Nursing Narrative Documentation Example: Urinary Catheterization and Removal
Date & Time c/o being unable to void; last voided 50 mL @ 0200. Unable to void this am. Bladder scan shows 600 mL urine retention. Assessment reveals suprapubic area is distended. Physician notified.
Date & Time Physician order received to anchor Foley cath if patient unable to void by 0900. Patient still unable to void. #14 Fr Foley cath inserted at this time; note clear amber urine draining; 650 mL urine output immediately after cath insertion; denied any discomfort during the procedure; resting quietly in bed and denies any other concerns.
Key Points for Nursing Documentation: Foley cath insertion
- Assessment data (*** this documentation will confirm the patient meets the criteria necessary to have a cath procedure):
- Document: c/o discomfort, inability to void, bladder distention upon palpation, frequency, urgency, etc.
- Document results of a bladder scan
- Describe type and size of the catheter (e.g. Foley, I&O, etc.)
- Data to be documented:
- physician order being followed
- urine draining: color, clarity, and amount drained at the time of catheter insertion
- how the patient tolerated the procedure
- patient status at the time of the nurse leaving the room after the procedure
Example of Nursing Documentation: Discontinuing a Foley Catheter
- Foley cath DC’d per physician order
- The amount, color, and clarity of urine in drainage bag at the time the cath is DC’d
- Catheter tip and balloon intact at the time of removal.
- The time that the patient is due to void (DTV) after catheter removal.
- How the patient tolerated the procedure and status of the patient at the time nurse leaving the room after the procedure.