chapter 22 Flashcards
How do you suction a tracheostomy catheter?
A. Insert catheter without suction
B. limit suctioning to 10-15 seconds.
C. Gently withdraw suction if patient is coughing.
D. Hyperoxengate before suctioning.
E. apply suction, twist and rotate while removing catheter.
what is the effect of heat treatments?
Increases blood flow or improvement of circulation.
steps for Foley catheter insertion?
- check the balloon by injection NORMAL SALINE or STERILE water - before catheter injection.
- Insert 2-4” for female and 6-7” for male
- when you see urine - insert 1-2 inches further.
when you see urine return after insertion of a Foley catheter, what do you do next?
Advance the catheter another inch or two.
How do you remove a Foley catheter?
deflate the balloon.
After removal of Foley catheter, what do you asses?
urinary retention.
how do you prepare a patient for MRI?
-Check for allergy to iodine or shell fish;; if the client has metals inside the body.
the category of patients that would require an indwelling catheter-
Patients in labor; UTI; enlarge prostate, urinary retention.
what is the early sign of hypoxia?
restlessness.
what is involved in a routine catheter care—
- cleaning the first 2–4 inches of the catheter with soap and water every shift.
ileostomy drains wha type of stool?
semi- liquid
Guaic test is ordered for what purpose?
GI Bleed.
explain paracentesis–
a needle is used to aspirate fluid from the peritoneal cavity.
how do you measure the tube for nasogastric insertion—
Tip of the nose to the earlobe to the xiphoid process.
what tube is used for gastric decompression in patient diagnosed with bowel obstruction?
Salem sump.
How do you direct the solution while performing eye irrigation and what is the rationale–
Direct the solution along conjunctive from inner to outer cants.
Rational- prevent contaminants being absorbed by nasolacrimal duct and to protect the nasolacrimal ducts.
what are the safety measures when administering oxygen-
- No smoking sign on the door.
- Use cotton blankets rather than wool blankets.
- Do not use wool carpeting.
- Avoid clothing that is not fire resistant.
- Avoid petroleum products- like petroleum jelly.
- Avoid electrical appliances - heating pads, razors, ETC.
What are the normal findings when assessing stoma?
- Stoma should be moist and pinkish red or reddish pink in color.
- It should protrude from the abdomen.
- Stool should come out from the stoma.
What is the abnormal finding of the stoma?
- Stoma appears gray.
What can increase the risk of acquiring UTI on a patient with indwelling catheter-
Hanging the bag on the side rails.
How do you position on a drainage bag correctly?
- Keep the drainage bag below the bladder level- to maintain a constant downward flow of urine.
What is the position for administering enema?
Left sim’s position.
what would you report in a patient using a partial non breather mask -
bag totally collapses during inspiration.
What are the normal assessment findings on a patient with a face mask?
- Mask go over the bridge of the nose and covers the mouth and nose.
- Strap should be snug around the head.
- Normal to have moisture accumulate inside the mask.
- ** Delivers 6-10 L/min.
What are the reasons for suctioning-
- Cyanosis
- Breath sounds are wet or noisy
- Ineffective cough
- Restlessness
Inserting a indwelling catheter is a sterile or non sterile procedure-
Sterile
how do you administer an enema?
- Left Sim’s position
- Hang container 12-18 inches above level of anus
- if patient c/o cramping- stop the flow and restart when cramping goes away.
nursing interventions for ileostomy and colostomy?
- Stoma should be moist and pinkish red or redish pink in color.
- if grey appears - report.
- Inspect color, size and condition of the stoma.
- Apply a skin barrier substance to excoriated skin as ordered to protect the peristomal skin.
- Avoid using alcohol around stoma- Peroxide irritates tissue.
- Clean around stoma with mild soap and water.
- Use dietary measures to control odor.
Type of enema used for fecal impaction?
Oil retention.
What are the effects of cold therapy?
Causes vasoconstriction .
Decrease swelling, decrease bleeding and reduce pain.
Nursing intervention when caring for a patient with NG tube?
- Mark where the use exits the nose.
- Verify placement before feeding.
1. injector into the tube while listening to the stomach with a stethoscope.
2. Aspirate gastric contents.
Secure tube to the nose with a tape or nose guard (athletes use this)
Fasten end of the tube to the gown by looping rubber band around the tube in a slip knot.
Pin rubber band to gown.
What is the minimum urine output in an hour?
30 cc/hr.
Nursing interventions when caring for a patient on nasal cannula?
Check for irritation behind the hear.
Check for pressure over the cheecks - q 2 hrs.
Place nasal prong into each nostrils - facing down wards.
Apply water soluble lubricant to nares as needed.
an effective way for clearing secretions?
Deep breathing and coughing
what is the advance of venture mask?
give a precise concentration of oxygen.
what are the uses of condom catheter?
to prevent skin breakdown for an incontinent male patent.
monitor urine out put.
for a male client having frequent urination.
early skin of hypoxia?
restlessness.
