Nurses’ Notes
Day 1 0800: Client admitted last evening from hospital with indwelling urinary catheter in place secondary to urinary retention. Upon entering room client found attempting to get out of bed unassisted stating “I need to feed the cat.” Client also grabbing at lower back yelling “it hurts.” Lungs clear to auscultation. Bowel sounds hypoactive x4 quadrants. Indwelling catheter draining cloudy yellow urine. Temp 100.1 F/37.8 C, P 96, RR 16, BP 122/68
➢ Select the orders from each of the categories the nurse anticipates including in the plan of care. Each category may have more than one order.
Categories
Orders
Nursing
◻ Monitor intake and output
◻ Discontinue catheter*
◻ Apply vest restraint
◻ Obtain urine culture
Medications
◻ Administer clindamycin
◻ Administer docusate sodium
◻ Administer donepezil
◻ Administer sertraline