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Urinary Catheterization Skills and Reasoning Case Study- Sheila Dalton 52 years old
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Urinary Catheterization Skills and Reasoning Case Study- Sheila Dalton 52 years old
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Urinary Catheterization Skills and Reasoning Case Study- Sheila Dalton52 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
•Clinical Judgment
•Patient Education
NCLEX Client Need Categories Percentage of Items from EachCovered 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: 152/82BP: 138/80 Duration: ongoing the past hour
O2 sat: 95% room airO2 sat: 96% room airAggravate: 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)
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