The nurse is caring for a patient who has had an indwelling urinary catheter inserted for the past 5 days.In reviewing and revising the plan of care,what is the most important nursing diagnosis for this patient?

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Anyone who has an indwelling catheter is at risk for infection.Indwelling catheters pose several risks: Failing to maintain a closed drainage system increases the risk for infection by allowing bacteria to enter the catheter,the catheter provides a pathway for bacteria to migrate up into the urinary system,the catheter irritates the mucosal lining of the urethra,which then creates a portal of entry for microbes.The longer the catheter remains indwelling,the higher the risk there is for the patient to develop a UTI.Although the patient may be embarrassed about having a catheter,a body image diagnosis (Disturbed Body Image)is rarely given priority over a basic need,such as remaining infection free.There are no data in the scenario to suggest actual Disturbed Body Image.A long-term indwelling catheter can cause irritation to mucous membranes,and sometimes to surrounding skin (Risk for Impaired Skin Integrity).Although the catheter may be a risk factor for Impaired Skin Integrity,that is less common and of a lower priority than Risk for Infection.Decreased urine output is primarily a problem of fluid intake or kidney function.Inserting a catheter does nothing to increase fluid intake,nor does it stimulate the kidneys to produce more urine.Therefore,it is not a risk factor for decreased urine output.If the patient had actual (instead of risk for)decreased urine output,a catheter might be inserted to relieve bladder pressure.However the appropriate diagnosis would then be Urinary Retention-an actual rather than a risk diagnosis.

The Nurse Is Caring for a Patient Who Has Had