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Comps > Ostomy, Enema, Glucose, IV, Foley, NGT > Flashcards

Ostomy, Enema, Glucose, IV, Foley, NGT Flashcards

0
Q

What is a stoma?

A

Piece of intestine brought out of the patients abdomen

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1
Q

What is an Ostomy?

A

Opening in abdominal wall for elimination of feces/urine

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2
Q

What is the stoma’s purpose?

A

To divert/drain fecal/urine material

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3
Q

Name the type of ostomies?

A

Gastrostomy: through abd wall into stomach (feeding)
Jejunostomy: through abd wall into jejunum (feeding)
Colostomy: opens into colon
Urostomy: urine

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4
Q

How are ostomies classified?

A

Permanent/temporary
Anatomic location
Construction of stoma

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5
Q

Why do you need temporary colostomies?

A

for traumatic injuries/inflammation condition of bowel.

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6
Q

Why do you need permanent colostomies?

A

to provide means of elimination when rectum/anus is nonfunctional.

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7
Q

What do you assess with periostomal skin?

A

Maceration, redness, itching, rash, excoriation

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8
Q

Types of colostomies and their effluent

A

Ileostomy: liquid effluent, minimal odor
Ascending: liquid, odor
Transverse: mushy, odor
Descending: solid odor

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9
Q

How much output for ileostomy drainage?

A

initially 500-1500 ml/day then decreased to 500-800 ml/day

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10
Q

How do you manage a colostomy bag?

A

change ostomy appliance Q7days/pouch leaks, empty pouch 1/3-1/2 full, rinse pouch with tap water only, ensure pouch connected to drainage bag (urostomy), below kidney level, appliances @ bedside

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11
Q

How often do you change stoma/dura adhesive?

A

stoma: 5-6 days
dura: 10-14 days

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12
Q

How big do you cut wafer/skin barrier?

A

1/16”-1/8” larger than the stoma

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13
Q

What so you assess first 48 hours post op?

A

Stoma color and excessive bleeding

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14
Q

How do you prevent premature leaking?

A

Dont wear tight garments, dont extra pouch, dont empty too late

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15
Q

What do you assess every 8 hours? (ostomy)

A

Color, itchiness/cleanliness of pouch, bowel/stoma function, ostomy output, periostomal skin, S/S UTI

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16
Q

When should you notify the MD?

A

necrotic stoma, hemorrhage, skin breakdown, change in appearance of output, rash

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17
Q

What do you document? (ostomy)

A

color, shape, size, output, condition of skin.

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18
Q

Dietary considerations for ileostomies?

A

chew food well, drink 8 glasses fluid/day, avoid high fiber

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19
Q

Showering techniques?

A

Leave bag on, water hit back, limit shower time

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20
Q

What is an enema?

A

instillation of solution into rectum and large intestine

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21
Q

What is its purpose? (enema)

A

Dx test prep, fecal removal (impaction/constipation), stimulate peristalsis, lubrication regulate habits, pre-op prevent escape of feces, expel flatus.

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22
Q

Name the 4 different types of enemas?

A

Cleansing: Hypertonic (fleet enema, exert osmotic pressure), Hypotonic (tap water; distends/stimulates peristalsis/softens feces), Isotonic (NS; safest; equal osmotic pressure), Soapsuds (castile soap; distends/irrigates mucosa), Oil (lubricates feces), return flow (relieves abdominal distention).
Carminative: expel fluids
Retention: lubricates rectum and anal canal
Return flow: relieve abd distention

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23
Q

How long is oil retention enema retained for?

