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

1) Gently insert the catheter into the urethra opening until urine begins to flow out.Then insert it about 2.5 centimetres more. Let the urine drain into the container or the toilet.Secure the drainage bag on the bed frame below her bladder level. Provide perineal care, then remove your gloves and wash your hands. Document the date and time, the catheter size and type, and the patient's response. Record the amount, odor, color, and consistency of urine and whether you obtained a specimen.

2) Document the date and time of the infusion when extravasation was noted, the type and size of catheter, the drug administered, the estimated amount of extravasated solution, and the administration technique used. Document the patient's signs and symptoms, treatment, and response to treatment.
Assess the IV insertion site and transparent dressing on IV site. Check IV insertion site for signs and symptoms of phlebitis or infection. Check for fluid leaking, redness, pain, tenderness, and swelling. IV site should be free from pain, tenderness, redness, or swelling.

3) 24 hour fluid balance record is:- intake 2000ml.