This assignment will focus on an account of patient care that I have provided to a patient who was unable to excrete urine during a long day shift in a secondary care setting. It will discuss regarding my contribution to a change in care while assessing the patient. The assessment will be evaluated to help analyse and synthesise information, make evidence- based decision and implement these decisions into clinical environment appropriately which is also known as clinical decision making according to Pritchard (2006). I will be using evidence based research and appropriate pathophysiology to understand why the patient had to be catheterized. Consent has been gained and a pseudonym is given to protect the patients’ identity as people have the right to confidentiality according to Nursing and Midwifery Council (NMC, 2008a). Therefore she will be addressed as Tania. Tania was a 68 years old lady who was admitted to Coronary Care Unit (CCU).
During her stay a coronary angiography procedure was done on her. Coronary angiography is used to diagnose a number of heart conditions and to help guide treatment according to National Health Service (NHS) (2012). After this procedure, she had tried to pass urine several times using a bed pan. She was unable to do this even with a full bladder sensation. As her discomfort was rising, I and my mentor concluded that she was experiencing urinary retention. This is one of the most common complication post angiography according to Walters Huang et al. (2008) who did a group research on it. As Pellatt (2007a) describes that urinary retention is the sudden inability to excrete urine, the decision to catheterise her was made. One aspect of the urinary system is to get rid of waste products as a result of cellular metabolism.
Hence it is referred as the excretory system according to Self (2006). The urinary elimination depends on effective functioning of kidneys, ureters, bladder and urethra (Kozier et al. 2008).Urine is produced by the two kidneys. The main component of urine are water, urea , uric acids, sodium, potassium , phosphates, sulphates and oxalates according to Lawson and Peate (2009).The two ureters transport urine from the kidneys to the urinary bladder. The urinary bladder is a temporary storage reservoir for urine. The bladder is able to distend and contract due to the detrusor muscle wall present in the bladder (Gosling, 2005). Stegall (2007) explains that as the bladder fills with urine at approximately 0.5 ml/kg/hour, the bladder wall stretches when a critical volume between approximately 200ml and 400ml in adults is reached.
This triggers a nerve impulse to travel to the spinal cord and into the brain– pons and cerebrum – providing the signal that the bladder is getting full. In order to empty the bladder, the brain transmits a different nerve impulse which comes from the spinal cord to the bladder muscle (detrusor) and the internal and external urinary sphincters. At this point according to Stegall (2007), the detrusor contracts and the internal and external sphincters open. Marieb (2009) declares that this allows the urine to flow out of the bladder through the urethra. During this process Stegall (2007) argues that urinary retention can develop if there is obstruction to outflow or damage or interruption to neural pathways.
On Tania’s arrival to the ward from the cath laboratory, I offered her a cup of tea and a jug of water. She drank a glass of water and a cup of tea. I encouraged her to drink plenty of water as Shepherd (2011) suggests that she may have been dehydrated since prior to the procedure she was on Nil By Mouth (NBM).
During the procedure a long, flexible tube called a catheter was inserted into a blood vessel in her groin. Using X-ray images as a guide, the tip of the catheter was fed up to the heart and coronary arteries and a special dye called contrast medium was injected into the catheter (NHS 2012). According to the study done by Fikret et al. (2012) contrast medium–induced acute kidney injury is a serious complication of coronary angiography. This can lead to decrease in the urine output (O’Donovan, 2010). Therefore, Kohtz and Thompson (2007) explain that frequently recording the fluid balance post coronary angiography is vital to identify kidney dysfunction in an early stage.
Fluid and electrolyte balance monitoring and management is vital and integral to nursing care (Jevon and Ewens, 2007). Callum et al. (1999) suggest that fluid imbalance can lead to serious postoperative morbidity and mortality. Therefore, I was able to accurately record Tania’s fluid output and intake on a fluid chart (see appendix 1) as this vital procedure will help identify fluid imbalance in an early stage according to Mooney (2007).Mooney (2007) also outlines that in order for the patients who have undergone a surgical procedure or patients in critical care wellbeing it is vital to closely monitor the fluid balance.
As Tania wanted to go to the toilet, she rang the bell for some assistance. I explained to her that due to the procedure she was not allowed to stand-up. Therefore, taking bed rest for at least 3 hours and lying flat at an angle no greater than 45° was necessary as suggested by Bowden (2009). I informed her that she could use a bedpan. I explained her about the procedure and gained her consent to assist her (NMC, 2008b). According to Pellatt (2007a), one of the important roles of a nurse is to assist patient with urinary removal. Thus, during this procedure I ensured that her privacy and dignity was maintained by pulling the curtains around, covering patients’ leg with and sheet and ensuring the call bell was within patients reach (NMC, 2008c).
As Tania had an urge to pass the urine, she tried to use the bedpan many times. But she was unable to pass any urine. I continuously checked her vital signs for example blood pressure, pulse, respiration and temperature which all appeared to be normal. I was concerned about her urine output as Bowden (2009) suggest that it is also part of vital sign assessment. She was also drinking good amount of water.
