Week 8 Urinary And Bowel Elimination And Abdominal Assessment Flashcards
Given primarily to expel flatus
Carminative enema
Dark blood in the stool, indication of bleed in upper GI
Occult blood
Removes feces with a veriety of solution
1) prevent escape feces during surgery
2) prepare the intestine for certain diagnostic tests
3) removes feces in instances of constipation or impaction
Cleansing enema
1) introduces oil or medication into the rectum and sigmoid colon
2) oil rentention acts to soften the feces and lubricate the rectum and anal canal, thus facilitating passage of feces
Retention enema
Describe nursing responsibilities associated with a collection of a stool specimen
1) gloves, clean cup, tongue blade
2) place clean cup on paper towel in bathroom
3) using tongue blade collect needed amount of feces from.patients bed pan
4) transfer stool to cup without touching outside surface of cup
5) dispose of tongue blade and seal cup
6) transfer labeled specimen into clean labeled biohazard bag for transport
7) remove gloves and perform hand hygiene
Use soapsuds enemas with caution in ______________ and ___________ because they could cause electrolyte imbalance or damage to the intestinal mucosa
Pregnant women and elderly
A type of enema that has magnesium, glycerin and water
Carminative- used for gas
Low volume enemas include
Sodium phosphate( hypertonic) Oil rentention
90-120mL
Volume for tap water and soap suds enema
500-1000 mL
Position for enema
Left side Sims
Volume of liquid for oil rentention and sodium phosphate enema
90-120mL
Volume for soap suds
500-1000mL
Volume for carminative
180
30mL magnesium
60 mL gycerin
90mL water
Enema which takes the longest time to be effective
Oil rentention
Fastest acting enema
Soap suds
Sodium phosphate enema is contraindicated in what patients
Infants and dehydrated
Soap suds enema is used with caution in patients___________
Who are pregnant, and whom are older adults
Which type of enema draws fluid into the interstitial space
Tap water
Which type of enema would draw fuild into the lumen of the intestine
Sodium phosphate/ hypertonic
Use this type of enema with caution when ordered multiple times
Tap water
Compare and contrast between cleansing enemas and retention enemas
Cleansing: promote evacuation by stimulation of peristalsis via large volume or local irritation
Oil retention: introduces oil or medication
Acts to soften feces and lubricate the rectum
Interventions and rationale when administering a rectal suppository
1) Lubricate rounded end of sup.
2) Lubricate the index finger of the Dom. Hand
3) Ask pt. To take slow deep breaths and relax the anal sphincter
4) retract buttocks with nondominant hand
5) instert sup. Past sphincter along rectal wall
6) ask pt. To lie on side or remain flat for 5 minutes to prevent expulsion
Double lumen catheter, large lumen drains urine from the bladder, a second small lumen is used to inflate the balloon near the tip of the catheter.
Foley/ retention/ indwelling catheter
Single lumen tube with a small eye or round opening about 1 1/4 centimeters from the insertion tip
Straight catheter
Back lying position with feet supported in stirups ; the hips should be inline with the edge of the table
Lithotomy position
Urine specimen collected when urine culture is ordered to identify microorganisms causing UTI
Clean catch urine
Determines the presence of microorganisms, the type of organism, and the antibiotics to use to destroy the microorganism
Urine for culture and sensitivity ( C& S)
Used to determine urine composition and possible abnormal components or infection
Urinalysis
Midstream catch is used for?
Urinalysis or to detect infection
Clean catch is used for
UTI
Describe timed urine specimen collection
Used to analyze kidney function.
1) place alerts on pt. Door
2) clean technique
3) specimen must be free of paper and feces
4) have patient void, discard this urine and begin 24 hour collection period
5) number specimen sequentially
6) have pt. Void five minutes before end of 24 he period
7) check to see if urine should be refrigerated
8) keep outside of containers clean
9) transport in labeled plastic bag
CAUTI
Catheter associated UTI
Cath. Care q ______ hours as minimal standard of care
8 hours
Empty drainage bag when _____ full
1/2 full
Normal bowel sounds
5-30/min irregular
Dullness upon abdominal percussion is generally heard over _______
Organs
When percussing the abdomen the right costal margin abdominal tympany should change to dullness over the border of the _______
Liver
When documenting a patients emesis what characteristics should be included?
Color
Odor
Volume
Duration
After applying pressure at a site away from the area of abdominal pain
, The nurse quickly lifts and removes the hand from the clients abdomen, pain upon realease of the pressure is reffered to as _________
Rebound pain
Rebound pain, and involuntary rigidity are signs that should be reported to the HCP
