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Nursing Fundamentals > Exam 6; Ch. 28 & 46 > Flashcards

Exam 6; Ch. 28 & 46 Flashcards

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1
Q

Sterile technique is also known as

A

Surgical Asepsis

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2
Q

Sterile technique prevents

A

Contamination of an area, such as an open wound.
Isolates an operative or procedural area from an unsterile environment
Maintains sterile feild for surgery or procedural intervention

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3
Q

Sterile technique includes

A

Creating a sterile feild and utilizing sterile objects to eliminate all microorganisms from an area or object

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4
Q

Sterile is

A

The absence if all viable life that has the potential to reproduce and spread dangerous and disease-causing germs and bacteria

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5
Q

Sterile technique is commonly used where.?

A

In the OR

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6
Q

When is sterile technique used outside of the OR.?

A

When performing any procedure that could possibly introduce microbes into a patients body

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7
Q

How does the nurse know when to use sterile feild.?

A

The provider will put in an order for when sterile feild is necessary

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8
Q

Sterile sites include:

A
  • Organs: Heart, Brain, Kidneys etc.
  • Central & arterial lines
  • Bone & Bone marrow
  • Cerebrospinal fluid (CSF)
  • Pericardial fluid
  • Peritoneal fluid
  • Plueral fluid
  • joint fluid
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9
Q

What is NOT a sterile site.?

A

Any passageways of the body that are open to the outside environment

EX: Nasal passages, Throat, Vagina, Stomach, Rectum, Skin, Abscesses, & local soft tissue infections

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10
Q

How does a sterile object remaine sterile.?

A

ONLY when it is touched by another sterile object

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11
Q

Sterile touching sterile…

A

Remains sterile

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12
Q

Sterile touching clean…

A

Becomes contaminated

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13
Q

When sterile state is questionable…

A

Discard the object/ resterilize tools even if it appears untouched

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14
Q

What items can be in the sterile field.?

A

Only sterile objects allowed in the sterile feild

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15
Q

How are sterile objects stored.?

A

In a clean, dry environment

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16
Q

The package containing sterile objects is considered…

A

Contaminated

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17
Q

Any package that is torn, punctured, wet or open is considered…

A

Contaminated

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18
Q

Where should objects as well as hands be at all times.?

A

In the range of vision; any object out of the range of vision or below the waistline is considered contaminated

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19
Q

Nurses NEVER…

A

Turn their back to the sterile field or leave it unattended.

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20
Q

What part of the sterile field is considered contaminated.?

A

The 1 inch border/outer edge of the drape

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21
Q

When performing sterile procedures

A

A sterile work area that provides room for handling and placing sterile items is a must

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22
Q

A sterile drape, dressing tray, &/or sterile wrapper is used for..

A

Creating a surface for the sterile field

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23
Q

Methods of adding sterile items to the sterile field

A
  • Using sterile forceps to place sterile items in sterile field
  • Dumping sterile items into the sterile field
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24
Q

Under what condition can the nurse touch sterile items.?

A

If the nurse is wearing sterile gloves all items in sterile feild may be touched

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25
Q

Steps if opening up the sterile kit

A
  • Wash hands
  • Open outermost flap aways from body, making sure not to reach over sterile field
  • Open side flap while holding tip of first flap to assure the flaps stay open
  • Repeat last step for other side flap
  • Grab very end of flap closest to body, take a full step back and pull flap back allowing it to fall
  • Adjust kit to where body will not graze the sterile field
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26
Q

Urinary elimination is

A

A basic human function; can be compromised by illness and conditions

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27
Q

Nurses role in urinary elimination

A

To assess pt urinary tract functions and provide support for bladder emptying

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28
Q

Kidneys

A

Filter blood through nephrons to make urine; many other funtions

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29
Q

Ureters

A

Transport urine from the kidneys to the bladder

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30
Q

Bladder

A

Reservoir for urine until the urge to urinate develops.

  • Smooth muscle which expands during bladder filling/contracts w emptying
  • Sphincter prevents reflux of urine from bladder traveling to ureter
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31
Q

Urethra

A

Where urine exits the body

  • 2 to 3 inches in females/ 7-8 inches in males
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32
Q

Function of the kidneys

A
  • Formation of urine
  • Excretion or conservation of water
  • Electrolyte balance
  • Acid-Base balance
  • Excrete end products of metabolism (Urea)
  • Activation of vitamin D
  • Erythropoietin production
  • Renin production
  • Excretes bacterial toxins, water-soluble drugs, and drug metabolites
  • Regulate BP via RAAS
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33
Q

Brain structures influence bladder function & act if urination by..

