Maternal Dis8
Jimmy, ten years old, was admitted to the pediatric intensive care unit after a fall from the second-story townhome were sustained a fractured left femur and mild head injury. Currently, Jimmy is two days post open reduction internal fixation of the left femur. Orders were updated to transfer Jimmy out of Intensive Care Unit (ICU) after being cleared by the neurologist. He has a long leg cast, indwelling foley catheter and will require neuro checks every two hours.
- What are two priority nursing diagnoses for this child?
- What are the priority nursing interventions for this patient after being transferred from the ICU?
- What are the risks of foley catheter placement?
- Does the patient still require an indwelling foley catheter? Provide a rationale to support your answer.
Answer:
Two priority nursing diagnoses for Jimmy could be:
- Risk for infection related to the presence of the indwelling foley catheter and the surgical wound.
- Risk for impaired skin integrity related to immobility and the long leg cast.
Priority nursing interventions for Jimmy after being transferred from the ICU could include:
- Performing neuro checks every two hours to assess for any signs of neurological deterioration.
- Encouraging ambulation as soon as possible to prevent complications such as pneumonia, deep vein thrombosis and pressure ulcers.
- Administering pain medication as needed and monitoring for signs of pain and adverse effects of the medication.
- Monitoring intake and output and ensuring adequate hydration.
- Performing routine wound care to prevent infection.
- Providing appropriate emotional support and education to the patient and family.
The risks of foley catheter placement include:
- Urinary tract infection
- Hematuria
- Catheter-associated bacteriuria
- Urinary retention
- Bladder spasms
- Trauma to the urethra or bladder
Regarding Jimmy’s foley catheter, it is important to consider the benefits and risks of catheterization, particularly since he has a fracture and is immobilized. If he is unable to use a bedpan or urinal, or if his condition requires strict monitoring of urinary output, the foley catheter may still be necessary. However, the nurse should assess Jimmy’s urinary function and determine whether the catheter can be removed as soon as possible to reduce the risk of complications such as catheter-associated urinary tract infections.
