Skip to main content

Kim-Ly is the in-charge RN for a multi-level care facility.  She receives a phone call from Cheri, an LPN from the special care unit, concerned about Mr. Carlson.

Over the phone, Cheri communicates her assessment findings: a firm and distended abdomen, grimacing during palpation, an urge to void, and a bladder scan that revealed 950 mL of urine. Cheri also shares Mr. Carlson’s history of benign prostate hypertrophy and episodic urinary retention.

Kim-Ly recalls Mr. Carlson and remembers treating his urinary retention in the past. Kim-Ly understands that it’s within her autonomous scope of practice to make a nursing diagnosis of a condition, determine treatment for that condition, and either carry out treatment or write a client-specific order that others may act on. Kim-Ly also knows the organization has a decision support tool (DST) that supports nurses initiating catheterization for urinary retention.

Diagnosing a condition

Based on Cheri’s assessment and her own knowledge of Mr. Carlson Kim-Ly, acting within her autonomous scope of practice and using her organization’s DST, diagnoses Mr. Carlson’s condition as urinary retention. She determines that an in-and-out catheterization is the most appropriate treatment. Kim-Ly returns to the unit and writes a client-specific order for an in-and-out catheterization in Mr. Carlson’s chart.

Kim-Ly accepts responsibility and accountability for the order she has given. Though Kim-Ly gave the client specific order, she is not responsible for determining whether the person carrying out the order has the competence to do so; the health care professional carrying out the order makes this determination. ​However, Kim-Ly is responsible for making sure the order is carried out in a timely manner.

After reading the order, Cheri knows it is within her scope of practice and she has the competence to perform the in-and-out catheterization to resolve Mr. Carlson’s urinary retention. She follows her organization’s DST to perform the activity and documents her actions and outcome in Mr. Carlson’s chart.

Kim-Ly discusses the outcome with Cheri. She also follows up with the facility’s nurse practitioner, informing her of Mr. Carlson’s situation and the team’s assessment, actions and outcome. She documents this communication in Mr. Carlson’s client record.

Keep in mind

Be aware that although these standards are in effect, practice will not change until your organization puts the necessary supports, resources and processes in place. If you have questions about implementing these standards in your organization, speak to your manager or Professional Practice office.

Resources

«Back to diagnosing page

900 – 200 Granville St
Vancouver, BC  V6C 1S4
Canada

info@bccnm​.ca
604.742.6200​
​Toll-free 1.866.880.7101 (within Canada only) ​


With great respect, we acknowledge that BCCNM’s office is located on the unceded territories of the hən̓q̓əmin̓əm̓ speaking peoples – xʷməθkʷəy̓əm (Musqueam), and sel̓íl̓witulh (Tsleil-Waututh) Nations, and the Sḵwx̱wú7mesh-ulh Sníchim speaking peoples - Sḵwx̱wú7mesh Úxwumixw (Squamish Nation) whose historical relationships with the land continue to this day.​