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152 Cards in this Set
- Front
- Back
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How many indicatiors are there when using the urinary protocoll tool?
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7 positive indicators for insertion / maintenance.
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how often do you assess a pt with a urinary system
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on admission / Q shift
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who does the scoring of the urinary protocoll
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RN or LPN ONLY
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Urianry protocoll scorebox
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5 or greater - keep cath, foley indicated
3-4 consider alternatives (straight cath) 2 or less remove cath |
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If the protocol score is a 2 or less......
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it is okay to remove foley without dr order
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facts about lower urinary tract system
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-bladder is a sterile cavity
-external opening to urethra can NEVER be sterilized -bladder has innate defense mechanism -pathogens introduced into the bladder can ascend and cause bladder / kidney infection -an injured bladder is susceptilbe to infection |
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Retrograde infection
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an infection that happens when pathogens introduced into the bladder ascend via ureters and cause bladder or kidney infection
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purpose of cath
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tube for injection or removal of fluids through the 2 inch or 6 inch urethra ( withdrawal of urine - instill fluids & meds)
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What is the most commod cause of nosocomial infections
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urinary catheterization!
must use strict sterile technique. |
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Two main hazards of urethral cahteterization
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sepsis and trauma
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purpose of performing a urinary cath
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-relieve discomfort due to bladder distention
-asses PVR -obtain sterile specimen for C&S -measure I & O -irrigate bladder or instill medication -prevent urine from contaminating wounds or irritating skin -promote comfort -allow urinary elimination for pts who can't get OOB |
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Indwelling
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procedure uses retention/foley cath to drain urine over extended time
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intermittent
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uses straight cath to empty urine from bladder, removed immediately after urine is drained.
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straight cath
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has only one lumen, used for intermittent cath only.
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double lumen
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has one lumen to remove urine and a second to keep cath from falling out (balloon)
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triple lumen
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has 3 lumen , one drains urine, second inflates balloon, third is for irrigating or insitilling meds
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Coude cath
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has a curved tapered tip that allows easier, less painful insertion if urethra stricture is present.
always insert with curved tip pointed up. |
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what size cath to use
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use standart #14 french size unless otherwise indicated.
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how are caths sized
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on the French scale of numbers according to diameter of a tube's lumen
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other cath sizes
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they range from #14- #18. men often have larger size as do women who have an indwelling cath for a long period of time
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children cath size
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#8-#10, infants sizes may be smaller, you may even you a sterile small feeding tube
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Ballon size
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varies from 3ml - 30 ml. Always inflate 10cc in adult unless otheriwse written.
Children size with a 1.5-3ml or a 5ml. |
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If an adult has bladder surgery
inflate ballon? |
use 30ml for hemstasis (stopping hemorrhage)
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Risk for trauma
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men are especially prone to trauma.
Normal curve can be straightened by elevating the penis to PERPENDICULAR position to the body. |
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Nursing assessments before catheterization
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why is the procedure ordered?
what type and size cath used? can female pt tolerate dorsal recumbent (lithotomy) position? can male pt tolerate supine? is pt allergic to brown iodine? when did pt last void? was bladder scan performed? |
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what do you use if pt has iodine allergy
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citostat
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Cath eqipment
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bright light
prepackaged sterile kit with #14 foley and draingae, or sterile kit with straight cath stat lock bath blanket, towel, wash cloth sterile gloves *for male only - 10cc lidocaine h20 soluble lubricant. |
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procedure for female pt
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always explain procedure and rational.
use good light source drape pt with bath blanket (use diamond configuration) wash hands stand on dominant side remove cath tray fromprotective wrapper slide sterile drape under butt don gloves open sterile lube and lube tube open iodine and pour over cotton balls attach 10cc syringe to cath injection port place non dominant hand on labia minora visualize meatus cleanse meatus front to back encourage slow deep breaths with a foley - hold tube in place - inject 10 cc of h20 tug gently to ascertain correct position use statlock to inner thigh leaving 5-6 inch loop b/w meatus and tube |
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Cleansing cath
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wash meatus and cath with soap and h20 after every BM or when visually soiled. foley care bid 9 and 1800.
