Nursing Management of Wounds and Sleep Hygiene in Adults, Exams of Nursing

Download Nursing Management of Wounds and Sleep Hygiene in Adults and more Exams Nursing in PDF only on Docsity! N134: CONCEPTS OF NURSING STUDY GUIDE EXAM 3 2023/24 NEW UPDATE Lecture on Inflammation & Tissue Integrity and Wound Lab: White (12 questions) • Assessment and staging of pressure injuries. o Pressure injury, pressure ulcer, pressure sore, decubitus ulcer, and bedsore all describe impaired skin integrity caused by unrelieved and prolonged pressure o Assessing Darkly Pigmented Skin Assessment ▪ Skin temperature ▪ Hardened skin ▪ Edema ▪ Level of moisture ▪ Localized pain ▪ Skin can appear taut, shiny, indurated. Observe for area that is darker than surrounding skin. o Stage I ▪ Nonblanchable erythema site of intact skin ▪ skin does not return to normal color when pressure is relieved (Rule of thumb:have to wait 30 -45 minutes to determine if normal color has returned) ▪ Discoloration of skin, warmth, edema , hardness or pain may be present. ▪ Dark skin may not have visible blanching. ▪ Site may also be painful, firm, soft, warmer, or even cooler that surrounding skin. o Stage II Patrial Thickness Skin loss or Blister ▪ Partial thickness skin loss ▪ Pink or red viable tissue in wound bed ▪ Tissue is moist and deeper tissues are not visible ▪ May have a serum-filled blister ▪ Note that this stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis , maceration or excoriation. o Stage III Full thickness skin and tissue loss ▪ Full-thickness skin loss ▪ Visible adipose (fat) tissue ▪ Granulation tissue or new skin tissue on the surface of the wound may be present ▪ Wound edges may be rolled, dead tissue may have formed ▪ Slough may be present ▪ Undermining and tunneling may be present ▪ Depth of tissue varies by where injury is located on body o Stage IV Full Thickness skin and tissue loss ▪ Muscle, fascia, tendon, ligaments, cartilage and/or bone is visible ▪ Dead tissue may be present ▪ Undermining and tunneling may be present ▪ Depth depends on location of wound ▪ Usually requires surgical repair o Unstageable/Unclassified Ulcer and Suspected Deep Tissue Injury ▪ Full thickness tissue loss, base of wound is not visible due to eschar, slough in the wound bed in the unstageable wound. Once removed, the wound will be staged a 3 or 4 pressure injury ▪ Deep Tissue Pressure Injury (DTPI)- skin may be intact or broken, purple or maroon localized area of discolored skin, the area may be preceded with mushy, boggy, warmer, or cooler skin surrounding the wound. ▪ DTPI caused by intense and/or persistent pressure and shearing force. ▪ Mucosal Membrane Pressure Injury • Be able to identify risk factors for pressure injuries and related nursing interventions. o Early and late in life o Impaired Mobility o Friction o Shearing Force o Inadequate Nutrition/Malnutrition o Reduced skin perfusion o Sensory Loss o Moisture (maceration) o Medical devices o Alteration in Level of Consciousness o Obesity o Immobility – Inability to move or change position o Friction causes abrasion of superficial skin surfaces o Shearing Forces are a combination of friction and pressure are associated with the fowler’s position (as the client slides down in the bed, the deeper internal tissues move downward while the skin tissues continue to remain in place). This causes damage to blood vessels and tissues. o Inadequate nutrition/malnutrition ▪ Weight loss – muscle atrophy – loss of subcutaneous tissue – increases risk for breakdown o Moisture ▪ Maceration secondary to being wet (MASD)- moisture associated skin damage, Form of dermatitis • Result of skin exposure to irritants (feces, Causes pain, burning, itching • Can lead to Pressure Injuries ▪ Excoriation secondary to fecal matter & being wet, urine, exudate, sweating, stoma effluent, increased body temperature, deep skin folds. o Alteration in Level of Consciousness o Confused o Disoriented o Expressive aphasia o Coma o As far as interventions go… use common sense… relieve the pressure on the bony prominences and reposition the pt when needed ▪ Provide wrinkle free foundation to sit or lie on – gowns, sheets, pads ▪ Correctly position and transfer client ▪ Use protective films (transparent dressing or skin sealants) Thick, yellow, green, tan, or brown Purulen t ▪ occurs when a wound that cannot be