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A tube used to drain or inject fluid through a body opening
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A tube used to drain or inject fluid through a body opening
Difficult or painful urination
the person has bladder control but cannot use the toilet in time. Immobility, restrains, unanswered signal lights, signal not in reach, not knowing where signal or bathroom is, difficulty removing clothing, confusion & disorientation are all causes
Frequent urination at night
scant amount of urine; less than 500 mL in 24 hours
Urine leaks when the bladder is too full
Abnormally large volume of urine
the loss of urine at predictable intervals when the bladder is full. Person does not feel need to void, nervous systemdisorders and ijuries are common causes
unrine loss occurs when involuntary pressure is put on the bladder by coughing or laughing or sneezing or lifting or straining. Leaks less 50ml, dribbles
Urine is lost in response to a sudden, urgent need to void; the person cannot get to a toilet in time, urinary frequency, urgency, night-time voiding are common
voiding at frequent intervals
The loss of bladder control, pride, diginty, self esteem are affected. Skin irritation, irritation, infection, pressure ulcers are all risks. Conidition is beyond persons control
the need to void at once
the process of emptying urine from the bladder, also known as micturition, voiding, and, more rarely, emiction, is the process of disposing urine from the urinary bladder through the urethra to the outside of the body
normal urination production
1500ml = 3pints, effected by age, disease, kinds of fluids ingested, dietry salt & drugs.
tea coffee, drugs, alcohol
salt cause water retention
rule for elimination
medical asepsis, standard & blood precautions, fluids Per care plan. Follow persons routine per care plan, provide commode, pan, urinal promptly on signal and give privacy.
Keep them warm & covered, run water to stimulate, signal light & TP in reach, stay near-by, dont rush, assist with cleaning person including hands
color, clarity, oder, amount, & particles report: dysuria, hematuria, oliguria, polyuria, frequency, urgency, incontinence
fracture bed pans
skinny and for persons with limited motion: in cast, traction, limited back motion, pinal cord injury, hip fracture or replacement, osteperosis, frail, small end under buttocks
fracture plan placement with help
intro, explain, ID pre gear, warm pan, person safety/privacy/comfort, staff safety, person in supine, fold back covers, have person flex knees & push feet into matress to raise buttocks, slide hand under low back to raise buttocks, slide in waterproof pad, slide in pan, provide comfort, TP, privacy, stay close, clean person with clean sheet of TP for each wipe front to back, wash persons hands
fracture plan placement w/o help
precedure, set leb with head slightly up, uncover, have person fles knees and push up on heels to allow you to place pad & pan. Slowly raise to semi fowlers then Folwlers ensuring comfort & avoid shearing. Provide TP & privacy & signal make sure pan is centered and person has best comfort. . Decomtaminate hands, leave but stay near. Knock before entering (check every 5mins) put on gloves. Have person raise buttocks, cover and remove pan, clean person including hands, wipe with fresh TP each swipe, post procedure signal/safety/comfort/needs. Disinfect gear, record observation, final person, signal & room safety check, wash hands
clean person, clean gear/laundry away, provide for persons comfort/needs, provides for safety & signal, room safety check, record observations
know delegation, understand procedure, what to do, observe, limitations, concerns & orders for all aspects. Prepare gear needed. ID Right person, right procedure, introduce, explain, provide privacy, safety check for person, staff/body mechanics, bed safety
make sure are against a wall, put foot behind leg to secure, know where its is uses, how long to leave person and what observations & procedures need done from care plan
know who, what, where, limitations, how procedure is done and what person. Know what gear is needed and prepare it. Always introduce self, ID right person, right procedure, explain, provide for privacy, provided for their safety, provide for you safety, gloves. Do procedure. Clean, comfort , safety & signal for person. Decontaminate & remove gear, wash hands. Provide for persons needs, comfort, safety, signal. Record observations. Final person & room safety check.
urine leaks when bladder is too full, person feels bladder is not empty, dribbles or has weak stream
nursing for incontinence
promote regular voiding & bowl movements at scheduled interviews. answer signal lights , follow bladder/bowel training care plan,encourage pelvic exercises, prevent infections, decrease fluid before bedtime, good skin, linen care, perineal care. good privacy & comfort. Follow standard & blood bourne precautions
nursing for indwelling catheters
follow asepsis, BB precausions, keep tubes so urine flows free, keep connected to drainage tubing, attach drainage bag to bed frame, chair or IV pole lower than bladder, tubbing must NOT loop below bag, keep coiled on bed and do not tug on it. Never allow bag to touch floor. Secure to inner thigh, prevent excess movement, friction, pressure points. Check for leaks. Clean catherter & person 1-2x a day.
