1241: The client arrived at the medical-surgical unit six hours post-operative from a TURP. The client was alert and oriented to person, place, time, and situation. The client has a three-way indwelling urinary catheter and is continuously irrigated with isotonic saline. Urine output is ketchup-like with medium to large clots. The client reports the need to urinate and reported pressure in the pelvic region, described as spasms.
Intake – Continuous bladder irrigation: 550 mL
Output – Indwelling catheter: 975 mL
1257:
Blood Pressure 100/60 mm Hg
Temperature 98° F (36.7° C)
Heart rate 110/min
Respiratory rate 19 breaths per minute
Oxygen saturation 95% on room air
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The client is demonstrating signs and symptoms of [urinary catheter obstruction / hyponatremia / shock / urinary tract infection]
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