hacc nursing 141 midterm

serous-sanguineous drainage

Clear and blood tinged drainage

Coude catheter

a catheter with a curved tip to allow passage through a hypertrophic prostate

carminative enema

enemas that provide relief from gaseous distention by stimulating peristalsis and the passage of gas

urgency

feeling the need to urinate immediately

Hartmann's pouch

oversewing of rectal stump after resection of a colonic segment, patient left with proximal colostomy temporary

anastomosis

surgical joining of two ducts, vessels, or bowel segments to allow flow from one to another

5ml in 1 liter

to perform a soapsuds enema instill this much castile soap in this much liquid

unintentional wound

A wound resulting from trauma

24 hour specimen

a collection of all urine produced in a full 24 hour period

straight catheter

a onetime use catheter used to drain the bladder and after is immediately removed

anuria

absence of urine production less than 50ml/24 hr

abd cramping, nausea, vomiting, stoma swelling, no output for 6 hours

common manifestations of food blockage in ileostomy, contact provider

three

do not administer more than this many enemas to reduce the risk of fluid or electrolyte imbalances

dysuria

painful or difficult urination

skin, tissue

places where antiseptics are used

urinalysis

the examination of urine to determine the presence of abnormal elements

return-flow enema

* also called a Harris flush * is occasionally used to expel flatus * alternates flow of 100 - 200 mL in and out * stimulates peristalsis * repeated 5 or 6 times until flatus is expelled and abdominal distention is relieved

indwelling urinary catheter

A catheter that remains in the bladder for a short time so that urine drains constantly. It is also called a Foley catheter.

oliguria

Decreased urine output, less than 30ml/hr

proctocolectomy with ileal pouch with anal anastomosis

IPAA connects the ileum to a new rectum (anal pouch) made of part of the ileum

urine collection bag

NEVER retrieve a urine sample from this, because it is unclean and can have bacteria that will lead to inaccurate lab results

loop colostomy

Usually performed in a medical emergency. Temporary large stomas constructed in the transverse colon. Surgeon pulls a loop of bowl onto the abdomen supported by a device such a a plastic rod, bridge, or rubber catheter temporarily placed under the bowel loop to keep it from slipping back. Two openings: proximal end drains stool, whereas the distal portion drains mucus. Within 7 to 10 days the surgeon removes the external supporting device

condom catheter

a latex or silicone sheath that fits over the penis and drains urine

hypotonic

a tap water enema is considered this

urine dipstick

a test stripe that immediately measures the pH, specific gravity, and other aspects of a patient's urine

intentional wound

a wound that is the result of a planned surgical or medical intervention

urinary retention

abnormal accumulation of urine in the bladder because of an inability to urinate

Kock's continent ileostomy

alternative to the standard ileostomy; internal pouch is created from the distal segment of the ileum, which serves as a reservoir for stool; patient empties the pouch several times a day and the stoma is covered with a protective dressing or a stoma cap; patients can be at risk of dehydration;

below the waist

always place the urine collection bag at this level to avoid urinary reflux

300-500 ml

amount of fluid for a large volume enema in a child

500-750 ml

amount of fluid for a large volume enema in an adolescent

750-1000 ml

amount of fluid for a large volume enema in an adult

150-250 ml

amount of fluid for a large volume enema in an infant

250-350 ml

amount of fluid for a large volume enema in an toddler

cardiac output

an increase in this increases blood flow through the kidneys and results in an increased production of urine

retention catheter

an indwelling catheter with multiple lumens for drainage and irrigation

open wound

an injury in which the skin is interrupted, exposing the tissue beneath provides a portal of entry

closed wound

an internal injury with no open pathway from the outside normally from blow, force, or strain and may cause a hematoma

laxatives, enemas, enteric coated/sustained release pills

ask a PCP or provider for guidance before using these things after a colostomy

redness, edema, ecchymosis, drainage, approximation

assess REEDA when assessing wounds

hypertonic enemas

avoid this type of enema in young clients

B vitamins and vitamin K

bacteria in the large intestine help to form these

1/3-1/2 full

because the ileum contains digestive enzymes that can irritate the skin, advise clients to use a skin barrier and to empty their bag when it is this full

double barrel colostomy

bowel is surgically cut and both ends are brought through the abdomen proximal end drains feces distal end drains mucous

wound

break in the integrity in the skin or mucous membranes

suprapubic catheter

catheter inserted into the bladder through a small abdominal incision above the pubic area

every 8 hours

catheter/peri care should be performed at this time interval

sterile specimen

catheterizing patient or taking urine from indwelling catheter already present, used for culture and sensitivity

normal saline (isotonic)

children and infants should only receive this type of enema because they are at an increased risk for electrolyte imbalances

serous drainage

clear, watery, straw colored drainage from a wound

increased intracranial pressure, glaucoma, rectal or prostate surgery

contraindications for enemas

ureterostomy

creation of an artificial opening into the ureter (ureter opening brought to the surface of the skin)

urostomy

creation of an opening in the urinary tract, normally to divert urine flow away from a diseased bladder

urine culture and sensitivity (C&S)