A
  1. Bladder wall stretching signals micturition center in the sacral spinal cord
  2. Impulses from micturition center in brain respond to/ignore this urge, thus making urination under voluntary control
  3. When a person is ready to void, the external sphincter relaxes, micturation reflex stimulates the detrusor muscle to contract, and the bladder empties.
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34
Q

Urinary retention

A

An accumulation of urine in the body due to the inability of the bladder to empty

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35
Q

Urinary Tract Infection (UTI)

A

Invasion of urinary tract by bacteria

  • Women have a greater risk for UTI
  • Contamination in perineal/urethral area
  • instrumentation (indwelling/straight catheters)
  • Reflux of urine
  • Previous UTIs can cause pt to be more susceptible
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36
Q

Stress incontinence

A

Involuntary urine loss from increasing abdominal pressure; coughing, sneezing, laughing, physical activities

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37
Q

Urinary diversions

A

Nephrostomy

Urostomy

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38
Q

Prevention strategies for UTIs

A

-Good personal hygiene; wipe front to back

  • Drink plenty of water; 3-4 glasses daily
  • Go pee when the feeling arises
  • Get recommended daily allowance of Vitamin C
  • Non-tight fitting Cotton underwear
  • Pee after sex
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39
Q

Cystitis (Lower UTI)

A

Affects bladder and urethra.

S/S include:
-Suprapubic tenderness 
-Urinary issues;
 •Dysuria
 •Urgency
 •Frequency
 •Incontinence
 •Foul-smelling cloudy urine
40
Q

Pyelonephritis (Upper UTI)

A

Affects the kidneys, along with the bladder and urethra
-If lower UTI not treated appropriately, bacteria will travel superior to kidneys

S/S include:
-Same symptoms as lower UTI
-CVA tenderness 
-systemic issues:
 •Fever
 •Chills
41
Q

Nursing care for UTIs

A
  • Monitor symptoms
  • Monitor I&O
  • Pain control
  • Keep area clean
  • Encourage fluids
  • Pt edu on meds; Take all antibiotics even when feeling better
  • PT edu on prevention
42
Q

What is important for the nurse to know regarding older adults and UTIs

A

Older adults may not be able to report typical UTI S/S

-Older adults may experience confusion, decreased LOC, Agitation, delirium, which all are S/S of infection.!

43
Q

Urge incontinence

A

Involuntary urine loss w abrupt/strong desire to void; unable to make it to the bathroom in time. Like an on/off switch: have to go as soon as the urge presents

Most common in older adults.

44
Q

Functional incontinence

A

Incontinence due to inability to get to the bathroom; physical limitations, loss of memory (progressed dementia) disorientation

These pts are usually dependent on others

45
Q

Overflow incontinence

A

Involuntary loss of urine associated with bladder distention; may occur due to prostate enlargement

46
Q

Total incontinence

A
  • Continuous, unpredictable loss of urine

- Neurological impairment, surgery, trauma

47
Q

Nursing care for urinary incontinence

A
  • Keep pt clean and dry, esp. w total incontinence
  • Ask pt about needing BR, esp. w urge and functional incontinence
  • Monitor for skin breakdown on booty and perineal area
  • Assess for S/S of UTI: malodorous urine
48
Q

Can the nurse place an indwelling catheter to manage incontinence.?

A

Absolutely not.! It adds unnecessary discomfort to the pt & is highly unethical

49
Q

Urin

A
50
Q

Acute urinary retention causes

A
  • Anesthesia
  • Meds
  • Local trauma to urinary structures
51
Q

Chronic urinary retention causes

A
  • Enlarged prostate
  • Meds
  • Strictures
  • Tumors
52
Q

Nursing actions for urinary retention

A

-Monitor Urine Output
-Palpate for bladder distention
-Perform bladder scan
•Assess volume of urine in bladder
•After urination, bladder should contain less than 50mL of urine
•Residual volume of 150-200mL urine indicates need for treatment

53
Q

Nursing assessments

A

-Selfcare ability
-Cultural considerations
-Health literacy
-Nursing history
-Fluid overloaded.?
•Lung sounds
•Edema
•Daily weights
-Is Pt dehydrated.?
•skin turgor
•oral mucousa
-Urination pattern
•time of day
•frequency
•Amount

54
Q

Focused urinary assessment questions

A

-Urinate more than usual.?
(Frequency, urgency, nocturia)
-Pain ir burning when urinating.?
-Color changes.?
-Difficulty starting or maintaining stream.?
-Changes in urination characteristics.? Peeing less or more.?
-Feel like bladder is still full after urinating.?
-Dribbling of urine after urinating.?
-Continent.? Incontinent.?