Foley, indwelling, rentention, condom, all promote comfort, prevent incontinence, can protect wounds and pressure ulcers from contact with urine. They do not treat cause of incontinence
emptying drainage bag
Preprocedure (read care plan, get gear, intro self, ID person, explain, provide privacy, provide for their safety, provide for own safety - gloves and body mech.) put papertowels & graduate on floor under bag. Check tube is proper coiled & secure. Empty regularly and at end of shift always. Release clamp and do not cross contamnate & release urine into graduate. Wipe the drainage tube end with wipe before placing back. Read on a level surface at eye leave in ml. Follow post procedure comfort, care, clean up, clear gear, their safety, signal, room safety) record observations
report complaints of pain, buring, irritation, need to void at once. Record crusting, abnormal discharge, drainage, secretions, color, clarity, order, particles and drainage system leaks
indwelling closed systems allow nothing to enter system keeoing it sterile, so microbes cant travel up and infect bladder & kidneys. Bag always lower than bladder, nver hung on bed rail, tubing higher than bag & secured.
disconnected drainage tubing
wear gloves, use wioe to disinfect end of catherter and end of drainage tube. Once they are sterile do not touch them. Reconnect. Discard wipes & gloves as biohazards, wash hands report to nurse.
hold less than 1000ml whereas drainage bags hold 2000ml. empty leg bag when 1/2 full
external catheter, texas catheter, urinary sheat. Temporary, changed daily after perineal care, wash & dry before applying. some self adhere other use ELASTIC tape in a spiral. Do not apply if penis red, skin is broken, swelling, report to nurse at once. Know what size to use, follow pre procedure, do procedure for peri care, then apply, penis tip MUST NOT touch condom, procedure to empty bag and post procedure comfort safety & signal.Report urine color, clarity, odor, particles
goal is to gain control of urination done as directed by nurse and care plan person uses toilet/pan at frequent regular intervals and is slowly increased. Person has catheter which is clamped to prevent urine flow for periods of time (1-2hrs at first then up to 3-4hrs) to train bladder
on privacy, promoting independence, asking qns about need to void/eliminate, know equipment, state laws, job & policy.
ammonia is not normal and only occurs it older urine
people void before bedtime, 1500ml per day and is normally clear & yellow
help person assume normal poistion, provide privacy, help on off commode, pan, toilet as requested, do not ALWATS stay with person - provide time alone, change gloves if left room
fowlers is best
remind each time to signal when done and hang on bedrail when not in use or on bedside stand
requires good skin care
never tape and leaks at connection site
a surgical operation that creates an opening from the colon to the surface of the body to function as an anus a pouch collect feces & flatus thru stoma.Temporary one allow bowel to heal and reconnected by surgery. permanent one intestine is removed. Feces consistency depends on site ranging from liquid to formed. Good skin care is needed, after cleane & dry, a skin barrier is applied to stoma can be part of pouch or seperate.
The passage of a hard, dry stool, commonly from low fiber diet, feces forms into hard marble size balls and ar e painful to pass. Activity, diet, stool softeners, oil retention enemas may help
The process of excreting feces from the rectum through the anus; a bowel movement
The frequent passage of liquid stools that rapidly move thru intestines reducing time for liquid absorption, urgentcy, abdominal cramping, vomiting may occur. Caused by infections, irratants, microbes in food & water, diet, drugs reduce peristalsis. Care for & report at once.
The introduction of fluid into the rectum and lower colon
The prolonged retention and buildup of feces in the rectum. Feces are hard & putty like, results when constipation is not relieved, person cant defecate, more liquid absorbed by previous hard feces. Liquid feces/mucuspass around hardened feces and seeps from anus. Abdominal discomfort, nausea, loss appetite, cramping, rectal pain are common report these to nurse
the inability to control the passage of feces and gas through the anus. Intestinal diseases, nervous system disorders, injuries, impactions, diarrhea, drugs, aging and unanswered signal lights are causes. Help prevent with elimination after all meals, bowel training, knowing habits & care plan.
semi solid waste material excreted from the large intestine expelled thru the anus; made of undigested food, water, bacteria, mucus, and shed intestinal cells, excreted from the large intestine
The excessive formation of gas in the stomach and intestines. Caused by swalling air, bacterial infection, gas forming foods, constipation, bowel & abdominal surgies, drugs that decrease paristalsis. Not expelled causes distention, cramping, pain, shortness of breath, bloating. walking, moving and laying on left side (SIMS) produce flatus. Dr may order enema.
