Which of the following nursing diagnoses would be appropriate for the nurse to select for a client who has a retention catheter if the drainage bag is found lying on the floor?
1. Risk for Impaired Skin Integrity related to catheter placement
2. Risk for Infection related to improper handling
3. Self-Care Deficit related to presence of a retention catheter
4. Urinary Incontinence related to an obstruction
2. Risk for Infection related to improper handling
Rationale:
The floor is the dirtiest place in any establishment, so the drainage device should never be placed on the floor. There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found. Even with a catheter in place, a client can still administer self care; the catheter does not restrict one from practicing basic hygiene. The client may need some assistance. The placement of a catheter prevents incontinence; it does not add to it. Patency of the catheter ensures flow, not obstruction.
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