unit 5 learning objectives Flashcards
Distinguish between fleets, tap water, and retention enemas and describe when each is used.
F-small volume—medication that helps to relive constipation and promotes bowel movements
T-Tap water enema-large volume-this is when larger volumes of water get placed into the rectum, causing the bowel movements to happen.
R this is oil that goes into the stool, allowing for the stool to be more slippery and pass the body easier.
Identify safety precautions to take/nursing interventions to be carried out for the client before, during, and after enema administration.
double check identity-full assessment of the patient-respcet for privacy
Recognize the different types of bowel diversions and implications for altered elimination patterns.
ileostomy/colostomy
stoma
Identify factors which contribute to skin/stoma damage and the nursing to make/interventions to carry out to maintain skin integrity.
Leakage of stoma output, type and structure of stoma, stoma site marking and nature of surgery, ostomy education, ostomy appliances, mechanical trauma, and demographic factors
Cite how often disposable ostomy appliances should be changed and the measures to control odor.
about every 2 to 4 days
Describe techniques to prevent complications which can occur during/following an ostomy irrigation.
Start the irrigation process by slowly opening the clamp and letting water flow into the stoma. Take about five minutes to let all the water in the irrigation container flow in.
Identify situations in which urinary catheterization, straight or indwelling, is required.
Patient has acute urinary retention or bladder outlet obstruction
Compare and contrast the procedure for male and female catheterization.
FEMALE – CLEANSE WITH BETADINE IN DOWNWARD MOTION
MALE – CLEANSE MEATUS FIRST, USING CIRCULAR MOTION OUTWARD
Describe nursing interventions to prevent catheter-associated urinary infections during catheter insertion, maintenance, and irrigation.
Secure the device and position the drainage bag below the bladder.
Maintain unobstructed urine flow by keeping the catheter and tubing free from kinking.
Maintain a closed drainage system. If any breaks in the closed system occur, the catheter and collecting system should be replaced.
using sterile techniques, and also using saline cleanings when inserting
Identify clinical situations in which catheter irrigation, intermittent/continuous, is required.
to prevent or remove blood clots in the bladder after urinary surgery
in order to keep the catheter free of mucous plugs, or blood clots so that urine is able to drain out and not back up into the kidney
Identify areas for potential contamination during catheter/bladder irrigation procedures.
the patient’s endogenous skin flora and by exogenous flora carried on health care workers’ hands
contaminated upon insertion
Indicate techniques for insertion and maintenance of supra-pubic catheters.
Perform hand hygiene
Prepare equipment using an aseptic non touch technique
Remove old dressing
Perform hand hygiene
Clean insertion site with 0.9% sodium chloride for irrigation
Apply keyhole dressing around tube
Cover with gauze
Apply transparent dressing per picture
Date dressing
Discuss the reasons that certain specimens/cultures (wound, sputum, throat, urine, stool, gastric, blood glucose) are ordered.
reasons that certain specimens/cultures
if you have symptoms of a serious infection, also known as sepsis.
if suspected of thing in that specific area
Discuss the differences between aerobic and anaerobic cultures.
aerobic lives with air
anaribc does not live with air and dies to it
Describe the procedure for obtaining a throat, sputum, urine, or stool specimen across the lifespan.
Your health care provider will rub a sterile cotton swab along the back of your throat near your tonsils
Take another deep breath and cough hard until some sputum comes up into your mouth. Spit the sputum into the plastic cup
collect pee mid stream
Using the stick provided, scoop a small amount of stool and rub on the white circle inside the test card.
Identify procedure for sending cultures/specimens to lab.
Specimens for bacterial culture should be transported at room temperature.
If transport is delayed the following specimens should be refrigerated: urines (within 30 min), stool (within 1 h), respiratory specimens.
Specimens for viral culture must be transported to the laboratory immediately on ice.
Determine why a culture/specimen is obtained before antibiotics are started.
improves the chances of identifying the offending microorganism, which improves patient care
so antibiotics don’t kill off the organisms in that one spot, gives more of a chance to see the right microorganism
Define hemoccult and gastroccult tests.
detect fecal occult blood.
Describe how to utilize the test strip when testing urine, stool, or gastric contents.
urine-dip strip in urine, hold strip sideways, compare colors on chart to bottle
Using the stick provided, scoop a small amount of stool and rub on the white circle inside the test card
queeze 1 to 2 drops of fluid onto the pH test strip. If you’re using a plastic test strip, make sure to cover the whole pH square. Hold the test strip up to the pH indicator on the pH strip package or containe
Indicate when blood glucose monitoring should be performed.
just before a meal or 2 hours after a meal
Identify normal blood glucose levels across the lifespan.
70-100
Indicate infection control techniques to use with blood glucose monitoring equipment.
Restrict use of fingerstick devices to individual persons. They should never be used for more than one person
Dispose of used lancets at the point of use in an approved sharps container
Compare techniques for acquiring the blood sample for blood glucose monitoring across the lifespan.
on side of finger tip
wipe once
take second blood sample
Identify clinical situations that would require oral-pharyngeal, nasal, and/or tracheostomy suctioning.
when the patient is unable to effectively move secretions from the respiratory tract.
A large object blocking the airway
Respiratory failure or arrest
Severe neck or mouth injuries
A swollen or blocked airway due to inhalation of harmful material such as smoke, steam, or other toxic gases
Cancer of the throat or neck, which can affect breathing by pressing on the airway
Paralysis of the muscles that affect swallowing
Surgery around the larynx that prevents normal breathing and swallowing
Long-term oxygen therapy via a mechanical ventilator
Recognize, report, and document significant deviations from the norms when suctioning or providing trach care on a client.
deviations in the following
Lung sounds
Skin color
Breathing pattern and rate
Oxygenation (pulse oximeter)
Pulse rate
Dysrhythmias if electrocardiogram is available
Color, consistency, and volume of secretions
Presence of bleeding or evidence of physical trauma
Subjective response including pain
Cough
Laryngospasm (spasm of the vocal cords that can result in airway obstruction)
Describe when medical versus surgical asepsis is required for suctioning.
surgical-going inside of body to clean out
medical- if outside of body and preparing
Describe the equipment/supplies needed for the various types of suctioning.
Sterile or distilled water.
Clean container for flushing solution.
Clean disposable gloves (to avoid direct contact with secretions from your child; sterile gloves are not needed)
Water-based lubricant for nasopharyngeal suctioning.
Hand sanitizer.
Good light source.
Describe the procedure for oral-pharyngeal, nasal, suctioning of a client across the lifespan.
O
Fill cup/basin w/ water
connect end of tubing to suction machine
insert catheter into mouth and move around until secretions are cleared
rinse and observe for cleared respiratory status
N
Sterile gloves and sterile field
pick up sterile catheter and connect to tubing and water
as patient takes deep breath, follow course of nares
Discuss methods of communication for a client with a tracheostomy tube.
Mouthing words.
Electrolarynges.
Leak speech.
Tracheal/digital occlusion.
Talking tracheostomy
tubes.
Speaking Valves.
State assessment data for evaluating the effectiveness of suctioning.
Clearance of secretions, improved breath sounds, improved air entry, good pulse oximetry readings, and improvement in respiratory distress in a patient.
Describe the process for providing tracheostomy care.
Supplies
wash hands
clean pair of gloves
cleaning solution
clean inner canula
clean trach area
change drain sponge
change trach ties
clean dirty inner canula
