Documentation Assignments
1. Document your initial focused urinary assessment of Ms. Johnson.
After obtaining Ms. Johnson’s 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 cath...
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wasKimJohnson
Documentation Assignments
1.Document your initial focused urinary assessment of Ms. Johnson.
After obtaining Ms. Johnson’s 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 procedure 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 would need to be assessed for color, odor and appearance to see if there are any
signs of infection. The simulation did not see anything about these aspects however. This would be an important part of the assessment since the patient cannot feel any burning or pain while urinating which could indicate a UTI. Therefore, the nurse relies on the urine to show if there is any infection present.
2.Document Ms. Johnson’s straight catheterization procedure.
The first step taken was applying gloves a preparing for urinary catheterization. However, the nurse thought that the tip may have been contaminated by Ms. Johnson’s leg so the urinary catheter was discarded. The nurse then removed the gloves and performed hand hygiene. Gloves were applied again and another urinary catheter was prepared. Urinary catheterization was performed as indicated by the order and then discarded. The patient’s urine output was assessed. Gloves were removed and hand hygiene was performed.
For step by step of the procedure, Ms. Johnson was first placed supine with her legs spread and knees bent. She then had her gentile cleansed and dried. After that the nurse opened the 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 their sterile gloves. The nurse proceeded to cleanse the labia from far side, near side, and then the middle. The swabs were discarded and the spread the labia with their non-dominate hand and picked up the catheter with their 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 intake and output, bladder management program, and activities, safety, and fall risk. The patient was receptive of all education presented and demonstrated a readiness for enhanced knowledge. She asked questions regarding intake
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