21.9 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation for Expected Findings
A size 14F Foley catheter inserted per provider prescription. Indication: Prolonged urinary retention. Procedure and purpose of Foley catheter explained to patient. Patient denies allergies to iodine, orthopedic limitations, or previous genitourinary surgeries. Balloon inflated with 10 mL of sterile saline. Patient verbalized no discomfort or pain with balloon inflation or during the procedure. Peri-care provided before and after procedure. Catheter tubing secured to right upper thigh with stat lock. Drainage bag attached, tubing coiled loosely with no kinks, bag is below bladder level on bed frame. Urine drained with procedure 375 mL. Urine is clear, amber in color, no sediment. Patient resting comfortably; instructed the patient to notify the nurse if develops any bladder pain, discomfort, or spasms. Patient verbalized understanding.
Sample Documentation for Unexpected Findings
A size 14F Foley catheter inserted per provider prescription. Indication was for oliguria with accurate output measurements required. Procedure and purpose of Foley catheter explained to patient. Patient denies allergies to iodine, orthopedic limitations, or previous genitourinary surgeries. As the balloon was being inflated with saline, patient began to report discomfort. Saline removed, catheter further advanced one inch and balloon reinflated with 10 mL of normal saline. Patient denied discomfort after the catheter advancement. Catheter tubing secured to right upper thigh with stat lock. Drainage bag attached, tubing coiled loosely with no kinks, bag is below bladder level. Urine drained with procedure 100 mL. Urine drainage is dark amber, noticeable sediment in tubing, with foul odor. Patient resting comfortably, denies any bladder pain or discomfort. Instructed the patient to notify the nurse if develops any bladder pain, discomfort, or urinary spasms. Patient verbalized understanding. Notify the health care provider of urine assessment. Continue monitoring patient for any new or worsening symptoms such as change in mental status, fever, chills, or hematuria.