Question

An 80 year old patient admitted to medical unit for dehydration and urinary tract infection. patient orders: Normal saline 50ml/hr, foley catheter x 24 hours, oxygen 2 litters as needed. The patient continues to pull at the IV line and foley catheter.

1. Identify behavior that will require restraint

2. Can the nurse implement alternative measures to reduce injury/ harm? Explain

3. Explain types of restraints.

4. Explain the purpose of oxygen

Answer 1

1.Preventive Health Behavior

2.Alternate measures: In such situations, carefully inspect the extracted Foley and make a clear note for documentation regarding whether the Foley balloon is fully intact. Physicians may want to examine the catheter, particularly the balloon, to determine if any pieces are missing that could still be in the bladder and might require surgical removal with cystoscopy. Such fragments left in the bladder can become calcified and eventually develop into stones.

3.Restrains

• Reposition the Foley Catheter Under the Thigh, Tape and Cover It
• Use a Diaper or Mesh Underwear with Pads
• Add Decoy Foley Catheters