Exam 2

Check health care provider’s orders

Perform hand hygiene

Provide patient privacy

Introduce self to the patient

Identify the patient using two identifiers

Explain the physician’s order and describe the insertion procedure to the patient

Examine the patient by palpating the patient’s bladder for distention

Gather equipment and supplies, use the smallest suitable device possible 

Perform hand hygiene

Raise the bed to a comfortable working height, adjusting the side rails accordingly

Lower the head of the bed to a comfortable position

Drape the patient for privacy

Place a water proof pad under the patient

Position the patient

Wash the perineal area with soap and water

Set up catheterization kit, opening away from your body first, then the sides, then the bottom

Apply sterile gloves from kit

Set up equipment from kit

• Place square drape, shiny side down, between patient’s legs

• Set up catheter, placing end into the lubricant and the syringe in the proper place

• Open cleaning supplies for labia and urinary meatus

Clean the labia and urinary meatus, working from the clitoris toward the anus

Examined and identified the urinary meatus

Insert catheter and put substance from syringe in

Pull back on catheter to make sure the balloon filled and push back in a little bit

Release labia

Place catheter bag on bed frame

Clean up work space

Perform hand hygiene 

Used to see how much urine is in the bladder

Would use to help determine if patient is suffering from polycystic kideny disease, pyelonephritis, ascites, and pregnancy

External female catheter

• Wick?

• Placed between the labia and gluteal folds

• Tubing is attached to low continuous suction to drain excreted urine

Condom catheter

• Perform hand hygiene 

• Perform perineal care with condom catheter off

• Use a clean washcloth with soap and water

  • Pull back the foreskin if the patient is uncircumcised

• Rinse and dry the penis 

• Pull the foreskin down over the head of the uncircumcised penis to prevent swelling before before placing a new catheter

Women: 

• Wipe front to back 

• Reduce bubble baths

• Dutching

• Peeing before and after sex

Drink enough fluids

Take the entire course of medications for UTI

• If the antibiotic is stopped, you will not get rid of the UTI

Catheteraztion can cause a UTI if left in for long periods of time

Bowel training

• 30 minutes after eating, get the patient onto a commode

  • No longer than 10 minutes on the commode

• Return to the previous level of function with the help of a schedule

Kegel exercises

• Increase muscular function in the pelvic floor

Assessment

• Is this a healthy ostomy?

• Is there skin breakdown from acidic stool

• Stoma should be pink, moist, and elevated

  • Black = dead

  • Blue = poor circulation

Putting on a pouch

• Changed every 3 days

• Change bag before eating

• Make sure it is no bigger than ⅛ of an inch from the outside

• Hand over the bag to help it stay on

Emptying a pouch

• Empty bag with it is ⅓ full

• If able, have patient move to the toliet to remove

• Put warm water in the bag and swish it around

• Wipe it down (at least on the outside)

Used to create a bowel diversion 

Types: 

• Ostomy: a surgically created opening in a GI, urinary, or respiratory organ that is exited onto the skin

• Colostomy: Surgically created when a portion of the colon or the rectum is removed and the remaining colon is brought through the abdominal wall at skin level to allow passage of stool waste

  • Ascending

    • Liquid and cause odor

  • Transverse

    • Proximal drains feces

    • Distal drains mucus

  • Descending

    • Solid fecal matter

  • Sigmoid

    • Produce solid fecal matter

  • Loop

    • Reuse part of intestine

Illeostomy: a surgically created opening in the small intestine, usually at the end of the ileum

Koch pouch: Surgical variation of ileostomy; a reservoir pouch is created, a valce is constructed at the pouch and stoma is made at the abdominal wall

Ileoanal pouch: the colon and most of the rectum are surgically removed and an internal pouch is formed out of the terminal portion of the ileum

Prolapsed ostomy: Part of the intestine is out

Steps

• Hand hygiene

• Place on clean gloves

• Place patient into the SIM positon

• Bring bag with warm water and insertion tube to the bed

• Lubricate the insertion tube

• Insert tube into rectum, about 4-6 inches

• Unclamp the stopper to release water

• Lower bag if needed to reduce flow and help with cramping

• Let bag drain completely 

• Clean up area 

Types:

