LP11: Care of Bowel Diversions, Urinary Catheter Insertion, Enema Administration & Specimen Collection

Created by aharteau 

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True

Care of Bowel Diversions: Applying Stomal Wafer & Pouch: True of False?
-Introduce self and explain procedure to the patient.
-Provide for privacy & perform hand hygiene
-Raise the bed to a comfortable working height
-Assist the patient to a low Fowler's position
-Drape patient exposing the stomal site & don clean gloves
-Place protective pad under the patient's side next to the stoma
-Remove skin barrier appliance and discard in plastic bag

True

Care of Bowel Diversions- Applying Stomal Wafer & Pouch: True or False?
-After removing the skin barrier appliance and discarding in a plastic bag, inspect the stoma for color, moisture, effluent (something that flows out), swelling and an intact suture line.
-Inspect the per-stomal skin for redness, irritation, intactness and drainage.
-Note the client's facial expressions and verbal comments.
-Remove any effluent that is discharging from the stoma with tissues and discard in bag or toilet. Repeat as necesary.

False (Care of Bowel Diversions- Applying Stomal Wafer & Pouch)

Urinary Catheter Insertion: True or False?
-After removing the skin barrier appliance and discarding in a plastic bag, inspect the stoma for color, moisture, effluent (something that flows out), swelling and an intact suture line.
-Inspect the per-stomal skin for redness, irritation, intactness and drainage.
-Note the client's facial expressions and verbal comments.
-Remove any effluent that is discharging from the stoma with tissues and discard in bag or toilet. Repeat as necesary.
-Remove gloves & perform hand hygiene. Don clean gloves.

True

Care of Bowel Diversions-Wafer change: True or False?
-Measure the size of the stoma w/ a stoma template; if none available, draw an approximate stoma size on plastic covering of wafer package. Cut out the stoma size and compare to acutual stoma. Adjust size as needed.
-Place correct template size against the wafer; cut the wafer to match the size.
-Remove protective backing (if present) from wafer and set aside w/ the adhesive side upright.
-After removing the adhesive backing, apply a thin layer of protective skin barrier paste to the adhesive side of the wafer along the periphery of the circle you cut out.
-Wash the peristomal skin gently with warm water on washcloth, pat dry gently.

B (2)

Care of Bowel Diversions-Wafer change:
-After washing the peristomal skin gently w/ warm water on washcloth, pat dry gently.
-If no evidence of peristomal skin breakdown, coat the peristomal skin w/ the liquid barrier. Move in concentric circles outward from the stoma until all the skin from the stoma to about __ inches beyond the anticipated wafer is covered. If peristomal skin breakdown is present, apply a thin layer of barrier powder.
-Allow liquid skin barrier to dry for several minutes and test it w/ fingers to feel if it is sticky or tacky.
-Place the wafer against the skin barrier centering the wafer opening accurately over the stoma. Press gently against the wafer. Ensure that no gaps are present between the wafer and the skin barrier.
-Remove gloves and perform hand hygiene. Don clean gloves.
A.) 1
B.) 2
C.) 3
D.) 4

B (10-15)

Care of Bowel Diversions-Wafer change:
-After applying the wafer, attach the pouch to the wafer by gently snapping the back of the pouch onto the lip of the wafer and have patient tighten their abdominal muscles to ese placement.
-If desired, place tape around the edges of the wafer
-If desired, insert ___-___ml mineral oil into the pouch; milk outside of pouch to evenly distribute.
-Fold distal edge of the pouch up once and secure with clamp. You will hear or feel it snap.
-Repostion client's bedclothing & remove protective pad.
-Discard all materials used, remove gloves & perform hand hygiene.
-Document stoma assessment, peristomal skin condition and size of wafer applied in patients chart.
A.) 5-10
B.) 10-15
C.) 15-20
D.) 20-25

Straight Catheter

Urinary Catheter Insertion: Do you use a straight catheter or a indwelling foley to get residual urine?