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sterile specimens
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must be sent in less then 20 mins
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male catheterization procedure
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-lie in supine
-drape legs to mid-thigh -stand on dominant hand side -place sterile dreap on pt's thigh to create sterile field -don glove -place sterile boat with catheter inside onto sterile field -with nondominant hand hold penis @ 90 degree angle -if pt is not circumcised pull back foreskin -use forceps pick up cotton ball and cleanse meatus -insill 10cc of lidocane into urethra, hold penis for 2-5 mins -pick up cath 5cm from tip -insert cath into urethra until urine flows. -advance to bifurcation -inflate ballon 10cc sterile h20 |
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What do you do after unsuccessful attempts to cath
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try a second time, if it doesn't go in, call MD
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key points for cath children
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-reassure the child, they will not feel pain, just pressure
-another nurse may need to assist -inserting a cath is much more traumatic for a child - you may ask the parents to leave -if child complains of pain, the cath may not be seated right, deflate ballon & advance fruther -only inflate balloon with amt of h20 listed by manufacturer. |
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when do you do foley care
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daily and after BM
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What may a dr order for the cath of infants and children
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2% xylocaine in water soluble lubricant
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how do you obtain a C&S from a foley?
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foley must be in place for less then 48 hours, clamp tube with a rubber band for 30 mins.
attach sterile leur-lock to cath access port, attach urinalysis tube until filled with urine. label specimen, bag and send to lab STAT |
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How do you obtain a C& S if the foley has been in place for >48hrs?
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remove foley, insert new cath.
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Suprapubic cath
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placed to reduce infection.
Puncture wound made through abdominal wall & cath is inserted |
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Why is there less incidence of infection with a suprapubic cath?
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Abdominal skin has lower bacterial count then urethra.
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removal of foley
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1. use sterile 10ml syringe, attach to ballon port, aspirate h2o, disconnect until resistance is met
2. withdraw cath with smooth movement as pt deep breaths 3.sm amt of urine may escape, use water proof pad under pt 4. measure urine and discard drainage bag 5. document time of removal & measure pt's first void |
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6 protocol for foley cath removal
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1. i&o has been stopped, or pt is able to cooporate with i&o
2. post-op pt is able to resume usual void 3. sacro-perineal wound is healed 4.pt returned from minor procedure not GU related 5. epidural cath is removed 6. urinary protocol score is less then 2 |
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When do you need a MD order to remove a cath.
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if the cath is in place due to pathology / GU surgery.
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What do you do if a pt is unable to void adequately after a foley removal
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1. baldder scan in 4 hrs, if urine volume is more than 300ml, straight cath (auto order)
2.repeat scan in 4 hrs, if greater than 300cc again, straight cath again. 3. after second straight cath notify MD for resinsertion of foley or intermittent cath timed order. |
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what is the maximum time to void after cath removal
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6-8 hours (normal is 2-4)
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Urinary irrigation
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flushing or washing out bladder with specified solution to ensure patency or instill meds. Requries MD order
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Closed urinary irrigation method
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uses triple lumen.
continuous irrigation solution flows into bladder through irrigation port and out through urinary drainage lumen of cath. |
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open urinary irrigation method
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double lumen
used ONLY to free blockage. intermittent irrigation. use sterile irrigation set, & sterile syringe. |
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gastrointestinal intubation
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insertion of rubber or plastic tube into the stomach, duodenum or jejunum.
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How is the GI tube inserted
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via the nose, mouth or abdominal wall.
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What are the indications for use of a GI tube
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decompression
lavage (gavage) diagnosis admin meds feeding treat obstruction compress a bleed aspiration of GI contents |
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Decompression
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removal of gas and fluid from stomach.
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Lavage ( gavage)
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putting fluid in and taking it out used to remove poison or bleeding problem. (overdose)
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What GI tubes are used to relieve obstruction?
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nasoduodenal or nasojejunal.
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Levine tube
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Low intermittent suction!
sucks and feeds radiopaque - can be used for xray Longer then salem. short-term tube feed |
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Salem sump
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thinner then levine
double lumen (pig -tail) SUCK AND SUCK ONLY! used for sucking and getting gastric secretions out. low continuous suction. |
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where must pig-tail stay?
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above waist, otherwise it can clog and change atmospheric pressure.
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small bore feeding tube
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dubhoff, keofeed, blakemore, entrafli
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small bore feeding tubes
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very flexible and comfortable for pt.
has guidewire for insertion and radiographs |
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dubhoff small bore feeding tube
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tungsten tip at end that is weighted.
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blakemore tube
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nasogastric tube used only for bleeding.
balloon is inflated w/ saline and it puts pressure on the esophageal. |
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why would you have a feeding tube go directly into the intestine?
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to prevent aspiration.
for feeding nasointestinal. |
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PEG tube
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has a ballon, placed outside body. surgically implanted.
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J tube (PEJ)
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percutaneous endoscopic jejunum.
