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Holly
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2011-02-06 20:51:57
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Fundamentals III
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  1. Charecteristics of Urine
    • - Volume: Normal - 500-3000mL/day
    • (50mL/hr)
    • Abnormal -less than 400mL/day
    • (30mL/hr)
    • - Color: Normal - light yellow
    • Abnormal - dark yellow, dark
    • amber, brown,
    • reddish brown
    • - Clarity: Normal - clear
    • Abnormal - cloudy
    • - Odor: Normal - faintly aromatic
    • Abnormal - foul, strong,
    • pungent odor
  2. Common Urine Specimens
    • - voided specimen
    • - clean-catch specimen
    • - catheter specimen
    • - 24-hour specimen
  3. Voided Specimen
    Nonsterile; most common and easiest; void into a clean container then transferred by a nurse into specimen cup, labeled, and sent to the lab

    Urine can only stay open to air for 15 minutes; within 15 minutes urine must be placed on ice, in the refridgerator, or taken to the lab
  4. Clean-Catch Specimen
    • Sterile; AKA mid-stream urine specimen; cleanse the urinary meatus and surrounding tissue; urinate first few drops into the toilet then hold urine and urinate the rest into a sterile cup
    • DO NOT TOUCH THE INSIDE OF THE CUP
    • label and send to the lab
  5. Lavage
    irrigating the stomach; uses an orogastric tube; typically done in an emergency situation such as poisons; administer normal saline then pull it back out with contents quickly

    Uses an orogastric tube called Ewald tube
  6. Compression or Tamponade
    Uses a special nasogastric tube; inflating a balloon to stop active bleeding; pressure

    Uses a nasogastric tube; sengstaken-blakemore
  7. Decompression
    Removing gas and liquid contents from the stomach or bowel

    • Uses a nasogastric or nasojujenum tube:
    • Salem Sump Tube
    • Maxter, Cantor, or Miller-Abbott Tubes
    • Transiabdominal Gastrostomy
  8. Ewald Tube
    An orogastric tube and its purpose is for lavage

    Single lumen
  9. Levin Tube
    a nasogastric tube and its purpose is gavig and obtaining gastric samples

    Single lumen
  10. Salem Sump Tube
    It is a nasogastric tube and its purpose is for decompression

    Double lumen which has an airvent that prevents tearing of the stomach wall
  11. Sengstaken-Blakemore Tube
    a nasogastric tube and its purpose is for compression or tamponade

    Triple lumen; 2 lumens lead to balloons in the esophagus and stomach and the thirs removes gastric drainage
  12. Keofeed Tube
    Nasointestinal (or nasojujenum or NJ) tube and its purpose is for intestinal gavage; feeds directly into the intestine

    Single lumen
  13. Maxtor, Cantor, or Miller-Abbott Tubes
    Nasointestinal (or nasojujenum or NJ) tube and its purpose is for intestinal decompression (which removes gas and intestinal contents)

    Double lumen
  14. Gastrostomy
    Transabdominal tueb and its purpose is for gavage

    Inserted surgically through abdominal tissue; placed into the stomach
  15. Jenjunostomy
    Transabdominal tube and its purpose is for gavage

    Inserted surgically through abdominal tissue; placed into the jejunum of the small intestine
  16. Percutaneous Endoscopic Gastrostomy Tube (PEG)
    Transabdominal tube and its purpose is for gavage

    Placed by endoscopic procedure into the stomach; anchored with internal and external crossbars called bumbers
  17. Gastric Decompression
    Continuous or intermittent suction; usually double lumen salem sump tube used; low pressure 40-60mm Hg; NPO can only receive isotonic IV fluids; nothing goes into the tube unless the tube becomes obstructed; monitor K+, Na, and glucose levels daily due to risk for fluid and electrolyte imbalances
  18. Catheter Specimens
    Sterile; collected from indwelling (foley) catheter by inserting a needle into a port on the catheter; if patient doesn't already have a catheter then a straight catheter would be inserted to obtain the sample then immediately removed
  19. 24-Hour Specimen
    • Nonsterile
    • A collection of all urine produced in a full 24 hour period; first sample obtained is discarded; every sample obtained after the first void is stored on ice to prevent urine breakdown; one last sample is obtained at the end of the 24 hours and all the urine is sent to the lab

