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.
SN assessed portacath insertion site every visit. SN instructed s/sx to report to SN / MD such as redness, pain, puffiness around port, drainage from insertion site, temperature above 100 degrees, shortness of breath and chest pain. Sn instructed on portacath care and protection of the skin over the port.
Instructed patient it’s important to routinely clean catheters to prevent infections. Wash your hands well before and after you handle your catheter. Clean the skin around the catheter twice a day using soap and water.
SN instructed patient on signs of central catheter problems. The signs of catheter infection and problems are similar for all types of central venous catheters. If you have any sign of infection or catheter problem, call your doctor immediately. In addition signs of infection, clotting, or other problems include: Redness, tenderness, drainage, warmth, or odor around the catheter site Fever of 100.5F (38 C) or greater, or chills, swelling of the face, neck, chest, or arm on the side where your catheter is inserted, leakage of blood or fluid at the catheter site or the cap, inability to flush the catheter, or resistance to flushing the catheter, displacement or lengthening of the catheter. Patient verbalized understanding
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
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.
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.
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.
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