Theory Exam 2 (Bowel Elimination), (urinary Elimination), (Skin Integrity and wound care)
◦Nephrons maintain and regulate fluid balance through:
-Selective reabsorption -Secretion of water, electrolytes, and other substances
When weighing absorbent pads, 1 g = ___ mL
1
What is the procedure for measuring the urine output of a patient who is continent?
1. Ask patient to void in a specimen hat, bedpan, or urinal 2. Put on gloves & pour into the appropriate measuring device 3. Place on a flat level and read at eye level 4. Discard in toilet is specimen if not required
Nursing considerations for scheduling diagnostic studies (Order)
1. Fecal occult blood test 2. Barium studies (enemas should precede UGI) 3. Endoscopic (EGD) examinations 4. The colonoscopy if you need it
Collecting Urine Specimens from a Patient with a Urinary Diversion: Sterile Specimen: 1 Catheterize the ________ 2. Use _______ technique and insert catheter __ to __ inches
1. Stoma 2. Sterile; 2 to 3
Performing careful hand hygiene
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?
Debride
B = Black =
immobility nutrition and hydration moisture mental status and age
Basic risk factor list for pressure injury development
melena stool indicates
Black tarry stool; upper GI bleed
Positive fecal occult blood test
Blue
contusion
Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma
puncture
Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental
Skin loses elasticity and becomes prone to breakdown
Dehydration and malnutrition: If fluid, protein and vitamin C is deficient... Then what occurs?
Nursing diagnosis: · adverse effects of pharmaceutical agents, abuse of laxatives, emotional stress, colon disease, radiation - Ex: at least 3 loos liquid stools a day, urgency, abdominal pain
Diarrhea
Unstageable Pressure Injury.
Extent of tissue damage cannot be determined due to slough or eschar.
results from the loss of both water and solutes in the same proportion from the ECF space (nutrition flashback)
Fluid volume deficit
Use positioning devices- •Pillows, foam wedges, and pressure-reducing boots. Use support surfaces. •Seating device (gel cushion). •Alternating air mattress. •Friction reducing sheets. •Lifting devices.
How can you prevent pressure injuries?
· Perform, hand hygiene. Put on gloves · Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down Mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin Remove the swab and measure the depth with a ruler
How do you measure the depth of a wound?
· Draw the shape and describe it · Measure the length, width, and diameter
How do you measure the size of a wound?
open so that the first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile surface touching unsterile clothing.
How do you open sterile packages?
about 2-3 days
How long does the inflammatory phase last?
A nursing diagnosis for a patient that is incontinent and has maceration
Impaired skin integrity
moderate
In the Braden scale, a score of 13 to 14 Is at _______ risk
· The lower, distal part of the GI tract that extends from the ileocecal valve to anus · 5 feet long and about 3 in. wide (width is narrow at cecum and gets wider as you go out) · Bacteria that resides here produces vitamin k and B-complex vitamins
Large Intestine
Desiccation
Local factor: Dry wound bed, results in cells dying and forming a crust
pressure
Local factor: Prolonged wound healing
walk away
Never ____________ from a sterile field
large volume enema, takes 15 minutes isotonic
Normal saline
associated with overflow of bladder and absent bladder signal; usually secondary to drugs, fecal impaction, or neurological conditions
Overflow or chronic retention
____________ is under the control of the nervous system.
Peristalsis
Protect
R = Red =
How does the bladder empty?
The detrusor muscle contracts and the internal sphincter relaxes
It will become compromised and breakdown. Placing the patient at increased risk for injury.
The nurse correctly identifies if this patient does not receive adequate nutrition what will most likely happen to the integumentary system?
discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist by holding the patient's hands and/or reinforcing what is happening.
The patient touches the sterile field:
chemical wound
Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis
the involuntary loss that happens because you get the urge to void and don't have time to get there; you can't wait
Urge incontinence
Dry dressing (dry gauze, telfa gauze)
Used to cover a wound and absorb some drainage.
epidermis & dermis
What are the 2 layers of the skin?
older adults
Who is at high risk for pressure ulcers?
cleanse
Y = Yellow =
whitish stools indicate
antacids
Normal odor of urine
aromatic
Alteration in bowel elimination may be r/t ___________
constipation
For an ascending colostomy, we will likely see _______ stool
dark liquid that is thinning - golden brown to brown stool
Metformin can cause
diarrhea
retained in the bowel for a prolonged period
retention enema
Dehiscence
the partial or total separation of wound layers that are not healed
What is a triple lumen catheter used for?
to instill irrigating solution (commonly to irrigate infection out because they had surgery, debris, or clots)
appears suddenly bc certain problems and only lasts for 6 months drugs caused by diuretics, confusion, infection
transient incontinence
LPN/LVN
who can collecting a wound culture can be delegated to?
Wound
· A break or disruption in the normal integrity of the skin and tissues
What are the factors affecting urination?
· Developmental considerations · Food and fluid intake · Psychological changes · Activity and Muscle tone · Pathologic conditions · Medications
analgesic
· Remember to assist with __________ 30- 40 mins before wound care and/or dressing changes
Irridation
· Ultraviolet light or radiation exposure
Bowel elimination: Implementing
• Promoting regular bowel habits. • Preventing and treat constipation. • Preventing and treat diarrhea. • Promoting elimination of feces.
What is the most common size catheter for the average adult?
•14-16 F; with 5 mL or 10 ML
What equipment is needed for collecting urine specimens from a patient with an indwelling catheter:
•Gloves •Syringe •Antiseptic swab •Sterile specimen container •Nonsterile gloves
Outcome identification and planning The patient will:
Have a soft, formed bowel movement without discomfort Explain the relationship between bowel elimination and dietary fiber, fluid intake, and exercise Relate the importance of seeking medical evaluation if changes in stool color or consistency persist Maintain skin integrity
A nurse is assisting a patient to change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is beefy red and slightly protruding into the bag. What would be the nurse's first action in this situation?
Have the patient rest for 30 minutes and reassess
the waist
Hold sterile objects above the level of _______
for several weeks
How long does the proliferation phase last?
redness, dry skin, burns, rashes
How may radiation therapy affect skin?
draws fluid out of the interstitial space into the colon takes 5-10 minutes
Hypertonic
They will become compromised and breakdown. Placing the patient at an increased risk for injury
If the patient does not receive energy rich nutrients, what may happen?
no
In the Braden scale, a score of 19 to 23 Is at _______ risk
· commonly performed through radiography (x-ray)
Indirect visual studies
Leukocytes
Inflammatory phase: _______________ arrive first and ingest bacteria and cellular debris.
Macrophages
Inflammatory phase: ____________________ arrive 24 hours later and release growth factors which attracts fibroblasts (fill in the wound).
stage I
Intact with area of nonblanchable erythema.
You need to have at least _____ in of stool to run; if liquid _______ mL
1 in; 15-30 mL
For males, lubricate 1 to 2 in of catheter tip and also Gently insert the tip of the syringe with a lubricant into the urethra and instill the ___ mL of lubricant
10
Decreased and dark (amber)
A nurse is providing care for an older adult patient that is currently dehydrated. What does the nurse anticipate regarding the patient's urine output and color?
destroy intestinal parasites
Anthelmintic
irritant
Casts are an ______ to the skin
What foods give a laxative effect?
Certain fruits and veggies bran chocolate spicy foods alcohol coffee
Bowel Elimination r/t School-Aged Child, Adolescent, Adult
Defecation patterns vary in quantity, frequency, and rhythmicity. IBS frequent in adults due to diet, stress, depression, or anxiety
results from too much retention of water and sodium in the ECF space in near equal proportions (another flashback) - May be caused from an enema
Fluid volume excess
The primary organ of bowel elimination
Large intestine
pressure ulcer, venous ulcer, arterial ulcer, diabetic ulcer
List the chronic wounds.
The _________ is the basic structural and functional unit of the kidneys
Nephron
Should there be sediment in urine?
No, if there is then it is abnormal
Obtain latex-free sterile gloves.
Patient has a latex allergy:
skin breakdown
Patients on bed rest have increased risk for ___________
Bowel Elimination r/t Toddlers ________________ is the first priority for bowel training.
Physiologic maturity
Bowel elimination as the problem:
Risk for constipation Bowel incontinence Diarrhea
irritates intestinal tract takes 10-15 minutes must use only castile soap
Soap (soapsuds)
inflammatory phase
WBCs move to the wound Leukocytes arrive first; macrophages 24 hours later Acute inflammation = pain, heat, redness, swelling at site of injury
1. infection 2. hemorrhage 3. dehiscence and evisceration 4. Fistula formation
What are the 4 wound complications?
carbs, proteins, and fats (proteins are the most important)
What are the energy rich nutrients to promote healing?
Increased risk for bleeding, tissue damage, infection, and delayed healing time
What are the infection risks and healing time for open wounds?
- Age - Circulation to and oxygenation of tissues (may be impaired in pt's with peripheral vascular disorders, cardiovascular disorders, diabetes, or hypertension) - Nutritional status - Wound etiology - General health status - Disease state (pt's taking corticosteroid drugs or require radiation therapy are at high risk for delayed healing) - Immunosuppression (AIDS, lupus, chemotherapy) - Medication use - Adherence to treatment plan
What are the systematic factors?
> temp, heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes
What can a surgical incision cause?
Maturation
What is the final stage of wound healing?
- Mechanical forces: surgical incisions - Physical injury: burns
What may a wound result from?
swollen and deep red, hot on palpation
When an infection is present the wound is ______
How do you assess for skin turgor?
