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99 Cards in this Set
- Front
- Back
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gavage |
giving |
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intubation |
placement of a tube into a body structure |
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types of intubation |
orogastric, nasogastric, nasointestinal, ostomy |
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orogastric |
mouth to stomach |
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nasogastric |
nose to stomach
-inserted by nurse |
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nasointestinal |
nose to intestine
-uses weights |
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ostomy |
surgically created opening |
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gastrostomy |
opening to stomach |
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gastric or intestinal tube uses include: |
performing gavage, administering oral medications, sampling sections for diagnostics, performing a lavage, compression/decompression |
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lavae |
leaving |
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what does performing gavage mean? |
providing nourishment |
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what does performing a lavage mean? |
removal of a poison |
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what does compression/decompression mean? |
to suction, removing gas and liquid -for bowel obstruction or progectil vomitting |
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nasogastric tubes: some have more than one lumen (part)
gastric sump tubes (double-lumens) |
can have a vent (pigtail)
used to remove gas and fluid from stomach |
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nasointestinal tubes: |
longer than nasogastric tubes
feeding, decompression |
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insertion assessments: |
level of consciousness; weight bowel sounds; abdominal distention nasal/oral mucosa integrity swallow, cough, gag ability nausea or vomiting present? |
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NEX method |
nose, ear, xiphoid process |
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determine proper placement using fluid aspiration inspection |
most acurite other than x-ray
visual inspection; pH testing (0-4 in stomach); abdominal auscultation |
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gastric decompression |
suction continuously or intermittently vented tubing protects stomach mucosa promote/restore patency administer ice chips or sips of water sparingly (need DR order) irrigation (by DR order only w/normal saline solution (NSS) |
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patency |
open |
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LIS |
low intermittently suction |
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insertion of nasointestinal tubes |
NEX measurement + 9 inches |
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checking tube placement |
"swoosh", initially via x-ray, subsequently, modified aspiration w/large volume syringe |
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transabdominal tube management: nurses responsibility |
is to care for inserted gastrostomy and jejunostomy tube and their insertion sites
conscientious care is necessary to prevent leakage and skin breakdown |
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inspect what daily? |
skin |
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what to report on skin |
redness, maceration, wash and soap and water; apply barrier cream to protect irritated skin |
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maceration |
pruney |
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tube feeding |
provided via stomach or small intestine rather than oral route |
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benefits and risks of enternal nutrition |
dumping syndrome (expecially if in intestines), risk for aspiration |
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bolus feeding schedule |
least desirable - increase reflux, can lead to aspiration, can descend the stomach |
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intermittent feeding schedule |
ex. giving every 6 hours over 1/2 hour |
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cyclic feeding schedule |
ex. on 12 hours off 12 hours |
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continuous feeding schedule |
all day and night best for stroke/unconscious pt least risk for aspiration |
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daily client assessment |
weight, vital signs, intake/output, bowel sounds, lung sounds, breathing, mucosal condition |
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residual |
determine how much of tube feeding remaining in the stomach - absorbing >150cc - stop the feeding recheck in an hour give additional water |
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what do you do before and after feedings |
flush |
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what can be used to clean out tubing |
carbinated beverage, if it can't be unclogged it needs replaced |
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gerontologic considerations |
-diminished efficiency of the gag reflex -precautions when tube feeding older adults related to hyperglycemia and hydration -tailor formula specifically to client condition -monitor older adults for agitation, confusion |
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elderly can have decrease gag reflex due to stroke |
choke easier |
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components of the urinary system |
kidneys, ureters, bladder, and urethra |
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urinary elimination |
process of releasing excess fluid and metabolic wastes |
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normal conditions of urinary elimination |
average person eliminates 1500-3000mL of urine each day |
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need to urinate becomes apparent when.... |
150-300 mL of urine |
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patterns of urinary elimination |
physiologic (feel the need), emotional (nervous), social |
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hematuria |
urine containing blood |
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aluminuria |
urine containing albumin, a plasma protein |
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pyuria |
urine containing pus |
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proeinuria |
urine containing plasma proteins |
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glycosuria |
urine containing glucose |
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ketonuria |
urine containing ketones |
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anuria |
absence of urine or a volume of 100 mL or less in 24 hours |
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urinary retention |
the client produces urine but not release it form the bladder |
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oliguria |
urine output is less than 400 mL per 24 hours; indicates inadequate elimination of urine |
