Urinary Catheterization
Skills & Reasoning
Sheila Dalton, 52 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
Clinical Judgment
Patient Education
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, History of Present Problem:
Sheila Dalton is a 52-year-old Caucasian female who has a history of chronic low back pain. She had a posterior spinal
fusion of L4-S1 yesterday and is postoperative day (POD) #1. Her pain is controlled at 2/10 and requires hydromorphone
0.5-1 mg IV every 4 hours. She is able to stand and sit in a chair with assistance. Her indwelling urinary catheter was
discontinued six hours ago and she has not voided since the catheter was removed. Sheila is tolerating oral fluids and has
had an oral intake of 1000 mL in the past eight hours.
Current Complaint:
Two hours later, Sheila puts on her call light and states that she is having moderate pain/pressure above her pubic bone
that she has not had before.
What data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data-Patient Story: Clinical Significance:
RELEVANT Data-Current Complaint: Clinical Significance:
Nursing Assessment Begins:
Current VS: Most Recent VS: Current WILDA:
T: 99.4 (oral) T: 98.9 (oral) Words: pressure/ache
P: 90 (reg) P: 72 (reg) Intensity: 8/10
R: 20 (reg) R: 18 (reg) Location: lower abdomen/suprapubic
BP: 152/82 BP: 138/80 Duration: ongoing the past hour
O2 sat: 95% room air O2 sat: 96% room air Aggravate: nothing
Alleviate: nothing
Current Assessment:
GENERAL Appears restless and appears uncomfortable, tense body posture in bed
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Lower suprapubic area tender and firm to palpation, bowel sounds active and
audible per auscultation in all four quadrants
GU: No urine output since indwelling urinary catheter discontinued six hours ago
SKIN: Skin integrity intact, 5 cm lateral incision down the lumbar spine with 4 steri-strips
intact, 4 x 4 gauze dressing dry, intact with scant amount of sero-sangineous
drainage, no odor, edges well approximated, surrounding tissue without redness
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
Skills & Reasoning
Sheila Dalton, 52 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
Clinical Judgment
Patient Education
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, History of Present Problem:
Sheila Dalton is a 52-year-old Caucasian female who has a history of chronic low back pain. She had a posterior spinal
fusion of L4-S1 yesterday and is postoperative day (POD) #1. Her pain is controlled at 2/10 and requires hydromorphone
0.5-1 mg IV every 4 hours. She is able to stand and sit in a chair with assistance. Her indwelling urinary catheter was
discontinued six hours ago and she has not voided since the catheter was removed. Sheila is tolerating oral fluids and has
had an oral intake of 1000 mL in the past eight hours.
Current Complaint:
Two hours later, Sheila puts on her call light and states that she is having moderate pain/pressure above her pubic bone
that she has not had before.
What data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data-Patient Story: Clinical Significance:
RELEVANT Data-Current Complaint: Clinical Significance:
Nursing Assessment Begins:
Current VS: Most Recent VS: Current WILDA:
T: 99.4 (oral) T: 98.9 (oral) Words: pressure/ache
P: 90 (reg) P: 72 (reg) Intensity: 8/10
R: 20 (reg) R: 18 (reg) Location: lower abdomen/suprapubic
BP: 152/82 BP: 138/80 Duration: ongoing the past hour
O2 sat: 95% room air O2 sat: 96% room air Aggravate: nothing
Alleviate: nothing
Current Assessment:
GENERAL Appears restless and appears uncomfortable, tense body posture in bed
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Lower suprapubic area tender and firm to palpation, bowel sounds active and
audible per auscultation in all four quadrants
GU: No urine output since indwelling urinary catheter discontinued six hours ago
SKIN: Skin integrity intact, 5 cm lateral incision down the lumbar spine with 4 steri-strips
intact, 4 x 4 gauze dressing dry, intact with scant amount of sero-sangineous
drainage, no odor, edges well approximated, surrounding tissue without redness
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
