baldder distention with Foley Cath
advance if necessary
irrigate if necessary
How to Advance an already instilled catheter
clean meatus with betadine and then advance
Irrigation is draining into collection bag while cath is clamped. Now what?
slow down the rate of irrigation. Check return amount vs. irrigation amount used
Bladder spasms during irrigation. Now what?
apply warm towels to abdomen
notify physician if spasms continue
no return on irrigation. Now what?
examine tube for kinks and clots
adjust I and O for amt of irrigation
notify provider is client complains of pain.
Pulled out the foley cath. Now what?
ask why and how?
check for trauma
monitor urine for breathing
insert new cath.
Return from cath exceeding 1000ml. Now what?
clamp and wait 30 minutes to prevent bladder spasms. Charge nurse may notify physician
Can't insert cath into male client
hold penis vertical to body and apply traction by pulling upward on penis. Rotate catheter during insertion and change angle of penis as necessary
Oops, inserted cath into vagina. Now what?
leave it there as a landmark. Obtain a new kit. Remove first catheter after the urinary catheter is properly in position
Contaminated my cath when I removed it from the kit. Now what?
Get a new kit. Ist importance is to provide maximum UTI protection.
Proper cleansing for male client when inserting a catheter
uncircumcised retract the foreskin. Return after cleansing.
antiseptic cottonball with forceps. clean in circular motion around meatus with swipe down shaft at end of circle.
Repeat with clean cottonball 3 times total.
Proper cleansing for female client when inserting catheter
hold open labia exposing meatus
using forceps and antiseptic cottonballs clean Far then near labia minora. Finally swipe down meatus with 3rd clean cottonball.
Insert male catheter
insert female catheter
factors that contribute to a UTI
number of days catheterized
biofilm on catheter surface
Size catheter for Neonate
Size catheter for an infant-3yr
Size catheter for a 4-8 year old
Size catheter for a 8- prepuburtal child
Male 8-10 Fr
Size Catheter for the Pubertal person
4 types of enemas
stimulates peristalsis through infusion of large volumes
acts by lubricating the rectum and colon. Feces absorb the solution and become softer and easier to pass. (small volume, works with natural bowel movement, w/o violent elimination)
helps to expel flatus
contains drugs to reduce bacteria or remove potassium.
Administered 500ml of soap suds enema and client can no longer hold fluid, some expels...now what?
give slowly to aid absorbtion. Hold buttocks together until absorbtion begins again.
Enema causes abdominal cramps and nausea, now what?
have client take slow deep breaths
decrease height of enema bag
slow rate of instillation
Client can't return enema...now what?
squat to promote defectation
give more fluid
if necessary, digitally remove blockage
Flow has stopped on a cleansing enema...now what?
Move the bag lower.
back up the tube---may be against fecal matter
When is postural drainage most effective in a child
before meals and after other respiratory therapies
Postural drainage client is dizzy...now what?
decrease degree of trendelenberg
likely caused by performing after meals. Don't do that
Can you brush your teeth if you need a sputum sample?
no. Brushing or using mouthwash interferes with the bacterial results of the sputum sample
Universal precautions. Things might get explosive
tissue around anus during insertion and removal of enema.
have toilet, commode, or bedpan in reach
do not force tubing
watch for abdominal distension
stop if bleeding occurs
signs of ABD pain or cramping
How to maintain peristomal skin integrity
remove pouch gently and place a towel underneath to reduce risk of urine leaking and skin breakdown.
avoid soap for cleansing
do not rub dry...pat dry
ostomy of descending colon - normal stool
ostomy of ilium. Thick liquid stool
ostomy dissecting small segment of ilium and then attaching it to the kidneys to pass urine from the body.
Adverse stoma assessments
grey purple or black stoma
sudden increase in stoma size
reddened raw or broken peristomal skin.
Expected outcomes for CPT
lung sounds improve
sputum more easily coughed and expectorated
Secretions more normal in color and consistency
2 methods for sputum collection
expectoration (client coughs it up)
suction (caregiver suctions it out. interferes with breathing so must be done within 5-10 seconds)
Types of oxygen aides in order of 02 inspiration concentration
Safety measures for Oxygen therapy
no adjustments w/o doc order
O2 in use sign
10 feet from open flames
don't let tanks fall over
all electrical must be grounded
no electrical toys or things that would cause a spark
check all levels before transporting.
promote bowel movements
high fiber diet
minimize refined sugars
normal fluid intake
impede bowel movements
ignore urge to defecate
age related issues (slow peristalsis)
neurological issues (spinal injury)
Symptoms of Hypoxia
decreased LOC, confusion or drowsiness
change in respiration pattern
decreased lung sounds
elevated B/P followed by a sudden drop
pulse ox less than 80%
clubbing of nails
When do I use aseptic technique
during procedures with intentional perforation of skin
when skin integrity is broken due to surgical incision or burn
during procedures where accessing normally sterile body cavities (catheter)
Factors that interfere with wound healing
poor oxygenation and tissue perfusion (smoking)
chemo and radiation
systemic conditions (renal disease or cancers)
type of wound and reason
extent of tissue involvement
type of tissue in wound base
size and depth