You grasp the skin between two fingers so that it is tented up. If it stays up, it is dehydrated
For females, advance the catheter until there is...
a return of urine (about 2 to 3 in)
excessive output (diuresis)
Polyuria
· Ideally is waterproof, may be used to extend the sterile working area. · Using sterile gloves allows the nurse to handle the entire drape surface. · For protection when positioning, fold the upper edges of the drape over the sterile-gloved hands · When sterile gloves are not worn, the nurse can touch only the outer 1 inch (2.5 cm) of the drape. · Use caution when gently shaking the drape open so as not to touch one's clothing or an unsterile object. · Hold the drape by the 1-inch upper edge and position the drape over the desired area. · Do not reach over the drape because this would contaminate the sterile area. · Outer 1-inch of the drape is considered contaminated. · Any item touching the area is also considered contaminated
Positioning a sterile drape
clay colored stool indicates...
absent of bile pigment
If postvoid residual is less than 50, it indicates
adequate bladder emptying
· Care is necessary when pouring sterile liquids onto a sterile dressing or into a sterile basin · After a solution has been opened, the outer bottle should be labeled with date and time if it is to be reused · Most solutions are considered sterile for 24 hours after they are opened · When pouring from a bottle, grasp the bottle so that the label is in the palm of your hand · This prevents any of the liquid from running over the label and making it illegible · Avoid splashing the liquid (this will contaminate the sterile field
Pouring sterile solutions
Pressure drainage
death of cells and tissue
•Drain the bladder for shorter periods of time. (single use-minutes)
intermittent catheter
Brown stool is due to __________
stercobilin
An intermittent catheter is also called a _______________
straight catheter
intentional
tattoos and colostomies are examples of _________ wounds
arterial ulcers
· Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis (clots)
NAP or UAP
· Irrigation of a wound and procedures requiring use of a sterile field and other sterile items are not delegated to?
False positive fecal occult blood test
(high iron) red meats, certain veggies, high vitamin C, salicylate intake of > 325 mg, steroids
opioids effect on stool (what does it cause?)
(used for pain i.e. after surgery) constipation (any narcotic)
Heals more slowly (air dries out). Exposed to more environmental factors and potential injury.
(wound care) if there is no dressing and the wound is open to air - It heals _________ - It is exposed to _______________
Nursing considerations for scheduling diagnostic studies
***Noninvasive procedures take precedence over invasive procedure · Cheaper for insurance · Less risk for infection · Its important to consider comorbidities, such as diabetes
· Pressure Ulcer Scale for Healing (PUSH)
- A quick, reliable tool to monitor the change in pressure injury status over time - Can track whether the injury/ulcer is healing, remains unchanged, or is deteriorating
asepsis
- All activities to prevent infection or break the chain of infection - Used to stop the spread of microorganisms and minimize the threat of infection
medical asepsis
- Clean technique, involves procedures and practices that reduce the number and transfer of pathogens - Ex: hand hygiene & wearing gloves
Debride (black)
- May indicate the presence of eschar (necrotic tissue) - Usually black, may be brown, gray, or tan - The eschar requires debridement (removal) before the wound can heal - These wounds are often cared for by APRN
cleanse (yellow)
- May indicate the presence of exudate (drainage) or slough, and requires wound cleaning. - Have oozing from the tissue covering the wound, with purulent drainage - Drainage can be whitish yellow, creamy yellow, yellowish green, or beige - To cleanse: use wound cleansers and irrigate the wound
sterile technique
- Sterile technique, practices used to prevent and keep objects and areas free from microorganisms - An object is considered sterile when all microorganisms have been destroyed - Operating room, labor and delivery changes, diagnostic tests
·Fecal Occult Blood Testing: Visual blood: - black indicates?: - bright red indicates?:
- black- upper GI bleeding - bright red- lower GI bleeding
protect (red)
- granulation tissue in the proliferative stage . Includes gentle cleaning, use of moist dressings, and changing of the dressing only when necessary
What would the nurse anticipate regarding kidney function when providing care for a patient with an acute kidney injury in which the nephrons are damaged?
-Compromised fluid regulation since the nephron is the basic structural and functioning unit of the kidney
A home health nurse is planning edu for a patient who is ordered 24 hour urine collection. What info should the nurse include in the patient teaching? (examples)
-Keep refrigerated -Collect all urine in 24 hours -Don't collect the 1st one -Write the date and time of when you started -Label with pt's name and follow organizations policy name and DOB or room #, medical record, etc.
A nurse providing care for a patient with an enlarged prostate will expect difficulty with urinating and feeling as if his bladder is not completely empty. Why is the nurse correct for expecting this finding?
-Urethra is being squeezed which results in the need for the bladder to apply higher pressure to get the urine out -Over time this causes the bladder walls to loose elasticity and result in residual urine remaining in the bladder
A nurse is providing care for a pt who is incontinent. In order to prevent the possibility of infection from an indwelling Foley catheter, what are 2 alternative methods to measure the patients's output?
-Weighing of absorbent pad -Measuring of output in drainage bag from a urinary sheath (only used on males)
What foods should a patient with an ostomy avoid?
-foods high in fiber (e.g. foods with skins, seeds, and shells) -foods that cause diarrhea or excessive flatus such as beans, cabbage, cauliflower, brussels sprouts, and simple carbs such as flour and potatoes
What would the nurse anticipate a patient with an obstructed ureter is at risk for if not promptly treated?
-infection, loss of kidney function. -Sepsis (systematic infection), which can lead to death
•Assess Assess the skin of at-risk patients daily. •Cleanse Cleanse the skin routinely. Mild cleansing agent, minimal friction, and avoid hot water. •Implement Implement turning and positioning schedules. Do not position HOB above 30 degrees (unless medically contraindicated). •Use Use protective film dressings on bony prominences.
Preventing pressure injuries
· An adequate blood supply is essential · Normal healing is promoted when wound is free of foreign material · The body's response to a wound is more effective if proper nutrition has been maintained
Principles of wound healing
What are the constipating foods?
Processed chesse lean meat eggs pasta rice white bread iron and calcium supplements
· Donned so that only the inside of the glove comes into contact with the hands · After on, only sterile items may be handled with the sterile-gloved hands · Careful removal of gloves reduces any hand contact with contaminated materials · Good hand hygiene before and after putting on sterile gloves is imperative
Putting on sterile gloves
For females, lubricate __ to __ in of catheter tip
1 to 2
Toilet training should not begin until the toddler is able to (3 things)
1. Hold urine for 2 hours 2. Recognize the feeling of bladder fullness 3. Communicate the need to void and control urination until seated on toilet
What 3 layers is the bladder comprised of?
1. Inner longitudinal layer 2. Middle circular layer 3. Outer longitudinal laye r
What is the order for physical assessment of the abdomen?
1. Inspection 2. Auscultation 3. Palpation 4. Percussion
Key points to remember about ostomy care
1. Keep the patient as free of odors as possible, empty the appliance frequently 2. Inspect the patients stoma frequently. Keep the skin around the stoma clean and dry 3. Measure the patients; I & O 4. Explain each aspect of care to the patient and self care role 5. Encourage (patients acceptance) to care for and look at ostomy
Collecting Urine Specimens from a Patient with an Indwelling Catheter: 1. Always collect specimen from? 2. If urine is not present in the tube, what do you do?
1. access port (NOT drainage bag) 2. Clamp for no more than 30 mins and reassess (if you can't get 10 mL, reassess)
How does lifestyle affect bowel elimination? (3 things)
1. depends on a person's acceptance of bowel elimination 2. preoccupation with bowel elimination 3. feeling that it is a "dirty" process
abnormal odor of urine 1. Asparagus causes______________ 2. High glucose causes _________ 3. Infected causes _________
1. musty odor 2. Sweet odor 3. Fetid odor
What 3 parts does the male urethra consist of?
1. prostatic 2. membranous 3. cavernous portions
The normal range for specific gravity of urine
1.015 to 1.025
How long is the female urethra?
1.5 to 2.5 inches long
Guidelines for Ostomy Care
1.Explain procedure prior to starting 2.Keep patient as free of odors as possible 3.Patient teaching and participation is crucial b/c they have to demonstrate self care before they go home 4.Equipment needed will vary •adhesive, bag, clip, and wafer 5.Use a template to measure size of the stoma 6.Cut opening of wafer 1/8 inch larger than stoma 7.Remove old equipment 8.Cleanse area 9.Apply adhesive(skin prep) and attach wafer 10.Attach pouch and clip
For a sterile specimen, you need at least ___ mL
10
For clean-catch or midstream, you need at least ___ mL
10
What is the volume of the desire to void?
150-250 mL
For females, once the urine drains, advance the catheter another __ to __ in
2 to 3
Toddlers: Toilet training begins at __ to __ years Voluntary control begins between ___ to ___ months
2 to 3 years 18-24 months
Start at a specific time and document that time. Post a sign on the patients bathroom door as a helpful reminder to not discard initiate collection by asking pt. to void (DISCARD) collect urine for the next 24 hours; at the end ask pt. to void, ADD this urine to the previously collected urine send entire specimen to lab Keep urine refrigerated.
24-hour specimen
for routine urinalysis, you need at least ___ mL
30
Leave oil enema in for _______ mins at ________ temp
30; body
If when auscultating and 1 min has passed and you heard no bowel sounds, keep listening in all 4 quadrants. It may take ______ mins to hear
5
How long is the male urethra?
5 1/2 to 6 1/4 inches long
Administering an Enema: Encourage the patient to hold until urge for bowel movement is strong ____ to______ mins for hyper/hypotonic _____ mins for retention
5 to 10 30
Frequency may range from __ to __ bowel sounds per min
5 to 30
Normal pH of urine
5 to 6 with a range of 4.5 to 8
What is the average amount of times a person urinates in a 24 hour period?
6 to 7 times
Hematoma
A collection of blood under the skin, deeper injury (like a hard lump of blood)
Stop procedure. Remove damaged gloves. Wash hands or perform hand hygiene (depending on whether soiled or not) and put on new sterile gloves.
A hole or tear is noticed in one of the gloves during the procedure:
Discard gloves and open a new package of sterile gloves.
