Catheterization

Planning/Implementation:

Prepare the client and the equipment, as follows: flashlight or lamp, mask, if required by agency policy, bath blanket and drape, soap, a basin of warm water, a washcloth and towel, disposable gloves, a sterile catheterization kit containing: water-soluble lubricant, sterile gloves, sterile drapes, fenestrated drape(optional) to place over the perineum, antiseptic solution, cotton balls or gauze squares, forceps, basin for urine (base of kit can be used), sterile catheter of appropriate size (eg, for an adult # 14 or #16 is often used), speciemen container as required, bag or receptacle for disposal of the cotton balls. In addition to the equipment used for a straight catheterization, the following equipment is needed: Sterile retention catheter, Prefilled syringes, Nonallergenic tape or Velero, Safety pin or clip, Urine collection bag and tubing (the tubing maybe attached  to the retention catheter if a closed drainage system is used.

Explain to the client why the retention catheter is not to be inserted, how it will be in place, and the urinary drainage equipments need to be handled to maintain and facilitate the drainage of urine. Reassure the client that the procedure is painless. Some client fear spillage of urine when they experience the urge to void during insertion of the catheter and for a short period of time after the catheter is in place. Reassure this client’s that the catheter drains the urine and that the urge to void will disappear. Follow procedure as for straight catheterization up to and including draping the client with a sterile drape. Assist the client’s to a supine position, with knees flexed and thighs externally rotated. Pillow can be used to support the knees and to elevate the buttocks. Drape the client. Cover the client’s chest and abdomen with a black blanket. Pull the client’s gown up over her hips. Cover the client’s chest and abdomen with a bath blanket. Pull the client’s gown up over her hips. Cover her legs and feet as for perineal care. Don disposable gloves. Wash the perineal-genital with warm water and soap. Wear disposable gloves. Rinse and dry the area well. Remove disposable gloves. Obtain assistance if the client requires help in maintaining the required position. Test the catheter balloon. Attach the prefilled syringes to the balloon valve, and inject the fluid. The balloon should inflate appropriately are not leak. Withdraw the fluid and set aside the catheter with the syringe attached for later used. If the balloon leaks or does not inflate adequately, replace the catheter. In such a case, withdraw the fluid, and detach the syringe for later use. Ask another nurse to obtain a second catheter and open the package for you then test the new balloon. Remove the equipment, and obtain another catheter. Then begin again with the new sterile equipment. Follow up steps as for straight catheterization. Lubricate the insertion tip of the catheter. Remove the sterile cap from the specimen container. Expose and clean the urinary meatus and surrounding tissues. Insert the catheter and inflate the balloon. Collect a urine specimen as required. Move the catheter an additional 2.5 to 5 cm (1 to 2 in) beyond the point at which urine began to flow. The balloon of the catheter is located behind the opening at the insertion tip, and sufficient space needs to be provided to inflate the balloon. Inflate the balloon by injecting the contents of the prefilled syringe into the valve of the catheter. If the client complains of discomfort or during the balloon inflation, withdraw the fluid, insert the catheter a little farther, and inflate the balloon size indicates (eg, 5 ml), and remove the syringe. A special valve prevents backflow of the fluid out of the catheter. Follow the agency policy when using a 30 ml balloon. Some agency policies state that only 15 ml of fluid I injected for inflation. Ensure effective balloon inflation.

When the balloon is safely inflated, apply slight tension on the catheter until you feel resistance. Then, release the resistance on the catheter. This keeps the balloon from exerting undue pressure on the neck of the bladder. Anchor the catheter. Tape the catheter with non-allergenic tape to the inside of a female’s thigh or abdomen of a male client. Some nurses prefer taping the catheter to the abdomen whenever there is increased risk of penile scrotal excoriation. Establish effective drainage. Ensure that the emptying base of the drainage bag to the bed frame, using the hook or strap provided. Suspend the bag off the floor, but keep it below the level of the client’s bladder. Coil the drainage tubing loosely beside the client, so that the remaining tubing runs  in a straight line down to the drainage bag. Fasten the vertical tubing to the bedclothes with tape, a tubing clamp, or safety pin and elastic band.

Evaluation:

Document pertinent data. Record the time and date of the catheterization; type and size of catheter, the reason; number of ml of fluid used to inflate the balloon; assessment before and after the procedure, including amount, color, and clarity of urine obtained; whether all urine was emptied from the bladder, and the client’s response.

Administering Oral Medications

Assessment:

Compare medications listed against physician’s orders. Assess psychological and physical status, weight, age, height. Assess ability to swallow medications. Check form of medications available and computes for a safe dosage. Check which vehicles are available for mixing with medications.

Planning:

Plan a method of measuring medication accurately, making medication acceptable to patient, approaching patient appropriately, restraining, if necessary. Determine need for special preparation. Determine needed equipment. Wash hands observing proper technique. Gather needed equipment.

Implementation:

Read from chart/kardex the name of drug ordered. Take drug from shelf, drawer or cubicle, checking label before picking it up. Check label and expiry date on medication. Check label again, with the medication ticket before removing the medication from the container. Prepare correct amount of medication. Pour correct Amount to medicine cup, while keeping bottle facing up. Wipe neck of bottle before replacing cap. Return bottle to shelf, drawer, cubicle or refrigerator, checking label the third time. Place medication on cart or tray with medication card/ticket. Approach and identifies patient through wrist ID or letting him state his name. Explain what to do to patient or watcher and any pertinent specifies related to drug. Add appropriate planned actions related to making medication acceptable to patient. Assist, if necessary, to a comfortable position for taking the drug. Restrain, if necessary. Give medication with a glass of water or juice, if not contraindicated. Watch to make sure medications was properly taken. Leave patient in comfortable position. Perform appropriate aftercare of medication containers, trays and tickets. Wash hands.

Evaluation:

The right patient received the right medication in the right dosage by the right dosage by the right route at the right time. The criteria, specified in the plan of care (NCP) established for ascertaining the effectiveness of a specific drug were used. Side effect, if present, were promptly identified and recorded. Necessary referrals were made.

Documentation:

Record appropriately according to the policy of the facility.