Urinary Elimination

The nurse is caring for an 82-year-old male who has been hospitalized after a fall.

Medical/Surgical History:
- History of Parkinson's disease x 10 years
- Hypertension x 20 years
- Coronary artery disease
- Heart failure
- Benign prostatic hypertrophy
- Fell 1 day ago sustaining a right femoral fracture

Social History:
- Smoked 2-3 packs of cigarettes per week, quit 10 years ago
- Denies use of alcohol or illicit drugs
- Lives alone

Family History:
- Mother died of a heart attack at age 83 years
- Father died from complications of Parkinson's disease at age 86 years
- No living siblings
- Widowed, 2 adult children, both healthy

Physical Assessment:
- Underweight male with BMI 18
- Frail in appearance
- Alert and oriented x 2, confused to time
- Moves upper extremities and left leg, grips and pushes weak
- Fine tremors of the hands
- Right leg immobilized in 5 pounds of skin traction
- Strong dorsalis pedis and posterior tibialis pulses bilaterally
- Capillary refill less than 3 seconds
- S1S2 heart sounds, fine crackles in the bilateral bases, moist cough
- Abdomen flat, hypoactive bowel sounds
- Last bowel movement yesterday
- Bladder moderately distended to palpation
- Voids "urgently" 30 mL every hour via the urinal, urine amber in color, and cloudy with foul smell. Some dribbling.

Medications:
- Lisinopril 10 mg daily by mouth
- Atorvastatin 40 mg daily by mouth
- Baby aspirin daily by mouth
- Carbidopa-levodopa 25-250 mg every 4 hours by mouth
- Amantadine 100 mg twice a day by mouth
- Acetaminophen and codeine 1 tablet every 6 hours PRN for pain

Nurses' Notes:

Vital Signs:

Laboratory Results:

Nurses Notes

12/3/XX

0830 - Morning assessment obtained. Client states, "I feel like my bladder is full, yet I don't make much urine each time I use the urinal."

0845 - Bladder scan performed with 600 mL of residual urine in the bladder. Review of the client's history, assessment, and lab reports cause concern. Provider notified of changes.

0905 - Received an order for an indwelling catheter to be placed and urine analysis and C&S to be sent to the lab. Procedure explained to the client with stated understanding.

0920 - Indwelling catheter placed by sterile technique; 550 mL cloudy urine drained. Catheter secured to the client's leg. Urine sample sent to the lab.

12/4/XX

0915 - Urine draining via indwelling catheter. No discomfort noted. Catheter care provided.

Vital Signs

12/3/XX

0830
- Temp: 99.6°F (37.5°C)
- HR: 98 bpm
- RR: 20 breaths/min
- SpO2: 95% on room air
- BP: 147/92 mm Hg
- Pain: 3 on 0-10 scale

Lab Results

12/3/XX

0630
- Sodium: 145 mEq/L (135-145 mEq/L)
- Potassium: 3.3 mEq/L (3.5-5.0 mEq/L)
- Calcium: 8.5 mg/dL (8.4-10.2 mg/dL)
- Phosphorus: 3.0 mg/dL (2.5-4.5 mg/dL)
- Magnesium: 2.0 mg/dL (1.6-2.2 mg/dL)
- BUN: 25 mg/dL (8-21 mg/dL)
- Creatinine: 1.8 mg/dL (0.5-1.2 mg/dL)

1030
- Urinalysis
- Color: Dark amber (pale yellow to deep amber)
- pH: 7.5 (5.0-9.0)
- Specific Gravity: 1.025 (1.002-1.030)
- Clarity: Cloudy (Translucent)
- Protein: 12 mg/dL (<20 mg/dL)
- Glucose: Negative (Negative)
- Ketones: Positive (Negative)
- Hemoglobin: Positive (Negative)
- Nitrite: Positive (Negative)
- Leukocyte esterase: Present (Negative)

What could be causing this client to have difficulty with emptying his bladder? Select all that apply.

- Enlarged prostate gland
- Parkinson's disease medications
- Pain medication
- Loss of privacy when urinating
- Excess fluid intake
- Bed rest
- Elevated creatinine level
- Elevated BUN

The factors that could be causing this client to have difficulty with emptying his bladder are: Enlarged prostate gland, Parkinson's disease medications, Pain medication, and Elevated BUN.

Enlarged prostate gland: The client's medical history includes benign prostatic hypertrophy (BPH), a condition characterized by enlargement of the prostate gland. BPH can obstruct the flow of urine from the bladder, leading to difficulty with emptying the bladder completely. This obstruction can result in urinary retention and symptoms such as urgency, frequency, and dribbling.

Parkinson's disease medications: The client is taking carbidopa-levodopa and amantadine for Parkinson's disease. Medications used to treat Parkinson's disease can have anticholinergic effects, which may contribute to urinary retention by relaxing the bladder sphincter muscle and impairing bladder emptying.

Pain medication: The client is taking acetaminophen and codeine for pain relief. Opioid medications, such as codeine, can cause urinary retention by reducing bladder contractility and delaying the sensation of needing to urinate.

Elevated BUN (Blood Urea Nitrogen): The client's BUN level is elevated at 25 mg/dL (normal range: 8-21 mg/dL). Elevated BUN levels can indicate impaired kidney function or dehydration, both of which can contribute to difficulty with urinary elimination. Dehydration can lead to concentrated urine, which may irritate the bladder and cause difficulty with emptying.

Other options:

Loss of privacy when urinating: While loss of privacy may contribute to stress or anxiety during urination, it is less likely to directly cause difficulty with emptying the bladder.
Excess fluid intake: Excess fluid intake can lead to increased urinary frequency and urgency but is less likely to cause difficulty with emptying the bladder unless it exacerbates underlying urinary retention.
Bed rest: Prolonged bed rest can contribute to urinary retention due to reduced mobility and decreased muscle tone, but it is not the primary cause in this scenario.
Elevated creatinine level: While an elevated creatinine level may indicate impaired kidney function, it is less likely to directly cause difficulty with emptying the bladder compared to other factors such as medication side effects or prostate enlargement.

Therefore, the factors that could be causing this client to have difficulty with emptying his bladder are: Enlarged prostate gland, Parkinson's disease medications, Pain medication, and Elevated BUN.