A hole or tear is noticed in one of the gloves:
tissue necrosis
A nurse is assessing the wound bed of a patient's acute open wound. The nurse correctly identifies the yellow stringy tissue as:
Moist sterile applicator held at a 90° angle
A nurse is performing a wound assessment and is measuring the depth of the patient's wound. Which technique is recommended for measurement?
longer
A nurse is planning education for a patient recently prescribes a blood thinner. The nurse understands it is most important to inform the patient that bleeding times will be:
Black wound
A nurse is providing care for a patient who has a pressure injury that requires debridement. The nurse correctly identifies according to the RYB wound classification scale that after debridement the wound should be treated as
Increased granulation tissue
A nurse is providing care for a patient who is malnourished with the nursing diagnosis of impaired tissue integrity r/t an acute open wound. The nurse correctly select which outcome as the most appropriate to demonstrate wound healing?
Disturbed body image
A nurse is providing care for a patient who received a facial wound from an automobile accident. The patient states, "I feel so ugly now." Based on this statement, which nursing diagnosis would be the most appropriate for the nurse to select?
When any portion of the sterile field becomes contaminated, discard the sterile field and any items on the field and start over.
A part of the sterile field becomes contaminated:
Braden scale
A tool for predicting pressure ulcer risk (for mental status, continence, mobility, activity, nutrition)
Potentially delayed healing; dead tissue (Treat as a Y wound)
A yellow sloughy tissue is present in the wound bed. This indicates?
visualizes all solid upper organs - Looking for organs with liquid in them (i.e. bladder issues, cysts)
Abdominal Ultrasounds
What are the functions of the large intestine?
Absorption of water formation of feces expulsion of feces from the body
What medications are nephrotoxic?
Abuse of aspirin or ibuprofen Gentamicin (antibiotic)
· Once a sterile field is established, objects may be handled only by using sterile forceps or with hands wearing sterile gloves
Adding sterile supplies to a sterile field
stage II
After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, the pressure injury would be classified as:
yellow, then red
After debridement, treat wound as __________
Assess the patient for any other signs and symptoms, such as pain, malaise, fever, and paresthesias. Place a dry sterile dressing over the wound site. Report the findings to the primary health care provider and document the event in the patient's record. Be prepared to obtain a wound culture and implement any changes in wound care as ordered.
After the dressing is removed, the nurse notes the incision edges are not approximated at the distal end, multiple staples are evident in the old dressing, the surrounding skin tissue is red and swollen, and purulent drainage is on the dressing and leaking from the wound:
If nothing else in the sterile field was touched, remove the contaminated gloves and put on new sterile gloves. If you did not bring a second pair, use the call bell to summon a coworker to provide a new pair of gloves.
After the nurse has put on sterile gloves, the patient moves too close to the edge of the bed and the nurse must support her with his hands to prevent the patient from falling
Bowel elimination as the etiology
Alteration in bowel elimination Deficient Fluid Volume Impaired Skin Integrity Ineffective Coping
Surgical incisions
An example of an acute wound is__________
-Provide physical, psychological, and aesthetic comfort. -Control infection. -Absorb drainage. -Maintain moisture balance. -Protect the skin surrounding the wound. -Debride (if appropriate). -Optimize healing.
An ideal dressing should:
24 hr output < 50 ml
Anuria
◦Note the location in relation to the nearest anatomic landmark ◦Document the size of the wound ◦Assess for approximation of wound edges (do edges meet?) and signs of dehiscence or evisceration ◦Assess the color of the wound and surrounding skin ◦Assess for the presence of odor (Pseudomonas aeruginosa - sweet; Proteus - ammonia like)
Appearance of the wound
Use standard precautions. Put on sterile gloves (clean gloves can be used when cleaning a chronic wound or pressure injury). Gently place the dressing at the wound center and extend at least 1 inch beyond the wound in each direction. Secure in place à do not apply tape under tension. Remove gloves and perform hand hygiene
Applying a new dressing
Discard this swab, obtain a new culture swab, and collect the specimen.
As the nurse prepares to insert the culture swab into the wound, the nurse inadvertently touches the swab to the patient's bedclothes or other surface:
- A radiopaque contrast (dye), the patient drinks it. It coats the esophagus, stomach, and small intestine to enhance visualization - Watch for constipation, allergies, make sure they are hydrated after test
Barium Enema
to visualize GI structures and reveal inflammation, ulcers, tumors, strictures, or other lesions
Barium studies
Normal healing; granulation tissue (Treat as a R wound)
Beefy red tissue is present in the wound bed. This indicates?
What foods may affect the color of urine?
Beets (darker) and carrots (orange)
ultrasound looking for fluid filled items •Can be performed at the bedside. •Assess patient (continent and incontinent) for postvoid residual- any urine residing in bladder after pt has voided (PVR). Poses no risk for infection
Bladder scanning
Factors affecting Urination Infants:
Born without voluntary control and little ability to concentrate urine.
Nursing diagnosis · dietary habits, general decline in muscle tone, laxative abuse, rectal sphincter abnormality, cognitive impairment - Ex: " I'm sorry, I couldn't get into the bathroom quickly enough" "it came so fast"
Bowel incontinence
the inability of the anal sphincter to control the discharge of fecal and gaseous material
Bowel incontinence
Stage II
Break in the epidermis with exposed dermis.
ecchymosis
Broken surface capillary under the skin is bleeding
What color does Levodopa (Parkinson's) turn urine?
Brown or black
thin beams of x-rays are directed at and move around the abdomen, resulting in computer-manipulated pics that are not obstructed by overlying anatomy - Takes pictures like slices of abdomen to see different levels of i.e tumors or masses
CT scan
Inserting female catheter: Urine flow is initially well established and urine is clear, but after several hours flow dwindles
Check the tubing for kinking. If patient has changed position, the tubing and drainage bag may need to be moved to facilitate drainage of urine.
Production of WBCs and release of growth factors are inhibited at the cellular level due to chronic medical conditions
Chronic wounds are stuck in inflammation phase? Why is this?
Pressure injury staging
Classified according to 6 stages. 4 numbered and 2 unnumbered. Stage I, Stage II, Stage III, Stage IV, unstageable, and deep tissue pressure injury.
Moisten a sterile gauze pad or swab with the prescribed cleansing agent. Use a new swab or gauze for each downward stroke. Clean from top to bottom. Work outward from the incision in lines parallel to it Wipe from the clean area toward the less clean area.
Cleaning wounds with approximated edges
Use standard precautions; use appropriate transmission-based precautions when indicated. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. Use a new swab or gauze for each circle. Clean the wound in full or half circles, beginning in the center and working toward the outside Clean to at least 1 in beyond the end of the new dressing. If a dressing is not being applied, clean to at least 2 in beyond the wound margins.
Cleaning wounds with unapproximated edges
A nurse is completing a urinary assessment on a newly admitted patient. The patient reports a new problem they recently noticed in regards to voiding patterns. What action should the nurse complete next?
Collect more assessment information- explore the duration, severity, precipitating factors
· Follow the steps for cleaning a wound, then dry the surrounding skin with gauze dressings · Put on clean gloves. · Twist the cap to loosen the swab on the Culturette tube · Carefully insert the swab into the wound · Press and rotate the swab several times over the wound surfaces · Avoid touching the swab to intact skin at the wound edges · Place the swab back in the culture rube · Do not touch the outside of the tube with the swab · Place a dressing on the wound · Label dressing and wound culture with date, time, and your initials
Collecting a wound culture
RYB Wound Classification
Color classification system that helps direct treatment of open wounds or wounds healing by secondary intention.
Pressure Ulcers
Compromised circulation secondary to pressure or pressure combined with friction
Bowel Elimination r/t older adult _______________ is often a chronic problem; fecal impaction; diarrhea and fecal incontinence may result from physiologic or lifestyle changes.
Constipation
Discard gloves and open new package of sterile gloves.
Contamination occurs during application of the sterile gloves:
Evaluating
Continuous process. Involves: -Reassessment at regular intervals to monitor response. -Determination of the effectiveness of treatment. -Changes in the plan of care. Considered effective when: -Progressive healing of the wound / pressure injury is visible. -Patient remains free of infection.
Assess & call physician
Dehiscence and Evisceration- What is the first action?
Place in low Fowler's position (this places less pressure on the wound) and call physician ASAP.
Dehiscence and Evisceration- What position do you place the patient in?
What are the variables influencing bowel elimination?
Developmental considerations Daily patterns Food and fluid Activity and muscle tone Lifestyle Psychological conditions Medications Diagnostic studies Surgery and anesthesia
Becomes increasingly resistant to injury and infection. Develop immunology
Developmental considerations affecting skin integrity: Child
Fragile, high risk for injury and infection.
Developmental considerations affecting skin integrity: Infants
easily damaged
Developmental considerations affecting skin integrity: Older adult
A nursing diagnosis for a patient with a urinary diversion
Disturbed body image
Why should a nurse who is caring for a client prescribed diuretics expect the patients urine to be pale?
Diuretics prevent the reabsorption of water and certain electrolytes in the nephron tubules
Inserting female catheter: Urine leaks out of meatus around the catheter:
Do not increase the size of the indwelling catheter. Make sure the smallest-sized catheter with a 10-mL balloon is used. Large catheters cause bladder and urethral irritation and trauma. Large balloon-fill volumes occupy more space inside the bladder and put added weight on the base of the bladder. Irritation of the bladder wall and detrusor muscle can cause leakage. If leakage persists, consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon. Underfilling the balloon can cause the catheter to dislodge into the urethra, causing urethral spasm, pain, and discomfort. If you suspect underfill, do not attempt to push the catheter farther into the bladder. Remove the catheter and replace. Assess the patient for constipation. Bowel full of stool can cause pressure on the catheter lumen and prevent the drainage of urine. Implement interventions to prevent/treat constipation.
Recommendations for the patient preparing for a fecal occult blood test:
Do not use laxatives, enemas, or suppositories for 3 days before testing. If a woman is menstruating, postpone the test until 3 days after her period has ended. Postpone the test if hematuria or bleeding hemorrhoids are present. Postpone the test if the patient has had a recent nose or throat bleed.