After nearly 6 hours post angiography, Tania was still unable to pass urine and her uncomfortable feeling appeared to be growing. As she complained that she felt like her lower belly was bloated and was also in some mild pain, I performed light palpation on her abdomen to feel her bladder. Emberton (2004) also agrees that by doing palpation of lower abdomen can help identify whether a patient is going through urinary retention. Consent was gained from her prior to this procedure (NMC, 2008b).After doing this procedure, her abdomen felt quite bloated. According to Emberton (2004) the early symptoms of urinary retention is usually bloated and painful abdomen.
According to Nathan (2004) urinary retention can be related to a past clinical history. As I was concerned about Tania not being able to pass urine, I wanted to know whether she had any urological or gynaecological past medical history. Therefore I looked through her medical notes. She had no past clinical history which affected her from passing urine.
Although there was no concern regarding her past clinical history, through my understanding and observation over the 6 hours period, all the signs and symptoms shown by Tania indicated that she may be experiencing urinary retention. Stegall (2007) insist that urinary retention occurs mainly due to outflow of urine. This may be due to the anatomical changes, constipation, immobility, anxiety, neutral pathway injury or secondary to drugs such as anaesthesia according to Srirangam and Preminger (2007). The anaesthesic drugs given during this procedure may have been the cause of Tania going through urinary retention. Since the anaesthetic drug can numb the nerves and this could have an effect on the neural pathway that transports impulses from the brain and alter awareness of fullness in the bladder as explained by Mosquera (2011).
As I was very worried about Tanias health, I informed my mentor regarding this matter. I also showed her the TPR chart which shows blood pressure, temperature and pulse record and fluid balance chart for evidence. My mentor also looked through the nursing notes. The fluid chart showed that there was no output in the past 6hours. This suggested that urinary catheterisation may be required according to Bowden (2009).Therefore, with the help of these evidence and by talking with my mentor, it was decided that catheterising Tania would help her with urinary retention. The doctor was also informed regarding this matter and gave consent to catheterise Tania.
I explained to Tania about the procedure and why it was necessary to catheterise her (NMC, 2008). I also explained her about how urinary retention could affect her health further if the she declines to do this procedure. I reassure Tania as this is also a part of nursing care according to Royal College of Nursing (RCN) (2006) by explaining her about her current health. She understood that urinary catheterisation would help her with the pain and discomfort that she is feeling. Consent was gained from Tania (NMC, 2008a) Therefore, I was able to catheterise her using aseptic technique under the supervision of my mentor. After this procedure Tania was able to instantly excrete urine out of her body. I also documented that Tania consented to do this procedure after the conversation I had with her and catheterised her using aseptic technique in the nursing notes which is recommended by the Department of Health (DH) (2011).
The decision- making is a process based upon the clues observed, analysed and interpreted. King and Clark (2002) suggests that nurses assess the situation as a whole and make judgement and decisions intuitively. Nurses learn this clinical decision making skill gradually by observing how their more experienced colleagues make decisions while taking care of the patients and also uses frameworks according to Prichard (2006). In Tanyas’ case I used the Carroll and Johnson (1990) framework which demonstrates the seven stages (see appendix 2).
The seven stages are recognition of the situation, formulation of explanation, alternative generation of other explanations, information search to clarify choices and available evidence, judgement or choice, action and feedback. According to Reid and Jeffrey (2002) patient assessment is a dynamic decision – making process that seeks to establish an accurate picture of an individual’s condition and through critical thinking enables the nurses to make an effective clinical decisions. Therefore I carefully assessed Tanais condition. I did this by encouraging her to drink fluids as she was kept NBM prior to the procedure which increases the risk of Tania going through dehydration according to Gosling (2004).Tania was sufficiently hydrated as she was drinking good of water.
During this process the assessment that I could have done differently according to Pellatt (2007b) was assessing the volume of urine using a portable ultrasound device. Although using this device is a non- invasive procedure, Pellatt (2007b) also suggests that catheterisation is necessary during urinary retention which is performed invasively and have a high risk of infection according to Rigby and Housami (2009). As the ward Tania was situated in did not have any portable ultrasound device, placing her on waiting list and making her wait until she had an ultrasound would have been ethically wrong. This could have lead to more pain in her abdomen and she could felt ignored by the nurses or other health professionals. As a result critical ethical thinking and ethics are essential part of nursing (Chaloner, 2007).
I know that catheterising Tania was the most appropriate decision as urinary retention can cause urinary tract infection and renal injury according to Stegall (2007). My previous experience with other patients who had angiography also helped me deal with Tanias situation. I used analytical process of making judgement based on some critical information. This process is known as pattern recognition (Muir, 2004). I believe that I also used knowledge and evidence based research as Bakalis (2006) claims that this has a great impact on decision making.
As Tania was feeling much better and relaxed after the catheterisation process, I was very pleased with the final result and the nursing care that I provided. The assessment during this process was carried out appropriately and my updated knowledge, critical thinking, skills and previous experiences helped me make an appropriate clinical decision (Watson, 2005).Overall, this experience has helped me to understand that nurses play a vital role in decision making and identifying urinary retention in patient’s life.
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