KimJohnson_DA(1) (1) (1),LATEST 2021 GRADED A.

Kim Johnson Documentation Assignments 1. Document your initial focused urinary assessment of Ms. Johnson. After I obtained the patients vital signs I asked the patient about her micturition output and color. The patient stated that both were normal. I confirmed this by assessing the urine output following utilizing straight catheritization. I The patient tolerated the catheterization process well. I educated the patient on the bladder management program and the patient was receptive to this information. I checked the patients skin turgor which was normal and asked the patient if she was in any pain in which the patitent stated there was none. Since the patient cannot feel the sensation of burning or discomfort when urinating due to her condition, it is necessary to rely on the urin color, odor, appearance and culture to show if there are any infections present such as a UTI. 2. Document Ms. Johnson’s straight catheterization procedure. I performed hand hygiene and put on gloves to prepare the urinary catheterization. I had Ms. Johnson lay in a dorsal recumbent position (supine with legs slightly bent and apart). Upon setting up equiptment and starting procedure the tip of the catheter may have become contaminated upon touching the patients leg. I discarded the equiptment, performed hand hygiene, put on new gloves and gathered new urinary catheterization equiptment. I cleansed the genitile area then lubricated the catheter with sterile syringe attached. I draped the patients legs and placed the kit between the patients legs. I donned sterile gloces and cleansed the labia from the far side with one swab, near side with another and final swab for the middle. With my non-dominant hand, I spread the labia and used my dominant hand to insert the catheter until I saw micturition flow. After micturition was taken out, I removed the catheter and cleansed the patient a final time. I removed my gloves and performed hand hygiene. 3. Record patient education provided for Ms. Johnson in the chart. I educated the patient on intake and output as well as letting me know when she is intaking fluids so that we can record the output for the time being. The patient verbalized understading and asked questions regarding that and the bladder management program. The patient did show some concern about how she would be abe to manage on her own. I also educated the patient on bladder management program and different activites, safety and fall risks. The physical therapist will also aid in education and is scheduled to see the patient at 1030.