Kim Johnson DOC Final - case study clinical PDF

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Kim Johnson Documentation Assignments 1. Document your initial focused urinary assessment of Ms. Johnson. First as I always do, I introduced myself to the patient and asked her to confirm her full name and date of birth. I explained to my patient that I needed to perform a head-to-toe assessment on her and that if she had any pain during this assessment to let me know. I started by asking my patient a series of questions about her health history. I asked if she was allergic to any medications, she said no. Then I asked her about about voiding patterns, habits, past history of problems. She said that she doesn’t have any of these. I listened to her heart and lungs. They were normal. Her temperature was 98 degrees farenheight. I checked her blood pressure, pedal pulse, and oxygen saturation level. They came back normal and were recorded in her chart. I also preformed a physical examination of the bladder and an assessment of the skin for hydration. I knew that she was paralyzed from the waist down,so I had to explain to her that I would be putting in a straight catheter so she could empty her bladder. 2. Document Ms. Johnson’s straight catheterization procedure. At first, it said that the catheter was contaminated, so I had to throw out the kit and start with a new one. I started with a sterile procedure, put on sterile gloves, and started to make my sterile field. Then, I placed a drape on Ms. Johnson’s perineal area and began to clean it. I took the tip of the catheter and lubricated it. Then,I slowly inserted it into her urethra. The bladder started to empty and the urine flowed into the basin. I removed the catheter, made sure she was comfortable, and asked her if she needed anything else. Finally, I educated the patient about intake and output. 3. Record patient education provided for Ms. Johnson in the chart. I educated Ms. Johnson on intake and output and the bladder management program. Intake is the act of consuming or taking foods, fluids, or substances into the body. This also includes tube feedings and IV solutions. Output is the process of waste exiting the body. Output is urine, emesis, GI suction, liquid stool, wound drainage, and chest tube drainage. Nurses need to make sure that they are completely documenting the pateint’s intake and output for each shift. It is important to teach a pateint about the bladder management program when a catheter has to be used. It allows individuals with a spinal cord injury to empty their bladder in a way that is appropriate for the nature of their injury and life style. By following this program, UTI’s, kidney damage, skin sores, and bladder accidents can be greatly reduced. This program allows individuals with spinal cord injuries to enjoy a higher quality of life.

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