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Nurses collaborating for client care


Cheri, an LPN working in a residential care facility, is returning from lunch.


Sylvia, a health care assistant, reports to Cheri that Mr. Carlson has not voided today, even though he was assisted to the bathroom at regular intervals.

Nursing assessment

Cheri performs a nursing assessment on Mr. Carlson. While palpating Mr. Carlson’s abdomen she notices that it is firm and distended. He grimaces during the assessment, but does not respond when asked if he is in pain.

Nursing diagnosis of a condition

Cheri reviews Scope of Practice for LPNs and determines that performing a bladder scan is a restricted activity that does not require an order.

Cheri follows the LPN Standards for Acting without an Order and performs a bladder scan, which reveals 950 mL of retained urine. Based on her nursing assessment and knowledge of Mr. Carlson’s history of Benign Hypertrophy Prostate (BHP) and episodic urinary retention, Cheri makes a nursing diagnosis of urinary retention. She documents her assessment and interventions in Mr. Carlson’s chart and prepares to discuss her assessment with Kim-Ly, a registered nurse.

What’s next?

Cheri reviews Scope of Practice for LPNs and determines the following:

  • Performing an in-and-out urinary catheterization is a restricted activity that requires an order from an authorized health professional
  • LPNs can carry out orders from nine different authorized health professionals including registered nurses
  • BCCNP has LPN Standards for Acting with an Order that she needs to follow

Cheri knows she is able to perform the activity safely and competently. She is aware that her employer policy supports RNs to provide LPNs with orders for in-and-out urinary catheterization.

Consultation with an RN

 

Cheri calls Kim-Ly to consult with her about Mr. Carlson’s condition. Cheri communicates her assessment of Mr. Carlson and her recommendation for an in-and-out catheter. After discussing the assessment findings, Kim–Ly agrees with Cheri’s nursing diagnosis and recommendation. She provides Cheri with a client-specific telephone order for an in-and-out catheterization. Cheri repeats the order back to Kim-Ly to ensure accuracy and processes the order according to employer policy.

Cheri performs the in-and-out catheterization, which resolves Mr. Carlson’s urinary retention. Cheri documents the procedure and the client’s response in the client record and communicates the outcome to Kim-Ly.

More information

Scope of Practice fo​​r LPNs:

  • Nursing diagnosis
  • Standards for Acting without an Order
  • Restricted Activities with Orders #12
  • Standards for Acting with an Order​

 Need help or advice?

​For further information on the Standards of Practice or professional practice matters, contact us:

  • Email practice@bccnp.ca
  • 604.742.6200 (Metro Vancouver)
  • Toll-free 1.866.880.7101 (within Canada only)