NURS 255 Exam 5 Flashcards
Inserting tube (Step 1-5)
- Prepare the tube
- Assist patient to high fowlers position
- Measure the tube for placement
- Drape the pad over the patient
- Prepare fixation device
Inserting tube (Step 6-10)
- Arrange a signal
- Don procedural gloves
- Wrap 10-15cm of hose around fingers
- Lubricate tube
- Hand the patient a glass of water with a straw
Inserting tube (Step 11-15)
- Instruct the patient to tilt back
- Pause for a moment
- instruct patient to lean forward
- Rotate the tube 180
- Direct the patient to sip
Inserting tube (Step 16-20)
- Continue advancing tube
- Temporarily secure tube CHECK 5 SIGNS)
- Advance tube if not in the stomach yet
- Clamp the tube after placement
- Secure the tube
Inserting tube (Step 21-24)
- Curve and tape the tube to patients cheek
- Fasten the tube to gown
- Elevate the bed to 30 Degrees
- Mark the tube
What should you do if you cant get aspirate from a newly inserted NG tube?
- Use syringe and aspirate slowly over 5 minutes then lay patient on left side and wait 20 minutes to try again
How often should you auscultate bowel sounds on patient with NG?
- Every time they are fed or every 4-6 hours.
Administering feedings: Closed system (Step 1-5)
- Check the medical prescription for type of food and amount
- Elevate bed to 30 Degrees
- Check expiration date of formula
- Prepare the formula
- Prepare the equipment for administration
- Gloves
- Label container
- Make sure tubes fit together
Administering feedings: Closed system (Step 6-10)
- Prime the tubing with the feeding solution
- Thread the administration tube through the machine
- Connect tube to tubing
- Turn on infusion pump
- Unclamp the tube
Administering feedings: Closed system (Step 11-15)
- Stop flow when bag is complete and flush tube
- Disconnect feeding tube
- Flush feeding tube with 15-50ml of water
- Cap the proximal end of the tube
- Keep the head of the bed elevated at 30 degrees for 1 hour after feeding
Administering feedings: Closed system (Step 16-17)
- Provide or assist with regular oral hygiene
- Perform universal end of procedure steps
Administering feedings: Open system
(Step 1-5)
- Prepare equipment for administration
- Remove plunger from syringe
- Clamp or pinch off feeding tube
- Attach syringe to the proximal end of the feeding tube
- Fill syringe
Administering feedings: Open system (Step 6-10)
- Unclamp the feeding tube
- Refill syringe until feeding bag is done
- When volume is infused, clamp or pinch the end of the tube
- Disconnect the syringe
- Cap the proximal end of the tube
Administering feedings: Open system (Step 11-13)
- Cap the proximal end of the feeding tube
- Keep the head of the bed elevated
- Provide or assist with regular oral hygiene
What should you do if when checking residual volume it is more than 250ml?
- Recheck in 1 hour and if it is still above stop infusion for 4 hours and if still greater contact provider
- if less than 250 after an hour, continue at 50% infusion rate.
What should you do if no residual volume is obtained when checking?
- Use a large syringe and inflate 20ml of air into the tube
Collecting Specimen Clean catch (Step 1-5)
- Perform hand hygiene and put on gloves
- Open the prepackaged kit
- Perform Peri care
- Grab container
- Tell them to pee a bit then catch 30-60ml mid stream
Collecting Specimen Clean Catch (Step 6-10)
- Remove container from stream
- Put on the lid
- Label the container
- Remove gloves and wash hands
- Return patient to bed
Collecting specimen Catheter (All 6 steps)
- Put on gloves
- Clamp tube
- Remove gloves
- insert syringe
- Put into container and discard syringe
- Undo clamp
When should you perform Peri care when removing a catheter?
