-year-old man, enters with a chief com-plaint of the inability to void. His initial vital signs (VS) are 168/92, 88, 20, 98.2° F (36.8° C).
- Are M.B.’s VS appropriate for a man of his age? If not, offer a rationale for the abnormal readings.
M.B.’s BP is elevated, and his respirations are at the top range of normal. Both elevations are prob-ably caused by the pain response or anxiety about having to go to the hospital. Or, it is possible that he might have hypertension; you need to ask whether he has a history of hypertension during the assessment.
- Given M.B.’s chief complaint, what would you expect to find during your initial assessment?
- Distended bladder on palpation
- Elevated BP
- Diaphoresis
- Agitation and restlessness
- Discomfort or pain
CASE STUDY PROGRESS
While you are taking M.B.’s history, he tells you he is generally in good health and leads an active life. His cur-rent medications include finasteride (Proscar) 5 mg/day and vitamin supplements. He reports that he has been unable to void for 12 hours and is very uncomfortable. He asks you to help him.
- What do you need to know about his use of the finasteride (Proscar)?
It is important to know when M.B. started taking the finasteride. Finasteride takes up to 6 months to reach its maximum effect. This drug can cause a risk of birth defects to male fetuses; women who are or might become pregnant should not handle the tablets. Wear gloves when administering this medication.
- What are your priorities for this patient?
- B.’s symptoms are probably the result of a distended bladder and urinary retention. First, obtain a bedside bladder US scan to get an estimate of the number of milliliters being retained in the bladder. Then you would expect an order to insert an indwelling catheter. Draining the bladder should alleviate his symptoms. Although rare, bladder rupture can occur, so placement of the catheter must be completed ASAP.
- Help reduce M.B.’s anxiety by keeping him informed about what is happening and updating him on his treatment plan.
- Be aware that if the urinary retention is being caused by an enlarged prostate gland, the attempt to advance an indwelling urinary catheter might be difficult and uncomfortable for the patient.
- After examining M.B., the ED physician asks you to insert an indwelling urethral Foley catheter. What will you include in M.B.’s teaching before placing the Foley?
Instruct M.B. that placement of the catheter will allow his urine to flow through the catheter into a col-lection bag. This procedure will require you to cleanse the head of his penis to decrease the risk for infec-tion; you will lubricate the catheter with water-soluble lubricant (e.g., K-Y Jelly) before inserting
it into his penis. Insertion of the catheter can be uncomfortable. He will feel pressure while the catheter is advanced through the urethra and past the prostate. Once the catheter is in place and the urine is drained, his symptoms should be relieved.
- After two unsuccessful attempts to advance the catheter into the bladder, you stop. What is your next intervention? Why? What could be causing this problem?
The ED physician should be notified that you are unable to pass the catheter. It is imperative that the catheter never be forced or internal trauma with resultant inflammation and bleeding can occur, mak-ing additional attempts at catheterization more difficult. M.B. might have some prostatic enlargement, which makes it more difficult to pass the catheter up to the bladder.
- The ED physician successfully inserts the indwelling catheter with the use of a coudé catheter, and urine begins to drain. How is this catheter different?
The coudé catheter has a curved tip at the distal end that allows for easier passage in the male around the enlarged prostate. The curve should be facing upward toward the sky when inserting a coudé catheter.
- As the physician begins to inflate the catheter balloon, M.B. winces in pain and states, “Ouch, you are hurting me!” What happened, and what will the physician do?
If the patient shows nonverbal and verbal signs of pain when the catheter balloon is being inflated, this could indicate that the catheter has not been advanced fully to the bladder and might still be in the prostatic urethra. Stop the balloon inflation, allow the fluid to flow back into the syringe, and then advance the catheter farther in before attempting to reinflate the balloon.
- You watch the urine drain into the bag and note that the amount is approaching 500 mL. What do you do at this time?
Be sure you know the institutional policy regarding the amount of urine that can be drained from the bladder at one time. Some policies restrict the amount of urine because of the belief that rapid decompression of the bladder can lead to a vasovagal response with unstable BP and bladder spasms. However, there is no evidence to support this practice. If there is a restriction, amounts vary from 500 to 1000 mL. Otherwise, allow the bladder to empty fully.
- After the catheter is in place, the ED physician writes orders to discharge M.B. with instructions to see his primary care provider (PCP) on the following day. It is your responsibility to give discharge instructions. Outline your care plan.
- Explain how to empty the Foley catheter without contaminating the drainage bag.
- Instruct M.B. to keep the bag below his waist to prevent reflux of urine into the bladder.
- Explain how to check the tubing for mechanical obstruction if urine ceases to collect in the bag.
- Instruct him when to contact the physician or go directly to the ED; for example, when urine is the consistency or color of tomato juice, when there’s no urinary drainage, or when pain is unrelieved by acetaminophen (Tylenol) as per labeled product instructions. Explain to the patient that acetaminophen intake should not exceed 4 g (4000 mg) per 24 hours in a patient with a healthy liver, to avoid liver damage and toxicity.
- The next day, M.B. is seen by his PCP, who changes M.B.’s medication to alfuzosin (Uroxatral). The catheter will be discontinued 2 days later. What teaching is essential regarding this new medication?
- Alfuzosin needs to be taken in the morning.
- This medication might cause fainting when he first starts taking it. c. M.B. needs to take each dose on an empty stomach.
- M.B. can stop taking the alfuzosin once the urinary symptoms subside.
Answer: B
Alpha-blocking drugs, such as alfuzosin, might cause orthostatic hypotension and first-dose syn-cope. M.B. needs to take special care when changing position and report any dizziness, lighthead-edness, or weakness. It needs to be taken with food and is usually taken at bedtime. The medication needs to be taken even after urinary symptoms improve.
RUBRIC
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