Nursing Skills & Reasoning

Urinary Catheterization
1. Which findings from the patient story are most important and noticed by the nurse as clinically significant?
Most Important Findings Clinical Significance
- Postoperative day #1 Postoperative patients are at risk for urinary retention due to
- Hydromorphone 0.5-1 mg IV q4h anestesia, immobility, and the use of opioids. 875 mL of fluid
- Oral fluid intake of 875 mL in the intake with 0 mL of urine output indicates urinary retention.
past 8 hours and has not voided since
the catheter was removed 6 hours
ago

2. Which findings from the present problem are most important and noticed by the nurse as clinically significant?
Most Important Findings Clinical Significance
New onset pain/pressure (moderate) Sign of urinary retention
above pubic bone

Patient Care Begins

3. Which current vital sign findings are most important and noticed by the nurse as clinically significant?
Most Important Data Clinical Significance
Slight increase in temperature and These changes could be a sign of pain and/or discomfort
respiratory rate and elevated BP

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 Nursing Skills & Reasoning

4. What assessment data are most important and must be recognized as clinically significant by the nurse?
Most Important Data Clinical Significance
- Restless and uncomfortable, Indicates the patient is in significant pain
tense body posture
- Pain 8/10 in the lower abdomen/
suprapubic

5. What additional data does the nurse need to collect to identify the current problem?
Additional Data Rationale
- Bladder ultrasound To differentiate urinary retention from other causes of abdominal
- Attempts to void/response pain and to confirm diagnosis before implementing interventions
- Medication review

After performing a bladder ultrasound,

the residual volume in the bladder is 765
mL. Michelle is unable to void despite
being placed on the bedside commode
with water running in the sink.

6. Interpreting clinical data collected, list at least two problems that are possible for this patient. Which
problem is the priority?
Possible Problems Priority Problem Pathophysiology of Priority Problem
- Acute - Acute urinary Urinary accumulation and bladder overdistention related
urinary retention to impaired bladder emptying (post-op, anesthesia,
retention opioids) leads to pain and risk for injury or infection
- Pain from
surgical site
- Risk for
infection

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 Nursing Skills & Reasoning

Nursing Management of Care

7. Identify the current nursing priority and which action(s) the nurse should take. List appropriate interventions,
rationale, and expected outcome.
Nursing Priority Relieve urinary retention
Priority Intervention(s) Rationale Expected Outcome
Perform intermittent straight To prevent bladder overdistention and relieve Urinary output,
cathetherization and monitor urine pain/discomfort pain resolved
output and patient pain level

There is a standing health care provider’s order to straight

catheterize the patient if >350 mL residual urine volume is in the
bladder. The nurse decides to perform a straight “cath” at this time.

Nursing Skill: Urinary Catheterization

8. What will you do if you have not performed intermittent urinary catheterization in the clinical setting?

I would review the steps of the procedure and seek supervision to ensure proper technique with the
help from an experienced nurse.

9. What supplies does the nurse need to gather to perform this skill?
A straight catheter kit, sterile gloves, waterproof pad, a urine collection container.

10. Review and summarize essential steps and knowledge the nurse will use to implement this skill.
- Explain the procedure to the patient
- Gather and set up supplies
- Perform hand hygiene and don sterile gloves
- Use sterile technique to insert the catheter
- Measure and document output
- Assess the patient for changes in symptoms

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 Nursing Skills & Reasoning

11. How many other staff will you likely need to ensure proper positioning and catheter insertion to ensure sterile
technique?

One other staff to assist the patient with positioning.

12. Define catheter-associated urinary tract infection (CAUTI) and what evidence-based practices must be initiated to
prevent this preventable complication.

A catheter-associated urinary tract infection is an infection caused by bacteria entering the

urinary tract through a urinary catheter. Symptoms include fever, suprapubic pain, flank pain,
and cloudy or strong-smelling urine. Evidence-based practice to prevent CAUTI includes
minimizing catheter use (only use if really necessary, promptly remove when no longer needed),
maintaining a closed drainage system, using sterile equipment and following aeseptic technique

Evaluation:
The nurse has successfully inserted the urinary catheter.
13. You reassess your patient fifteen minutes later and collect the following assessment data. For each
finding, make a clinical judgment by placing an "x" in the appropriate column if the patient's condition has
improved, has not changed, or has declined.
Assessment Finding Improved No Change Declined
T: 99.7 F/37.7 (C) (oral) X
P: 81 (reg) X
R: 20 (reg) X
BP: 136/76 X
O2 sat: 95% room air X
800 mL clear yellow urine after straight cath X
Abdominal pain is no longer present X

14. Is the overall status of the patient:

a. Improved
b. Declined
c. No change

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 Nursing Skills & Reasoning

15. After evaluating the patient, identify the current nursing priority and which action(s) the nurse should take. List
interventions by priority and the expected outcome.
Nursing Priority Monitor for recurrence of urinary retention and signs of UTI

Priority Intervention(s) Rationale Expected Outcome

- Encourage fluids To prevent infection or injury No recurrence of
- Monitor I/O urinary retention
- Educate patient on signs of and no signs of
retention and infection infection

Documentation
Write a concise nurse's note to document what was most important in the medical record.
Pt is POD #1 following L4-S1 spinal fusion reports new suprapubic pressure/pain. Pt appears
restless with tense body posture. Pain increased from 2/10 to 8/10. Bladder scan showed 765 mL
residual volume. Pt is unable to void independently. Straight catheterization performed, per standing
order, with return of 800 mL clear yellow urine. Continue to monitor I/O and reassess bladder
function.

Nurse Reflection
To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by
answering the reflection questions below.
Reflection Question Nurse Reflection
As you worked through this This simulation was pretty straightforward. It gave me a sense of
simulation, how did it make you
confidence as I worked through the clinical reasonoing process to
feel?
determine how to best support the patient’s needs.
What did you already know and do I was already familiar with causes as well as signs and symptoms
well on this simulation?
of urinary retention, especially in postoperative patients. I felt
confident interpreting vital signs. I also knew the proper steps of
What areas do you need to I need to improve my confidence in making clinical decisions
develop/improve?
without second guessing. I also want to strengthen my knowledge
of how anesthesia and specific surgical procedures can impact
What did you learn? How will you I learned the importance of timely recognition and respone to
apply what was learned to improve
urinary retention, especially in vulnerable populations, like post-op
patient care?
patients.

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN