Preventing Postoperative Urinary Retention (POUR)
SBAR
Situation
On 5/9/13, a 49 year old patient had a successful laparoscopic-assisted bilateral salpingo-oophorectomy. The patient was discharged to drive home to Cheyenne, WY that evening. Due to the level of pain and inability to void, the patient’s husband drove her from UCH directly to Cheyenne Regional Medical Center’s (CRMC) ED. In CRMC’s ED the patient had a foley placed that yielded three liters of urine over two hours. The patient was discharged from CRMC with the foley in place for the next three days.
Background
Epic Screenshot of RN's voiding documentation:
On 5/9/13, a 49 year old patient had a successful laparoscopic-assisted bilateral salpingo-oophorectomy. The patient was discharged to drive home to Cheyenne, WY that evening. Due to the level of pain and inability to void, the patient’s husband drove her from UCH directly to Cheyenne Regional Medical Center’s (CRMC) ED. In CRMC’s ED the patient had a foley placed that yielded three liters of urine over two hours. The patient was discharged from CRMC with the foley in place for the next three days.
Background
- Foley catheter removed in OR at 12:24
- Patient arrived in Post Anesthesia Care Unit (PACU) at 12:48
- Patient transferred to PACU's discharge area (Phase 2) at 13:44
- At 13:50 patient had not voided
- RN was told verbally that patient not to be discharge until she voids. No orders placed in EPIC with parameters or to call surgeon.
- Patient drinking water throughout stay in PACU
- She was given Zofran at 1716 for nausea
- Patient was bladder scanned at 1800 for 117
- Nurse concerned bladder was incorrect so rescanned at 19:32 for 225 had another nurse verify that this number was correct.
- Patient complained of nausea and received phenergan
- At 2015 patient went to bathroom and voided. She reported this to the nurse. No amount documented.
- At 2030 patient went to bathroom and voided. No amount documented.
- At 2100 patient went to bathroom and voided. No amount docuemented.
- At one point patient asked to have IV removed
- Nurse contacted Charge Anesthesia at approximately 2100-2110 to speak about concerns and ask him to come and see patient. (This did not get documented).
- Tobias Eckle Anesthesia Charge came and spoke with patient at 2130 for about 15-20 minutes.
- Patient discharged at 2157 to home.
Epic Screenshot of RN's voiding documentation:
Assessment
Patient was voiding in PACU, however, probably was voiding small amounts which could indicate overflow, meaning the bladder was full and dumping small amounts of urine. Documentation was appropriate other than documentation of call to the provider (Charge Anesthesia) and bladder assessment. Based on the clinical documentation nurse believed she had covered the care of the patient.
Recommendations
Patient was voiding in PACU, however, probably was voiding small amounts which could indicate overflow, meaning the bladder was full and dumping small amounts of urine. Documentation was appropriate other than documentation of call to the provider (Charge Anesthesia) and bladder assessment. Based on the clinical documentation nurse believed she had covered the care of the patient.
Recommendations
- Orders placed in Epic for voiding parameters and when to call surgeon prior to discharge
- Measurement of urine and documentation in Epic
- Documentation of bladder assessment
- Develop specific guideline based on literature for cases that need to void and educate for possible complications
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