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Miller-abbott tube
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nasoduodenal or nasojejunal tube.
Very long rubber tube (4ft) use for obstruction, insert and every few hours push 3inches down. Uses perastalsis. |
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insertion of ng tube
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pt in high fowlers
measure from nostril to earlobe then measure from earlobe to xiphoid process. check patency of nostrils. lube tube aim toward ear take sip of h2o when swallowing push tube in further. secure to nose confirm placement attach to suction. |
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how do you confirm placement
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BEST WAY - X RAY
instill air and listen for shwww sound. measure tube from nose to end every shift. look at gastric aspirate (measure ph) |
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What will happen if the tube in in the lungs
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coughing , gaging, pulling tube out.
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what does gastric aspirate look like
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cloudy
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PH values
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1-5 acidic - stomace
6 or higher - intestine 7 or higher - lungs |
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why does the levine pump need to be on intermittent suction
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to avoid stomach erosion.
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Irrigation of NGT
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instilling saline
prevents electrolyte imbalance |
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Removal of NGT
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trial clamping
turn off suction flush tube with 30cc of saline remove slowly while pt holds breath provide oral hyg. |
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fluid volume deficits what do you assess for?
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dry mucous membranes, dry skin, decrease urine output, lethargy, increased heart rate to maintain BP
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how do you ensure that fluid volume deficit does not occur
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ensure accurate i & o
check lab values check skin turgor |
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what do you assess for if a pt has pulmonary complications
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listen to lungs, coughing, deep breathing, measure tube and instill air. Pulmonary complications occur because of coughing.
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tube-related irritations occur because of.......
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erosion of gastric lining
clogged pig tails wrong suction pressure on tube decubitis ulcer inside stomach |
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what physical assessments do you do for nutritional assessments
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height - weight
BMI - (calculated by using height and weight) skin assessment -(skin turgor, wasting, GI |
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What does albumin do?
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maintain h2o balance
protein balance |
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What does low albumin signify?
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long term protein defficiency
Break down visceral proteins, breakdown of muscles. |
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Decrease albumin
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increased mortality, decrease wound healing
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what influences albumin
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influenced by hydration
it is a magnet that can pull water inside and out. if it can't break down food, it breaks down muscle |
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Prealbumin
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not influenced by H20
good indicator of response to nutrition therapy in acute situations. |
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what does a low pre-albumin level indicate?
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altered insulin in the body
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if a pt is on enteral feeding.......
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they will always have a glucose chem stick even if they are not diabetic
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BUN
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measures the nitrogen fraction of urea which is the chief end product of protein metabolism.
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What does the BUN level indicate
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protein intake and renal excretory capacity.
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When is BUN level low
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if a pt has malnutrition.
no protein intake for a long period of time. |
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Creatine
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a nonprotein end product of metabolism.
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creatine is proportional with
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the amount of muscle mass your body has
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creatine is low in pts with.....
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deficient levels of protein in the diet, and indicates a loss of muscle mass.
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increased BUN and increased creatine =
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Renal disease.
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what is the purpose of providing alternate nutrition
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to meet pts nutritional requirements when oral intake is not possible or when the GI tract is not funcioning
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Enteral nutrition
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providing nutrition via feeding tube in GI tract (also called TEN- total enteral nutrition)
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Parenteral nutrition
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Providing nutrition via IV infusion (also called TPN - total parenteral nutrition)
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what are the indications for a tube feeding
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protein/ energy malnutrition
inability to ingest food obstruction of upper GI tract impaired ability to digest or absorb food. |
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contraindications for tube feed
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small bowel obstruction
high-output fistula (with inability to feed below area) severe diarrhea illeus (small blockage) poor prognosis that does not warrant aggressive nutritional support. |
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what are the advantages of enteral feeding
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safe - cost effective
preserves gi integrity preserves normal sequence of intestinal and hepatic metabolism maintains fat metabolism and lipoprotein synthesis maintains normal insulin and glucagon |
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osmosis
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water moves from low to high.
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What can happen with feeding formulas that have a high osmolality?
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dumping syndrome.
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dumping syndrome
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when a solution of high osmolality is taken in large amnts, water moves to the stomach and intestines from fluid surround the organs and vascular compartment.