    if any urine is disposed of within the 24 hours then the entire test must be started again from the beginning
  20. Hematuria
    • Abnormal urine charateristic
    • Urine containing blood
  21. Pyuria
    • Abnormal urine characteristic
    • Urine containing pus
  22. Proteinuria
    • Abnormal urine characteristic
    • Urine containing plasma proteins
  23. Albuminuria
    • Abnormal urine characteristic
    • Urine containing albumin, a plasma protein
  24. Glycosuria
    • Abnormal urine characteristic
    • Urine containing glucose
  25. Ketonuria
    • Abnormal urine characteristic
    • Urine containing ketones; has a sweet or fruity smell
  26. Abnormal Urinary Elimination Patterns
    • - Anuria
    • - Oliguria
    • - Urinary Stasis
    • - Polyuria
    • - Urinary Retention
    • - Residual Urine
    • - Nocturia
    • - Dysuria
    • - Frequency
    • - Urgency
    • - Urinary Incontinence
  27. Anuria
    Absence of urine or volume of 100mL or less in 24 hrs; can occur as a result of renal failure or can be urine retention in the bladder
  28. Urinary Retention
    Urine is produced but not released from the bladder; can lead to infection

    S/S include: distended bladder, bladder tender to palpation, or decreased or absent urine output

    Causes urinary stasis
  29. Oliguria
    Urine output is less than 400mL per 24 hours; indicates inadequate elimination of urine; can be caused by dehydration or by residual urine
  30. Residual Urine
    More than 50mL of urine that remains in the bladder after voiding; can lead to infection
  31. Urinary Stasis
    • Lack of movement of urine which leads to infection
    • Microorganisms grow when urine sits still for long periods of time
  32. Polyuria
    Greater than normal urinary volume (>3000mL) caused by diaretics, diabetes mellitus, or diabetes insipidus
  33. Retention Catheters
    Sterile hollow tubes inserted into the bladder and left in place usually for a long period of time; also called an indwelling catheter or foley catheter; catheter is held in the bladder by a balloon inflated with sterile water (10mL or 30mL.
  34. Straight Catheter
    Sterile hollow tubes inserted into the bladder, but not left in place; used for collecting urine specimens and emptying bladder of residual urine.
  35. External Catheter (Condom Catheter)
    Urine cellecting device applied around the penis; does not enter the urethra; cleanse the penis before applying the adhesive strips in a spiral pattern and ensure a tight seal around the penis with the catheter.
  36. Types of Catheters
    • - External Catheter
    • - Straight Catheter
    • - Retention Catheter
  37. Reasonings for Catherization
    • * - Keeps incontinent patients dry when risk for skin breakdown increases
    • - Relieves bladder distention when patients void
    • - Assess fluid balance accurately
    • * - Keep the bladder from becoming distended during procedures such as surgery
    • - Measures the residual urine
    • - Obtaining sterile urine specimens
    • - Instilling medication within the bladder
  38. Urinary Catheterization
    Inserting a sterile hollow tube through the urinary meatus into the bladder

    Introduces an additional portal of entry for microorganisms
  39. Overflow
    Patient is continent other than leakage of residual urine after urination; common with patients with enlarged prostate
  40. Total
    No pattern to incontinent episodes
  41. Functional
    Inability to control the bladdere due to inaccessibility to toileting

    (nonambulatory patients, nurses not responding quickly to call-lights, nurses not offering toileting every 2 hours
  42. Reflex
    The bladder fills with urine, the stretch receptors extend and immediately release without any feeling of the need to void
  43. Urge
    Patient will feel the urge to void but will not be able to hold the urine; common with UTI or patients who have recently had an indwelling catheter removed
  44. Stress
    Lots of small amounts of urine when intraabdominal pressure rises; common after women give birth

    (sneezing, laughing, coughing, lifting etc.)
  45. Urinary Incontinence Types
    • - Stress
    • - Urge
    • - Reflex
    • - Functional
    • - Total
    • - Overflow
  46. Urinary Incontinence
    Inability to control urine elimination; increased risk of skin breakdown

