Sheila_Dalton_case_study

SHEILA DALTON Urinary Catheterization Skills & Reasoning Urinary Catheterization Skills & Reasoning 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 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%  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: RELEVANT Data-Current Complaint: Clinical Significance: 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 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 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. 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: RELEVANT Assessment Data: Clinical Significance: 1. What additional clinical data do you need to collect to identify the primary problem to guide your plan of care? (Management of Care) 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): 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: opyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Procedural Safety Principles 1. Review urinary catheterization and summarize essential steps and knowledge that the nurse will use in this scenario. (Management of Care) 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) T Chis study source was downloaded by from CourseH on :31:24 GMT -05:00 What does the Nurse Need to KNOW to Be Safe in Practice: 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. You obtain 800 mL clear, yellow urine after performing a straight catheterization. Sheila states that her abdominal pain is no longer present. Evaluation: 1. What data do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Data: Clinical Significance: 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: 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: 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: T Chis os ptu y d r y igso hu t rc ©e w 2a 0s 1do 8w Knl eoa it d hed Rby is 1 c 0 h00 e0 r 0 , 8 d3 / 5 b36 /a15 K05 ef i r t o hm RC No . u c rs oemHe . ro. Aco llm Ro i n g0 h9 t - s 30 r - e20 s 2 e2 r 0 v 5 e:3 d1 . :24 GMT -05:00