Question

Patient Name: Sheila Dalton, 52 years old

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 and a walker. 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.

Personal/Social History:

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 history of present problem and current complaint do you NOTICE as RELEVANT and why is it clinically significant?

RELEVANT Data: Patient Story

Clinical Significance:

RELEVANT Data Current Complaint

Clinical Significance:

Vital Signs: T:99.4, BP 152/82, HR 90, RR 20 SaO2 95% on room air

Pain 8/10, Lower mid abdomen/pelvic, described as pressure/ache, pain has been increasing over the past hour, nothing makes the pain worse and nothing makes it better.

Physical Assessment

Appears restless and uncomfortable, tense body posture in bed

Head Face, Neck: Head is round, face symmetrical, neck range of motion intact, no swelling.

Eyes, Ears, Nose, Throat: eyes symmetrical, scleral white, conjunctiva is pink, teeth white, lips, tongue and oral mucous membranes are pink and moist, hearing intact

Neuro: Awake and Alert, Oriented X 4. Speech clear.

Respiratory: Respirations are easy and regular at rest. Respiratory rate is 20 breaths per minute. Lung sounds are clear. No adventitious sounds. She denies any shortness of breath

Cardiac: S1, S2 auscultated, rhythm regular. No chest pain.

Peripheral Vascular: Radial pulses and pedal strong and equal, skin of upper and lower extremities is warm, and color is appropriate for ethnicity, capillary refill of is less than 3 sections on fingers and toes.

Integumentary: Skin warm and dry. Skin turgor is brisk.

Braden Scale:

Sensory perception no deficit

Moisture no problem

Activity ambulates occasionally

Nutrition no problem

Friction and shear no problem

Musculoskeletal: Upper and lower extremities and are strong, with full range of motion.  

Morse Fall Scale

History of falling: no

Secondary diagnosis: yes

Ambulatory aid: walker

IV: yes

Gait/Transferring: assistance X 1

Mental status: intact

GI: Abdomen is round. Lower suprapubic area tender and firm to palpation. Bowel sounds in all 4 quadrants. Last BM was yesterday, soft brown stool.  

GU: Urinary catheter was removed 6 hours ago. Has not voided since catheter was removed

Mental Health: Behavior is appropriate for the situation. Coping well. He is retired.

Intervention (lines, drains, etc.): IV: saline lock left forearm, site clean and dry, dressing dry and intact.  

Wounds/Incisions/Ostomies: 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

What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?  

RELEVANT Vital Sign Data:

Clinical Significance

RELEVANT Physical Assessment Data:

Clinical Significance

What additional clinical data do you need to collect to identify the primary problem and guide your plan of care?

The bladder scan (ultrasound) is performed. Results indicate the urine volume in the bladder is 810 mLs. Sheila is unable to void despite being placed on the bedside commode with water running in the sink.  

INTERPRETING relevant clinical data, what is the primary problem? What is causing this problem? What is the potential complication if the nurse does not intervene?

Primary Problem

Etiology

Potential Complications

Is it appropriate to delegate a bladder scan to the PCT?

What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND? (What should you do now?

Priority Nursing Action

Rationale

Complete the SBAR Communication form based on all the information you have:

S

B

A

R

The Patient Care Provider orders a straight (intermittent) urinary catheterization.

Procedural Safety Principles

1. Review urinary catheterization and summarize essential steps and knowledge that the nurse will use in this scenario.

You are a new nurse, and this is the first time you have performed this procedure for a “real” patient. How should you proceed?

How many other staff will you likely need to ensure proper positioning and insertion with sterile technique? Explain your answer.  

What will you communicate to the patient to educate her about the need for urinary catheterization?

Define (CAUTI) and what evidence-based practices must be initiated to avoid it?

You successfully performed the urinary catheterization. 800 mL of clear yellow urine is obtained. Sheila states that her abdominal discomfort is relieved

What data do you NOTICE as RELEVANT and why is it clinically significant?  

Relevant Data

Clinical Significance

Reflect on Your Thinking to Develop Clinical Judgment

To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions:

What did you do well in this case study?

What knowledge gaps did you identify?

What did you learn?

How will you apply learning caring for future patients?

Answer 1

Most relevant data is history of not passing urine after removal of urinary catheter. Abdominal examination reveals tense lower abdomen which is firm, indicate full bladder.

Relevant vital sign data and it's significance :BP 152/82:can be due to the general discomfort produced by sympathetic overactivity.The same is applicable to heart rate of 90/min.Due to inability to pass urine patient is having some anxiety that produce hyperventilation, thats why she is having a respiratory rate of 20/min.

Relevant physical assessment data and Its significance :Lower suprapubic area firm and tender on palpation, it indicates the bladder is filled and being stretched by urine. Hence the patient is having post operative urinary retention. Intact skin integrity and presence of seosanguinous discharge indicate healthy wound.

Additional data required is ultrasound scan to confirm the presence of urine and amount of urine. The patient is suffering from post operative urinary retention. The primary management should include urinary catheterisation or suprapubic aspiration to drain the urine. Care must be given to avoid the same problem by giving drug like bethanacol.