A

1-3 hours

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24
What are the times the enemas take effect?
Hyper: 5-10 mins Hypo: 5-20 mins Iso: 15-20 mins Soap: 10-15 mins
25
Enema is given in what position?
L lateral sims with R knee flexed
26
Enema bag is how many inches above anus?
12" above anus
27
Enema bag is how many inches above mattress?
18"
28
What do you assess prior to administration?
MD orders, Pts last BM, Abd distention, Sphincter control, If pt uses toilet/bedpan
29
How do you prepare patient? (enema)
explain reason for enema, relaxation-breathing techniques, use of call light, provide privacy, may feel full
30
Why and how much do you lubricate?
3-4", to prevent trauma and facilitate insertion
31
What should you do after lube and why?
Run some solution through tube to expel any air in the tubing b/c causes unnecessary distention.
32
Why do you place patient in left lateral position?
this side facilitates flow of solution by gravity into the sigmoid/descending colon on the L side
33
How do you insert enema tube?
Smoothly, slowly, toward the umbilicus bc it follows the natural contour of the rectum. Slow prevents spasms of the sphincter
34
Insert tube how much total?
7-10 cm= 3-4 inch past sphincter
35
Insert tube how high?
The higher the solution container above rectum, the faster flow and greater force in rectum
36
What if patient complains of fullness or pain?
lower container, stop flow for 30 se, and restart slower
37
What position should patient be after instillation?
Laying down because easier to retain enema
38
Adverse effects to enema?
Fluid overload and F/E imbalance
39
What should enema temp be?
37.7 cel or 100 far
40
Volume instilled by age
18 months: 30-150 mL 18mo-5yrs: 160-300 mL 5-12yrs: 300-500 mL 12yrs+: 500-1000mL
41
What should you document? (Enema)
response to enema, adverse effects, type of enema/solution/size of tubing, volume given
42
State the purpose of glucose monitoring
ID trends in glucose levels, enables pt to make self-management decisions regarding diet/exercise/meds, detect hyper/hypoglycemia, ID where changes in tx should be made
43
What is the purpose of insulin?
provide glyoemic control for nutritional needs
44
Name types of Insulin used
Rapid: lispro "Humalog," aspart (onset 5-15 mins//peak 30-90//duration 2-4hrs) Short acting: Regular (CZI) (onset 30mins//peak 2-4hrs//duration 6-8hrs) Intermediate: NPH, Lente (onset 1-2 hrs//peak 6-12 hrs//duration 18-24 hrs) Long acting: Ultra lente (onset 6-8hrs//peak 12-16 hrs//duration 20-30hrs) Very long acting: Lantis "glargine" (onset 1 hr//No peak//duration 24 hours)
45
When should BG be checked for RISS (regular insulin sliding scale)?
Immediately before insulin dose admin
46
What kind of pts have RISS?
Pts whose baseline insulin requirements are hard to predict, NPO pts, high than desired GLU level before meals
47
When is BG measured?
Qac and Qhs
48
QC means?
quality control
49
What do you assess for insulin preparation?
color, clarity, expiration date, drug compatability
50
Which insulin is only one you can give IV and cont?
Regular insulin
51
Name the supplies you need for insulin prep
alcohol pad, insulin syringe, insulin vial
52
What is independent double check?
another RN/LVN verify amount aspirated. Vial still attached
53
Which one do you withdraw first?
clear then cloudy
54
When should insulin be given?
Qday at a chosen site x1 week
55
How far apart should injections be?
1.5" apart at a site area each day
56
Injection sites?
butt, love handles, stomach, arms, thighs
57
Where should you avoid injecting?
2" from umbilicus, atrophied, hypertrophied, reddened, scarred or edematous tissue
58
Complications of same needle/site
lipoatrophy, lipohypertrophy, lipodystrophy
59
How long can you store insulin?
OK for 1 month after opening, not to exceed 86 degrees (room temp)
60
How long can you store insulin with refridgeration?
1 month, 36-46 degrees
61
Hypoglycemic S/S
dizzy, diaphoresis, deceased LOC, trembling, HA, tachycardia, seizures
62
Hyperglycemia S/S (gradual onset)
dehydration, polydipsia, polyphagia, polyuria, N/V, fruity breath increased breathing
63
State purpose of IV therapy
fluid restriction, electrolyte replacement, titrated meds, access to vein.
64
How do you prepare medication?
MD order/Kardex/MAR Gather supplies from the supply room 3 checks (at time of pulling, prior to spiking, before infusion) date/time/initial label
65
What do you inspect IV bag at onset of shift/bag change for?
type of solution, additives, cloudiness/precipitation, label
66
Complications of IV maintenance
Infiltration (stop infusion, remove catheter, restart at another site) Phlebitis (stop infusion, warm compress, restart at another site) Extravasation of vesicant drug is considered a medical emergency (stop infusion, disconnect tubing from cath and aspirate any fluid left in hub, elevate arm, cold/hot, take picture)
