Tiffany Jones, age 17, is scheduled to undergo an ovarian cyst biopsy under local anesthesia. She has been NPO since midnight. Her ID bracelet is on and her consent form is signed. Her mother is in the waiting room. You are to provide Tiffany's immediate preoperative care. You place an IV in her left hand without difficulty. The next procedure is to insert an indwelling urinary (Foley) catheter. You set up the sterile field between her legs. As you clean the urinary meatus, Tiffany keeps drawing her legs closer together. When you remind her, she opens her legs and says, “Sorry, I didn't mean to move.” As you insert the catheter into the urethra, Tiffany is startled and slams her knees together. When she opens her knees, the catheter appears to be inserted, but no urine is flowing.
Prescribed Interventions
- Intravenous fluids: D5 ½ NSS at 50 mL/hr
- Foley catheter to straight drainage
Developing Clinical Reasoning and Clinical Judgment
- Where might the urinary catheter be positioned, and should you advance the catheter further?
- How do you determine whether the catheter and the sterile field are still sterile?
- How could you have set up a more stable sterile field?
- Identify issues of concern to patients before surgery.
- Describe methods of responding to Tiffany's nervousness.
Suggested Responses for Integrated Nursing Care
- The female urethra is short, only about 1.6 inches (4 cm) long (Norris, 2020). If the catheter is advanced that far and no urine is flowing, the catheter may be in the vagina. Do not remove the catheter; it will serve as a guide to locate the urethral opening, which is just above the vagina (refer to Chapter 12). You would not advance the catheter further even if it were in the urethra, because when Tiffany closed her legs, the catheter probably came into contact with her skin and is no longer sterile. Advancing a nonsterile catheter into the urethra would increase her risk for developing a urinary tract infection. Because you are not certain whether her legs touched the sterile field, the sterile field is also no longer considered sterile (refer to Chapters 1 and 12).
- You will need to obtain another complete catheter insertion kit. Cover Tiffany and verify that she understands your plans. As you set up the new kit, place it on the bedside table, not between her legs, to prevent accidental contamination (refer to Chapter 12).
- Teenagers are generally uncomfortable with urinary catheterization because in this procedure, the nurse must look at and touch a very private area. Such an invasion of privacy is traumatic at an age when girls are easily embarrassed. Teenage girls may have “nervous legs”: As you touch their inner thighs or labia, the knees slam shut almost involuntarily. Have a second nurse, caregiver, or a relative attend to the teenager. The nurse or relative can distract and soothe the teen, minimizing the unpleasantness of the experience, and can also keep a “reminder” hand on Tiffany's open knee to help you maintain sterility.
- As with most preoperative patients, Tiffany has several reasons to feel nervous. She is facing surgery, an unknown and anxiety-producing experience. The preoperative procedures, such as IV insertion and urinary catheterization, are unpleasant and uncomfortable. You can implement several strategies to reduce preoperative patients' anxiety. Have a familiar person stay with the patient. Tell the patient your name. Clearly explain procedures and provide instructions to the patient before you begin. Instructions should include the rationale and the length of time the procedure will take. For urinary catheterization, the patient may also want to know how long they will have the catheter in place. Emphasize to the patient that it is all right to ask questions. Describe how the procedure will feel to the patient—for example, “when I clean you, it will feel cold and wet.” Keep your voice calm and very matter-of-fact throughout the procedure (refer to Chapters 6 and 12).