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30 Cards in this Set

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Foley catheterization equipment?
sterile gloves, bed protecter, drape, antiseptic cleansing unit, lubricant, prefilled syringe w/ sterile water, appropriate catheter and size for patient, cotton balls, pick up forceps, sterile drainage tubing and collection bag, tape, safety pins, basin (bottom of catheterization tray), tape, specimen container, pen light, bath blanket, and bed bath supplies
Assess need for procedure. Questions need answered before procedure?
last voided, level of awareness, mobility and physical limitation of patient, gender, age, distended bladder, pathologic conditions such as enlarge prostate gland, does patient know why he/ she is getting a catheter?
Foley catheter position for a male?
supine w/ thighs slightly abducted
Foley catheter for female?
dorsal recumbant w/ knees flexed flat on bed, 2 feet apart
After equipment if ready and in range and nurse has put waterproof absorbent under buttocks, what comes next?
cleaning of perineal area with warm water, mild soap , and disposable washcloth
If indwelling catheter is used, the nurse should check for?
integrity of balloon. test balloon by injecting normal saline into balloon until it is inflated. if it does not inflate.. another sterile catheter is needed.
For males, lubricate catheter ___ to ___ inches?
1.5 - 2
For females, lubricate catheter __ to __ inches
6-7
When cleaning the perineal are which piece of equipment does the nurse use?
forceps to hold cotton ball, and antiseptic solution
When dealing with an UNcircumsized male..
remember to pull down fore skin and pull back when finished
When cleaning the labia monora in a female in what direction do you clean?
cleanse are from clitoris to anus using different sterile cotton ball each time (right of the meatus, left, then down)
If a nurse is inserting an indwelling catheter and urine starts flowing, the nurse should?
insert catheter 1.5 inches further in
After insertion, inflate ballon with 10mL of sterile water. If patient shows facial grimaces the nurse should>?
deflate balloon and re-position catheter.
A standardized catheter is..?
16 or 18 French, smaller or bigger catheters consult with facility's policy.
What to INCLUDE when documenting?
Type and size of catheter, characteristics of urine, amount of solution to inflate balloon, amount of urine, reason for catheter, specimen collected, patient's response to procedure
What to report if any unusual findings
NO urine output, bladder discomfort, leakage from catheter, inability to insert catheter
What equiptment do you assemble for NG tube?
14 or 16 French NG tube, water soluble lubricating jelly, stethoscope, tongue blade, flashlight, asepto bulb (cone tip syringe), nose gaurd, saftey pin and rubber band, clamp, suction container, suction machine, bath towel, glass of water with straw, facial tissues, normal saline, tincture of benzoin, nonsterile gloves
Assess for what when person is receiving NG tube?
cavities, appropriate oral care post NG tube
What position is patient is for NG tube?
High fowler with pillows behing head and shoulder. (patient should be able to swollow after procedure)
Stand on __ of bed if patient is right handed and __ if patient is left handed?
right; left
When selecting a naris for NG tubing, how will you know which one?
Choose naris with more air flow
When measuring distance of tubing, which distances do you measure starting out with which part of body?
Measure from nose to ear to xiphoid
How much does the tubing need to be lubricated?
3 - 4 inches
If patient feels discomfort what should the nurse do?
take out tube, allow patient to rest, insert into other naris
The esophagus requires swallowing when inserting a NG tube. T or F?
True
Can a patient have a glass of water when inserting an NG tube? Y or N
Yes, water advances tube with each swallow and reduces coughing and gagging.
The patient is able to talk when NG tube is passing through vocal cords. T or F
False
What is the most effective way of knowing the NG tube procedure went well?
x-rays
What should the nurse document on successful procedure of NG tubing?
time, type of tube, tolerance to procedure, confirmation of placement, amount of gastric content and character, is tube clamped or connected to suction, Patient teaching
What abnormalities might there be to report?
inability to advance the tube