Exam #2 Flashcards
What are the stages of wound healing?
- Primary Intervention: closed edges with sutures or staples
-
Secondary Intervention: burn, pressure ulcer, severe laceration
Tertiary Intervention: wide open wound that will be closed later
How to insert a catheter
- use sterile technique
- clean the meatus
- apply lubricant
- insert catheter tell pt to bear down
- insert until urine appears insert 2 inches after urine appears
- inflate catheter balloon
- pull back until resistance is felt
- secure w securement device
How to do an enema
- place client left side position with upper thigh flexed to chest
- warm solution
- lube 2-3 of tube
- slowly insert 3-4 inches
- hang bag 12-18 inches above anus
- ask client to retain solution
What are the different types of enemas?
- Tap Water: hypotonic; do not repeat, can cause water toxicity or circulatory overload
- Normal Saline: infants and children; does not create danger of excess fluid absorption
- Osmotic Hypertonic Solution: DO NOT USE on dehydrated pt; 120-180ml
- Soapsuds: pure castile soap; do not use in pregnant woman
- High enemas: 12-18 in; cleanses entire colon
- Low enemas: 3 inches; cleanses only rectum and sigmoid colon
- Oil Retention
- Carminative: relief from gaseous distention
- Kayexalate: treats pt with dangerously high serum potassium levels; resin that exchanges sodium ions for potassium ions in large intestine
- Neomycin Solution: antibiotic used to reduce bacteria in the colon before bowel surgery
What should you do if someone gets stomach cramps during an enema?
- slow the flow of the solution by lowering the bag
- if they’re experiencing severe cramping; discontinue
How far in should you place an enema?
3-4 inches for an adult
How far off the bed does an enema bag need to hang?
no higher than 18 inches
What kinds of enemas can kids have?
children can ONLY have normal saline enema; if not it will put them at risk for fluid imbalance
How does the digestive tract work?
- Digestion starts at the mouth
- Esophagus: peristalsis moves food into the stomach
- Stomach: stores the food
- Small intestine: duodenum, jejunum, and ileum
- Large intestine: primary organ for bowel elimination
- Anus: expels feces
What is mass peristalsis?
- pushes food though intestines
- mass peristalsis happens 3x a day; strongest 1 hr after you eat
When is the best time to do Stoma care?
3-4 hr before they eat
What is the Valsalva Maneuver and the response?
- when you bear down (usually for bowel movement)
- can trigger fatal arrhythmias
Why do older adults have poor temp regulation?
- lose adipose tissue
this puts them at risk for maintaining body temp
What can you do to help pt have a normal bowel habit?
- add fiber to diet
- make sure they’re positioned properly to make it to bathroom
- give privacy if using bedpan or bed side commode
What is a symptom of dry hard stools that are hard to eliminate?
constipation
What is the difference between Constipation vs. fecal impact?
Fecal Impact
due to unrelieved constipation when stool gets lodged in rectum and builds up.
- give oil enema or impaction removal
What is flatulent?
Gas
What is it called when we have dilated or enlarged veins?
hemorrhoids
What pt are at higher risk for hemorrhoids?
pregnant women
- due to more pressure on the intestines, rectal wall, and increases venus pressure
Why might you see hemorrhoids in a patient with chronic heart failure?
due to high venous pressure in the vessels
Does an ostomy have to be placed in a specific spot?
No
- can be in any spot, doesn’t have to be in one spot
– stool will look different depending on location
– ostomy on small intestine called illiostomy: secretions are more liquidy
What color should a stoma be?
pink/red
- dark dusty (dull grey) purple color: sign of tissue circulatory issue
What is proper placement of a bedpan?
have the pt sitting upright and in a squatting position if able
– do not have the pt laying down
What medication can a pt take to decrease constipation?
laxative