55
Q

Physical assessment regarding urinary system

A

KIDNEYS:
-Costovertebral (CVA) tenderness
•If present, possible pyelonephritis or polycystic kidney disease

BLADDER:
-Palpate for distention, fullness & tenderness

  • External genitalia and urethral meatus
  • Perineal skin
56
Q

How is a CVA tenderness test performed.?

A
  1. Have Pt sit up on side of bed
  2. Place flat palm over kidney
  3. With other hand, make a fist and thump the hand resting over PT kidney

If pt reports pain or discomfort, CVA tenderness is present

57
Q

What characteristics should the burse ask about regarding the PT urine.?

A
  • Color
  • Clarity
  • Odor
  • Amount
58
Q

If a PT has kidney disease what restrictions may they have.?

A

Fluid restriction. Carefully measure intake in order to avoid fluid overload

59
Q

What labs can tell the nurse how well the PT kidneys are functioning.?

A
  • BUN
  • Creatinine
  • eGFR
  • 24 hr urine (Creatinine clearance)
60
Q

What is a urinalysis.?

A

A common test performed to asses the urinary system, kidneys, and systemic disease

61
Q

How can a urine sample be taken.?

A
  • Midstream collection
  • Straight catheter
  • Indwelling catheter
62
Q

How much urine is needed to perfome a urinalysis.?

A

At least 10mL

63
Q

Urine culture and sensitivity

A

Used to identify specific bacteria and what that bacteria is killed by

  • Usually collected w urinalysis
  • Ensure urine is collected before starting antibiotics to ensure accuracy
64
Q

24 Hour Urine

A

Starts at 0800 (or per policy), pt discards the very first urine and is to save all urine after that for 24 hours on ice

65
Q

How is a clean catch performed?

A
  1. Educate PT on how to properly lrovide the sample
  2. Pt cleans perineal area front to back
  3. Females are to hold the labia open the entire time
  4. Begin urine stream into toilet
  5. Stop stream and place the cup under the urethral opening
  6. Begin urine stream into cup, after cup is filled continue stream into the toilet
66
Q

Guidelines for collecting urine samples:

A
  • Give pt adequate time to produce urine sample, provide privacy
  • Provide pt edu on what to do when they have to urinate, leave sterile cup at bedside (tell pt to lyk when sample is ready)
  • collect sample w gloves
  • Time, Date, Initial
  • Take to lab ASAP
67
Q

Normal amount of urine

A

1,000-2,000 mL/24hrs

68
Q

Normal urine color

A

Straw or amber

69
Q

Normal urine clarity

A

Clear

70
Q

Normal specific gravity of urine

A

1.005-1.030

  • Lower= more fluid than waste present
  • Higher= More waste than fluid present
71
Q

Normal urine pH

A

4.5-8.0

72
Q

Normal urine constituents

A

95% Water

Urea, Creatinine, Uric Acid

73
Q

What is a urinary catheter

A

A pliable tube that is placed through the urethra open into the bladder to drain urine

-urinary catheters are always placed using sterile technique

74
Q

Why would a healthcare provider insert an indwelling catheter.?