    (moisture and pressure = skin breakdown)

    • - offer toileting at least every 2 hours
    • - apply barrier cream
    • - allow patients to wear briefs during
    • the daytime only
    • (briefs speed up the breakdown
    • process)
  47. Urgency
    Strong feeling that urine must be eliminated quickly
  48. Frequency
    Need to urinate often
  49. Dysuria
    Difficult or uncomfortable voiding; often indicative of infection
  50. Nocturia
    Nighttime urination; common in older males due to an enlargement of the prostate
  51. Tube Placement
    based on where it enters and ends in the body
  52. Acid Content of the Stomach
    1-4 on a pH scale
  53. Orogastric Intubation
    (OG Tube)
    Insertion of a tube through the mouth into the stomach
  54. Nasointestinal Tube Management
    • Tube measurement = NEX plus 9 inches, then measure tube past the last mark and document (check measurement before each feeding); after tube placement is verified in the stomach turn patient onto right side for 1 hour to promote movement through the plyoric valve; stimulate peristalsis to move tube forward: if able to ambulate then ambulate to stimulate, if unable then massage the abdomen;
    • ABDOMINAL X-RAY IS THE ONLY WAY TO VERIFY PLACEMENT!!
  55. Preintubation Assessments
    Current weight, level of consciousness, nasal inspection (check for the presence of ployps or deviated septum), ability to swallow, abdominal assessment (look then listen, then feel)
  56. NEX Measurement
    • Length from the nore to the earlobe to the xiphoid process.
    • First mark - should be marked at the distance from the nose to the earlobe; indicates the distance to the oro-pharynx (back of the throat but ABOVE where the gag reflex is stimulated.
    • Second mark - should be marked at the point where the tube reaches the xiphoid process, indicating the depth required to reach the stomach
  57. Nasogastric Tube Insertion
    Position patient in high Fowler's position with head at a 30 degree agnle and patients neck hyperextended looking towards the ceiling, drape patients with a towel, don gloves and lubricate 6-8 inches or to the first mark with only water soluable lubricant, slowly insert tube to first mark and inspect mouth to make sure you see the tube in the back of the throat, lower chin to chect and instruct patient to take sips of water if able, advance tube 3-5 inches each time the patient swallows until the second mark is reached, secure tube and verify placement in at least two different ways
  58. Checking Tube Placement
    • Aspirating Fluid - 50-60 mL, draw out a small amount of fluid, fluid should be brownish, greenish, yellowish which indicates that the tube is in the stomach
    • Auscultate the Abdomen - By instilling 10-20mL or air while listening with a stethoscope in the LUQ for a swooshing sound
    • Test pH of Gastric Content - should be 1-4 but could be 4-5.5 if patient is on antacid medications
    • X-Ray - to verify placement = most accurate but least cost effective
  59. Transabdominal Tube Management
    Assess inserttion site every 24 hours for redness, irritation, and skin breakdown; apply skin barrier if needed; asses fro drainage by pressing on the skin at the base of the tube; clean the skin with 1/2 strength hydrogen peroxide diluted with saline for the first week then after first week use plain soap and water; rotate direction of bumper 90 degrees every day to prevent skin breakdown associated with pressure; make sure the tube is not kinked or the skin is not stretched
  60. Formula Considerations
    Is determines by:

    • - client's weight
    • - nutritional status
    • - concurrent medical conditions
    • - projected length of therapy

