Mark Klimek Blue Book
What are the top 2 diagnoses for a client with a catheter? Which is #1?
#1- Potential for infection; Potential impairment of urethral tissue integrity
What cranial nerve is affected in Bell's Palsy?
#7, facial nerve
An individual is overweight if they are ________% above the ideal weight.
10
What temperature is appropriate for the water used to bathe an infant?
100 to 105
What is the normal adult blood pressure?
120/80
An individual is obese if they weigh ________% above the ideal weight.
20
Proteins provide __________ Kcalories per 1 gram.
4
carbs provide ____________ Kcalories per 1 gram
4
Complete recovery from the paralysis of Bell's Palsy should occur in _______ to ______ months.
4 to 6
Water accounts for ________ to ___________% of an adult's total weight?
50 to 60%
How long does it take for the umbilical stump to fall off?
7 to 14 days
Water acounts for __________ to _________% of an infant's total weight?
70 to 75%
What solution is commonly used for care of umbilical cord?
70% alcohol to promote drying (trend is toward soap and water)
Fats provide ___________ Kcalories per 1 gram.
9
When sponge-bathing with tepid water the correct temp is _____________.
98.6 F
Fats carry vitamins
A,D,E,K (Remember FADE K!)
What type of diet is used in BPH?
Acid Ash
What urinary pH prevents UTI?
Acidity, low pH
How fast do you run the CBI?
At whatever rate it takes to keep the urine flowing and free of clots
What drug is use to treat bladder spasm?
B&O suppositories (Belladonna & Opiates)
What does BPH stand for?
Benign Prostatic Hypertrophy
Which artery is most commonly used to measure blood pressure?
Brachial
You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing.
Bright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.)
When 2 values are given in a blood pressue, the bottom number stands for the change in sounds or cessation of sounds?
Cessation of sounds
Give some signs of infection in a Foley catheter
Cloudy urine, foul smelling urine, hematuria
Name foods that make acid urine
Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine)
Give three eye interventions for the client with Bell's Palsy.
Dark glasses, artificial tears, cover eye at night
Vasodilation will ____________ blood pressure.
Decrease
Acid Ash diet
Decrease pH (makes urine acid) Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes.
The man with BPH has hesitancey. What does this mean?
Difficulty starting to void
What is the best way to screen men for BPH?
Digital rectal exam
How should the temperature of the water be tested if no thermometer is available?
Dropping water on inside surface of your forearm.
What is the most common organism to cause UTI with catheterization?
E. coli
Will the man with BPH have enuresis, nocturia or hematuria?
Enuresis-No, Nocturia-Yes, and Hematuria-Maybe
How often should the drainage bag be emptied?
Every 8 hours
With which body part do you begin when bathing an infant?
Eyes always
You may use friction to remove vernix caseosa from an infant's skin. (T/F)
False, it causes damage/bruising
The primary reason why an infant is draped during the bath is to provide privacy. (T/F)
False, the primary purpose of draping is to prevent chilling.
Vitamins and minerals provide energy for the body. (T/F)
False- they are necessary for a body's chemical reactions.
The change in the character of the sounds is known as the ________
First diastolic sound
If you use too narrow of a cuff the reading will be too high or low?
High
If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why?
High, venous congestion makes the arterial pressure higher (increases resistance)
Abnromally high blood pressure is called____________.
Hypertension
Will the post prostectomy patient be impotent?
If TURP, no impotence, if perineal prostatectomy, yes impotence
Vasoconstriction will ___________ blood pressure.
Increase
If you see clots in the tubing you would first ____________.
Increase the flow-rate.
What is glycogen?
It is a stored formed of glucose/energy manufactured by the liver
What is the most effective way to decrease UTI with catheters?
Keep the drainage system closed, do not disconnect junction of tubing
What is the #1 purpose of a tepid sponge bath?
Lower body temperature during fever.
Name the four basic food groups
Milk & Cheese, Meat & Legumes, Veggies & Fruits, Bread & Cereal
Is glycogen eaten in foods?
NO! It is a stored form of glucose MANUFACTURED by the liver.
What is important about the level of the urinary drainage bag?
Never have the bag at a higher level than the bladder.
Is it ok to routinely irrigate indwelling catheters?
No
Is urinary incontinence an indication for catheterization?
No
Should the drainage bag ever touch the floor?
No
Should you take a rectal temp after prostatectomy? Give stool softeners?
No rectal temperatures, yes stool softeners
Should you cover an unhealed umbilical site with the diaper?
No, fold the diaper down.
When cleansing an infant's eye, cleanse from outer to inner canthus?
No, inner to outer
Can you use the same cotton ball/washcloth edge for both eyes?
No, it would cross contaminate
Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area?
No, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced.
Can you use cotton swabs to clean the eyes, nares or ears of an infant?
No, this is dangerous
What solution is used for CBI?
Normal saline (0.9 NaCl)
What is the #1 symptom of Bell's Palsy?
One sided (unilateral) facial paralysis
The most radical prostate surgery is the ____________ prostatectomy.
Perineal
What exercises should the post prostectomy patient do upon discharge? Why?
Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op
What solution and material are used to cleanse the eyes of an infant?
Plain water, cotton balls, washcloths
If you see an increase in blood content of urine coming out of the catheter, you would first ___________.
Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon.
The cessation of sounds is known as the _________
Second diastolic sound
What agents are best for catheter care?
Soap and water
When 2 values are given in a blood pressure the first is the __________measurement.
Systolic
When pressure is auscultated the first sound heard is the ____________ measurement.
Systolic
What is diastole?
The LOWEST force of blood on artery walls
What is systole?
The MAXIMAL force of blood on artery walls
What is the pulse pressure?
The difference between the systolic and the diastolic blood pressure
What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP?
To keep the catheter clear of clots and to drain urine
How is the catheter taped in a male client?
To the lateral thigh or abdomen
How is the catheter taped in a female client?
To the upper thigh
What does TURP stand for?
Transurethral resection of the prostate
Water is present in ALL body tissues. (T/F)
True (even bone)
Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm.
Two-thirds
What is the most common problem due to catheterization?
UTI
What is the most common route for organisms to enter the blader when a catheterization is used?
Up through the inside of the catheter in the days following catheterization
As the prostate enlarges it compresses the ___________ and causes urinary ________.
Urethra, rentention
Give three appropriate indications for bladder catheterization?
Urinary retention, to check for residual, to monitor hourly output
Can the thigh EVER be used to obtain a blood pressure?
Yes, but this is rare.
The major source of energy for the body is
carbs
Name the five/six essential nutrients
carbs, fats, proteins, vitamins, minerals, water
In BPH the force of the urinary stream is (increased/decreased).
decreased
The most concentrated source of energy for the body is ___________.
fats
Should fluids be forced or restricted in BPH?
forced
The man with BPH has a _________-stream of urine
forked
Sucrose is a sugar found in ____________ and _____________.
fruits, veggies
Enuresis
inability to control the flow of urine and involuntary urination
IN BPH the man has (increased/decreased) frequency of urination
increased
At what age does BPH occur?
men over 50 years of age
Lactose is a sugar found in ?
milk
Will the patient be able to close their eye on the affected side?
no
The nutrient needed most for growth and repair of tissues is _____________.
protein (second best is Vit C)
When the body does not receive enough carbs it burns ___________ and _____________.
protein, fat
In addition to the facial paralysis, the sense of ______ is also affected.
taste