stitched causes a large amount of tissue loss. Doctors will leave the wound to heal naturally in these cases o Delayed Primary Closure (Tertiary Intention) ▪ healing by delayed primary closure, occurs when there is a need to delay the wound-closing process. ▪ may allow the wound to drain or wait for the effects of other therapies to take place before closing the wound. • Demonstrate understanding of wound assessment, documentation and wound care. o Nursing Management – Assessment ▪ Client history ▪ Skin assessment ▪ Nutritional assessment ▪ Risk assessment – *Braden Scale: sensory perception, moisture, activity, mobility, nutrition, friction/shear- Score range 6-23 ▪ Energy levels – weakness / fatigue ▪ Presence of edema ▪ Wound assessment – color, type of wound, integrity of surrounding tissues - tunneling ▪ S/S of infection – odor, exudate ▪ Untreated wounds • If bleeding apply direct pressure to site and elevate. • Prevent infection – flush clean, cover with dressing – preferable sterile and reinforce as needed • Apply ice if swollen and painful • Assess for signs of shock if bleeding is profuse • When was their last tetanus shot? ▪ Treated wounds • Assess for healing, appearance, size, drainage, presence of swelling, pain, status of drains • Pressure ulcers – assess location, size (length, width & depth) in centimeters, tunneling, stage, color, condition of skin margins, integrity of surrounding tissue & S/S of infection. ▪ Lab Data • Decreased leukocyte or WBC counts delay healing and increase risk of infection • Low Hgb decrease healing - hypoxia • Blood coagulation levels – excessive blood loss or slow absorption of wound • Serum albumin – indicative of proteins in body when low there is poor healing and risk for infection. Protein are building blocks of the body • Wound cultures confirm infection • Proper care and assessment of drains. o Types of Wound Drainage Serous • Clear, watery plasma Serosanguineous Pale, red, watery: MIXTURE of clear and red fluid Sanguineous Bright Red : Indicates active bleeding. • Describe factors to promote wound healing. o Nursing Management – Implementation ▪ Encourage fluids – intake of 30-35 mL per kg/day of fluid per day unless contraindicated ▪ Include high calorie and high protein, Omega-3 and Omega-6 fatty acids, and vitamin C, A, Zinc as part of nutrition ▪ Monitor lab data – albumin, WBC ▪ Change dressing as ordered ▪ Assess wound for signs of infection ▪ Assess VS ▪ Prevent infection – good hand washing ▪ Positioning • Keep pressure off wound • Change positions q 1.5 to 2 hours • Enhance mobility if possible • ROM ▪ Maintain skin hygiene • Skin assessments daily • Minimize friction when bathing or positioning • Mild cleaning agents nothing drying • Skin needs to be dry and clean – if extremely dry use lotion • Do not massage over bony prominences. Lecture on Immunity: Casto (1 question) • Be able to identify risk factors for altered immunity o RISK FACTORS FOR SUPPRESSED IMMUNE RESPONSE ▪ Age ▪ Non-immunized state ▪ Environmental Factors ▪ Chronic Illness ▪ Medical Treatments ▪ Genetics ▪ High-Risk Behaviors and Substance Abuse ▪ Pregnancy o RISK FACTORS FOR EXAGGERATED IMMUNE RESPONSE ▪ Gender, Race and Ethnicity ▪ Genetics ▪ Environmental or Medication Exposure • Immune response o SUPPRESSED IMMUNE RESPONSE o Primary Immunodeficiency ▪ some or all of the parts of the immune defense system are missing resulting in an inadequate immune response. o Secondary Immunodeficiency ▪ a loss of immune functioning as a result of illness or treatment. CHEMO • Review all reading assignments, powerpoint slides, notes from class Lecture on Infection and Infection Prevention and Control Lab: Casto (10 questions) • Know the risk factors for infection o (This is from the Fundamentals of Nursing ATI Book) ▪ Recent travel or exposure to an infectious disease ▪ Behaviors that can put the client at increased risk ▪ Increased temperature, heart, and respiratory rate; thirst; anorexia ▪ Presence of chills, which occur when temperature is rising, and diaphoresis, which occurs when temperature is decreasing ▪ Presence of hyperpyrexia (greater than 41º C [105.8° F] ), which can cause brain and organ damage o Risk Factors • A nurse should assess each client for the risks of infection specific to the client, the disease or injury, and the environment. The most common risks include: • Inadequate hand hygiene (client and caregivers) • Individuals who have compromised health or defenses against infection, which include: • Those who are immunocompromised • Those who have had surgery • Those with indwelling devices • A break in the skin (the body’s best protection against infection). • Those with poor oxygenation • Those with impaired circulation • Those who have chronic or acute disease (diabetes mellitus, adrenal insufficiency, renal failure, hepatic failure, or chronic lung disease) • Be able to identify a patient with an infection o Stages of an infection ▪ Incubation: interval between the pathogen entering the body and the presentation of the first finding ▪ Prodromal stage: interval from onset of general findings to more distinct findings; during this time, the pathogen multiplies ▪ Illness stage: interval when findings specific to the infection occur ▪ Convalescence: interval when acute findings disappear, total recovery taking days to months • Chain of Infection and measures to take to break a link in the chain (Collaborative Learning Group Activity~we reviewed this in-depth in lab): o Control of Infectious Agent ▪ Definition • Bacteria, virus, fungus, prion, parasite ▪ Prevention • Cleaning and disinfection of equipment, surfaces, etc… o Protecting the Susceptible Host ▪ Definition • Compromised defense mechanisms (immunocompromised, breaks in skin), leaving the host more susceptible to infections ▪ Prevention ▪ Use an N95 or high-efficiency particulate air (HEPA) respirator if the client is known or suspected to have tuberculosis or SARS-CoV-2. • Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure. • If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection. • Clients who have an airborne infection should wear a mask while outside of the room/home. o Droplet Precautions (Influenza and Pertussis) ▪ Droplet precautions protect against droplets larger than 5 mcg and travel 3 to 6 ft from the client (streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). ▪ Droplet precautions require: • A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment. • Masks for providers and visitors. • Clients who have a droplet infection should wear a mask while outside of the room/home. o Contact Precautions (MRSA and C.diff) ▪ Contact precautions protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro- organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms). ▪ Contact precautions require: • A private room or a room with other clients who have the same infection. • Gloves and gowns worn by the caregivers and visitors. • Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag. o Protective Environment (the immunocompromised patient ie. Stem Cell Transplant) ▪ Protective environment is an intervention (not type of precautions) to protect clients who are immunocompromised. This includes clients who have had an allogeneic hematopoietic stem cell transplant. ▪ A protective environment requires: • Private room. • Positive airflow 12 or more air exchanges/hr. • HEPA filtration for incoming air. • Mask for the client when out of room. • Correct order and procedure for donning and doffing PPE (ATI resources, lab handout, and lab skills practice). ▪ DONNING • Gown • Mask or Respirator • Goggles or face shield • Gloves • “Gowns make girls giggle” ▪ DOFFING • Gloves • Goggles or Face Shield • Gown • Surgical mask/N-95 respirator. • “Gloves grip gowns surgically” • Review all reading assignments, powerpoint slides, notes from class • Review the following ATI content for Immunity, Infection and Infection Control and Islolation: o ATI Content Mastery Series Fundamentals for Nursing book/ebook Chapter 11 and Chapter 56 ▪ Chapter 11 • THESE ARE JUST SOME MAIN POINTS FROM THE CHAPTER • Types of Pathogens o Pathogens are the micro-organisms or microbes that cause infections. o Bacteria (Staphylococcus aureus, Escherichia coli, Mycobacterium tuberculosis) o Viruses: Organisms that use the host’s genetic machinery to reproduce (HIV, hepatitis, herpes zoster, herpes simplex virus [HSV], SARS-CoV-2 [COVID-19]) o Fungi: Molds and yeasts (Candida albicans, Aspergillus) o Prions: Protein particles (new variant Creutzfeldt-Jakob disease) o Parasites: Protozoa (malaria, toxoplasmosis) and helminths (worms [flatworms, roundworms], flukes [Schistosoma]) • Virulence is the ability of a pathogen to