Indwelling Foley

Urinary Catheter Insertion: Do you use a straight catheter or a indwelling foley for long term use?

True

Urinary Catheter Insertion: True or False?
-When catheterizing patients, begin by teaching them about the procedure and ways to relax.
-Teach how to deep breathe during procedure to decrease resistance.
-Provide privacy and introduce self. Verify patient allergies (to latex or iodine) and verify the primary care provider's orders and perform hand hygiene.
-Explain procedure to the client and identify patient using 2 forms of ID.
-Raise bed into good working positon and place waterproof pad under client. Position patient in supine position w/ knees slightly flexed and drape client.
-Don disposable gloves, wash perineal area w/ soap and water and arrange equipment at bedside, maintaining sterility of catheterization kit.

True

Urinary Catheter Insertion: True or False?
-After washing the perineal area w/ soap and water, place a sterile drape between the patients legs, TOUCHING CORNERS ONLY!
-Don sterile gloves and organize supplies on sterile field. Apply sterile drape, males only!
-Open pack containing antiseptic cleansing solution, and pour contents over sterile cotton balls being sure not to pour solution in receptacle that is to receive urine/iodine swabs.
-Remove plastic cover over catheter tubing and attach syringe to the inflation port. Open sterile lubricant and lubricate catheter using surgical lube.
-Maintaining sterile technique, bring supplies to bed and position between patients thighs.
-Using non-dominant hand, spread the labia to expose theurethral meatus or retract forskin on males, maintain this position throughout the procedure.

B (1-2)

Urinary Catheter Insertion:
-After spreading the labia to expose theurethral meatus or retracting forskin on males with your non-dominant hand, cleanse the urethral meatus by retracting labia and cleansing FRONT TO BACK 3 times w/ new cotton ball each time for female.For male, grasp penis and holding it at a 90% angle retracting foreskin (if present) and cleansing ni curcular motions from meatus to base of glands.
-Hold catheter with your sterile dominnat hand, insert the catheter into the urethra. Instruct patient to bear down during insertion.
-Advance catheter until a flash of urine is seen in the tubing and then advance another __-___inches.
-Release the labia or foreskin w/ non-dominant hand and hold the catheter to secure tubing.
-Inflate balloon by slowly injecting total amount of solution and remove syringe from port.
A.) 0.5-1
B.) 1-2
C.) 2-3
D.) 3-4

True

Urinary Catheter Insertion: True or False?
After inflating the balloon, gently pull on the catheter to point of resistance. In male patietn return foreskin to original position.
-Remove gloves, perform hand hygiene and don clean gloves.
-Tape catheter to inner thigh allowing for slack so that movement of thigh does not create tension on catheter for female, or to top of thigh or lower abdomen allowing slack so that movement does not create tension the catheter for male.
-Coil excess tubing on bed and hang collection bag below level of bladder & attach to bed frame.
-Assist to comfortable position, wash & dry perineal area as needed and dispose of equipment, remove gloves and perform hand hygiene.
-Document procedure, character and amount of urine in collection bag and patient tolerance to the procedure.

True

Urinary Catheter Insertion: True or False?
-Children catheter sizes are smaller for children ask for family assistance.
-Elders may have limited mobility and flexibility; many need to use modified sims for female for position.

clean

Removal of Urinary Catheter:
-Bring supplies into room, provide for privacy, introduce self, and verify primary providers orders to remove catheter. Perform hand hygiene.
-Explain procedure to the patient and answer any questions. Identify the patient using 2 forms of ID and don ____(clean or sterile?) gloves.
-Raise bed to good workign position and drape abdomen for warmth if needed.
-Place a waterproof pad under client and untape the catheter from clients thigh. Drain any residual urine for catheter tubing and place towel between patients thighs.
-Attach appropriate size syringe to balloon port and aspirate the water.
-Pinch catheter between thumb and forefinger to prevent urine from filling the urethra during removal.
-Gently pull on catheter to remove it and use towel to catch any urine draining from catheter. Remove teh cateter and drainage system from the bedside and measure urine in drainage system. Provide the client w/ soap and water for cleansing the meatus, if necessary.
-Lower bed, position patient for comfort and document amount of urine and the time the catheter was removed.