- before and after removing the catheter
Blood Stool Occult test (All steps)
- Put on gloves
- Ask patient to go in cup
- Smear on card
- Put drops
- Send away test and remove gloves
Removing stool digitally (All Steps)
- Place patient in sims position
- Put on gloves and lubricate
- Break into smaller pieces and pull out as much as possible
- Remove gloves
Placing an ostomy bag (All steps)
- cleanse the stoma with pH of 5.5 or so
- Measure the stoma
- Trace the size onto the paper and cut
- Put on gloves
- Apply ostomy care products
- Place hand on New stoma paper for 30-60 seconds
Is it normal for stomas to be yellow, blood tinged or dried blood on it?
- Yes when it is new.
Should you change an ostomy bag after a meal?
- No because juices may still be coming out
What factors influence how often a stoma should be changed?
- type of stoma
- type of equipment used
- the effluent
- patients preference
- the climate
How often should an ostomy bag and patch be changed?
- Bag every 3-5 days
- Patch every 3-7 days (NEVER DAILY)
What type of ostomy should never be irrigated?
- illeostomy, because they can expel sodium, chloride, potassium, magnesium, and bicarbonate ions
What 13 things should be monitored for a person with an NG tube?
- Position of feeding tube
- NG tube insertion site
- Gastronomy/PEG insertion site
- Fluid balance
- Weight
- Residual volume
- Frequency of bowel movements
- Bowel sounds
- Abdominal dissection
- Serum electrolyte levels
- Skin turgor, hematocrit, and urine specific gravity
- Serum blood urea nitrogen and sodium levels
- Urine for sugar and acetone
What is neurogenic bladder?
- Impairment of neurological function that means a person cannot perceive bladder fullness
What medications affect urination? (AAAAEDMB)
- Analgesics
- Diuretics
- Anticholinergics
- Antidepressants
- Antispasmodics
- Muscarinic receptor antagonists
- Estrogen
- Botulinum toxin
Common diuretics (Thiazide and Potassium sparing)
- Thiazide: Lower blood pressure by reducing sodium and water levels in the body
- Potassium sparing: Promote water loss but do not affect potassium loss
Common Diuretics (Loop-acting)
- Cause kidneys to secrete more urine by telling them to reabsorb less water.
What physical assessments can you perform to assess urination? (2 types)
- Blood studies (such as BUN tests)
- Direct visualization studies (they are invasive)
How much urine is produced by the body in a day?
- 50-60ml per hour
-1500ml per day
What are the 4 types of ways to collect urine specimens?
- Freshly voided specimen: simply collect from a urine sample
- Clean-catch specimen: Clean the genitals and catch after some pee has already been released
- Sterile urine specimen: Withdraw from a catheter to identify a UTI
- 24-hour urine collection: Collect all urine for 24 hours straight if one is missed you must restart
What are the 5 types of UTI’s
- Urethritis: Infection of the urethra
- Cystitis: Bladder infection
- Pyelonephritis: Infection that progresses upward to the ureters or kidneys
- Catheter-associated urinary tract infections
- Complications: can lead to many things
How much water should be consumed in one day?
- 64 oz of water
What are 4 Diagnosis related to Urinary elimination problems?
- Urinary elimination impaired
- Urinary incontinence
- Urinary retention
- Urinary tract injury, risk for
What are 4 Ethology’s related to Urinary incontinence?
- Anxiety r/t urinary urgency and recent episodes of incontinence
- Acute pain r/t bladder spasm and urinary tract infection
- Social isolation r/t frequent periods of incontinence
- Fluid volume deficit risk.
What practices promote normal urination? (5 ways to help)
- Provide privacy
- Assist with positioning
- Facilitate toileting routines
- Promote adequate fluids and nutrition
- Drink 8-10 8oz glasses a day - Assist with hygiene
What are 7 ways to increase patients fluid intake?
- Keep water or other liquids in reach
- Remind young children to drink
- Provide goals for intake
- Provide foods with high liquid content
- Offer liquids in a straw
- Chilled drinks can be more appealing
- Provide good mouth care
How often should a catheter bag be emptied?