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S & S of dumping syndrome
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feeling of fullness
N & V Diarrhea (dehydration hypotension and tachycardia) Sweating Pallor Fainting. |
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what to do when a pt gets dumping syndrome
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start with a more dilute feeding formula
increase concentration slowly over several days may have to stop feeding for a period of time and restart with a dilute formula |
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what to do if a tube is clogged
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attempt to flush with 60ml of warm h20.
attempt twice then go to viocase protocoll. |
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maintaining patency of PEG or PEJ tube
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flush frequently with warm h2o
60cc h20 flush before and after meds flush before and after bolus feed flush every 8 hours. |
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cleasing of peg or pej
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day 1-7 clean with sterile saline, after day 7 clean with soap and h20
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Rotating the bumper
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every shift, 1/4 a turn
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measure peg or pej
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q shift
from skin to tip |
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Residuals PEG or PEJ
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PEG tube do not check residual unless md order
PEJ tube never check residual |
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Residual small bore tube
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Dubhoff and blakemore, do not check residual
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Residual large bore / bolus intermittent gastric feedings
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check prior to each feeding
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Residual large bore continuous
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check q4hours,
check any time rate changes if 2 checks <100ml, then check q 8 h |
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What do you do with gastric aspirate when pulling a risidual
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you should refeed the aspirate unles pt is symptomatic (eg nv, feeling of fullness, or a high risidual)
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if residual is greater then..........
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200ml hold feeding for one hour and recheck if stays above 200 ml notify physician
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Peptic ulcer disease
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formation of an ulcer in the esophagus, stomach, deuodum.
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Gastritis
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chronic inflammatory reaction in gastric mucousa
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zollinger-ellison syndrome
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excessive secretion of gastric acid., treated by long term medication
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heartburn and gerd are caused by
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spicy food, red wine, pregnancy, pepermints, smoking, NSAIDS,
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antacids
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use an alkaline substance to neutralize acids
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Commonly used antacid compounds
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magnesium
calcium aluminum |
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Magnesium antacid
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do NOT give to renal pt, increases diarrhea
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calcium
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eg tums, can get a rebound acid effect, b/c stimulates gastric effect
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aluminum
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binds with phosphorus, can give to renal impaired pts.
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Heliobacter pyloric agents
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destroy h-pilory, a gram- bacteria, spread by fecal oral route , impairs mucous from being secreted causing an erosion and ulcer.
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how do you treat h-pilory
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2 antimicrobials and one PPI, or H2RA.
PPI or H2RA protect the mucousa |
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H2RA
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histamine is released - strong gastric acid, causes H2 receptors to increase hydorchloric acid production.
H2RA decrease acid and pepsin content of gastric juices. |
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what do H2 blockers end with
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tidine
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what don't you take warfarin with
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cimetidine
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proton pump inhibitors
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stops proton pump from making acid, reduces acid secretions of stomach by squishing paretial cells
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PPI ends with
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prazole
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PPI and plavix
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if a pt takes prilosec (omeprazole) and plavix they will have a 25% - 36% increase chance of a second heart attack.
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What is the only PPI that can be given with plavix
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protonix or pantoprazole
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what is the only PPI that can be given to children
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prilosec (omeprazole)
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what are the classifications of meds used to treat constipation
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laxatives (soften stools)
cathartic (cleans you out) |
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when don't you use a medication to treat constipation
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when you have undiagnosed abdominal pain.
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what do you use to treat c-diff
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flagyl (antibacterial)
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bulk forming laxative
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increases bulk, similiar to high fiber diet, high osmolality.
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surfactant laxative
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colase, decreases tension of fecal mass, given to stop straining
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saline laxative
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milk of magnesia, quick release of stool, same effect of dumping syndrome.
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lubricant laxative
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mineral oil, lube up stool so it can slip out
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stimulant cathartics
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stimulates GI tracts, irritates mucousa
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lactulose
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not absorbed in GI tract, goes straight into intestine, binds to ammonia, pulls H20 in. used to treat high ammonia levels in pts with liver impairment.
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time released tablets
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never crush or chew unless it is scored.
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syrup
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contraindicated in diabetics
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emulsion
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dispersion of droplets of water in oil or oil in water. no cheeking, greater compliance
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what medication do you administer last
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Liquid
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where do you read a liquid medication
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at the bottom of the meniscus (surface tension to the walls of the plastic container.)
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where do you measure liquid meds that are under 5mls
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plastic syringe
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what drug do you need to take a apical pulse with
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lanoxisn
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inhaled medications are administered to
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open narrow airways
liquefy or loosen thick secretions reduce inflammation in airways |
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what inhaled meds are used to open narrow airways
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bronchodilators
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what inhaled meds are used to loosen thick secretions
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mucolytic agents
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what inhaled meds are used to reduce inflammation in airways
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corticosteroids
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