This has not been documented as happening with previous irrigations: Stop the procedure. Assess the patient for other symptoms. Obtain vital signs. Report the findings to the primary health care provider and document the event in the patient's record.
During the wound irrigation, the nurse notes bleeding from the wound.
painful or difficult urination
Dysuria
Collecting Urine Specimens from a Patient with a Urinary Diversion: Routine:
Empty urine from diversion appliance into clean container. (a wafer, bag, clip) Note: this does not have to be sterile, you can draw directly from the bag
to visualize an abnormality, locate source of bleeding, and if necessary, provide biopsy tissue samples
Endoscopic (EGD) examinations
esophagus, the stomach, and the duodenum
Esophagogastroduodenoscopy (EGD)
•Ongoing and deliberate. •Compare patient's health status with previously defined expected outcomes. •Adjustments are made to the plan accordingly based on patient's ability to meet previously identified goals.
Evaluating
sterile technique
Ex: inserting an indwelling/urinary catheter, inserting an IV catheter, sterile dressing changes,
wounds r/t diabetes, arterial or venous insufficiency, and pressure injuries
Examples of chronic wounds
- Ischemia (deficiency of blood in a particular are) - Hypoxia (inadequate amount of o2 available to cells) - Edema, inflammation, necrosis, ulcers
External pressure on pressure injury results in:
Local factors Systematic factors
Factors affecting wound healing
Age lifestyle variables changes in health state illness Diagnostic measures therapeutic measures
Factors that place a person at risk for skin alteration
· Used to detect "hidden" blood in the stool
Fecal Occult Blood Testing
Test to detect GI bleeding
Fecal Occult blood test
Who is more likely to get a UTI (males or females)? Why?
Females because there is a shorter distance to the bladder
An indwelling catheter is also called a ____________
Foley catheter
migrate more rapidly to maximize healing alterations in body image
For closed wound care- dressing is applied to keep wound moist -Epidermal cells migrate____________ Helps patients cope with alterations in ______________
· Explain what will be done · If wound care is uncomfortable, administer a prescribed analgesic 30 to 45 minutes before changing the dressing · Plan to change the dressing midway between meals so that the patient's appetite and mealtimes are not disturbed · Provide privacy by properly screening the patient; close door & curtain · Help the patient into a position that is comfortable and also convenient for changing the dressing -perform hand hygiene
For dressing changes, make sure you......
penetrating
Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues
Stage IV
Full thickness tissue loss with visible tendon.
Stage 3 Pressure Injury: Full-Thickness Skin Loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (black looking scab) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed.
Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location.
urine loss caused by inability to reach toilet b/c of environmental barriers, physical limitations, loss of memory, confusion, disorientation
Functional incontinence
· Check the wound care order or nursing care plan · Perform hand hygiene · Use standard precautions; use appropriate Transmission-based Precautions when indicated · Check the patient identification · Explain what you are doing to patient · Provide privacy by closing the door and pulling the bedside curtain · Put on gloves · Cleanse the wound, and periwound skin, as prescribed · Apply a skin barrier, such as skin prep, to the areas of skin where the dressing adhesive or tape will be placed; to areas around the wound where drainage may come in contact with the skin, · Gently place the dressing at the wound center and extend it at least 1 inch beyond the wound in each direction · Alternately, follow the manufacturer's directions for application · Remove gloves when the dressing is in place, before handling tape, if used · Do not apply tape under tension to prevent blisters and skin shearing · Perform hand hygiene
General guidelines for applying a new dressing
Inserting male catheter: Patient is obese or has retracted penis
Have an assistant available to place fingers on either side of the pubic area and press backward to bring the penis out of the pubic cavity. Hold the patient's penis up and forward. The catheter still needs to be inserted to the bifurcation; the length of the urethra has not changed.
If there is not an immediate flow of urine after the catheter has been inserted, several measures may prove helpful:
Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles. Rotate the catheter slightly, because a drainage hole may be resting against the bladder wall. Raise the head of the patient's bed to increase pressure in the bladder area. Assess the patient's intake to ensure adequate fluid intake for urine production. Assess the catheter and drainage tubing for kinks and occlusion.
Acute wound
Heal within days to weeks. Normal healing process (no interruption) The wound edges meet to close skin surface; risk of infection is low
thermal wound
High or low temperatures; cellular necrosis as a possible result
in as little as 1 to 2 hours if the pt. hasn't moved
How quickly can a pressure injury occur?
It delays the formation of a blood clot
How would a medication like a blood thinner (anticoagulant) do to affect wound healing phase of hemostasis?
Reassess the patient's condition. Perform assessment to differentiate pressure injuries from wounds and/or injuries due to other causes. Consult with the patient's health care provider to report the injury and collaborate on a revised care plan. Review and revise the current nursing care plan to reflect the change in the patient's status and ensure implementation of appropriate interventions. Implement appropriate wound care as prescribed and indicated in facility policy. Continue vigilant preventive interventions to avoid further pressure injury.
If a patient develops a pressure injury, the nurse should....
Inserting female catheter: Patient moves legs during procedure:
If no supplies have been contaminated, ask patient to hold still and continue with the procedure. If supplies have been contaminated, stop the procedure and start over. If necessary, get an assistant to remind the patient to hold still.
Inserting male catheter: You cannot insert the catheter past 3 to 4 in; rotating the catheter and having the patient breathe deeply are of no help
If still unable to place the catheter, notify the primary care provider. Repeated catheter placement attempts can traumatize the urethra. The primary care provider may order and insert a coudé catheter.
Post-residual is 450 mL via bladder scanner "It hurts when I pass my water and I have to go every hour" "I have to get up frequently at the night to urinate"
Impaired Urinary Elimination
A nurse is planning care for an older adult patient with urinary incontinence and limited mobility. The nurse correctly identifies which nursing diagnosis as priority?
Impaired skin integrity
Sensory motor impairment UTI Anatomic obstruction
Impaired urinary elimination
-Preventing infection. -Promoting wound healing. -Preventing further injury or alteration in skin integrity. -Promoting physical and emotional comfort. -Facilitating coping.
Implementing: Preventing pressure injuries: Focus on
very high
In the Braden scale, a score of < 9 Is at _______ risk
Inflammatory phase
In this phase, the patients response is mildly elevated temp, leukocytes, and malaise
Venous ulcers
Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
Stage 1 Pressure Injury: Nonblanchable Erythema of Intact Skin
Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration
Hyperglycemia because it causes more damage; it slows and delays wound healing
Is a patient more opt to get a foot ulcer when they are hyper or hypoglycemia?
A nurse is administrating a large volume cleansing enema to a pt. prior to survey. Once the pt. solution is introduced, the pt reports severe cramping. Why is this occurring? What should the nurse do next?
It may be due to the temp, rate, or position of patient The nurse should Stop instilling the solution, check the temp, check the rate, reposition the pt
Help maintain the composition and volume of body fluids through filtering and excreting
Kidneys
Inserting female catheter: No urine flow is obtained, and you note that the catheter is in the vaginal orifice
Leave the catheter in place as a marker. Obtain new sterile gloves and catheter kit. Start the procedure over and attempt to place the new catheter directly above the misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Because of the risk of cross-infection, never remove a catheter from the vagina and insert it into the urethra.
ecchymosis and hematomas (look like bruises)
List examples of closed wound
results from surgery, IV therapy, or lumbar puncture
List examples of intentional wounds
incisions and abrasions (scrape that is bleeding)
List examples of open wounds
accidents, forcible injury (stabbing, gunshots), and burns
List examples of unintentional wounds
Biofilm
Local factor: Wound bacteria that grows in thick clumps, results in delayed healing
Maceration
Local factor: Wound bed is too wet, results in skin breaking down
Necrosis
Local factor: Dead tissue (yellow, stringy, sloughy, black) in wound bed, results in delayed healing
infection
Local factor: Requires a lot of energy from the body, results in delayed wound healing
provides physiologic information and detailed anatomic views of tissue using a superconducting magnet and radiofrequency signals - Make sure patient has NO metal on them - You must assess them for metal
MRI
· Provide physical, psychological, and aesthetic comfort · Prevent, eliminate, or control infection · Absorb drainage · Maintain a moist wound environment · Protect the wound from further injury · Protect the skin surrounding the wound · Remove necrotic tissue, if appropriate
Many different types of dressings are available but essentially have the same purposes:
Medications
May cause: Allergic skin reactions Photosensitivity Impaired healing
1.Length 2.Width 3.Depth (moist sterile applicator at 90°) Tunneling (moist sterile applicator)
Measuring a wound includes:
◦Wound healing ◦Reducing the risk for complications ◦Promoting psychosocial adaptation
Nursing interventions are planned for returning the patient to health by facilitating:
•Skin is dryer and itching may occur
Older Adult: Activity of the sebaceous and sweat glands decreases.
lose elasticity.
Older Adult: Collagen fiber is less organized, so it causes skin to?
•Increased risk for injury. •Less capacity to insulate. •Sensation of pressure and pain is reduced
Older Adult: •Subcutaneous and dermal tissues become thin.
Prolonged healing time
Older Adult: Cell renewal is decreased. This causes?
24 hr output < 400 ml
Oliguria
acute care
On admission, then every shift and with any changes in condition
home health care
On admission, then reassess at every visit
long-term care
On admission, then reassess weekly for 4 weeks, then quarterly and with any changes in condition
· Open sterile packages on a flat surface · Sterile item must be covered if not used immediately · Reapply the cover by touching only the outside of the wrapper and reversing the opening order
Opening a sterile package and preparing a sterile field:
Stage 2 Pressure Injury: Partial-Thickness Skin Loss With Exposed Dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present.