    • decreased weight = increased kcalorie
    • decreased albumin = increased nitrogen
    • (protein)
    • long therapy = decreased kcalorie
    • short therapy = increased kcalorie
  61. Intermittent Feeding
    Gradual instillation of liquid nourishment 4-6 times per day in 30-60 minutes; 250-400mL of formula through feeding bag: prime tube then set drop factor for running an hour; bag gets changed every 24 hours
  62. Cyclic Feeding
    Continuous instillation of liquid nourishment for 8-12 hours followed by a 12-16 hour pause (used to wean patients from tube feeds or maintain nourishment during sleep); feedings done at night and patient eats during the day
  63. Nursing Management of Tubes
    • Responsibilities:
    • - maintaining tube patency ; flush with 30mL (for the intestine use sterile water), check for signs of obstruction, kink in tubing, or nonfunctioning suction machine (nausea, vomiting, abdominal distention), flush every 4 hours
    • - clear obstruction: MD oder needed to irrigate, use water to try and loosen up the obstruction (meat tenderizer or pancreatic enzyme if water not effective)
    • - provide hydration: inadequate hydration = diarrhea, vomiting, constipation
    • - prompt resport of feeding problems: diarrhea, vomiting, or constipation
  64. Dumping Syndrome
    weakness, dizziness, sweating, and nausea caused by an overload of calories in the small intestine
  65. Gastric Residual
    Must be measured and refed before administering any feedings

    • greater than 100mL, refeed residual and hold feeding for one hour and ambulate if possible
    • greater than 100mL after one hour call the doctor
    • less than 100mL refeed residual and administer feeding as usual

    Formula can only be kept open to air for 4 hours or less and can only be kept refrigerated for up to 24 hours (date, time, and intial formaula after opening it), pull out of the fridge 15 minutes prior to feeding
  66. Patient Teaching for Home
    Management of Tubes
    • - Place to obtain equipment and formula
    • - The amount and schedule for each feeding and flush, using household measurements
    • - Guidelines for delaying a feeding
    • - Special instructions for skin, nose, or stomal care, including frequency and types of products to use
    • - Problems to report: weight loss, decreased urination, weakness, diarrhea, nausea, vominting, and breathing difficulties
    • - Names and numbers of people to call for questions
    • - Date, time, and place for continued medical follow-up
  67. Bolus Feeding
    Instillation of liquid nourishment 4-6 times per day in less than 30 minutes approximately 250-400mL of formula; must remain in high fowlers and 30 degree elevation for a few hours after feeding
  68. Assessment for Tube Discontinuation
    (assess before discontinuation)
    Check the doctors orders, bowels must be working, listen for bowel sounds (5-24 sounds), if tube is fro feeding check patients ability to swallow, check current weight, check albumin levels, check patients willingness to eat and ability to sustain nutrition
  69. Esophageal Sphincter Dilation
    Dilation = risk for reflux = risk for aspiration

    Head of bed much be 30 degrees or higher
  70. Sphincter
    Allows food to go down but then closes off and doesn't allow food to come back up
  71. Risk for Aspiration
    Place patient in high fowlers position with a 30-45 degree head elevation
  72. Aspiration
    Anytime food or fluid enter the airways
  73. Nasointestinal Intubation
    Insertion of a tube through the nose into the small intestine; about 9 inches past the NEX measurement
  74. Nasogastric Intubation
    Insertion of a tube through the nose into the stomach
  75. Continuous Feeding
    Instillation of liquid nutrition without interruption, administered at a rate of approximately 1.5mL per minute; slow rate; MUST be ina high fowlers position with a 30 degree head elevation; if you have to lay the patient flat at anytime, pause the pump for 15 minutes first.
  76. Transabdominal Intubation
    Artificial opening into the stomach or small intestine

