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