A
  • Urinary obstructions
  • urinary retention
  • strict intake and output necessary
  • coma
  • surgery and anesthesia
  • urinary incontinence with skin breakdown
75
Q

Why would a healthcare provider insert an intermittent catheter

A

What a urinary sample is necessary but the patient is unable to provide a clean catch

-Urine retention present, drain bladder and then attempt to see if pt can void on own

76
Q

External catheters

A
  • condom catheter

- female external catheter

77
Q

Intermittent (Straight) catheters

A

Temporary in and out catheters

78
Q

Indwelling (Foley) catheter

A

Catheters that are inserted for longer duration

79
Q

Triple lumen catheter

A

Irrigation of the bladder

80
Q

Coude catheter tip

A

A catheter with the firm, bent tip use for males with an enlarged prostate

81
Q

Suprapubic catheter

A

An indwelling catheter surgically inserted through the abdominal wall and into the bladder

82
Q

Indwelling catheter balloons

A

The indwelling catheter tubing allows for a balloon to be blown up at the tip of the catheter

  • this balloon resides in the bladder and keeps the catheter in place
  • The balloon volume is located on the catheter tubing
83
Q

Catheter sizing

A

Catheters Are measured in French, the larger the number the larger the diameter

-catheter sizing is located on the catheter tubing

84
Q

How often should catheters be changed.?

A

If a long-term indwelling catheter is placed it is changed every 4 to 6 weeks

85
Q

Closed drainage systems

A

There is a seal that connects a Foley catheter to the drainage tubing you do not separate the Foley catheter from strange tubing unless absolutely necessary (Reduces the risk of a CAUTI)

86
Q

Stabilization devices

A

A device that keeps the external piece of the catheter tubing and drainage tubing in place; The nurse should ensure that there is slack, and the catheter isn’t pulling or tugging creating tension

  • StatLock
  • Leg Bag
87
Q

With a catheter is in place the nurse should be sure to do what.?

A

Provide perineal care at least once per shift with warm soap and water. if the patient has a suprapubic catheter keep the site clean

88
Q

Steps for indwelling catheter insertion

A
  1. Open sterile kit, apply sterile gloves
  2. Prepare sterile area
    - connect syringe
    - prep lube
    - prep betadine
    - ensure foley bag is intact & closed
    - Remove wrapping from catheter
    - place catheter tip in lube
  3. Move kit to workable area on bed in between patient thighs
  4. Secure perineal area with a non-dominant hand, cleanse urethral meatus with betadine using dominant hand
  5. Insert catheter until urine return is seen, advance another 1 to 2 inches
  6. Inflate the balloon tug for resistance
  7. Secure the statlock to the inner thigh
  8. Play strate bag on a nonmovable part of the bed
89
Q

Steps to insert an intermittent catheter

A
  1. Open sterile kit apply sterile gloves
  2. Prepare sterile area
  3. Move kit to workable area on bed in between patients thighs
  4. Secure perineal area with non-dominant hand, cleanse urethral meatus with betadine using dominant hand
  5. Insert catheter until urine return seen
  6. Drain urine into plastic tray that comes with kit
  7. Once all urine is drained from bladder remove catheter slowly
  8. Perform perennial care and clean up equipment
90
Q

How often should perineal care be provided.?

A

At least once a shift

91
Q

Steps to perineal care

A
  1. Expose urethral meatus and catheter secure with non-dominant hand
  2. Clean urethral meatus and catheter with soap and water
  3. Remove all traces of soap
92
Q

Before moving a patient with a catheter what should be done.?

A

Always double check the statlock placement before you move the patient make sure no tubing is caught anywhere

93
Q

What is a CAUTI.?

A

A catheter associated urinary tract infection

94
Q

How can the nurse prevent CAUTI.?

A
  • keep drainage tubing without any loops or kinks to avoid urine backflow
  • clean the catheter tubing away from the meatus with soap and water
  • keep drainage bag below the level of the bladder
  • avoid touching the spigot to the receptacle when emptying the drainage bag
95
Q

How often should the nurse drain the catheter bag.?

A

At least every four hours

96
Q

Steps to removing an indwelling catheter

A
  1. Perform hand hygiene and put on gloves
  2. Release catheter from stabilization device
  3. Drain all urine from tubing and bag
  4. Secure catheter at urethra with non-dominant hand
  5. Connect syringe to port to empty water from the balloon
  6. Inform patient to take a deep breath in and out slowly remove catheter
  7. Inspect tip to ensure it is intact 
  8. Provide perineal care
  9. Discard all supplies
97
Q

What education should the nurse provide the patient after removal of the catheter.?

A
  • tell patient to drink adequate amount of water
  • patient should void within 4 to 6 hours of removal and that it may be uncomfortable the first couple of times

-if they do not void within six hours of removal catheter may be replaced
-give the patient signs and symptoms of a urinary tract Interport any signs of symptoms to one of their healthcare providers ASAP


Nursing Fundamentals (5 decks)

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