    Gastrostomy (stomach), Jejunostomy (small intestine), and PEG Tubes
  77. Insertion of a Foley Catheter
    (Male)
    Insert catheter 6-8 inches then urine should be visually flowing through the catheter tubing; continue to progress the catheter to the Y-port or until resistance is met; inflate the balloon with either 10-30mL of water; gently pull back on the catheter until resistance is felt; if patient indicates pain with balloon inflation, that means the balloon is still in the urethra - deflate and progress further; if early resistance could mean enlarged prostate
  78. Insertion of a Foley Catheter
    (Female)
    Insert catheter 2-3 inches through the urinary meatus then urine should be visually flowing through the catheter tubing; progress another 1/2 - 1 inch; inflate balloon 10-30mL of water; gently pull back on the catheter until resistance is felt; if catheter accidently inserts into vagina, leave catheter in place while placing a different catheter in the meatus; if pain is present with inflation then the balloon is still in the urethra - deflate and progress further
  79. Nursing Responsibilities With a Foley Catheter
    • - Insert catheter utilizing steril technique
    • - Secure catheter to leg band or tape (prevents pulling tube)
    • - Position urine bag to promote gravity drainage
    • - Irrigate catheter as needed per MD /order with sterile solution to keep catheter patent
    • (insert 30-60mL of NSS into catheter and allow it to flow back out; repeat until urine flows free of debris)
    • - Encourage fluids to decrease risk of UTI
    • - Provide peri-care and foley-care to decrease the risk of UTI
    • - Remove catheter per MD order and provide and provide patient education
  80. Catheter Removal
    • - No assesment before catheter removal
    • - Assessment with urinary catheter remaoval takes place 4 hours after removing
    • * - If patient does not void within 4 hours after removal MD needs to be called and notified
    • - Encourage Fluids
    • - Provide a hat/urinal to collect first void
    • - Warn patient that discomfort with the first void is a normal finding
  81. Urinary Diversions
    • - Ileal Conduit (long term) and Cutaneous Ureterostomy (short term)
    • - Urostomy: urinary diversion that discharges urine from an opening on the abdomen
    • - Assess peri-stomal skin for signs of skin breakdown
    • - Keep peristomal skin dry by ensuring a good seal between the urostomy appliance and the skin
    • - Apply skin barrier products to decrease skin breakdown
  82. Medications
    Chemical substances that change a body function; nurses should be thoroughly knowledgeable about a drug before administering; cannot be administered without an order
  83. Medication Knowledge
    • Nurses should know:
    • - Action
    • - Safe dose ranges
    • - Side effects
    • - Adverse reactions
    • - Special consideration
  84. Medication Order
    Lists the drug name and direstions for its administration

    Components include:

    • - clients name
    • - date and time the order is written
    • - drug name
    • - dose to be adminstered
    • - route of adminsitration
    • - frequency of administration
    • - signature of the person ordering the drug
  85. Telephone Medication Order
    • - the nurse must write the order directly onto the physicians order form
    • - nurse should perform repeat and verified after wrinting the order
    • - nurse writes T.O. after the order to signify that it is a telephone order
    • - the nurse signs their own name and then prints the prescribers name
  86. Drug Name
    The trade and generic are the same medication (exception is some psychiatric drugs); the binder could be different but the inside medication components are the same; generic or Trade may be given unless the prescriber specifies "tade name only' on the order
  87. Drug Dose
    Drug doses are generally ordered in weights; nurses do not weigh medications instead nurses use the D over H times Q formula to convert the weight to tabs or mLs
  88. Oral Route
    • - eneteric coated tablets
    • - scored tablet
    • - sustained release tablets
    • - liquid
  89. Enteric Coated Tablets
    Solid drug covered by a susbstance that dissolves beyond the stomach to protect it from irritation; should not be cut or crushed; medicine will not break down unitl in the intestine and past the stomach; written as EC on medication order; completely changes the drug
  90. Scored Tablet
    Solid drug manufactured with a groove in the center and is convenient when only part of a tablet is needed; best to use pill cutter than breaking pill manually to ensure you have the same size and same dose everyday
  91. Sustained Release
    • Drug that dissolves at time intervals and should never be opened, cut, or crushed; call doctor if patient had difficulty swallowing; SR = sustained release,
    • CR = controlled release, LA = long acting, XR = extended release; completely changes the drug
  92. Liquid
    Drug in liquid form (elixirs, syrups, suspensions); best method for deliverying medications through gastrointestinal tubes; administered in calibrated cups, with droppers or syringes, or with a dosing spoon
  93. Frequency of Administration
    • STAT = now
    • Daily = everyday
    • BID = twice a day
    • TID = 3 times day
    • QID = 4 times a day
    • QH = every hour
    • Q4H = every 4 hours
    • Q6H PRN = every 4 hours as needed
    • QAC and HS = before meals and bedtime
  94. Medication Administration Record
    (MAR)
    • An up-to-date record of all active medication orders for a client; ensures timely and safe medication administration
    • Documentation include:
    • - intials next to the time the medication was given
    • - signature
    • - title
    • - intials of each nurse who administered medications
    • (don't document until medication is given)
  95. Methods of Supplying Medications
    • - Individual; supply: container with enough of the prescribed drug for several days or weeks
    • - Unit dose: self contained packet that holds one tablet or capsule (single dose)
    • - Stock supply: stored drugs which remain on the nursing unit in case of an emergency so the nurse can give them without delay; still needs a doctors order even with over-the-counter medications
  96. Narcotics
    Controlled substances regulated by law; kept in a double locked or 2 key system; nurses must keep accurate count of each narcotic used; must count narcotics at the beginning and end of every shift (narc counts); if a nurse disposes of a narcotic, another nurse must witness the waste
  97. Medication Administration: Avoiding Errors
    • - 5 rights of medication administration
    • - calculating drug doses accurately
    • - preparing medications carefully
    • - recording (documenting) their administration
    • * Safety is the main concern in medication administration *
  98. Five Rights of Medication Administration
    • - right client
    • - right drug
    • - right dose
    • - right route
    • - right time
    • * Nurses must check the 5 rights three times before administering
    • Check 1 - at the cart as medications are being pulled
    • Check 2 - at the chart before entering patients room
    • Check 3 - * at the clients bedside; do not take medications out of their packages until your in the patients room*
  99. Medication Administration Via Gastro-Intestinal Tubes
    (When the tube is used for feeding)
    Obtain medication in liquid for if possible; if not then crush tablets finely and dilute in 10-30mL of warm water per tablet (seperate); verify tube placement; flush tube with 30mL of water before administration; administer one medication at a time using a 50-60mL piston syringe; insert 10-30mL of water between each medication; after all meds are administered flush tube with 30mL of water; if medications can't be given with food pause the pump 30 minutes prior to and after giving
  100. Medication Administration Via Gastro-Intestinal Tubes
    (When the tube is used for decompression)
    Same as for administering via tube for feeding except isotonic solutions must be used for diluting medications and flushing tube; turn off suction machine, administration the same as for tube feeding, then leave suction off for 30 minutes after drug administration
  101. Documentation for Withholding A Medication
    If a nursse withholds a medication he/she documents its omission according to agency policy (must notify doctor if withheld); circle the time of administration if the medication is withheld; reason for omission is documented in the comment section in the client's record
  102. Procedure for Medication Errors
    • 1) Check the client's condition immediately after medication error is recognized and note any adverse reactions; inform patient of error
    • 2) Report the error to the prescriber and your supervisor
    • 3) You and your supervisor will fill out an incident report which is not part of a clients record; very factual reports
  103. Premedication Administration Procedures
    • - Place patient at a 30 degree head elevation or higher prior to medication to prevent aspiration
    • - Know the patients swallowing ability
    • - When receiving shift report ascertain how your patient takes their oral medications; moisten patients mouth before have them swallow meds
  104. Overview of Urinary Elimination
    • - Process of releasing excess fluid and metabolic wastes
    • - Consequences of urinary elimination can be life threatening
    • - normal urination is 1200mL or more per day (50mL/hr average)
    • - bladder distends with approxiamtely 150- 300mL of urine when the need to urinate becomes apparent
    • - distention causes increased fluid pressure, stimulating stretch receptors in the bladder wall and creating a desire to empty
  105. Urinary Elimination Starts:
    Starts at the kidneys. the kidneys act as the body's filter, then urine goes to the bladder which acts as the body's holding tank

    --> kidney into the urethra --> bladder out through the urethra
  106. Infection (UTI)
    Normal volumes, dark yellow or dark amber in color, cloudy urine, foul offensive strong odor (kind of like ammonia)

    • Other signs and symptoms:
    • pockets of pus, painful urination, and urgency and frequency
  107. Dehydration
    Decreased volume (<50mL), dark yellow or dark amber in color, clear not cloudy, strong urine odor
  108. Nasogastric Tube Management
    • - insertion (With doctors order)
    • - maintaining tube patency (flush with 30mL of water)
    • - implementing the prescribed use
    • - removing the tube when it has accomplished its therapeutic purpose (must assess first before removing)
  109. Gavage
    • Providing nourishment - tube feeding
    • Uses a nasogastric tube: Levin tube
    • Also a nasointestinal tube: Keofeed

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