• Cleaning: tap water, normal saline, soap suds

  • Order if the person is constipate or prepared for colonoscopy

  • A side effect is cramping

  • 120-1000mL

• Oil

  • 120-150mL

  • Lubricating

• Medicated-Kayexalate

  • Cation exchange resin

Assessment

• Bowel elimination patterns

• Surgeries or illnesses affecting the GI tract

• Family history of GI cancer, Crohn’s disease, and other GI disturbances

• Diet

  • 20-35 grams of fiber

  • 2 L of water

• Medications

• Stress - Diarrhea

• Pain 

Constipation

• Prevention

  • Activity increase peristalsis

  • Medications

    • Laxatives 

    • Stool softners

• Patient education

• Complications

Diarrhea

• Prevention

  • Medications

    • Antidiarrheal

  • Enemas

• Patient education

• Complications

Prevention measure in hospitals: Bed rails (not all 4) up, call light within reach, personal belongings within reach, cleaning floors, make sure floor is clear/has no obstacles or things in the way, use restraints minimally, 6 rights of medication administration, EMRs/good communication with the patient/other healthcare workers, cleaning equipment thoroughly, Morse/Hopkins/Hendrich II Fall risk scales, seizure pads/linens wrapped on side rails, bed alarms/gait belt/wheelchair/lift for falls, patient sitters, hourly rounding, putting cords away, and special gowns/socks/armband for fall precautions, . 

Education for elderly: teaching them to use their call light or ask for assistance when wanting to get up, movement to prevent pressure injuries, high fiber, high protein diet, at least 2 L of fluid every day, using handlebars at home when going to the bathroom/bathing,

Home Safety Education: use of handlebars when going to the bathroom/bathing, clean, dry floors c no obstacles, putting cords away/anything you could trip on, walker/cane/ambulatory aid, not using multiple appliances on same extension cord, turning straighteners/curling irons/irons off, always supervising children around water, clear crib to avoid suffocation, throwing medication away properly, disposing of sharps correctly, being careful when handling household/any chemicals, no idling of cars, avoiding toxic plants indoors/outdoors, cleaning furnaces/stoves/ovens, turning off space heaters when not in use, and blowing candles out when leaving the room. 

Intentional 

• Things planned to hurt someone

  • Suicide

  • Homicide

  • Mass shootings

  • Abuse

Unintentional

• Falls

• Suffocation

• Poisioning

• Drowning

• Fire

Throwing expired food away

Do not thaw food in room temperature

RACE

• Rescue

• Activate alarm

• Contain

• Extinguish

PASS

• Pull

• Aim

• Squeeze

• Sweep

Extinguisher use and types

Used to prevent falls but can cause injury

Do not use chest restraints, can cause someone to choke and die

Must have a physician orders

Tied down to bed and not side rails

Use a slip know

Circulation distal to restraint

• Check hourly

• Undo one arm at a time

Two fingers under restraint to make sure it is not too tight

Assess the situation

Call the provider

Document and report the incident

Respiratory: Heart disease and COPD can impact mobility. Atelectasis in lungs causes inadequate oxygenation due to impaired mobility. Bed rest affects this system. Cardiac workload is increased when the body is in supine position due to increased venous return to the heart. Lung expansion is decreased because the body’s weight against the bed puts pressure on the rib cage. Diaphragm has less room to expand them in upright position due to pressure from abd organs. Decreased lung expansion and dependent positioning of areas of lungs = pooling of secretions in lungs, pneumonia, or atelectasis. Circulatory stasis → pooled blood combined with weakened calf muscles can lead to DVT  (especially in LE). Position changes in immobile pts = postural/orthostatic hypotension due to pooling of blood in LE and lack of vasoconstriction → heart suddenly has less blood to pump = drop in bp. Edema from decreased peripheral circulation. Activity intolerance due to bed rest. Impact of bed rest: SOB, DOE, fatigue c minimal activity. 

Skin: pressure injuries due to lack of mobility, skin breakdown due to poor nutrition, bony prominences contribute to pressure injuries. 

Musculoskeletal: weakness, decreased muscle tone, decreased bone et muscle mass, muscle atrophy, et contractures. Foot Drop, lack of physical activity = diminished muscle strength, resorption of bone (calcium reabsorbed into bloodstream), disuse osteoporosis and pathologic fractures, joint stiffness and pain with movement. Poor diet of calcium/vitamin D = fractures, injuries affect mobility.  

supine: flat in bed; looking up (bony prominences needs to be considered—back of head, coccyx, heels, elbows—can lead to skin breakdown)

prone: down (skin breakdown)

semi-fowlers: 30 degrees – relieves some pressure

fowlers 45-90 degrees (more pressure on coccyx and heels)

sims position: pressure on side (iliac crest, shoulder, arms, knees, ears)

Bony prominences: buttocks, coccyx, heels, hips, shoulders, elbows, and ears. 

Lateral flexion

Rotation

• Head rotation

• Arm: external and internal

Flexion

Extension

Hypertension

Abduction

Adduction

Supination

Pronation

Ulnar flexion

Radial flexion

Eversion

Inversion

Dorsiflexion

Plantarflexion

BUN: 6-20 nml is normal. Immobility decreases this value. Negative nitrogen balance → tied into muscle breakdown.

Albumin: normal is 3.5-5. It is a protein. Immobility decreases this value → tied into muscle breakdown.

Calcium: 8.6-10.2 is normal. Immobility causes an increase in this level because no exercise/movement. High levels for a long time can lead to kidney stones.