D (3-4)

Enema Administration:
-Assess clients status, check physician's order and check for allergies. Gather equipment to bring into room.
-Provide for client privacy, introduce self, perform hand hygiene and determine clients identity using 2 forms of ID. Explain procedure to client and raise bed to a comfortable working height.
-Use Universal precautions and don clean gloves and a gown.
-Assemble equipment. Clamp tubing & fill bag w/ ordered solution, ensure correct amount and temperature of solution.
-Expel air from enema bag tubing and position client in side lying or sims position.
-Lubricate tubing and insert into anus ___-___inches.
A.) 0.5-1
B.) 1-2
C.) 2-3
D.) 3-4

True

Enema Administration: True or False?
-After lubricating tubing, insert into anus 3-4 inches and administer solution slowly, assessing client comfort/response throughout procedure. Clamp off tube before last of fluid clears tubing.
-Gently remove enema tube and encourage client to hold solution (if appropriate)
-Assit cilent to toilet or place on bedpan prn
-Cleanse or discard equipment, dispose of gloves and gown, wash hands.
-Provide for client safety and comfort.
-Document the type and amount of solution used, stool return and client tolearnce of procedure.

True

Enema Administration: True or False?
-Children will need smaller volume of solution, usually using NS and may need to hold buttocks together for those w/o sphincter control.
-Elders fatigue easily and there is a concern for fluid and electrolyte imbalances so watch for a vagal episode or dysrhythmias.

B (30-60)

Specimen Collection-Midstream (Clean-voided) Urine Sample:
-Assess voidng status of the patient and verify primary care provider's order.
-Explain to the client that a urine specimen is required and eplain the method to be used to collect it. Discuss how the results will be used in planning further care or treatment.
-Perform hand hygiene, provide privacy and identify patient using 2 forms of ID.
-Ask the client to wash and dry the genital and perineal area w/ soap & water.
-Instruct the client how to clean the urinary meatus w/ antiseptic towelettes.
-Collect the specimen from the client by instructing them to start voiding. Place the speciment container into the stream of urine and collect the specimen w/o stopping the stream, taking care not to touch the container to the perineum or penis. Be sure not to touch the inside cap container.
-Collect ___-___ml of urine in the container. Allow client to empty bladder post specimen collection.
-Cap and label the container and transport to lab using appropraite collection bag.
-Verbalize how to use urine dip stick, remove gloves and perform hand hygiene.
A.) 15-30
B.) 30-60
C.) 30-45
D.) 60-90

C (30-45)

Specimen Collection-Urine specimen with indwelling catheter:
-Introduce self, perform hand hygiene, provide for privacy, identify patient using 2 forms of ID and verify primary care provider's order explainnig procedure, and don clean gloves.
-If there is no urine in the catheter, clamp the drainage tubing using a rubber band or clamp for about 30 minutes. This allows freshurine to collect in the catheter.
-Locate the injection port. Wipe the area where the needle will be inserted w/ a disinfectant swab and allow the port to dry. Insert the needle at a ___-___degree angle or attach a lure lock syringe.
-Withdraw the required amount of urine and transfer urine to the specimen container or cap syringe w/ non-sharp cover.
-Remove the clamp or rubber band from tubing and label container for transport to the lab.
-Remove gloves and perform hand hygiene.
A.) 15-30
B.) 30-60
C.) 30-45
D.) 60-90

True

Specimen Collection-Stool Specimen: True or False?
-Introduce self, perform hand hygiene and provide for privacy. Identify patient w/ 2 forms of ID and verify primary care provider's order. Explain procedure and don clean gloves.
-Prepare equipment and supplies and instruct patient to void and discard urine.
-Provide container in which to defecate such as a hat.
-Take covered specimen container into bathroom and otain specimen using procedure appropriate for purpose of collection, including cultures, other tests and timed stool specimens.
-Place lid on container tightly, label and transport.
-Remove gloves and perform hand hygiene.