67
Why would the alarm trigger?
IV solution low, occlusion, air in tubing, tubing not high enough
68
Which med do you run first?
shirt first, longest med last
69
What to do if drug is not in dictionary of pump?
basic secondary screen to add drug to IV pump
70
How often do you change bag?
IV bag: 24 hours
71
How often do you change tubing?
Q96H if cont, Q24H if intermittent
72
How ofter do you check IV site?
Q2H for redness, swelling, dressing intact
73
Categorize solutions (IV)
Hypertonic: D5NS, D51/2NS, D10NS, D20W, D50W Hypo: 1/2NS Iso: NS, D5W, LR
74
What are some nursing responsibilities for foley?
insertion, irrigation, removal, change per MD order
75
State the purpose of indwelling catheter
provide continuous bladder drainage/irrigation, prevent urine from contracting infection (skin breakdown) post perineal surgery, relieve discomfort from bladder distention, assess residual urine, manage incontinence, accurate I&O
76
State purpose of external catheter
collect urine/control urinary incontinence, permit physical activity while controlling UI, prevent skin irritation as a result of UI
77
State purpose of straight catheter
obtain sterile urine sample, measure residual urine, empty bladder before surgery
78
What should you assess prior to catheterization?
MD orders, allergies, ID patient
79
How much can you drain at once and why?
700-1000 mL d/t hypovolemic shock
80
What is the commonly sized balloon?
10mL
81
Name your equipment (foley)
sterile gloves, syringe, foley cath, cotton balls, drape, tape, benadine, forceps, collection bag, lubricant
82
How much do you go in M/F?
6-9" for males 3-4" for females
83
How much do you lubricate the catheter?
5-6" males 1-2" females
84
Why do you advance the catheter 2" farther after urine?
to be sure it is fully in the bladder
85
How much urine do you collect for specimen?
3 mL for culture, 30 mL for UA
86
Where do you tape the catheter?
upper thigh males, inner thigh females
87
Instructions on foley catheter
never pull on it, below bladder, shower than bath, ensure no kinks/twists, S/S UTI
88
What do you assess Q4H?
bladder distention, UO, leakage, S/S UTI, cath secured, tubing not looped, bag below bladder
89
What are unusual orders after d/c?
Monitor I&Os Q8H for 24 hours after D/C
90
How much do you irrigate with?
30-50 mL NS for cath irrigation, 100-200 mL for bladder irrigation
91
Extra information (foley)
document french size, peri care, UO. Clean with soap and water Q8H. Empty bag when 3/4 full
92
State 4 reasons for NGT insertion
decompression, feeding, lavage, gastric analysis
93
When do you use vented tubes? (salem sump)
continuos suction. Vent lumen allows in flow of air to prevent vacuum of gastric tube adheres to stomach, so stomach irritation avoided.
94
When do you use non vented tubes? (levine)
gravity drainage or low intermittent suction
95
Complications from insertion
aggravated esophagus, esophageal ulcer, encephalitis
96
What position will patient be placed?
high fowlers. easier to swallow and gravity helps
97
Why does patient need gag reflex/cough reflex?
accidental placement into lungs is much higher
98
Why do you need water soluble lubricant?
it dissolves. Oil based doesnt and can cause respiratory problems
99
Nam the supplies you need (NGT)
safety pin, lopez valve, cup of water, rubber band, tape, emesis basin, lube, salem sump, stethoscope, 60 mL syringe, gloves, penlight, towel
100
How much do you flush with (NGT)
10-30mL
101
What do you assess for (NGT)
abd distention, BS, N/V, drainage color, patency
102
Why do you tilt your head forward
helps tube into esophagus and not into airway
103
when do you check residuals
prior to med/feedings, Q4H for cont feeding, Q8H if pt is NPO
104
When collecting specimens, what are some nursing responsibilities?
check MD order, standard precautions, label specimen, timely, C&S to lab ASAP or refrigerated, documented
105
Urine Speciemen
test glucose, SG, pH, albumin C&S culture for bacteria growth and sensitivity to antibiotics, protein ketones Collection (clean: midstream specimen; sterile: catheter/indwelling cath- clamp 30 min prior, gloves, clean port with alcohol)
106
Stool Specimen
analyze for tumors, hemorrhage, infection tests for pus, OB, ova and parasites Guaiac test (FOBT): colorectal screening test, Hct slide test (repeat x3times) collection (chemical preservatives, aseptic tech, label, lab on time, document)
107
Sputum
ordered to ID organisms growing | 3 types: C&S, acid fast bacilli (AFB) x3 days, cytology to ID cancer cells x3days.
108
Throat swabs
AC meals or 1 hr prior, tilt head back "AHH"- use tongue depressor if pharynx isnt visible, swab tonsils or exudate
109
Nose culture
blow nose, check nostril patency, swab inflamed mucosa or exudate and advance into nasopharynx.

Comps (9 decks)

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