KVCC Nursing 140 Quiz 2 (everything else)
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Created by:
JanetStocker on December 4, 2011
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48 terms
Terms | Definitions |
|---|---|
 baldder distention with Foley Cath | check placement 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? | slow down. reposition client teach relaxation 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 notify provider 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 | 7-9 inches |
| insert female catheter | 2-3 inches |
| factors that contribute to a UTI | nonmedical catheterization number of days catheterized biofilm on catheter surface |
| Size catheter for Neonate | 5-6Fr |
| Size catheter for an infant-3yr | 5-8Fr |
| Size catheter for a 4-8 year old | 8Fr |
| Size catheter for a 8- prepuburtal child | Female 10-12Fr Male 8-10 Fr |
| Size Catheter for the Pubertal person | 12-14Fr |
| 4 types of enemas | cleansing retention harris flush medicated |
| Cleansing | stimulates peristalsis through infusion of large volumes |
| retention | 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) |
| Harris Flush | helps to expel flatus |
| Medicated | 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? | reposition enema. 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 |
| Enema Precautions | 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. Wick stoma avoid soap for cleansing do not rub dry...pat dry |
| sigmoid colostomy | ostomy of descending colon - normal stool |
| ileostomy | ostomy of ilium. Thick liquid stool |
| Urostomy | 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 Dyspnea decreased asceities |
| 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 | Cannula Hood-baby venturi mask partial rebreather nonrebreather |
| Safety measures for Oxygen therapy | no adjustments w/o doc order O2 in use sign 10 feet from open flames no smoking 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 lean proteins minimize refined sugars normal fluid intake adequate hydration |
| impede bowel movements | ignore urge to defecate chronic illness poor nutrition lengthy bedrest age related issues (slow peristalsis) neurological issues (spinal injury) medications |
| Symptoms of Hypoxia | anxiety decreased LOC, confusion or drowsiness increased pulse change in respiration pattern decreased lung sounds elevated B/P followed by a sudden drop pulse ox less than 80% dyspnea cardiac dysrhythmia cyanosis 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) Poor nutrition infection diabetes corticosteroid therapies chemo and radiation age stress immunosupression hematopoietic disorders systemic conditions (renal disease or cancers) |
| wound assessment | location type of wound and reason extent of tissue involvement type of tissue in wound base size and depth exudates odor periwound area |
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