Ostomy

Bowel Diversion: Ostomy or Colostomy?
-Diverts and drains fecal material from diseased/damaged bowel
-Can be permanent or temporary

Colostomy

Bowel Diversion: Ostomy or Colostomy?
-An opening (stoma) which connects the colon to the surface of the abdomen

B (Small Intestine)

Where does liquid absorption mostly take place? A.) Stomach
B.) Small Intestine
C.) Large Intestine
D.) Colon

A (Ascending Colostomy)

Ostomy Sites: What location?
-Located within the ascending colon
-Output is liquid to semi-solid
-Rich in digestive enzymes
-Irritating to the skin around the stoma
A.) Ascending Colostomy
B.) Transverse Colostomy
C.) Descending Colostomy
D.) Sigmoid Colostomy

B (Transverse colostomy)

Ostomy Sites: What location?
-Located within the transverse colon
-Usually liquid to semi-formed (enzyme content decreases as the stoma moves farther to the left of the transverse colon)
A.) Ascending Colostomy
B.) Transverse Colostomy
C.) Descending Colostomy
D.) Sigmoid Colostomy

C (Descending Colostomy)

Ostomy sites: What location?
-Located within the descending colon
-Output is semi-formed to formed
-Much of the water is absorbed as waste moves through the ascending and transverse colons
A.) Ascending Colostomy
B.) Transverse Colostomy
C.) Descending Colostomy
D.) Sigmoid Colostomy

D (Sigmoid Colostomy_

Ostomy sites: What location?
-Located within the sigmoid colon
-Output has a normal, formed consistency
A.) Ascending Colostomy
B.) Transverse Colostomy
C.) Descending Colostomy
D.) Sigmoid Colostomy

Stoma

This is a shiny, wet and red in color
-Round or oval in shape
-Rich in blood vessels (may cause slight bleeding)
-It will shrink in size in time after surgery
-Types: Double-barreled colostomy
-Loop colostomy
-Ostomy or Stoma?

True

True or False?...These Reasons why urinary catheters are used:
-Urinary retention (trauma, disease process/neuromuscular disorder, outlet obstruction)
-Specimen collection
-Management of incontinence
-Types of Catheters: Intermittent (specimens, residual urine), Indwelling (long term), single use (straight) catheters, Coude tip, Condom catheter

True

Guidelines for Preventing a Catheter Associated UTI: True or False?
-FORCE FLUIDS! 3000ML/DAY
-Acidify Urine: Meat, cheese, poultry
-Cranberries, tomatos, plums, whole grains
-Good catheter care/perineal care

C (Urinary Diversion)

Term used when bladder is removed or the normal structures are being bypassed and an opening is made in the urinary system to divert urine.
-Involves connecting the ureter to a segment of intestine and then bringing the intestine to the surface of the abdomen.
Two types:
-Continent
-Non-Continent
A.) Urinary Deviation
B.) Urinary Excretion
C.) Urinary Diversion
D.) Urinary Stoma

Non-Continent

What type of urinary diversion..Continent or Non-Continent?
-Patient wears an ostomy bag
-Urine continuously draining
-Paitent still able to participate in normal daily activities
-Ureterostomy: most frequently performed
-Sometimes the only urinary diversion is taught in med schools
-Ileal Conduit: increased incidence of ureter or stoma strictures, increased incidence of reflux to kidneys, red w/ mucous discharge

Continent

What type of urinary diversion..Continent or Non-Continent?
-(Term) used when the bladder is removed or the normal structures are being bypassed and an opening is made in the urinary system to divert urine
-Flow of urine is diverted through an opening in the abdominal wall
-Patient is able to urinate at his or her discretion

C (Large Intestine)

Where does most digestion take place?
A.) Stomach
B.) Small Intestine
C.) Large Intestine
D.) Colon

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