(1) Document your initial focused urinary assessment of Ms. Johnson.
After obtaining Ms. Johnson vital signs, the patient was asked about her urine output and color. She stated that both were normal which would be confirmed by assessing the urine output following catheterization. The patient tolerated the straight catheterization and was educated on her bladder management program. The nurse also checked the skin turgor in which the skin snapped back quickly and did not tent. The patient reported no pain. The urine was clear and yellow with no odor, assessed after straight catheterization was complete. Patient does not have lower sensation so unable to assess burning or pain while urinating which are systems of urinary tract infection.
(2) Document Ms. Johnson’s straight catheterization procedure
The first step taken was applying glove in preparation for urinary catheterization, But the nurse believed that the tip was contaminated by Ms. Johnson leg, so the catheterization was discarded. The nurse then removed the gloves and performed hand hygiene. The gloves were put on and another catheterization was performed again as indicated by the order and discarded. The patient urine output was assessed, gloves were removed and another hand hygiene was performed.
Based on the step by step of the procedure, Ms. Johnson was first placed supine with her legs spread and knee bent. She then had her gentle cleansed and dried. After that, the nurse opened her catheterization kit sterilely and all the components. The catheter was then lubricated with the sterile syringe attached. Ms. Johnson was draped with the kit placed between her legs and the nurse donned with her sterile gloves. The nurse proceeded to cleanse the labia from far side, near side, then the middle, The swabs were discarded and spread the labia with her non dominate hand, and pick up the catheter with her dominate. They then proceeded to insert the catheter until urine began to flow. After the urine was expelled, the catheter was removed and the patient was cleansed again before being positioned for comfort.
(3) Record patient education provided for Ms. Johnson in the chart.
The patient received education on input and output, bladder management program, and activities, safety and fall risk. The patient was receptive of all education, and demonstrated a readiness for enhanced knowledge. The patient educations provided for Ms. Johnson in the chart are bladder management, urinary catheterization, intake and output, fall risk, use of pulse oximeter, positioning.