Nursing Care Plan : Hematuria/Acute CHF

Nursing Assessment:
Our patient is a 93 year old woman that came
to the ED with hematuria , SOB, and urinary
retention secondary to clots. She was admitted
on last Friday 02/10/17. She indicated that she
noticed some mild blood in her urine and it
became much heavier. Her daughter also
reported that she noticed blood clots in her
mother's urine. The client admits to having
sensation to urinate but has been unable to do
so. She also has a history of CHF as well as
Kidney Cancer that was embolized but didn't
require any further treatment. She underwent
renal artery embolism on Monday 02/13/17
that was successful and her gross hematuria is
improving. They are changing out her foley to
a 3-way for bladder irrigation. Her urine
cultures show no growth, She has no
complaints of pain or SOB currently. She is not
on any anticouagulants.
Diagnostic Data:
Physical Examination:
Reported as of 02/15/17
CBC: normal
Weight: 50.5kg
Temp: 98.8
HR: 61bpm dark red,
Urinalysis:
RR: 18bpm
BP: 143/65
cloudy urine, ph: 7.0,
SpO2: 99%

Specific Gravity:for
Catheterrization L urinary retention yielded
300 mL dark red urine; foley in place. Changing
out floeyUrine
<1.005 to a 3-way
WBC: for bladder irrigation

H159., Glucose H

122, Ketone: normal

(15) RBC:L 3.61;

WBC: H 110, Cardiac

BNP: H 563, Platelets:

L 144
 Assessment
Assess voiding pattern (frequency and amount).
Compare urine output with fluid intake. Note specific
gravity.
Urgency
Encourage adequate fluid intake (24 L per
day), avoiding caffeine and use of aspartame, and limiting
intake during late evening and at bedtime. Recommend
use of cranberry juice/vitamin C.
Observe for cloudy or bloody urine, foul odor.
Dipstick urine as indicated.
Cleanse perineal area and keep dry. Provide
catheter care as appropriate.
Obtain periodic urinalysis and urine culture and
sensitivity as indicated.
Indwelling catheter is used during acute phase
for prevention of urinary retention and for monitoring o/p
Rationale:
identifies characteristics of bladder function
(effectiveness of bladder emptying, renal function, and
fluid balance). Note: Urinary complications are a major
cause of mortality.
Strong desire to void may be caused by
inflammations or infections in the bladder or urethra
Sufficient hydration promotes urinary output and
aids in preventing infection
Proper perineal hygiene decreases risk of skin
irritation or breakdown and development of ascending
infection.