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Narrative Documentation - Catheter - Fall 2018 Nursing I (NUR 1021C) Valencia College

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John Marsh
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Narrative Documentation – Catheter – Fall 2018 Nursing I (NUR 1021C) Valencia College

Orders to insert a 14 French Foley catheter; verified pt name, DOB, and MR number. Pt
AAOx3; NKA; with a reported pain level of 4/10 in the abdominal area described as “dull
pressure”. Pt MAR shows pain medication given at 1200; pt declines additional pain

medication at this time. Verbal consent given to proceed with procedure. Pt has not voided in
over 9 hours; has abdominal distention. Assessment completed on the perineal area; cleaned
with antibacterial wipes. Pt covered with additional towels for comfort and pt privacy.

Foley
catheter tip was verified as intact with 10mL of sterile water connected to the catheter port.

Perineal area cleaned distal to proximal to medial, top to bottom, with iodine-soaked cotton
balls. Catheter tip lubricated with supplied lubricant prior to insertion.

Pt instructed to bear
down as catheter was inserted into urethra approximately 4-5 inches until urine was present
upon entry into bladder. Catheter inserted an additional 1-2 inches and 10mL sterile water
inflated into catheter balloon.

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Narrative Documentation - Catheter - Fall 2018 Nursing I (NUR 1021C) Valencia College

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