Binders, restraints, catheter and condom care Flashcards
What is the definition of a restraint?
a chemical, mechanical/physical, environmental device used to restrict the behavior or actions of a person
What is the optimal goal regarding restraints?
provide a restraint-free environment
What are some methods to protect pts and to prevent accidents?
Orientation of patients (show them what is around them, keep items in reach)
Call bell in reach
Dec hazardous objects/situations
Assess risk for falls
What are some ways that restraints may be avoided?
orient pt to surroundings
communication aids (to help them tell you what they would like)
sensory aids
ROUTINE TOILETING
exercise/ambulation regimes
Consult other HCPs
Medication review
door guard
increased observation
encourage family to visit
What are some complications that come from restraint use?
Agitation, humiliation, fear, dec self-esteem
disorientation
contractures, nerve dmg, circulatory impairment
What happens to the amount of care the pt receives when they are restrained? what can this lead to?
Tend to get less care
Can result in:
- pressure ulcers
- constipation
- incontinence
- pneumonia
What are the 3 indications for restraint use?
decrease risk of injury to pt and others. (must be a significant risk)
prevent interruption of therapy
prevent confused or combative pt from removing life-support equipment
What are the 6 criteria for restraint selection?
1) least restrictive of movement
2) least obvious to others
3) noninterfering with treatments
4) readily changeable
5) safe
6) agency policy
If a restraint is put into place, what should you make sure you check?
that it is quick to remove
maintains skin integrity and circulation
ends are tied to appropriate place
knots do not tighten and when pulled
it is the correct fit
remove q2-4 hrs for ROM and skin care
Reassess need for continuation
What guidelines should be followed
ensure you know policies
assess underlying reasons for need of restraint
never apply for convenience
do not be influenced by family to take of restraints (can not legally pass on care to a family member)
try to obtain a phys. order prior to implementing
Recognize competent adults right to choose
principle of least restraint
proper fit
documentation
re-assess the need
What data should be included in your documentation if a restraint is applied?
type time of application response to treatment skin condition frequency of removal
what are the 5 type of restraints?
Soft hand mit
Freedom arm splint
Pelvic soft belt
Segufix or Pinel (this is used in acute)
Chemical
When would you use a soft hand mitt?
when scratching is a problem and needs to be prevented
When would you use a freedom arm splint?
when IVs need to be protected from being pulled out
When would you use a pelvic soft belt?
when a sitting restraint is needed (usually to prevent falls from chairs/WC)
What is the purpose of bandages and binders? (7)
Create pressure
Immobilize body part
Provide support
Dec/prevent edema
Secures splints and dressings
Applies warmth
Shapes or molds stump
What are the principles relevant to the application of bandages and bindings? (4)
microorganisms flourish in warm, damp environment
pressure upon tissues can affect circulation (esp excessive/uneven)
friction can cause trauma to skin
natural anatomical position must be maintained
When applying a bandage which direction do you work in?
distal to proximal
What do you need to have before you can apply a bandage?
a dr order
What are the 5 types of bandage turns?
Circular Spiral Spiral-reverse Figure 8 Recurrent
Describe a circular turn
each turn completely covers the last
When would a circular turn be used?
to initiate/terminate a bandage
to cover a small part; finger or toe
Describe a spiral turn
angles slightly upward overlapping 1/2 to 2/3
What is the use of a spiral turn?
used to ascend a cylindrical body part (ex wrist, arm)
describe a spiral reverse turn.
same as spiral, but requires a twist of the bandage 1/2 through each turn
When would you use a spiral reverse turn?
on cylindrical parts with varying circumferences (lower leg)
Describe a figure 8 turn
overlapping turn, alternating between ascending and descending over bandaged area
when would you use figure 8 turns?
for joints or for full extremity
What is a recurrent turn?
anchored with a circular turn, then turned across the center of tip then alternates right and left followed by circular turns to secure.
When would you use recurrent turns?
for uneven body parts (head, stump, finger, toe)
What should be assessed prior to application of bandages/binders?
CWMS Swelling Wound status Drainage Pain Pts ability to reapply bandage/binder
What should be assessed after applying bandages for ongoing assessment?
CWMS pain swelling drainage effectiveness status of bandage
What should be considered in terms of safety for bandaging?
be careful for pins and clips that the pt may harm themselves on
be aware of what pressure can cause and reassess
What information should be documented when applying a bandage?
application of the bandage/binder alignment circulatory status tolerance of the individual pt teaching performed
What should be done/checked to ensure proper functioning of a catheter?
gravity aids flow; no looping of tubing, bag lower than bladder
secure connection
secure tubing to thigh to prevent pull on catheter
What is assessed in on-going catheter care?
Skin (peri, urinary meatus)
Thigh
Output: amount, characteristics
Intake: 1500ml/day for normal, need 2000 for a person on catheter
emotional/social support
What output characteristics should raise concern?
low volume
amber colour
odour
sediment
blood
What should be assessed after removal of the catheter?
Voiding; time of first void, amount, discomfort, frequency
Signs of distension; unable to void, burning/pain on voiding, signs of fullness
What can be done to help reduce the chance of infection when a pt has a catheter?
Increase fluid intake
Acidify urine to inhibit growth (cranberry juice)
Clamp tubing to prevent back flow if bag/tubing will be elevated
Pericare (BID min)
Hand-washing
Proper positioning
Empty bag regularly
Maintain closed system
Individual measuring containers
What sites are risk for causing infection when a pt has a catheter?
catheter insertion
drainage bag
spigot on bag
tube junction with bag
Describe the correct method for emptying a catheter bag
put on gloves
use a measurement container
clean spigot after
record time, amount, and urine characteristics
How do you perform pericare and catheter care?
do pericare first
clean catheter; avoid pull, wash proximal 1/3 of cath
What should you ensure there is when taping a catheter?
that there is slack
What equipment do you need to remove a catheter?
sterile syringe, receptacle, disposable gloves
How do you remove a catheter?
remove tape
deflate bulb fully
pinch tubing to prevent backflow, withdraw the catheter in a smooth quick motion (do not rip it out, but do not go slowly)
If a person is using a condom catheter, how much space should there be between the tip of the penis and the condom?
at least 1 inch
What is the minimum volume of urine that should be voided with a catheter per hour?
30mL/hr
