Do you need a doctors order for this?

bluenurse85 · Jul 25, 2014

I would say get an order unless you have an order that specifically covers you. Inserting a Foley is an invasive procedure, which usually requires some type of order (although this may vary from state to state, also LTC vs. acute setting.) CYA.

eeffoc_emmig · Jul 25, 2014

In the LTC facilities I have worked in, you need an order to even apply lotion... get an order for EVERYTHING.

toomuchbaloney · Jul 25, 2014

Here is the bottom line...can you decide to insert a foley catheter as a portion of your nursing assessment and plan of care? Is a foley catheter a nursing intervention? Does the initiation of a foley require a medical order? Can the nurse decide to discontinue the foley independently?

While we may enjoy work environments with standing orders and relationships which allow us a reasonable amount of autonomy in these areas we are still not allowed to write medical orders without consulting a medical provider.

CapeCodMermaid, RN · Jul 25, 2014

It is NOT necessary to change a catheter every 30 days. You're more likely to develop an infection if you change a catheter that is functioning well.

Karou · Jul 26, 2014

As she yells down the hallway "I can't get it in him, I tried several times; it keeps rolling" ... OMG; I'm surrounded by morons! I exit stage left and as I stand at the bedside of the man I found him sweating profusely with an extended abd (looked about a good 5 months if you know what I mean) and when I looked straight into his eyes they told me with a desperate plea I swear I could hear; "pleeeeease help" (and keep that nurse away from me).
Without hesitation I called 911 stat.
One hour later I called the ER to check on him and the nurse giving me report was giving me razz about how the nurses at the SNF couldn't change a foley. Found out later from a friend in the ER that the nurses at the ER couldn't do it either, that a doc finally came in and showed the nurses how to put a coude catheter in him.
Of course we all know why the doc decided on a coude...When the, hmmm, RN was trying to put in the foley, she said it rolled. The rolling indicates prostrate concerns and the coude is a special foley that is specific for that due to it's stiff nature. After that incident the facility ordered coudes to keep in stock. I've never seen a doc change a foley. Not saying there is a case where only a doc can do it; but I live on a small island ...
FYI, I may have had only a few years of experience at the time this happened, but the RN who attempted to change the foley had 20 years in the field...I expected a little more from her.

How long did he go without a foley? Why was he already distended? If she quickly removed and went to reinsert then he couldn't be distended that much from a few hours of retention.

I deal with a lot of urology patients, and have seen many that are difficult to catheterize. Like you describe, men with prostate problems can be tricky, including post TURP patients. I have seen women that locating their meatus is like finding a needle in a haystack! I've had women who had theirs below the lady parts, next to it, or once a crazy fistula where the patient urinated feces. That wasn't a sterile insertion....Then there are the morbidly obese patients (500lb +) that take multiple staff members and flashlights.

Often when I receive an order to insert a foley I will have a discussion with the urologist over what size, type, ect... And what to try if that doesn't work. It is not common, but not unheard of, to have to grab the urology cart and the urologist has to come to the bedside to insert the foley. They do this in the ED if necessary and occasionally on my unit.

A coude is preferred for patients with prostate problems, but in some settings this must be specifically ordered by the physician. Had this patient been there for a while, and already had a coude? If so, why weren't there any in stock already? As an aside, Frank blood should always be investigated, but can be normal after a difficult insertion/attempt and monitored as long as the physician is aware.

Sounds like this guy was actually a really difficult insert if the ED nurses had trouble as well, and the doc had to do it. So perhaps your coworker wasn't as incompetent as you think.

CapeCodMermaid, RN · Jul 26, 2014

We usually write discontinue orders: Remove foley catheter at 6am. Due to void in 8 hours. If no void, may reinsert foley #_____French with____cc balloon.

That way we don't have to call the doctor back. AND....we've had plenty of old guys who had to have a urologist place/replace a foley. Don't blame the nurse because you didn't have the right equipment or the guy's parts weren't exactly like everyone else's.

tyvin, BSN, RN · Aug 2, 2014

How long did he go without a foley? Why was he already distended? If she quickly removed and went to reinsert then he couldn't be distended that much from a few hours of retention.
I deal with a lot of urology patients, and have seen many that are difficult to catheterize. Like you describe, men with prostate problems can be tricky, including post TURP patients. I have seen women that locating their meatus is like finding a needle in a haystack! I've had women who had theirs below the lady parts, next to it, or once a crazy fistula where the patient urinated feces. That wasn't a sterile insertion....Then there are the morbidly obese patients (500lb +) that take multiple staff members and flashlights.
Often when I receive an order to insert a foley I will have a discussion with the urologist over what size, type, ect... And what to try if that doesn't work. It is not common, but not unheard of, to have to grab the urology cart and the urologist has to come to the bedside to insert the foley. They do this in the ED if necessary and occasionally on my unit.
A coude is preferred for patients with prostate problems, but in some settings this must be specifically ordered by the physician. Had this patient been there for a while, and already had a coude? If so, why weren't there any in stock already? As an aside, Frank blood should always be investigated, but can be normal after a difficult insertion/attempt and monitored as long as the physician is aware.
Sounds like this guy was actually a really difficult insert if the ED nurses had trouble as well, and the doc had to do it. So perhaps your coworker wasn't as incompetent as you think.