diagnostic lab procedure that identifies bacterial infection of urinary system and determines best antibiotic to treat it; involves growing bacteria in culture medium and testing different antibiotics on it

cover

do this to the urine collection bag to protect a client's dignity

dominant

don the sterile glove on this hand first

sanguineous drainage

drainage that is bright red and indicative of active bleeding

moist

evidence shows that this type of wound may heal faster

polyuria

excessive urination

nocturia

excessive urination at night

purewick

female external catheter

glycosuria

glucose in the urine

clean catch specimen

have the patient start voiding and catch the urine midstream

cloudy

if the client has a urostomy, it is normal for the urine to be somewhat this

small, rapid breaths (panting)

if the patient experiences abdominal cramping during enema administration, instructing the patient to do this may help relieve their pain

as long as possible, minimum 30 minutes

in order for a oil retention enema to be effective, have the patient retain it in their rectum for this long

urinary incontinence (UI)

inability to control urination

dehydration, electrolyte imbalance

initially after getting and ileostomy, clients are at risk for this because they lack a colon to absorb water drink 80-96 ounces of water per day

2-3 inches

insert the enema tube this far into the rectum of a child

1-1.5 inches

insert the enema tube this far into the rectum of an infant

3-4 inches

insert the tube this far into the rectum for an enema

knee-chest position

instruct a patient to assume this position if they believe they have a food obstructed ileostomy, it will help relieve abdominal pressure

take a deep breath

instruct the patient to do this

Indiana continent urinary reservoir

is formed from the colon and the cecum; patient self-catheterizes to empty the reservoir

end stoma

is formed when the proximal end of the bowel is brought to the outside abdominal wall. Permanent

avoide

it is best to ______ these foods initially after a colostomy stringy vegetables, coconut, coleslaw, mushrooms, popcorn, seeds, berries, celery, fresh tomatoes

morning, before bed

it is important to empty the colostomy pouch at these times during the day, even if the pouch is not 1/3-1/2 full yet

insoluble fiber

limit the amount of this to help reduce the amount of effluent after a colostomy

oil retention enema

lubricate the stool and intestinal mucosa, easing defecation

Rowasa (mesalamine)

medicated enema given for ulcerative colitis

Kayexalate

medicated enema given to treat hyperkalemia

closed end pouches

most commonly used for sigmoid colostomies; discarded after one use

14-16 fr

normal foley catheter size for a adult patient

5-6 fr

normal foley catheter size for a pediatic patient

4.6-8

normal pH of urine

autonomic dysreflexia

patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

objects

places where disinfectants are used

proteinuria

presence of protein in urine

pyuria

presence of pus in the urine

subungual

referring to the area underneath the nail

2-4 hours

remove a colostomy pouch this time after a meal when the colon is the least active

Kegel exercises

repetitious contraction and relaxation of the pubococcygeal muscle to improve vaginal tone and urinary continence

mucocutaneous separation

separation of the stoma from the peristomal skin; also called mucocutaneous detachment

peristomal skin

skin surrounding an ostomy that is prone to break down

cleansing enema

soapsuds, stimulates peristalsis thorugh distention and irritation of colon and rectum, average adult is 500-1000ml

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

steps in the chain of infection

transureteroureterostomy

surgical connection of one ureter to another, and then that one ureter being opened to the outside world through a stoma

objects in a sterile field must be sterile sterile objects are unsterile when touched by unsterile objects sterile items out of vision are unsterile sterile objects are unsterile by prolonged air exposure fluids flow with gravity moisture contaminants through capillary action edges are unsterile skin cannot be sterilized be alert and honest to maintain sterility

the 9 principles of sterility

effluent

the material that comes out of a stoma

shiny, moist, red

the skin of a stoma should appear like this, similar to the mucous membranes of the mouth

colostomy

the surgical creation of an artificial excretory opening between the colon and the body surface

ileostomy

the surgical creation of an artificial excretory opening between the ileum, at the end of the small intestine, and the outside of the abdominal wall

stoma

the surgically created opening in the skin of the abdomen

alkaline

the urine will be more this in the presence of bacteria (UTI)

purulent drainage

thick green, yellow, or brown drainage

100 ml

this amount of urine or more remaining in the bladder is considered residual urine and puts the patient at and increased risk for a urinary tract infection

alcohol

this inhibits the release of ADH and results in the increased need to urinate

sigmoid colon

this location for a colostomy is usually used during rectal cancer and produces a formed excrement

descending colon

this location for a colostomy produced a semi-formed feces

transverse colon

this location for a colostomy produces pasty feces and is usually for a temporary loop colostomy

ascending colon

this location for a colostomy produces semi-liquid feces that is very irritating to the skin around

1 foot

those not practicing sterile technique must stay at least this far away from the sterile field

ileal conduit

urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall, used when the entire bladder has been removed

sterile water

use this to inflate the retention ballon on a urinary catheter

frequency

voiding more than 4-6 times per day

below waist, above shoulders

when you wear sterile gloves ensure your hands remain within your site and do not go into these places

chronic wounds

wound that persists for an extended period of time and does not follow the normal path of healing

acute wounds

wounds that heal in days to weeks