Clara Guidry Scenario 2
Assessment reveals a very distended bladder, displacing fundus 3 cm above the umbilicus and displaced to the patient's right patient unable to void due to lingering effects of epidural. A physician order is received to insert an indwelling urinary catheter. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1Educate patient regarding indwelling urinary catheter placement, Wash hands.Education allows for planning and implementation of patient care; washing hands prior to indwelling urinary catheter placement prevents nosocomial infection during invasive procedure and is the first step.
2Insert indwelling urinary catheter and connect to collection bag, secure to patient's thigh.Insertion of Indwelling urinary catheter is done according to established protocols, under sterile technique and is the second step. The patient is unable to void, and a full bladder is a common cause of uterine atony and early postpartum hemorrhage.
3Measure urine return in collection bag; Reassess uterine tone, response to massage, level in relation to umbilicus, and position in abdomen.Assesses adequate emptying of bladder; emptying bladder returns uterus to normal and position and facilitates normal contraction of the uterus.
4Reassess vaginal bleeding and presence for clots; change underpads as needed.A firmly contracted uterus clamps off blood vessels at the placental site, preventing uterine atony and excessive bleeding, changing underpads for patient comfort and prevention of infection.
5Wash hands, document findings and completion of procedure.Prevents spread of infection; accurate documentation is to be performed after patient care is performed, NEVER BEFORE!