___________ of the abdomen is only performed by advanced practice professions
Percussion
Removing the indwelling catheter
Perform hand hygiene before and after the procedure, and wear gloves. Deflate the balloon before attempting to remove the catheter by inserting a syringe into the balloon inflation port. Allow the pressure within the balloon to force the syringe plunger back and fill the syringe with water. Do not cut the tubing with scissors. Ask the patient to take several deep breaths to relax while you gently remove the catheter. Wrap the catheter in a towel or disposable waterproof drape. Dispose of catheter and drainage system according to facility policy. Clean the perineal area after the catheter is removed. Ensure that the patient's fluid intake is generous, and record the patient's fluid intake as well as time and amount of fluid output for at least 24 hours (or according to facility policy) following catheter removal. Instruct the patient to void into a bedpan, urinal, or specimen hat, either in bed or in the bathroom. Inform the patient that it may take a little while for the bladder to reestablish voluntary control and that an accident at this time is not unusual. Tell the patient that there may be a slight burning sensation when voiding the first time or two after catheter removal. If the catheter was in place for more than a few days, decreased bladder muscle tone and swelling of the urethra may cause the patient to experience difficulty voiding or an inability to void. Monitor the patient for urinary retention. Check facility policy regarding the length of time the patient is allowed to accomplish successful voiding after catheter removal. If patient does not void within 8 to 10 hours of removal of the indwelling catheter (or timing according to facility policy), notify the primary care provider. Observe the urine carefully for any abnormalities. Document the volume of the first void to validate adequate emptying of the bladder post removal. Record and report any unusual signs or symptoms, such as discomfort, a burning sensation when voiding, bleeding, or changes in vital signs, especially the patient's temperature. Be alert to any signs or symptoms of infection, and report them promptly.
· Using your nondominant hand. Gently apply pressure to the basing against the skin below the wound to form a seal with the skin · Gently direct a stream of solution into the wound · Keep the tip of the syringe at least 1 inch above the upper tip of the wound · When using a catheter tip, insert is gently into the wound until it meets resistance · Gently flush all wound areas
Performing irrigation of a wound
· Contractions occur every 3 to 12 minutes, moving waste products along the intestine · Mass sweeps occur 1 to 4 times each 24-hour period (often after food is ingested). · 1/3 to 1/2 of food waste is excreted in stool within 24 hours, the remainder within the next 24-48 hours · Formed bowel movement every 1 to 3 days without discomfort. · Always ask when their last bowel movement
Peristalsis
· parasitic intestinal worms that live in the cecum · migrate to the anal area during the night to deposit eggs and retreat into the anal canal during the day · most common symptom is perianal itching · collect early in AM and use clear cellophane tape to collect specimen
Pinworms
A pale stoma The patient needs_______ and ________ This ______ a medical emergency, but needs _____
RBCs and iron Is not; reported
injury
Reduced sensation (paralysis, nerve damage):If patient has an inability to sense temperature extremes, pressure, and friction... •Then what is he/she at an increased risk for?
the need to void; sensation is gone; usually spinal cord injuries
Reflex incontinence
Cleansing enemas are used to remove feces from the colon, commonly to:
Relieve constipation or fecal impaction Prevent involuntary escape of fecal material during surgical procedures Promote visualization of the intestinal tract by radiographic or instrument examination Help establish regular bowel function during a bowel-training program
1. Expose only the area necessary to perform the wound care while maintaining proper draping 2. Using appropriate aseptic techniques when changing the dressing is crucial. 3. Be especially vigilant in performing hand hygiene before and after changing dressings and in adhering to standard precautions and transmission-based precautions 4. Among the most common causes of hospital-inquired infections is carelessness in practicing asepsis during dressing changes 5. Perform hand hygiene and put on clean (nonsterile) gloves. 6. Remove tape and dressings in the direction of hair growth to minimize trauma to the skin. 7. Use a push-pull method; lift a corner of the dressing away from the skin, then gently push the skin away from the dressing/adhesive 8. Continue moving fingers of the opposite hand to support the skin as the product is removed 9. Carefully lift the adhesive barrier from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If there is resistance, use an adhesive remover as this allows for easy, rapid, and painless removal without the associated problems of skin stripping ( 10. Slowly remove the dressing, noting the amount, type, color, and odor of the drainage. 11. Discard the dressing according to facility policy. 12. Remove gloves and perform hand hygiene
Removing a dressing
Use standard precautions. Put on clean gloves. Remove the tape and dressing in the direction of hair growth (edges first, then center). Remove any packing if present. Visual inspect the amount, type, color, and odor of drainage. Remove gloves and perform hand hygiene.
Removing a dressing
Unintentional wounds
Result of an accident occur from unexpected trauma, forcible injury, and burns Occurs in an unsterile environment, contamination in likely, Edges are usually jagged and bleeding is uncontrolled
· Inadequate nutrition and dehydration, skin moisture, altered mental status, and advanced age · Poor skin hygiene · Diabetes mellitus · Diminished sensory perception (pain awareness) · Fractures · History of corticosteroid therapy · Immunosuppression · Increased body temperature · Microvascular dysfunction · Multiple organ dysfunction syndrome (MODS) · Previous pressure injuries · Significant obesity or thinness · Terminal illness/end-of-life/dying process
Risk factors for pressure injury development:
·Nursing diagnosis insufficient fluid and fiber intake, inactivity, delaying defecation when urge is present, abuse of laxatives - Ex: opioid use and decreased mobility
Risk for constipation
Alcohol and caffeine consumption, fecal impaction, ineffective toileting habits
Risk for urge urinary incontinence
Debriding dressing (Wet-to-dry (packing))
Saline moistened packing material (Secondary Intention).
1. Use standard precautions; use appropriate transmission-based precautions when indicated. 2. Perform hand hygiene. Put on gloves. 3. Determine direction: Moisten a sterile, flexible applicator with saline and gently insert a sterile applicator into the site where tunneling occurs. View the direction of the applicator as if it were the hand of a clock 4. The direction of the patient's head represents 12 o'clock. Moving in a clockwise direction, document the deepest sites where the wound tunnels. 5. Determine the depth: While the applicator is inserted into the tunneling, mark the point on the swab that is even with the wound's edge, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin. 6. Remove the swab and measure the depth with a ruler 7. Document both the direction and depth of tunneling.
Steps for wound tunneling
Weak pelvic muscles and structural supports Patient reports involuntary leakage of urine with sudden movement, coughing, sneezing, and laughing
Stress Urinary Incontinence
occurs when involuntary loss of urine because of intra-abdominal pressure; coughing sneezing, running, pregnancy
Stress incontinence
purulent drainage increased drainage pain redness and swelling in and around the wound increased body temperature increased white blood cell count delayed healing discoloration
Symptoms of an infection
Circulation and Oxygenation
Systematic factor: Decreased in older adults with vascular issues, COPD, Cardiovascular disorders
Age
Systematic factor: Skin "thins", increase in chronic and pathologic illnesses.
Medications
Systematic factor: •Corticosteroids (decrease inflammation process), prolonged antibiotics (increased risk for superinfection), and immunosuppressive medications (halts the proliferation phase).
Nutritonal status
Systematic factor: •Protein deficiency, lack of Vitamins A and C impacts all phases of wound healing.
skin assessment
Systematically; head-to-toe Include bony prominences On admission and then at regular intervals
large volume, takes 15 minutes; can lead to fluid and electrolyte imbalance
Tap water (hypotonic)
· eat well-balanced meals; drink 6-8 glasses of fluid, rest periods, modifications in ADLs until healing is complete
Teaching tips: wound healing
Avulsion
Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures (part of the body has fallen off)
intact skin
The first line of defense is _______
Consider the outer 1-in edge of a sterile field to be contaminated. Any item within the outer 1-in is considered contaminated.
The item being added falls close to or on the edge of the field:
Discard this swab. Obtain the additional supplies needed to clean the wound according to facility policy and a new culture swab. Cleaning the wound prior to obtaining a specimen for culture removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results. Clean the wound using a nonantimicrobial cleanser and then proceed to obtain the culture specimen.
The nurse has inserted the culture swab into the patient's wound to obtain the specimen and realizes that the wound was not cleaned:
Call for help. Do not leave the sterile field unattended. If you are unable to visualize the sterile field at all times, it is considered contaminated.
The nurse realizes a supply is missing after setting up the sterile field:
Less drying time to protect granulation tissue = ↑ healing
The nurse should discuss with the physician the need to change wound care orders if the packing is found sticking to the wound bed (e.g., instead of changing every 8 hours; change every 6 hours). What is the rationale for requesting this change in wound care orders?
kidneys reabsorbing fluid
The nurse understands the reason for the decreased urine output and concentrated urine color is the result of what?
Stop the procedure and administer an analgesic, as prescribed. Obtain new sterile supplies and begin the procedure after an appropriate amount of time has elapsed to allow the analgesic to begin working. Note the patient's pain on the nursing care plan so that pain medication can be given before future wound treatments.
The patient experiences pain when the wound irrigation is begun
f the patient touches your hands and nothing else, you may remove the contaminated gloves and put on new, sterile gloves. It is a good idea to bring two pairs of sterile gloves into the room, depending on facility policy. If the patient touches the sterile field, discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist you by holding the patient's hands or reinforcing what is happening.
The patient touches the nurse's hands or the sterile field:
A nurse is performing care for a patient whose CNS is compromised. What should the nurse anticipate regarding the patient's bladder control?
The patient will most likely have urinary incontinence
A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching would the nurse stress?
The stool from an ileostomy is normally liquid. You should eat dark green vegetables to control the odor of the stool. You may have a tendency to develop food blockages
Stage 2 Pressure Injury: Partial-Thickness Skin Loss With Exposed Dermis
These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
A nursing diagnosis for a patient who cant change their briefs or make it to the commode in time
Toileting self-care deficit
Moisture absorbing dressing (alginate)
Type of dressing that absorbs exudate while maintain a moist environment.
moisture adding dressing (hydrophilic foam)
Type of dressing that maintains a most environment.
Secondary intention
Type of intention rough wound edges, require more tissue replacement, often contaminated. •Traumatic, unplanned
Primary intention
Type of intention: Well approximated wound edges (surgical incision).