Oh; yes, yes...I prefer not to make the posts too long but happy to answer questions. The man's foley had clogged earlier. This was a noc to day shift situation and at report they told me they found the man slightly distended due to a clogged foley and they tried to irrigate with no success so the order came in to change it. They had figured that out due to he had no output to record in the am. Now this man was also a continuous tube feeder and I was told they had turned off the pump and he was resting fine...no one turned off the tube feeding and he wasn't resting fine. I take this as my fault for not actually going to personally see that the machine was off. Take that, and no one really knows how long he was like that. It took the day shift nurse about an hour to get to him and then she just didn't insert, re-insert.

I didn't say she was incompetent for not being able to insert the foley. I say she shouldn't have attempted or been as aggressive to insert the foley up to the point of drawing frank blood. She should have known something was off when it kept curling...that's where I find it difficult to imagine that I would do the same thing. I know I would have consulted after 2 attempts with no resistance. She had to have met a lot of resistance with the amount of blood there was. Also, I should have taken the patient's situation a lot more serious than I did at first.

The resident didn't get a coude until he went to the ER and of course you need an order for any type of foley. I didn't know what a coude was until that point. Who knows how long the foley was actually clogged from the previous shift. I would also like to mention that they drained 1800 cc of urine out of that poor man in the ER. He was barely 140 lbs.

When I went into that patient's room after the nurse reported the problem to me and when I saw the pump still going I can't even explain how I felt since I was the charge. I was sick to my stomach...quite the lesson. I kept thinking...how many staff have actually passed this pump knowing of this man's situation?

I think it's important for all of us to have these types of conversations so that nurses everywhere can be aware. I was a very young RN at that time and have learned many a valuable lesson since then.

Thanks,

casi, ASN, RN · Aug 3, 2014

Everywhere I've worked we needed orders. Normally when someone admits with foley or gets one put in we get orders, "Change monthly and PRN"

VANurse2010 · Aug 4, 2014

If urology placed the Foley, it was done like that for a reason - I strongly advise you not remove or replace their Foleys without speaking to them first. I highly, highly doubt you'd be able to get it in anyway. If you're in a LTC facility with a urology placed Foley that's occluded and they can't come in - I'd send the patient to the ED. You likely don't have everything they need in house anyway.

Guests · Aug 4, 2014

You need an order, no matter what. It can be in different firms, though..

Direct order

Standing order

PRN order

Indirect order via facility policy or protocol

Somewhere, though, a doc needs to authorize it

Karou · Aug 5, 2014

Oh; yes, yes...I prefer not to make the posts too long but happy to answer questions. The man's foley had clogged earlier. This was a noc to day shift situation and at report they told me they found the man slightly distended due to a clogged foley and they tried to irrigate with no success so the order came in to change it. They had figured that out due to he had no output to record in the am. Now this man was also a continuous tube feeder and I was told they had turned off the pump and he was resting fine...no one turned off the tube feeding and he wasn't resting fine. I take this as my fault for not actually going to personally see that the machine was off. Take that, and no one really knows how long he was like that. It took the day shift nurse about an hour to get to him and then she just didn't insert, re-insert.
I didn't say she was incompetent for not being able to insert the foley. I say she shouldn't have attempted or been as aggressive to insert the foley up to the point of drawing frank blood. She should have known something was off when it kept curling...that's where I find it difficult to imagine that I would do the same thing. I know I would have consulted after 2 attempts with no resistance. She had to have met a lot of resistance with the amount of blood there was. Also, I should have taken the patient's situation a lot more serious than I did at first.
The resident didn't get a coude until he went to the ER and of course you need an order for any type of foley. I didn't know what a coude was until that point. Who knows how long the foley was actually clogged from the previous shift. I would also like to mention that they drained 1800 cc of urine out of that poor man in the ER. He was barely 140 lbs.
When I went into that patient's room after the nurse reported the problem to me and when I saw the pump still going I can't even explain how I felt since I was the charge. I was sick to my stomach...quite the lesson. I kept thinking...how many staff have actually passed this pump knowing of this man's situation?
I think it's important for all of us to have these types of conversations so that nurses everywhere can be aware. I was a very young RN at that time and have learned many a valuable lesson since then.
Thanks,

Thank you for expanding, I think I understand the situation better now. The foley had been clogged, already irrigated without success, and the patient had gone without output for an extended amount of time.

Now I see the emergency. I agree that I would have called the physician after a second unsuccessful attempt, especially with the catheter tubing curling like that. At that point the insertion is too difficult and since you didn't have coude's on hand to try, he needed a higher level of care. The blood still wouldn't concern me too much unless it persisted after the patient was successfully catheterized.

I would be really peeved in that situation as charge nurse as well. Mostly at the nurse who didn't realize that the patient went that length of time with no output from the foley. If declotting did not work, then the foley should have been addressed a lot sooner.

I really hope I didn't come off as acidic in my original post. My impression of the situation was different, the added details gave me a better picture.