- Every 8 hours or less is high output
- Intake and output should be monitored the same time
What are the 5 goals during Catheterization?
- Prevent UTI’s
- Maintain free flow urine
- Prevent transmission of infection
- Promote normal urine production
- Maintain skin and mucosal integrity
How long is the GI tract in total?
10m
What are the functions of the GI tract?
- digest and absorb nutrients
- Eliminate food waste products as feces
What are the three parts of the small intestine and what order do they go in?
- Duodenum (1-2ft)
- Jejunum (6-8ft)
- Ileum
What medications affect bowel movements? (AAAPAIL)
- Antacids: slow peristalsis
- Asprin and NSAIDS: Irritate stomach
- Antibiotics: Hurt normal flora
- Iron: Causes constipation
- Pain medication: Constipation
- Anti-mobility drugs: Slow peristalsis
- Laxatives: Can cause diarrhea
Ileostomy (What is it?)
- Very liquid as it avoids the large intestine entirely.
- Koch’s pouch
- Pouch must be emptied several times per day
Colonoscopy (what are the three types?)
- Portion of the colon
- Double barrelled
- Loop colostomy
(ALSO THE 4 TYPES DEPENDING ON LOCATION)
What are 8 bowel elimination problems?
- Bowel incontinence
- Constipation
- Chronic constipation (3 months or more)
- Fecal impaction
- Risk for constipation
- Perceived constipation
- Diarrhea
- Gastrointestinal mobility alteration
What should be assessed when a new stoma is created? (4 things)
- assess the stoma itself as it will change within the first 6-8 weeks
- Assess the output of the stoma.
- Assess the skin for breakdown
- Teach dietary changes
Acute renal failure (what is it?)
An acute rise in the serum creating level of 25% or more may be caused by inadequate blood flow to the kidney, injury to the kidney or glomeruli or tubules, or obstruction of kidney outflow.
Anuria (what is it?)
The absence of urine often associated with kidney failiure or congestive heart failure. This term is used when urine output is less than 100ml in 24 hours
Dysuria (what is it?)
Painful urination may be associated with urinary tract infection
End-stage renal disease (ESRD) (What is it?)
A chronic rise in serum creatine levels associated with loss of kidney function that must be treated with dialysis or transplantation. Also known as chronic renal failure.
Enuresis (what is it?)
Involuntary loss of urine
Hematuria (What is it?)
Blood in the urine. May be due to trauma, kidney stones, infection, or menstruation.
Nephropathy (what is it?)
A broad term meaning dresses of the kidney
Nocturia (What is it?)
Frequent ruination after going to bed that may be caused by excessive fluid intake as well as a variety of urinary tract and cardiovascular problems
Oliguria (What is it?)
Urine output of less than 400ml in 24 hours.
Pessary (What is it?)
An incontinence device that is inserted into the vagina to reduce organ prolapse or pressure on the bladder
Polyuria (what is it?)
Excessive urination. May be caused by excessive hydration, diabetes mellitus, diabetes insipidus or kidney disease
Proteinuria (What is it?)
The presence of protein in the urine may be a sign of infection
Urgency (what is it?)
A sudden almost uncontrollable need to urinate
What are the 7 types of incontinence?
Urgency incontinence: strong urge to go
Stress incontinence: caused by pressure
Mixed incontinence: mix of stress and urgency
Reflex incontinence: loss when not realized is full as there is no urge
Functional incontinence: loss from cognitive or physical disability
Transient incontinence: short term incontinence
Overflow incontinence: leakage of urine when bladder is too full
How much water is absorbed by the colon?
80%
What is a paralytic ileus?
A cessation of bowel peristalsis
Diverticulosis (what is it?)
When the colon must frequently move compacted fecal matter and becomes enlarged over time which creates patches for it to be trapped in