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residual urine |
more than 50 mL of urine remains in the bladder after voiding (can lead to infection) |
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urinary stasis |
lack of movement of urine from bladder |
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polyuria |
greater than normal urinary volume, such as increased fluid intaked |
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disorders |
diabetes mellitus & inspidus, antidiuretic |
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nocturia |
nighttime urination |
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dysuria |
difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection frequency: need to urinate often urgency: strong feeling that urine must be elinated quickly |
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incontinence |
inability to control either urinary or bowel elimination |
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commode |
chair with an opeining in the seat under which a receptacle is placed |
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urinal |
cylindrical container for collecting urine
pull the privacy curtain, don gloves, ask the client to spread his legs, hold the urinal by its handle
direct the urinal at an angle between the clients legs so that the bottom rests on the bed, lift the penis and place it well within the urinal |
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what is used to document normal voidings and stools |
flow sheet |
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cath could be inserted into the..... |
bladder, ureter, or kidney |
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size and type of cath used are determined by... |
location, and cause of the urinary tract problem |
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measured in... |
Fr French system |
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ranges of size |
14 - 24Fr |
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ureteral caths are usually what size? |
4-6Fr and must be inserted by the Dr |
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coude cath |
selected for ease of insertion when enlargement of the prostate gland is suspected (curved) |
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foley cath |
designed with a balloon near the tip so the balloon may be inflated after insertion holding the cath in place
AKA indwelling |
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straight cath |
in and out with no balloon |
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cystostomy, vesicostomy, or suprapubic catheter |
introduced through the abdominal wall above the symphysis pubis
used to divert urine flow from the urethra to treat injury to the bony pelvis, urinary tract, or surrounding organs; strictures; or obstructions
inserted via surgical incision |
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condom catheters |
aka texas
not a cat but a drainage system connected to external male genitalia, used for incontinent male to minimize skin irritation from urine
removed daily to clean - don't tape to penis |
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catheter irrigation |
maintain or promote patency |
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closed catheter irrigation system |
irrigated without separating the catheter from the drainage tubing |
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continuous catheter irrigation system |
ongoing instillation of solution using a 3 way catheter |
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open catheter irrigation system |
disconnect the system |
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indwelling catheter removal |
catheter is removed when it needs to be replaced or when its use is discontinued
remove water from balloon with syringe - never cut it |
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potential nursing diagnoses |
self-care deficit; toileting, risk for infection, impaired skin integrity, functional; stress; urge; reflex; total urinary incontinence, impaired urinary elimination |
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older adults are likely to experience... |
urinary urgency and frequency |
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kegel exercises |
promote strengthening of plevic floor |
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enlargement of the prostate can totally obstruct urinary outflow |
make catheterization difficult or impossible |
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chronic residual urine |
excessive urine to the bladder after urinating |
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teach double-voiding |
client voids, then waits a few more minutes to allow any residual urine to be voided |
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diuretic therapy |
commonly prescribed for older adults; can increase the risk for urinary incontinence |
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loss of urinary control threatens older adult independence and self esteem |
may result in self-restricting activities |
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plan toileting breaks every 60-90 minutes |
routine |
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institutionally |
incontinence may occur due to untimely assistance for toileting, not assisted to bathroom regularly |
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careful evaluation necessary regarding.... |
absorbent products or medications |
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where to put urine bag |
moveable part of bed, below bladder, check tube for compression |
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self catheterization |
used for pt who experiences spinal cord injuries neurological disorders that interfere with urinary elimination |
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intermittent slef cath |
promotes independent function for the pt, less infections |
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routine cath care |
perineal care and the cleaning of the first 2 inches of the cat every 8 hours min. use of powder or lotions on perineum is contraindicated asses the urethral meatus and surrounding tissues for inflammation, swelling, and discharge. Note amount, color, odor, and consistency of discharge prevents growth and spread of pathogens |
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when to change the bag |
only if there are signs of leakage, odor, or sediment buildup |
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empty and record urine output of foley cath into gradulated container when? |
every shift |
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bladder training |
prep for removal of cath, pt w/stress incontinence instruct kegel exercises, habit training void schedule |
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managing incontinece |
kegel exercises, bladder training, credes method, disposable adult undergarments or underpads |
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credes method |
push on bladder |
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foley insert |
insert till urine is obtained, go in another 1 1/2inch, don't force, tug gently after balloon inflated, sterile |
