Urinary Catheterization Skills and Reasoning Case Study- Sheila Dalton 52 years old

Urinary Catheterization Skills and Reasoning Case Study- Sheila Dalton 52 years old Primary Concept Elimination Interrelated Concepts (In order of emphasis) • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Covered in Category/Subcategory 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%  Sheila Dalton, 52 years old Urinary Catheterization 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 can 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 IMPORTANTT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) IMPORTANT Data-Patient Story: Clinical Significance: • Hydromorphone q4h per IV • 1000 mL of fluid intake w/ no output • Spinal infusion • Could be stopping the urge to void • Adequate fluid intake but no output • Anesthesia from surgery could be having adverse affects on patient IMPORTANT Data-Current Complaint: Clinical Significance: • Pain is moderate • Pressure above pubic bone ,was not present before surgery • Pain could be caused by fully distended bladder due to no output of urine Nursing Assessment Begins: YOU COLLECT THE FOLLOWING ASSESSMENT. 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 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 serosanguineous drainage, no odor, edges well approximated, surrounding tissue without redness What clinical data do you NOTICE that is IMPORTANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) IMPORTANT VS Data: Clinical Significance: • Temp rising • BP, HR, and pulse rising • Could be due to infection being present • Could be a result of the pain IMPORTANT Assessment Data: Clinical Significance: • Catheter removed 6 hrs ago, no urinary output since • Suprapubic (upper pubic) area firm and tender to palpation • No output can cause serious complications to urinary system • Due to bladder being distended from urinary retention 1. What additional clinical data do you need to collect to identify the primary problem to guide your plan of care? (Management of Care) After performing a bladder ultrasound, the residual volume in the bladder is 810 mL. Sheila is unable to void despite being placed on the bedside commode with water running in the sink. 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) Problem: Pathophysiology of Problem in OWN Words: Primary Concept(s): Urinary retention Related to general anesthesia , as evidenced by distended bladder and inability to void 2. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: • Encourage client to try to void at least 1x every hour • Catheterize and measure urine • Decompress bladder slowly • Frequent attempts may help patient void • To decompress bladder and avoid UTI • To avoid shock • Patient may or may not void • Voiding of urine • Avoidance of shock by slow decompression of bladder There is a standing health care provider’s order to straight catheterize the patient if >350 mL residual urine volume is in the bladder. The nurse decides to perform a straight “Cath” at this time. Procedural Safety Principles 1. Review urinary catheterization and summarize essential steps and knowledge that the nurse will use in this scenario. (Management of Care) Chapter 57 Surgical Asepsis p. 835- 837, Nursing Procedures: p. 841- 847. Also, Skills Packet Urinary Catherization. 2. What will you do if you have not done a catheterization before in the clinical setting? (Safety and Infection Control) 3. How many other staff will you likely need to ensure proper positioning and insertion with sterile technique? (Safety and Infection Control) 4. What will you communicate to the patient to educate them about the need for urinary catheterization? (Health Promotion and Maintenance 5. Define (CAUTI) and what evidence-based practices must be initiated to avoid it? (Safety and Infection Control) Evaluation: 1. What data do you NOTICE as IMPORTANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) IMPORTANT Data: Clinical Significance: • Suprapubic pain is not present any longer • Urine is clear with a yellow tint • Catheter removed urine resulting in relief of pain • Urine has no abnormalities 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: • Client is stable and comfortable • Sufficient amount of urine has been drained • Record input & output • Monitor bladder for distention and discomfort 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: Continue to treat and monitor postoperative pain as well as the possible reoccurrence of urinary retention. PRIORITY Nursing Interventions: Rationale: Expected Outcome: • Monitor bladder for discomfort & distention • Provide pain medicine PRN or as needed • Record input & output • Check to see if patient is voiding • Ensure bladder does not become full and distended again • Keep the client’s pain at a manageable level • Ensure enough urine is being voided • You will be able to see if the client is actually voiding urine • Bladder will not distend causing pain to abdomen • Client will be comfortable • Know if there is urine being retained in the bladder • Client will void and there will be no need for catheterization again Use Reflection to THINK Like a Nurse What did I learn from this scenario? How can I use what has been learned from this scenario to improve patient care in the future? What Did You Learn? How to Use to Improve Future Patient Care: • General anesthesia can affect the bladder and the urinary system • Straight catheter is only to be used one time • Monitor input & output anytime client has a procedure that involves the use of general anesthesia. Check for discomfort and bladder distention • This should be your LAST resort. Use all other options before catheterization