Tertiary intention
Type of intention: •wounds left open for several days for therapeutic reasons, and then are closed. •Large dehiscence, huge stage IV ulcer
•People with normal functioning kidneys who void less frequently (e.g., because of work circumstances, limited mobility, travel) are at an increased risk for ?
UTIs
If there is residual urine, the patient most likely has what?
Urinary retention
How do you get the most accurate measurement?
Use a graduated cylinder
A nurse is ordered to catheterize a patient following surgery? What guideline should the nurse follow?
Use the smallest appropriate appropriate French size
Assessment Ask about:
Usual patterns of urinary elimination •How often do you urinate? Do you awaken at night? Recent changes in urinary elimination. • Have you noticed any changes un voiding patterns? Present or past voiding problems. •Are you experiencing any current problems with voiding? Do you have any history of urinary problems? Presence of urinary diversion. •Tell me about your usual routine with your ileal conduit
How do you decide what time to start a 24-hour specimen?
Wait until the pt. needs to void (don't collect first specimen bc you want to start when the bladder is completely empty) When the 24 hour period is done, encourage them to try to empty again and include it with the sample
•Nursing Care for the Patient with an Indwelling Catheter:
Wash hands both before and after patient care. Make sure catheter is secured & patient is not laying on drainage tube Clean from meatus outward Use mild soap and water or perineal cleanser Clean perineal area thoroughly daily and after each bowel movement. Note volume and characteristics of urine, and record. Record I&O every 8 hours. Empty collection container into graduated cylinder that is calibrated for correct measurement Encourage patient to be up and about, as ordered Change indwelling catheters only as necessary
◦Disturbed Body Image ◦Deficient Knowledge r/t wound care ◦Impaired Tissue Integrity ◦Risk for Impaired Skin Integrity ◦Risk for Infection
What are some appropriate nursing diagnoses?
·protection-barrier temperature regulation- compensates for both heat and cold psychosocial- external appearance sensation- touch, pain, pressure, temperature vitamin D production-activated by ultraviolet rays from the sun immunologic-triggered when the skin is broken absorption- medications elimination-sweat (water, electrolytes, and nitrogenous wastes)
What are the functions of the skin?
- Pressure - Desiccation (dehydration) - Maceration (overhydration) - Trauma - Edema - Infection - Excessive bleeding - Necrosis (death of tissue) - Presence of biofilm (a thick grouping of microorganisms)
What are the local factors?
•Increase amount of serosanguineous fluid from the wound 4-5 days post up. •Patient might say something like, "something has suddenly given away".
What are the signs of dehiscence and evisceration?
-They have comprised skin integrity due to instability with blood glucose levels- vascular problems increases delayed healing
What compromises individuals with diabetes?
a hematoma
What does an internal hemorrhage cause the formation of?
It will heal by secondary intention (from the base upwards) Healing time and scar tissue will be increased
What happens if a wound healing by primary infection becomes infected? What will result in terms of healing time and scar tissue?
Adequate nutrition, oxygenation, and prevention of strain on the suture line
What is important to consider when in the proliferation phase?
to promote tissue repair and regeneration so that skin integrity is restored.
What is the goal of wound care?
Skin, subcutaneous layer, and appendages of the skin
What is the integumentary made up of?
Skin (essential for maintaining life)
What is the largest organ in the body?
1. hemostasis 2. inflammation 3. proliferation 4. maturation (remodeling)
What is the order of the phases of healing?
Risk for infection is decreased and healing is facilitated
What is the risk of infection and healing time for intentional wounds?
High risk for infection and longer healing time
What is the risk of infection for and healing time for unintentional wounds?
the inflammatory phase
What phase of healing do chronic wounds remain in?
-Formation of granulation tissue will be delayed -They need nutrition and oxygenation (a good blood supply)
What should the nurse expect regarding the proliferation phase of wound healing for a nutritionally compromised (not enough nutrition) patient?
high protein diets
What type of diet promotes healing?
Vitamin A and C (and high protein)
What vitamins do you need to help heal a wound?
Assess skin daily and implement a turning schedule
What would be appropriate nursing interventions for the patient with a Braden Score of low risk?
initially and before applying any new dressing
When are wounds cleaned?
move, turn, and reposition
When assessing mobility, we assess the patient's ability to:
perspiration, wound drainage, urine, and stool
When assessing moisture, the sources of moisture include:
malnutrition
When assessing the patient's lab values r/t urine output, the nurse notes a BUN and Creatine level below normal limits. The nurse correctly identifies the patient's nutritional status as what?
2 to 7 days after injury or surgery
When do symptoms of wound infections usually appear?
before starting a procedure
When do you prepare a patient for a dressing change?
immediately after initial injury
When does the hemostasis phase occur?
3 weeks after the injury (may continue for months or years)
When does the maturation phase begin?
Notify the primary health care provider or wound care specialist, as a different treatment modality and/or debridement may be necessary. Note: The presence of eschar in a pressure injury wound precludes staging the wound. The eschar must be removed for adequate pressure injury staging to be done. However, stable (dry, adherent, intact, without erythema or movement) eschar on pressure injuries on the heels serves as "the body's natural (biologic) cover" and should not be removed
When removing a patient's dressing, the assessment reveals eschar in the wound:
abdominal surgery obese or malnourished smoke tobacco use anticoagulants infected wounds excessive coughing, vomiting, straining
Who is at greater risk for dehiscence and evisceration
older adults spinal cord injuries traumatic brain injury neuromuscular disorder impaired sensory perception
Who is at-risk for pressure injuries?
b/c contaminations with fecal material is high
Why is the risk of infection increased for a surgical wound involving the intestines
To ensure collection of enough specimen as possible that is covering the wound bed.
Why should you rotate the swab several times over the wound bed for a wound culture?
sterile towels moistened with sterile 0.9% NSS.
With evisceration, what should you cover the area with?
cough or sneeze
With secondary intention, a patient could ______ or _______ and it could open up
appearance, odor, drainage, pain
Wound assessment involves inspection of:
Impending dehiscence
Wound edges appear pulled or separated. This indicates?
infection
Wound is swollen and deep red. It feels hot on palpation, and drainage is purulent. This indicates?
How do you measure urine output for an incontinent patient?
You weigh the absorbent pads
unstageable
a full-thickness loss where the true depth cannot be determined; may also involve deep tissue injury usually tunneling, necrosis, slough
Serosanguineous drainage
a mixture of serum and red blood cells. It is light pink to blood tinged.
Fistula formation
an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another. May be created purposefully, or as the result of an infection that has developed into an abscess. It > the risk for delayed healing, fluid and electrolyte imbalance
fistula
an abnormal passage from an internal organ to the skin or from one internal organ to another
For medications: ____________ increase motility and _______ decrease
antibiotics; narcotics
slows clotting factor down, causes increased bleeding
anticoagulants
_________, ____________, ___________ can cause diarrhea and constipation
anxiety, stress, fear
Each nephron consists of a complicated system of __________, _________, and ________.
arterioles, capillaries, and tubules
What foods may affect the odor of urine?
asparagus or onions
In a double lumen, one lumen is connected directly to the _____________ (inflated with sterile water) and the other is the lumen through with the urine _______
balloon; drains
Do you clamp the tube above or below the access port?
below
Secure the drainage bag _______ the level of the bladder
below
Bismuth subsalicylate (Pepto): effect on stool
black
Iron's effect on stool
black
-remains relaxed and stores urine until it is full -when filled to capacity, signals are sent to the brain
bladder
A smooth muscle sac that serves as a temporary reservoir for urine
bladder
If postvoid residual is greater than 100, it indicates
bladder is no emptying correcty
ischemia stoma means lack of______________
blood flow turns black, grey
What are abnormal constituents?
blood, pus, ova, mucus, foreign bodies
When auscultating the abdomen listen for: You want to note:
bowel sounds in all quadrants, systematic clockwise approach - Note frequency and character, audible click, and flatus (usually high pitched, gurgling, and soft)
Yellow stool is normal for a _________
breast fed infant
If slight resistance is met, as the patient to ___________ and ________ the catheter gently
breathe deeply; rotate
help to expel flatus and provide relief from gas distention (crampy, miserable, can't pass the gas) a lot of times given as tests that require gas. Those w gas end up with pain in their shoulder or in their colon
carminative enema
Highest risk for a UTI happens when.....
catheterizing someone
debridement
cleaning away devitalized tissue and foreign matter from a wound
normal turbidity of urine
clear or transcluent
large intestine from the anus to the ileocecal valve
colonoscopy
an opening into the colon that permits feces to exit through the stoma
colostomy
formed opening in the colon
colostomy
What are some nursing interventions r/t the 24-hour specimen?
communicate start time make sure everyone knows put a sign on the wall give multiple indicators
serous drainage
composed primarily of the clear, serous portion of the blood and from serous membranes. clear and watery.
