Mrs. Jean Vallero is a 65 year old woman. She has been in the hospital for the past four days. She has a history of heart failure, fluid retention and diabetes. Due to her diabetes she has lost the sensation of needing to urinate at times. While she is in the hospital the nurse inserts an indwelling catheter. Mrs. Vallero’s output is clear yellow urine at 20 cc/hr or 480 cc per day. Mrs. Vallero’s physician decides to remove the catheter after two days so that she won’t develop a urinary tract infection (UTI). The nurse removes the indwelling catheter at 2:00 pm. At bedtime (10:00 pm) Mrs. Vallero still had not voided on her own.
What can the nurse do at this point?
What nursing diagnoses do you possibly have?
What nursing interventions can be used?
How will you evaluate the effectiveness of the interventions?