Documenting elimination route

Tenebrae, BSN, RN · Sep 17, 2015

I would document it as "patient HPU (has passed urine)" or "patient HPUDIT (has passed urine in the toilet", or bowels opened. If patient is wearing a pull up or moli, I would also document "patient has moli insitu". If patient has a catheter, I would document amount passed in my shift, and quality of urine, eg clear non malodourous"

When they say method of elimination, you can cover that in how you document your patients output without having to resort to documenting as you described

RagingRaptor · Sep 17, 2015

Thank you so much!

icuRNmaggie, BSN, RN · Sep 17, 2015

Incontinent of small, adequate or large amount in adult brief.

Tenebrae, BSN, RN · Sep 17, 2015

No troubles.

I remember in nursing school the tutors always used to talk about nursing assessment as though it was this scary dark mysterious thing that there was no way in hell I could ever master.

Now that I've been qualified for almost three years, I realise that nursing assessment is in every thing we do and often we can get information from just talking with our patient. For example on med/surg, when ever I take a set of vitals, I'm also asked about the patients mental status (alert and orientated) and is their airway patient? If I'm able to have a conversation with the patient, its fairly safe to say the patient has a patent airway and is alert and orientated.

Its also why I get very annoyed when I have a student who tells me they wont do toileting or bed washes/showering. These are areas where a nurse can get soo much information

If a patient is able to mobilise to the toilet, the nurse can assess their mobility, do they need an aid?, are they steady on their feet?, do they have an increase in pain? (an indicator that it may be a good idea to get extra pain relief on board prior to further extertions or perhaps that their current analgesia may need to be reevaluated)

Showering (particulalrly for an elderly patient who may be recuperating after an illness or injury) how they are in the shower allows me to assess if they are safe to go home on their own. Whether they may need to have support services in the home. Or whether they are not going to be safe to go home and may need to go into a long term care facility.

A bed sponge I can check the patients skin and ensure that there are no break downs or wounds, and if I find a wound I can ensure that its being treated and hopefully on its way to healing.

I could go on. I'm passionate about assessment, but also about demystifying it for students/new nurses

RagingRaptor · Sep 17, 2015

Perfect, thank you!!

RagingRaptor · Sep 17, 2015

Thank you so much!

RagingRaptor · Sep 17, 2015

You're so right. I feel so overwhelmed with the assessment and documentation, but I am very slowly learning how to assess on the fly. Thank you!

dishes, BSN, RN · Sep 17, 2015

Consider why the patient is wearing depends, are they incontinent? If so, what is the reason, do they have a urological or neurologicial condition that interferes with the storage of urine and/or micturition?

rnforforty · Sep 17, 2015

Void, incontinent, qs (quantity sufficient).

RN403, BSN, RN · Sep 18, 2015

Voiding adequate amounts of clear yellow urine in bathroom/urinal/ BSC.

Incontinent of yellow urine in brief.