gas expelled through the anus
surgical procedure that creates an opening from the ileum through the abdominal wall to function as an anus. Entire colon is removed. Liquid drains constantly and contains digestive juices that is an extreme irritant so puch must fit good.
a surgically created openning
a surgically created openning. No nerve endings.
excreted feces, usually brown. soft, formed, moist and shaped like rectum, normal odor
a small cone shaped solid drug/ medication designed for insertion into the rectum or vagina where it melts
color, amount, consistency, shape, size, frequency of defecation, complaints of pain. Ask nurse to observe abnormal stools.
factors affaecting elimination
lack of PRIVACY, HABITS & routine, balanced DIET with high fiber, low irritations, gas forming stimulates peristalsis but causes bloating. FLUIDS - intake is poor or instestings absorb too much, ACTIVITY stimulates, DRUGS can prevent or cause constispation & diarrhea, DISABILITY can cause bowel incontinence, AGE slows passage of feces
goal is to gain control of bowel movements. Develop a regular pattern of elimination to prevent fecal impaction, constipation & incontinence. Factors that promote defecating are noted in care plan
cleansing enema, small volume, oil retention. Enemas introduct fluid into the rectum & lower colon. Dr orders to remove feces, relieve constipation, fecal impaction or flatulence. Dr orders the solution to use
pre-procedure & make sure things ready for elimination, person void first, measure solution temp, give as ordered, position as ordered SIMs is preferred. Lube tip of tube, check with nurse how far but usually 3-4inches. Stop if any resitence. Ask nurse how high to raise bag usually 12 inches from anus & 18 inches from bed, unclap tube and start flow, stop if there is a need to defecate, cramping or solution starts to expel. unclamp when sympotoms subside. Give slowly 10-15 mins for 750-1000ml. Hold tube in place while giving. Ask nurse how long they need to hold depending on solution. Ask nurse to observe results do not give any that contain drugs Nurse MUST give these. Post procedure & clean up. Doucment observations
enema delegation safety
procedure is legal and in job description, right education, training, review with nurse. Know what types to give, how to give how long to give it. Size of enema tube, poistion, lube type, elimination needs, clean up needs,
reporting on enema
what solution, what was done, how long, bleeding or resisitence, retention, color, amount, consistancy, shape, odor, complaining, cramping, pain or discomfort. How person tolerated procedure
cleans the bowel of feces 7 flatus, relieve constipation & fecal impaction. Needed before certain surgeries. Dr orders type soapsud, tap-water, saoline. May order until clear, ie repeat until clear liquidask nurse howmany, agency policy may be 2-3 times
preparing enema solution
run water until right temp, unclamp bag fill bag for amount ordered. Add solution, seal bag, hang on IV pole.
small volume enema
irritae & distend rectum to cause defecation, ordered for constipationor when bowel doesnt need a complete clean. Ready to give solution given at room temp. Prepare person & place. Be ready for elimination. Lube endSqueeze & roll up bottle from bottom. Don not release pressure until bottle is clear of anus. Urge person to retain for 5-10 minutes staying in SIMs that helps with retention
after meals especiallt breakfast, regular times to go are in care plan and toilet, bedpan commode are offered at this time. Dr may order a supository to stimulate.
from faucet usually 500-1000ml, warmed to 105F 40.5C
soapsuds enema SSE
3-5ml castile soap to 500-1000ml, warmed to 105F 40.5C
1-2 teaspoons of table salt to 500-1000ml, warmed to 105F 40.5C
relieve constipation and fecal imapctions, mineral, olive or cotton seed oil held for 30-60 minutes. Retainings softens feces and lubricates the rectum. LEts feces pass with ease. Usually commerically prepared. Like giving small volume enema. Sims, cover person, lube insert, squeeze, remove. Use extra water proof pads and be prepared for elimination. check on person often.
small volume enema
small amount of solution (about 4 oz), often prepared in ready to use bottle
has adhesive backing, fitted to stoma size, drains from bottom through a clamp whenever feces present. deooderant put in pouch. Person has to avoid gas-forming foods, Peristalsis increases after eating so quiet during breakfast but expelled after. If showering & bathing is done with pouch off then best done before breakfast. Otherwise wait -12 hrs after new pouch before showering. Dont flush pouches.
from rectum back: sigmoid, descending, transverse, ascending. Double barrel for temporary. ileostomy for small intestine
assiting with bowel elimination
provide for physical & mental comfort, control verbal & non verbal responses, know persons routines & care measures, ask questions. Law - leaving a person in their feces is neglect, this is abuse it is reported to registery you can never work as CNA again. Answer lights promptly work as a team
unique, every persons normal pattern varies
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