Mr. I.P. Knightly: congestive heart failure & indwelling urinary catheter

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Mr. I.P. Knightly: congestive heart failure & indwelling urinary catheter by Mind Map: Mr. I.P. Knightly: congestive heart failure & indwelling urinary catheter

1. Care Goal: Adequate hourly urine drainage through indwelling catheter at a minimum rate of 0.5 mL/kg/hr with no migration, obstruction or encrustation. Maintain adequate hydration of patient (1500-2000ml per day). Catheter tubing remains free of kinks and knots throughout duration of catheter placement.

1.1. Nursing Intervention: Assess for client’s hydration. 1500-2000 mL/day is recommended. Consider the client’s diagnosis, diet and any fluid restrictions. Provide client with alternative sources of fluid (e.g. Jello, soups and smoothies). Rationale: Ensure appropriate hydration for urine production and flow. (Online Clinical Skills Lab)

1.2. Nursing Intervention: Cleanse meatus and the first 3-4 inches of the catheter twice daily with soap and water, or as per agency protocol. Ensure absence of mucous and encrustations until catheter is discontinued. Wipe the catheter tubing away from the body. Rationale: Maintaining catheter clean, free of mucous and encrustations reduces risk of biofilm development and lumen obstruction. (Stickler, 2008)

1.3. Nursing Intervention: Assess tubing hourly and ensure it's securely taped to inner thigh and has enough slack to allow usual range of movement. Rationale: Reduces risk of catheter migration, helps prevent client from physically compressing the catheter and obstructing flow. (Potter & Perry, 2015)

1.4. Nursing Intervention: Assess hourly to ensure tubing is positioned over legs and drainage bag kept below the bladder while lying, sitting or standing. Rationale: Prevents urine back-flow and promotes drainage through gravity and prevents the client from physically compressing the tubing. (Potter & Perry, 2015)

1.5. Nursing Intervention: Assess drainage bag hourly and do not allow bag to exceed ⅔ full. Rationale: Prevents backflow of urine from drainage bag into the tubing. (National Health Service Quality Improvement Scotland, 2004).

2. Care goal: Insertion of indwelling foley catheter with minimal client discomfort, as evidenced by clients verbal report of pain. Client appears comfortable, relaxed and has no facial grimaces.

2.1. Nursing Intervention: Lubricate the distal portion of the catheter before insertion Rationale: Decrease friction to facilitate catheter insertion (Potter & Perry, 2015)

2.2. Nursing Intervention: Ask client to bear down prior to insertion of catheter Rationale: Release of tension in urethral sphincter & pelvic floor muscles aids in catheter insertion. (Potter & Perry, 2015)

2.3. Nursing Intervention: Select appropriate size of catheter for patient. Rationale: Prevent damage to urethra and client pain upon insertion. (Potter & Perry, 2015)

2.4. Nursing Intervention: Once urine is flowing, advance the catheter an additional 2.5-5cm before inflating the balloon. Rationale: Prevents trauma to urethra and ensures balloon placement in bladder (Potter & Perry, 2015)

2.5. Nursing Intervention: Wipe perineal area of any remaining lubricant and return client to a comfortable position. Rationale: Avoid irritation of perineal skin. (Potter & Perry, 2015)

2.6. Nursing Intervention: Position client in supine position with legs spread and feet together. Rationale: Comfortable position for client, reduces muscle tension and allows nurse to visualize the urethra. (Potter & Perry, 2015)

3. Nursing Diagnosis #1: Risk for catheter-associated urinary tract infection (CAUTI) related to transmission of microorganisms secondary to indwelling urinary catheter

3.1. Care Goal: Client will remain free of catheter-associated urinary tract infection following insertion of urinary catheter and 48 hours following catheter removal, as evidenced by the absence of fever, malaise, chills, flank pain, and suprapubic tenderness; clear non-foul smelling urine; and WBC count within normal limits. Client is educated upon prevention of CAUTI, as evidenced by client verbalization and demonstration. Catheter remains securely placed on client’s thigh while catheter is in-situ. Principles of asepsis and sterile catheterization are adhered to for insertion, removal, and duration of catheter placement; closed urinary system is maintained.Skin remains intact throughout the duration of catheter placement.

3.1.1. Nursing Intervention: Measure and monitor urine output hourly for colour, amount, clarity, sediment, blood, and odour to observe for signs of infection. Monitor WBC count and temperature q 2 hrs. If infection is suspected, obtain urine sample from sampling port using aseptic technique and perform urine culture and sensitivity. Rationale: Abnormal urinary characteristics (cloudy, foul odour, hematuria), high WBC count, and elevated temperature may be indicative of CAUTI; C & S test will determine type of bacteria present and identify antibiotic required to treat infection. (Doenges, Moorhouse, & Murr, 2013).

3.1.2. Nursing Intervention: Cleanse meatus and and the first 3-4 inches of the catheter twice daily with soap and water, or as per agency protocol. Report and record characteristics of drainage, condition of perineal tissue, or client discomfort. Rationale: Reduces presence of microorganisms; promotes early detection of infection. (Online Clinical Skills Lab)

3.1.3. Nursing Intervention: Client education surrounding catheterization procedure, rationale for insertion, hygiene practices, and potential complications. Perform prior to catheter insertion while catheter is in-situ, and following catheter removal. Rationale: Reduces patient anxiety; promotes good hygiene practices and catheter care; promotes patient reporting of any side-effects that may occur while the catheter is in-situ. (Doenges et al., 2013)

3.1.4. Nursing Intervention: Perform perineal care with soap and water twice daily, after every bowel movement, or as needed. Rationale: Prevents catheter encrustation and bacterial growth. (Doenges et al., 2013)

3.1.5. Nursing Intervention: Assess tubing hourly to ensure catheter remains securely placed on inner thigh. Rationale: Prevents risk of infections secondary to pulling of the catheter, movement-induced urethral trauma, or need for catheter reinsertion. (Potter & Perry, 2015)

3.1.6. Nursing Intervention: Adhere to sterile catheter insertion technique and principles of asepsis; ensure closed urinary drainage system is maintained and drainage bag never touches the floor. Rationale: Prevents transmission of microorganisms; prevents contamination of urinary drainage system. (European Association of Urology Nurses, 2012)

3.1.7. Nursing Intervention: Remove catheter as soon as clinically warranted, as per physicians order. Rationale: Prolonged catheter insertion associated with increased bacterial growth and risk for CAUTI. (Potter & Perry, 2015)

4. Nursing Diagnosis #2: Risk for inadequate urine drainage related to catheter migration, obstruction, encrustation or dehydration.

5. Nursing Diagnosis #3: Risk of client discomfort related to indwelling urinary catheter insertion.