Urinary Cath Care and Change
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Patient identified with Name, DOB, ID and Address prior to perform all procedures. SN performed skilled observation and assessment, monitored vital signs, assessed mental, physical and behavioral status. Instructed, evaluated and assessed pt compliance, effectiveness and side effects to medications. Instructed on diet plan. Assessed patient understanding of disease process. Patient education provided. Assessed & educated patient knowledge of signs and symptoms re: complications necessitating medical attention. Instructed patient in any knowledge deficit. Assessed home for safety & Risks for Falls. Safety & preventative education provided. Implemented safety measures as needed. Patient has a Foley FR 16 – 10 cc in place, using mild soap and water the skin from around the tip of the penis down was cleaned. Holding the catheter at the urethra point and then down, the catheter was cleaned, without tension on it. The area was rinsed well and dry it gently. Old Cath-Secure was removed and attach the catheter to her leg with a new Cath-Secure. The drainage bag was replaced for new one, good flow of yellow urine. Patient tolerated procedure well without bleeding at site, complaint or complication. Patient is incapable of perform wound care due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. Skilled nurse assess patient for S/S of complication related to diagnostic. Instructed caregiver about your Foley catheter daily Care: Keep the skin and catheter clean. Clean the skin around your catheter at least once each day. Clean the skin area and catheter after every bowel movement. Call the patient MD if: you cannot get the catheter to drain urine into the bag, the catheter comes out or it is leaking, the urine is thick and cloudy. Your urine has mucus, red specks, or blood in it. Urine with blood in it may appear pink or red. the urine has a strong (bad) smell, no urine has drained from the catheter in 6 to 8 hours, have pain or burning in your urethra, bladder, abdomen, or lower back, have shaking chills or your temperature is over 101° F (38.3° C). Patient/caregiver verbalized understanding teaching.
VIEW COMPLETED NOTE
Patient identified by name, ID with picture and facial recognition. SN performed skilled observation and assessment of all body systems from head to toe. No signs or symptoms of acute distress noted. SN assessed home for safety & Risks for fall. Safety & preventative education. SN performed skilled observation and assessment, monitored vital sign and blood pressure and found them within normal limits. SN assessed mental and physical status, evaluated compliance, effectiveness and side effects of medication, diet and nutritional status, and patient’s and/or caregiver’s knowledge of signs and symptoms of complication. SN cleaned area around Foley catheter insertion site with betadine, using syringe withdrew 10 cc water from catheter, removed catheter intact. Using sterile procedure SN cleaned area again with betadine and inserted 16 FR catheter, with syringe inserted 10 cc water, good flow of yellow urine. Patient tolerated procedure well without bleeding at site, complaint or complication. Patient is incapable of perform wound care due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient about suprapubic catheter care, always wash your hands with soap and water before and after handling your catheter, make sure that the catheter tubing does not get twisted or kinked, and that urine is flowing out of the catheter into the urine collection bag, keep the urine collection bag below the level of your bladder, make sure that the urine collection bag does not drag and pull on the catheter, you can shower with your catheter and urine collection bag in place unless you have been told not to, clean the bag every day after removing it from the catheter. Use another container while you clean the bag. To clean the bag, fill it with 2 parts vinegar to 3 parts water and let it stand for 20 minutes. Then empty it out, and let it air-dry. Patient/caregiver verbalized understanding teaching.
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