Urinary Catheterization Skills & Reasoning Suggested Answer Guidelines Sheila Dalton, 52 years old

Interrelated Concepts (In order of emphasis)  Clinical Judgment  Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment  Management of Care 17-23%   Safety and Infection Control 9-15%  Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12% Physiological Integrity  Basic Care and Comfort 6-12%  Pharmacological and Parenteral Therapies 12-18%  Reduction of Risk Potential 9-15%   Physiological Adaptation 11-17%  This study source was downloaded by from CourseH on :38:39 GMT -06:00 Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. History of Present Problem: Sheila Dalton is a 52-year-old Caucasian female who has a history of chronic low back pain. She had a posterior spinal fusion of L4-S1 yesterday and is postoperative day (POD) #1. Her pain is controlled at 2/10 and requires hydromorphone 0.5-1 mg IV every 4 hours. She is able to stand and sit in a chair with assistance. Her indwelling urinary catheter was discontinued six hours ago and she has not voided since the catheter was removed. Sheila is tolerating oral fluids and has had an oral intake of 1000 mL in the past eight hours. Current Complaint: Two hours later, Sheila puts on her call light and states that she is having moderate pain/pressure above her pubic bone that she has not had before. What data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Data-Patient Story: Clinical Significance: Her pain is currently controlled at 2/10 and requires hydromorphone 0.5-1 mg IV every 4 hours. Her Foley catheter was discontinued six hours ago and she has not voided since the catheter was removed. Sheila is tolerating oral fluids and has had 1000 mL the last eight hours. Though hydromorphone is commonly given for postoperative pain, a urologic side effect of opiates is urinary retention. Clustering additional clinical data in this scenario will make this problem evident. You would expect to have a first void within 6 to 8 hours after a catheter is removed. No void six hours after removal is a clinical RED FLAG that needs to be recognized by the nurse. This is an adequate amount of oral intake that should result in urine formation. Accurate Is and Os would show a + balance, meaning that Shelia has had more fluid in than out RELEVANT Data-Current Complaint: Clinical Significance: Moderate pain/pressure above her pubic bone that she has not had before. With any onset of pain that is new and different, the nurse must ask and determine why. Nurse must investigate the cause by gathering information about the pain and completing a focused physical exam In this scenario, new onset of low abdominal pain/pressure sensation is most likely due to a distended bladder caused by urinary retention. ***Emphasize the importance of pathophysiology and understanding the mechanism of action of narcotic pain medications and how this can influence the development of urinary retention. Nursing Assessment Begins: Current VS: Most Recent VS: Current WILDA: T: 99.4 (oral) T: 98.9 (oral) Words: pressure/ache P: 90 (reg) P: 72 (reg) Intensity: 8/10 R: 20 (reg) R: 18 (reg) Location: lower abdomen/suprapubic BP: 152/82 BP: 138/80 Duration: ongoing the past hour O2 sat: 95% room air O2 sat: 96% room air Aggravate: nothing Alleviate: nothing This study source was downloaded by from CourseH on :38:39 GMT -06:00 Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. What clinical data do you NOTICE that is RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: P: 90 (reg) BP: 152/82 Words: pressure/ache Intensity: 8/10 Location: lower mid abdomen/pelvic Duration: ongoing the past hour Aggravate: nothing Alleviate: nothing Though her heart rate is not technically tachycardic, trending clinical data show the heart rate is elevated and most likely due to physiologic discomfort. Also, patient is resting in bed and on pain medication so an elevated HR should be investigated Though her blood pressure is mildly elevated, when compared to the most recent reading, it, too, is trending upward. Though blood pressure and heart rate do not always increase with acute pain, it is commonly seen in clinical practice and is the most obvious reason for this upward trend. New onset of moderate to severe pain that is a pressure sensation over the suprapubic area is consistent with the pain seen with urinary retention. The nurse needs further data collection and assessment to confirm this potential problem. RELEVANT Assessment Data: Clinical Significance: GENERAL APPEARANCE: Appears anxious, uncomfortable, tense body posture in bed GI: Lower suprapubic area tender and firm to palpation, bowel sounds active and audible per auscultation in all four quadrants GU: Has not been able to void since catheter discontinued six hours ago This nonverbal body language confirms that she is uncomfortable and is consistent with the level of pain she reports. The nurse must understand the influence of anxiety in this scenario. If the patient is fearful and obsessing over her inability to urinate this can hinder her ability to void. Help the patient calm down and use relaxation techniques or distraction to help minimize anxiety that is present. Performing an assessment and identifying that her lower abdomen/pelvic area is firm and tender to LIGHT palpation is consistent with urinary retention as the most likely cause. Abdominal pain can also be caused by an ileus but active bowel sounds make this unlikely. Clustering all of the data that has been collected, urinary retention post discontinuation of an indwelling urinary catheter is the most likely source of her pain. 1. What additional clinical data do you need to collect to identify the primary problem to guide your plan of care? (Management of Care) Current Assessment: GENERAL APPEARANCE: Appears restless and appears uncomfortable, tense body posture in bed RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Lower suprapubic area tender and firm to palpation, bowel sounds active and audible per auscultation in all four quadrants GU: No urine output since indwelling urinary catheter discontinued six hours ago SKIN: Skin integrity intact, 5 cm lateral incision down the lumbar spine with 4 steri-strips intact, 4 x 4 gauze dressing dry, intact with scant amount of sero-sangineous drainage, no odor, edges well approximated, surrounding tissue without redness To definitively determine if urinary retention is present, a bladder ultrasound must be obtained by the nurse to determine the amount of residual urine currently in the bladder. If the patient is able to void, the residual amount of urine in the bladder must be ascertained. This study source was downloaded by from CourseH on :38:39 GMT -06:00 Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. 1. INTERPRETING relevant clinical data, what is the primary problem? What primary health related concept(s) does this problem represent? (Management of Care/Physiologic Adaptation) 2. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND? (Management of Care) Nursing PRIORITY: Empty the bladder! Clinical reasoning captures the essence of the current problem. Simply stating the obvious problem in non-NANDA language concisely captures the nursing priority! PRIORITY Nursing Interventions: Rationale: Expected Outcome: Assess location, level of pain and the number of hours since the last void Assess for presence of firmness and distention in the suprapubic area Give patient opportunity to void. Sit upright if tolerates and run water in the sink, provide privacy If patient does void, measure amount and then repeat bladder ultrasound. If the bladder is distended because of retention, it typically is hours after the last void. This time frame needs to be determined. Firmness and distention in the pelvic area is consistent with a distended bladder. Catheterization is a last resort, and the patient should be given the opportunity to void. Being upright is more natural and will facilitate expression of urine if patient is able to void. The gold standard to determine if urinary retention is present post-void if able to do so. Follow institution policy. Location and level of pain is determined. Firmness is expected if urinary retention is suspected. May not be able to void if retention is present Bladder ultrasound will confirm high residual volume if retention is present. Problem: Pathophysiology of Problem in OWN Words: Primary Concept(s): Urinary retention When emptying of the bladder is impaired, urine continues to accumulate and the bladder becomes over distended. Acute urinary retention is the most common postoperative complication. In addition to the inability to urinate, they may also experience overflow incontinence and able to urinate 25 to 50 mL of urine at frequent intervals (Berman, Snyder, & Frandsen, 2016) “Postoperative urinary retention (PUR) is a common complication of surgery and anesthesia. The risk of retention is especially high after anorectal surgery, hernia repair, and orthopedic surgery and increases with advancing age. Certain anesthetic and analgesic modalities, particularly spinal anesthesia with long-acting local anesthetics and epidural analgesia, promote the development of urinary retention.” (Darrah, Griebling, & Silverstein, 2009, p.465).