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).
Hand washing performed. Assembled supplies and created sterile field. Foley catheter removed and discarded using a double bag technique. Peri hygiene performed. Donned sterile gloves Insertion site area prepped using 3 swabs betadine. Foley catheter 20 Fr. 5 ML balloon inserted using sterile technique. Blood tinged urine immediate return that cleared to yellow noted. Catheter attached to collection bag for gravity drainage. Pt. tolerated well.
Instructed patient call your nurse right away if you have any of the following: Signs of infection at the catheter site (pain, redness, drainage, burning, or stinging) Coughing, wheezing, or shortness of breath, a racing or irregular heartbeat. Call your nurse right away if you have any of the following: Muscle stiffness or trouble moving, gurgling noises coming from the catheter, the catheter falls out, breaks, cracks, leaks, or has other damage.
Instructed patient a secure, clean and intact dressing is essential to prevent catheter migration and infection. Never pull on the catheter. Protect the lumen so they do not inadvertently get caught or tugged on. Call your nurse right away if you have any of the following: Pain in your shoulder, chest, back, arm, or leg, fever of 100.4°F or higher, chills.
Patient with biliary catheter instructed patient do not eat after midnight on the night before your procedure. You may have sips of water with your medicines
Patient with biliary catheter SN instructed patient when to call the doctor or go to emergency: Active bleeding at the drain site that does not stop after you put finger, pressure on it, more pain or swelling at or around the drain site, your temperature is greater than 101 degrees fahrenheit, with or without chills
SN instructed patient/CG keep the skin around your biliary catheter dry. You can take showers if you cover the area with plastic wrap. If the area does get wet, dry the skin completely after you shower.
SN instructed patient/cg if you notice leakage of bile around the biliary tube, this may be a sign that the catheter is blocked, call your nurse.
The patient was instructed in cardiac catheterization on care of the puncture site. The patient was advised that bruising of and around the insertion site is normal.