Question

Sandy Docker is a 25-year-old patient admitted for a cholecystectomy. Sandy recently lost 75 lb on a low-calorie diet. During her weight loss she developed upper back and abdominal pain, particularly after meals. She was diagnosed with gallstones and scheduled for surgery. Her pre-op orders were written last night at 2000 and include:

a. IV NS at 125 mL/hr

b. Cefazolin 1 g IV 60 minutes before surgery

c. Foley catheter

d. Intake and output

e. NPO at midnight

It is 0600. Your patient is scheduled for the OR at 0830. Your 12-hour shift ends at 0700. Fluid intake on your shift included:

* 8 oz tea at 1900

* 4 oz jello at 2100

* 12 oz water at 2330

Output was not measured but patient states she voided a large amount of clear, pale yellow urine at 0530.

While you are inserting the urinary catheter, the RN inserts the IV (20 g cathlon) in her left hand. She starts NS at 125 mL/hr.

The patient will be leaving for the OR at 0800.

For this case scenario, you will provide the following documentation:

• Nursing notes documenting your insertion of the foley catheter

• Peripheral IV record

• 24 hour fluid balance record

Answer 1

Nursing documentation including

Foley's catheter insertion done under strict aseptic technique.No adverse effects occur.Patient comfortable.Checked the patency.

Peripheral IV record

IV(20g catholin) inserted in the left hand.

put adhesive tape

check the patency

put date and time

checked for inflammation

24hr fluid balance

24oz oral intake upto 12 midnight

from 6am to 7am 125ml IV given

output not measured by the patient