Question

Scenario 2: It is now 11:30 pm. You are caring for a client with an indwelling urinary catheter (14fr). You are emptying the collection device and measure a total of 130mL of cloudy urine. You enter the amount and notice that there has not been any other output charted since 3pm, which was 275mL. You check the tubing for any kinks and do not find any. The Foley remains secured and in place. The client’s abdomen is distended and firm over the suprapubic area. The client complains of tenderness with palpation and communicates an urge to void. You notify the on-call physician (Dr. Watt) at 11:49 pm and receive an order to irrigate the catheter with normal saline PRN for decreased urine output. After irrigating the catheter with 50mL NS, urine flows into the collection device. You empty 280mL of dark yellow urine. The patient reports relief of pain and no longer has the urge to void. You also note that the suprapubic region is no longer distended.

Document the following:

• Physician notification •

Telephone order •

Nursing intervention and any other information you feel is necessary to include.

Answer 1

Physician notification:

11:49 PM: Notified the physician regarding the urine output of the client at 11: 30 PM was 130 ML and cloudy. Informed the physician that The last urine output was mentioned at 3 Pm which was 275 ml. Checked for any tube kinking and found none, cathether No 14 secured and in place. On examnation the client's abdomen is distended and firm over suprapubic area. There is tenderness with palpation and the client complains of the urge to void.

Telephone order:

11:49 PM: The on call physician Dr Watt ordered to irrigate the catheter with normal saline PRN for decreased urine output.

11:30 PM: Nursing intervention:

Ascertained quantity, frequency, and character of urine, such as color, odor.

Reviewed previous patterns of urine output.

Assessed vital signs.

Monitored the time intervals between emptying the collection device and documented the quantity voided.

Palpated and percussed suprapubic area.

Examined verbalization of discomfort, pain, fullness and urge to void

Assessed for patency and kinking of the catheter

Maintained the drainage tubing kink-free.

11:49 PM: Irrigated the catheter with 50mL NS as per advice over the phone from the on call physician Dr Watt

Emptied 280mL of dark yellow urine.

Palpated the suprapubic region and is no longer distended.

Patient reports relief of pain and no longer has the urge to void.

Secured the catheter.

Informed the patient and significant other to observe the different signs and symptoms of bladder distention like reduced or lack of urine, urgency, hesitancy, frequency, distention of lower abdomen, or discomfort.