Question

You are working on a medical unit in an acute care hospital and had been assigned to care for M. Z., an 89-year old widow. She was admitted after experiencing a sudden onset R-sided weakness, followed by mental confusion and expressive aphasia. This combination of factors leads to problems with urinary continence. Foley catheter is placed to facilitate urinary drainage.

1. Insertion of the catheter places M. Z. at risk for a urinary tract infection (UTI). What are the symptoms of urinary tract infection?
2. If M. Z. did not have a Foley catheter, how would your list of signs and symptoms be different?
3. M. Z. developed diarrhea. What special instructions are you going to give the nursing assistant assigned to give basic care to M. Z.?
4. The nursing assistant reports that M. Z.’s 8-hour intake is 520 mL, the output is 140 mL. Is this significant? Generate at least 3 possible factors that could account for the difference. Next to each identify which item would be assessed and how?
5. What factors will you teach M. Z. and her daughters about her Foley catheter?
6. You are the nurse assigned to M.Z.’s care. You notice that the nursing assistant emptying the gravity drain is not wearing personal protection devices. You also observe that the spout is contaminated during the process. What issues need to be considered in protecting M. Z.’s safety? Describe your actions in working with the nursing assistant.
7. M. Z. is scheduled for a chest x-ray. You help the transportation technician transfer M. Z. onto a stretcher and notice that he raises the gravity drain to chest level to make sure the tubing is not caught to anything, then, lays the bag on its side on top of M. Z.’s legs. The air vent becomes wet with urine. What breach of technique have you witnessed and what is your next responsibility?
8. As you are changing M. Z.’s Foley gravity drain, she says to you, “Honey, I’m just a lot of trouble. I’m not much use to anyone anymore. Why don’t you just let me go?” How are you going to respond?

Answer 1

1)Symptoms of urinary catheter infection.

a)A bladder infection may cause pelvic pain.

c)Blood in urine

e)cloudy urine

f)Fever and fatigue

g) Cramping or vaginal irritation

2)If therevis Foley's how would the signs and symptoms to be different?

In the absence of Foley's the symptoms will be different; patient may feel

a)A frequent intense to pee but little amount will come out.

b)Pelvic pain

c)Foul smelling of urine

d)cramping and vaginal irritation

3)During the diarrhoea what are the instructions to be given?

a)Have to provide immediate care

b) Replace the fluid by giving iv fluids if can't take orally.

c) Administer antidiarrhoeal drugs.

d)Rest

_Diarrhoea will cause impaired skin integrity, and will cause to develop ulcer on the skin, so have to clean affer opening bowel, clean the vaginal area also otherwise it will leads to UTI.

4)8hours intake is 520 ml output is 140ml is this significant?

No it is not significant,because for normal adult person normal output is 1_2 ml/kg/hour.

Calculation:urine output×patient weight×hours

140×89×8=0.20ml/kg/hr

Fluid balance is 380 ml

_Three possible facters that could account for the difference?

a)Due to diarrhoea

b) Urinary tract infection

c)Any blockage in catheter or any leakage

d)Any kinking in catheter

_Which item would be assigned and how?

_There will be fluid loss dring the diarrhoea, have to see the catheter tubing,urine leakage or any kinking. We can see urine leakage by keeping a under pad and see for any leakage,flush the catheter and see for blockage.

5)What factors will you teach the patient and her daughter about Foley's catheter.

Teach them regading need for the catheter, and care for the catheter.Should not pull the catheter,take care during turning the patient. Always keep the drainage bag below the bladder level.Take care of the catheter while giving bathing and clean the area regularly.

6)While handling and emptying the Foley's catheter have to use personal protective gloves to prevent infection.Because the person emptying the urine bag for many patients it will leads to spread of infection.and any contamination occure during emptying it will leads to urinary tract infection.For that wear the personal gloves for each patients.and should not keep the bag on the floor.

7)Should not take the bag above the bladder level it will leads to backflow of urine and cause infection,before transferring or turning the patient we have to clamp the catheter so it will prevent from backflow.If the bag is not in under bladder level take it into under the bladder level,and educate them that how to handle the bag with care.

8)Patient is saying she is already in trouble and live her let it go, Support the patient with good talking like we are the persons to take care for you so we can do anything for your situation so don't worry about that ,feel comfortable to say your problems,now you are unable to do the things that's why we are here to help you so don't sorry for that,everybody is in same situation n their disease conditions.