Sanguineous drainage
consists of large numbers of red blood cells and looks like blood. Bright-red drainage is indicative of fresh bleeding darker drainage indicates older bleeding.
passage of dry, hard fecal material
constipation
If postvoid residual is about 75, what do you do
contact physician for a parameter and assess
For inspection of abdomen observe:
contour (flat, rounded, concave) any masses, scars, distention
A nurse is providing care for a febrile patient with pneumonia, what kind of urine would they have?
decreased and highly concentrated urine
Foods and beverages with high sodium cause reabsorption and retention of sodium and water which results in ______________________
decreased urine
For males, when advancing the catheter, ask the male to take ___________ and advance the catheter to the ___________ of the ports
deep breaths; "Y" level
emptying of the intestinal tract; synonym for bowel movement; increased by sitting
defecation
ischemia
deficiency of blood in a particular area
the total body loss of fluids that leads to the kidneys reabsorbing fluid - Concentrated and in decreased amount
dehydration
The three layers of the bladder make up the ________ muscle
detrusor
Remains relaxed to allow the bladder to store urine, and contracts during urination to release urine.
detrusor muscle
antacids with magnesium cause ___________
diarrhea
antibiotics cause _________ (what happens to the stool)
diarrhea
passage of more than 3 loose stools a day
diarrhea
Significant findings of the abdomen during inspection may include the presence of ____________ or _____________
distention (inflation) or protrusion (projection)
Alcohol produces a __________ effect resulting in _____________urine production.
diuretic; increased
Chronic wounds
do not progress through the normal sequence of repair normal healing time is delayed (> 30 days)
What position is the patient in for catheterization?
dorsal recumbent or Sims or lateral for females, if needed
Nephrons remove the ____________ product of metabolism (urea, creatine, and uric acid)
end
direct visualization of hollow organs of the body using an endoscope (a flexible, lighted tube)
endoscopy
introduction of solution into the lower bowel
enema
FUll-thickness
entire dermis is gone (exposed bone, tendon, or muscle)
eroded skin around stoma is likely cause by ___________
erosion from cutting the paper too wide, proper cleaning, allergic reaction,
local
factors that occur directly on the wound, not related to the wound itself
systematic
factors that occur throughout the body
collection in the rectum of hardened feces that cannot be passed
fecal impaction
excessive formation of gases in the gastrointestinal tract
flatulence
exudate
fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells
For a sigmoid colostomy, we will likely see _____ stool
formed
What is the consistency of feces in the colostomy bag?
formed
Bowel elimination r/t infants: Characteristics of stool and frequency change depend on _____________________
formula or breast feedings
Presence of glucose in urine
glycosuria
What color does Amitriptyline (used for depression) turn urine?
green or blue
antibiotics effect on stool (color?)
green-gray color
Concentrated urine (dehydrated) will have a __________ specific gravity
higher
A nurse is caring for a client with renal insufficiency. Which type of enema is contraindicated?
hypertonic bc it pulls water and electrolytes out of cells; it increases circulating phosphorus level (hyperphosphatemia)
What do you want to describe bowel sounds as?
hypoactive (indicate diminished bowel motility) hyperactive, absent for infrequent (signify the absence of bowel motility)
opening from the ileum of the small intestine
ileostomy
opening into the small intestine allows fecal content from the ileum to be eliminated through the stoma
ileostomy
Where is the stomach located?
in left upper portion of abdomen (LUQ)
Ineffective Coping may be r/t ______________________________
inability to accept permanent ostomy
This catheter remains in place and contains a balloon (can be double to triple lumen)
indwelling
Erythema indicates _______ and leads to ___________
inflammation; infection
diabetic ulcers
injury and underlying diabetic neuropathy (nerve damage), peripheral arterial disease, diabetic foot structure
•Gold standard (best way) for management of bladder-emptying dysfunctions and following surgical interventions. •Lower the risk of CAUTI ad complications.
intermittent catheter
When administering enemas, place patient in _____________
left-side lying position (sim) (knee-to-chest)
the less time in the intestine the more _________ the stool
liquid
For an ileostomy, we will likely see ______ in the stool
liquid feces; liquid, yellow, undigested food particles
hematoma
localized mass of usually clotted blood
Diluted urine (overhydration) will have a ___________ specific gravity
lower
Purulent drainage
made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
hemorrage
may occur from a slipped suture, a dislodged clot at the wound site, infection, or erosion of a blood vessel by a foreign body
A stoma that is ischemic is a ________________
medical emergency
provide medications that are absorbed through the mucosa
medicated
the patient voids and discards a small amount of urine continues voiding in a sterile specimen container removes container and continues voiding then discards the last amount
midstream or clean-catch
light brown stool indicates a diet high in ________
milk
symptoms of urge & stress incontinence are present, one type may predominate
mixed incontinence
For a descending colostomy, we will likely see _______ stool
more softly formed or a very thick liquid
For a transverse colostomy, we will likely see _______ stool
more thick brown liquid stool, occasionally mushy
Obtain a _____ cotton ball/swab for each stroke, continue to clean the other labial fold, then directly over the meatus.
new
In older adults, the diminished ability of the kidneys to concentrate urine may result in __________
nocturia
awakening at night to urinate
nocturia
Deep tissue pressure injury
nonblanchable purple or maroon discoloration of intact or nonintact skin. May be firm, mushy, or boggy feeling.
For an ileostomy, what is the nurse most concerned about?
nutrition, dehydration issues, vitamin supplements
Open wound
occurs from intentional or unintentional trauma. Incision and abrasion Skin surface is broken, and creates a portal of entry.
(most common type) to lubricate or soften stool at the end of the rectum so it can come out easier.
oil
What foods give a gas-producing effect?
onions cabbage beans cauliflower eggs
What color does Phenazopyridine (used for bladder spasms) turn urine?
orange
general term referring to an artificial opening; usually used to refer to an opening created for the excretion of body wastes
ostomy
What color does diuretics (dilutes urine) turn urine?
pale yellow
normal color for urine
pale yellow, straw-colored, or amber
If postvoid residual is 200 Ml, what does this mean?
patient has urinary retention due to enlarged prostate.
What color does anticoagulants turn urine?
pink or red
aspirin, anticoagulants effect on stool
pink to red to black stool
If urine is cloudy, what does that indicate?
presence of RBCs, WBCs, bacteria, vaginal discharge, sperm, prostatic fluid
nonsterile
pressure injuries are ___________ wounds
Deficient Fluid Volume may be r/t _______________
prolonged diarrhea
Impaired Skin Integrity may be r/t _____________, _________________
prolonged diarrhea, fecal incontinence
evisceration
protrusion of viscera through an incision
For a patient who is uncircumcised, make sure you...
pull the excessive skin back (and put it back when done)
Pus in urine
pyuria
Dark brown stools may result from
red meats; dark-green vegetables (darkens when standing)
erythema
redness of the skin
Bedridden patients have _____________ muscle tone
relaxed
infection
results when the pt's immune system fails to control the growth of microorganisms
From each kidney, urine is transported by _________ _____________ movements through the _____________ to the _________________
rhythmic wavelike; ureters to the urinary bladder
Administer enemas at ____________ temperature to _____________
room; minimize muscle contractions
If there is resistance when collecting a sterile specimen from a urinary diversion, what do you do?
rotate gently until catheter slides forward. (Never push)
use aseptic technique doesn't require sterile specimen collect by voiding in bedpan, urinal or hat avoid contamination w feces no tissue in sample, do not leave urine sit out for more than 1 hr
routine urinalysis
dehiscence
separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound
sigmoid colon, the rectum, and the anal canal
sigmoidoscopy
Introduce the enema solution ______ about ______ to ______ mins
slowly; 5 to 10
What does surgery and anesthesia do to the GI tract?
slows down Gi tract, Paralytic ileus (up to 3-5 days)- paralyzes
- Large diarrheal stools suggest a disorder in the ___________________ or ______________
small bowel or proximal colon
· 20 ft long (6 m) and 1 in. wide · Made up of duodenum, jejunum, and ileum · Secretes enzymes that digest proteins and carbohydrates · Digestive juices from liver and pancreas
small intestine
· Where most digestion occurs
small intestine
Hypertonic solutions (i.e. fleets-pulls water and electrolyte out of cells) are contraindicated in pt's whom _______
sodium retention is a problem renal impairment (causes severe hyperphosphatemia), reduced renal clearance dehydration (it shrinks cells)
maceration
softening through liquid; overhydration
· Hollow, j-shaped muscular organ · Stores food during eating, secretes digestive fluids, churns food to aid in digestion · Has a pyloric sphincter that controls movement of chyme to small intestine
stomach
If there is continues resistance when collecting a sterile specimen from a urinary diversion, what do you do?
stop the procedure
oval- or cone-shaped substance that is inserted into a body cavity and that melts at body temperature
suppository
sterile technique
surgical wounds that have dehisced
When palpating the abdomen you want to do it in a _________ manner. Note:
systematic - Note muscular resistance, tenderness, enlargement of organs, or masses - Regular nurses do not do deep palpation
What does the volume of stool depend on?
the amount the person eats
evisceration
the most serious complication of dehiscence. Occurs with abdominal incisions. The abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area
Dehiscence and evisceration
the most serious postoperative wound complications a medical emergency- treat like an open wound
When urine leaves the nephrons, it empties into what?
the pelvis of each kidney
Intentional wounds
the result of a planned invasive therapy or treatment. Purposefully created for therapeutic purposes, Edges are clean and bleeding is controlled, Wound made under (normally) sterile conditions with sterile supplies.
What is the bladder normally positioned below?
the symphysis pubis (cannot be palpated or percussed when empty)
eschar
thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur
exudate
this is the outward drainage and it forms the scab
a continuous unpredictable loss and we are not sure of the cause; trauma, surgery, physical abnormalities
total incontinence
What is metformin used for?
type 2 diabetes
When is the only time a sterile specimen can be collected from the bag?
upon initial insertion
black stool indicates
upper GI tract bleeding; or from iron
Hold the penis with slight __________ tension and ______________ to the patient's body. Use the dominant hand to pick up the lubricant syringe.
upward; perpendicular
A _________ is attached to each kidney
ureter
Tube that carries urine from the kidney to the bladder
ureter
transports urine from the bladder to the exterior of the body
urethra
A calibrated measuring device
urinary sheath
What can not voiding as frequently result in?
urinary stasis
forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure
valsalva maneuver
Physical Assessment of bladder: May be indicated in patients who are experiencing difficulty in _________ -distended and tender
voiding
What are the characteristics of stool?
volume color odor consistency shape constituents
Large volume (500-1000mL) are dangerous for patients with __________
weakened intestinal walls, such as bowel inflammation or infection
fluid and cells that escape from blood vessels and deposited in or on tissue surfaces
what is the exudate composed of?
When do you empty an ostomy bag?
when it is 1/3 to 1/2 full
Partial thickness
where all or a portion of the dermis is intact
antacids effect on stool
white discoloration or speckling in stool
Negative fecal occult blood test
yellow, brownish
How do you measure urine output for a patient with an indwelling catheter?
you used a calibrated measuring device and collect from the urine collection bag
Nursing responsibilities for indirect visual studies: Before
· Adhere to diet restrictions · Confirm pt. can adhere to bowel prep · Confirm pt does not have allergies to iodine, IV contrast, or shellfish · Assess for renal impairment ·Abdominal CT: - Discontinue Metformin at the time of the study)contrast induced renal insufficiency)
Nursing responsibilities for before a direct visualization study
· Adhere to direct restrictions · Confirm patient can tolerate ordered bowel prep
Nursing responsibilities for after a direct visualization study: Esophagogastroduodenoscopy (EGD)
· Check vital signs · Monitor signs for perforation (there could be bleeding) - Withhold foods until gag reflex returns (They spray with a numbing medication; so you can't give them foods or drinks until they have a gag reflex)
Nursing responsibilities for after a direct visualization study: Colonoscopy
· Check vital signs · Monitor signs for perforation (there could be bleeding) - Advance diet as tolerated, make sure colon is empty (you want to introduce more soft food slowly at first) - Patient may experience flatulence or gas pains b/c air was used
Nursing responsibilities for after a direct visualization study: · Sigmoidoscopy:
· Check vital signs · Monitor signs for perforation (there could be bleeding) - Monitor for rectal bleeding if biopsy was taken - Patient may experience flatulence or gas pains b/c air was used
Nursing responsibilities for indirect visual studies: After
· Check vital signs · Resume diet, unless contraindicated Abdominal CT - Hold Metformin for 48 hours after the procedure (window for contrast induced renal insufficiency to occur)
outer 1 in
· Consider the _________ of a sterile field to be contaminated.
incision
· Cutting or sharp instrument; wound edges in close approximation and aligned
LPN/LVN/vocational nurses
· Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to?
Outcome identification and planning Goals:
· Maintain or restore optimum function r/t bowel elimination (w/out medications or enemas) · Alleviate symptoms or side effects of disease or treatment · prevent complications (i.e.don't want to have constipation to be an issue= may have a bowel blockage)
How do you collect stool?
· Medical aseptic technique is imperative. · Hand hygiene, before and after glove use, is essential. · Needs to have 1 inch of stool to run test; is liquid need 15-30 ml · Wear disposable gloves. · Do not contaminate outside of container with stool. · Obtain stool and package, label with name, date and time, type of specimen being collected, and transport according to agency policy.
Patient guidelines for stool collection:
· Patients may need specific instructions about collecting a stool specimen. · Void first, because the laboratory study may be inaccurate if the stool contains urine. · Defecate into the required container, such as clean or sterile bedpan or the bedside commode (depending on the specimen required), rather than the toilet, because the water in the toilet bowl may affect the analysis results. · Do not place toilet tissue in the bedpan or specimen container because contents in the paper may influence laboratory results. · Avoid contact with soaps, detergents, and disinfectants as these may affect test results. · Notify the nurse when the specimen is available, so that it may be collected and transported to the laboratory as required.
Individuals at high risk for constipation:
· Patients on bedrest and/or taking constipating medicines are at extremely high risk · Patients with reduced fluids or bulk in their diet (should have 2,000 to 3,000 mL or minimum 1.8 to 2.4 L), (should have 20-35 g of fiber for good bulk; less than 20 is not enough) · Patients who are depressed, any person with high emotion (depressed, high anxiety, afraid) · Patients with central nervous system disease (lesions, tumors, spinal cord injury) or local lesions that cause pain while defecating
Individuals at risk for constipation:
· Patients on bedrest taking constipating medicines (iron, analgesics, narcotics) · Patients with reduced fluids or bulk (fiber) in their diet · Patients who are depressed, any person with high emotion (depressed, anxiety, afraid) · Patients with central nervous system disease (Parkinson, MS, muscular dystrophy, lesions, tumors, spinal cord injury) or local lesions that cause pain
Physical assessment of the rectum
· Perform a superficial examination each time you wash a patient's anal area or assist with bowel evacuation · Physicians or advanced practice professionals typically conduct physical assessment of rectum and anus · Inspection: - Lesions, ulcers, fissures (linear break on the margin of the anus), inflammation, and external hemorrhoids - Ask the pt. to bear down - Inspect perineal area for skin irritation secondary to diarrhea or incontinence
What are the 4 warning signs of colon cancer?
· Rectal bleeding · Change in the bowel elimination pattern · Blood in the stool · Cramping pain in the lower abdomen
Signs & symptoms of infection with Foley:
· Strong odor to urine · Cloudy urine · Irritation or burning at meatus · Patient fever or chills
laceration
· Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
abrasion
·Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded
Pressure injury (ulcer)
·Localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is r/t use of a medical device - may be acute or chronic most occur in older adults
drainage
·The inflammatory response results in formation of exudate which then drains from the wound
Closed wound
·results from a blow, force, or strain caused by trauma such as a fall, an assault, or car crash. Skin surface is not broken, but soft tissue is damaged underneath the epidermis Internal injury and hemorrhage may occur
What is an appropriate size for catheterization?
•14F, 5-mL or 10-mL balloon is usually appropriate unless ordered otherwise.
Wound healing
•A process of tissue response to injury. •Normally occurs without assistance. •Occurs by primary, secondary, or tertiary intention.
Hemostasis Phase
•Blood vessels constrict and clotting begins through platelet activation. •Same blood vessels then dilate, plasma and blood components leak into the area. •Exudate results causing pain and swelling. •Clot loses fluid and a hard scab is formed to protect the injury.
Maturation phase
•Collagen is restructured and scar tissue is formed. •Scar tissue is less elastic than normal tissue (becomes flat)
An indwelling catheter remains in place for:
•Continuous drainage. •Gradual decompression of an overdistended bladder. •Continuous or intermittent bladder irrigation. •Dwell inside body for a length of time
Diabetic Ulcer (chronic condition)
•Cuts and sores that do not heal. •Lesions on the lower extremities that ulcerate and become necrotic. •Recurrent bacterial and fungal infections.
How do you prepare a patient for catheterization?
•Explain the procedure and the reason for it. •Inform what to expect (sensation of pressure and some discomfort). •Place in dorsal recumbent position on a solid surface. •Sims' or lateral is the alternate position for females
Patient teaching for ostomies
•Explain the reason for bowel diversion and the rationale for treatment •Demonstrate self-care behaviors that efficetively manage the ostomy •Describe follow-up care and existing support resources •Report where supplies may be obtained in the community •Verbalize related fears and concerns (so they can deal with them) •Demonstrate a positive body image
Physical Assessment of skin integrity •Assessment may be indicated for patients experiencing a disturbance in:
•Hydration •excretion of body wastes •Incontinence -can lead to skin breakdown or maceration •Color, texture, and turgor
Diagnosing Urinary Function as the Etiology (cause)
•Impaired Skin Integrity •Disturbed Body Image •Toileting Self-Care Deficit
Diagnosing Urinary Function as the problem
•Impaired Urinary Elimination •Stress Urinary Incontinence •Risk for Urge Urinary Incontinence
How do you obtain a sterile specimen?
•Intermittent catheterization •Have to draw directly from the catheter line= specimen port (not in the bag bc it has bacteria)
For all collected urine specimens, what should the nurse do?
•Label with patient's name - etc. (as per organization's policy). •Do not leave standing at room temperature for a long period of time. •Must be received in the lab and refrigerated within 1 hour of collection
outcome identification and planning Goal:
•Maintain or restore optimum function. •Alleviate symptoms or side effects of disease or treatment. •Prevent complications. Such as UTI or skin breakdown; fluid and electrolyte imbalance, fever
Implementing Focus is on:
•Maintaining and promoting normal urinary patterns. •Improving or controlling urinary incontinence. •Preventing potential problems associated with bladder catheterization. •Assisting with care of urinary diversions.
Proliferation phase
•New tissue is built to fill the wound space, through the action of fibroblasts. •New tissue is referred to as granulation tissue (vascular and bleeds easily). •Granulation tissue forms the foundation for scar tissue development.
Why do we need to use catheters?
•Relieving urinary retention. •Obtain a sterile specimen. •Accurate measurement of urinary output in a critically ill patient. •Assist in healing open sacral or perineal wounds in incontinent patients. •Provide improved comfort for end-of-life care.
What equipment is used for catheterization?
•Sterile pre-packaged tray (same for males and females). •Gauges range from 8 (on child) to 26F. •Smallest appropriate size should be used to prevent CAUTIs.
•Catheter-Associated Harm:
•Urinary Tract Infection (UTI) •Trauma •Pain and bladder spasm (can medicate for it with pyridium) •Sepsis (systemic- throughout the blood stream)
Nursing Care is Considered Effective When the patient is able to:
•Verbalize the relationship among bowel elimination and nutrition, fluid intake, exercise, and stress management •Develop a plan to modify any factors that contribute to current bowel problems •Promote bowel functioning as appropriate •Provide care for bowel diversion and know when to notify primary care provider
◦Maintain skin integrity ◦Demonstrate evidence of wound healing ◦Remain free of signs and symptoms of infection
◦Appropriate outcomes include - The patient will:
What diseases are associated with renal problems?
◦Congenital urinary tract abnormalities ◦Polycystic kidney disease ◦Urinary tract infection ◦Urinary calculi (stone) ◦Hypertension ◦Diabetes ◦Gout ◦Connective tissue disorders ◦Central nervous system disorders
pain
◦Determines the status of the wound ◦Identifies barriers to the healing process ◦Identifies signs of complication
Older adults may experience what r/t urination?
◦Increased urinary frequency related to decreased bladder muscle tone. ◦Urine retention (and increased risk for UTIs) due to decreased balder contractility. ◦Urinary incontinence associated with structural changes in the bladder and urethra.
Albumin level <3.2 g/dL (normal 3.4 to 5.4) Hemoglobin A1c >6.5% (normal <6%) Glucose >126 mg/dL (fasting normal <110 mg/dL)
◦Laboratory criteria that indicates a patient is nutritionally at risk for developing a pressure injury includes or compromised wound healing: Albumin level Hemoglobin A!c Glucose