invade and injure a host. • Immune Defenses o Nonspecific innate o Native immunity restricts entry or immediately responds to a foreign organism (antigen) through the activation of phagocytic cells, complement, and inflammation. This occurs with all micro-organisms, regardless of previous exposure. o Passive: Antibodies are produced by an external source. ▪ Temporary immunity that does not have memory of past exposures ▪ Intact skin, the body’s first line of defense ▪ Mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins ▪ Inflammatory response with phagocytic cells, the complement system, and interferons to localize the invasion and prevent its spread • Specific adaptive immunity o Specific adaptive immunity allows the body to make antibodies in response to a foreign organism (antigen). This reaction directs against an identifiable micro-organism. • Active: Antibodies are produced in response to an antigen. o Engage Fundamentals>Foundational Concepts of Nursing Practice>Infection Control and Isolation Module Lesson and Test ▪ I am assuming this means they will take a question or 2 from the test here. Review it and try to memorize the answers. Young, Middle, and Older Adult Development: Casto (10 questions) • Be able to apply developmental theories of adults (REVIEW Erikson Psychosocial stages). o Erikson’s Stages ▪ Intimacy vs. Isolation (Young Adult) • Develop close, personal relationships with others and make the sacrifices that loving, reciprocal relationships require ▪ Generativity vs. Stagnation (Middle Adult) • Reflect on their accomplishments and engage in meaningful ways to support future generations • Parenthood, teaching, mentoring, and community involvement ▪ Integrity vs. Despair (Older Adult) • Looking back on their life with a sense of closure and completeness • Life review and reminiscing • Review physical, psychosocial and cognitive changes for the young adult and how the nurse can support patients in this stage. o Physical changes ▪ Growth completed by age of 20 ▪ Active, less frequent severe illnesses ▪ Ignore physical symptoms and delay treatment ▪ Physical strength peaks ▪ Weight and muscle mass changes as a result of diet, exercise, and lifestyle ▪ Assessment findings are normally as expected o Cognitive ▪ Critical thinking increases ▪ Conceptual, problem-solving, and motor skills increase due to general life experiences, educational experiences, and occupational opportunities o Psychosocial Stage ▪ Intimacy vs Isolation • Emotional health is related to an individual’s ability to address and resolve personal and social tasks • Review health risks and health promotion for young adults. o Health Risks ▪ Lifestyle Habits ▪ Substance abuse ▪ Personal hygiene habits ▪ Unplanned pregnancy ▪ STI/STD ▪ Infertility ▪ Environmental or Occupational Factors ▪ Violent Death and Injury o Health Promotion ▪ Family history • DM, High cholesterol ▪ Increased Cancer Risks • Perform monthly skin, breast, or male genital self-exams ▪ Behavior change ▪ Anorexia ▪ Fatigue o Risk factors for atypical presentation ▪ Age greater than 85 ▪ Multiple co-morbidities ▪ Polypharmacy ▪ Cognitive or function impairment • Know common physiological changes that are a normal part of aging o Nurses need to be aware of normal age-related changes. ▪ Some changes are normal not pathological ▪ Physical Development • Integumentary o Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin • Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures • Thinning and graying of hair, as well as a sparser distribution • Thickening of fingernails and toenails ▪ Cardiovascular/pulmonary • Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infections • Reduced cardiac output • Decreased peripheral circulation • Increased blood pressure ▪ Neurologic • Slower reaction time • Decreased touch, smell, and taste sensations • Decline in visual acuity • Decreased ability for eyes to adjust from light to dark, leading to night blindness, which is especially dangerous when driving • Inability to hear high-pitched sounds (presbycusis) • Reduced spatial awareness ▪ Gastrointestinal • Decreased production of saliva • Decreased digestive enzymes • Decreased intestinal motility, which can lead to increased risk of constipation • Increased dental problems ▪ Musculoskeletal • Decreased height due to intervertebral disk changes • Decreased muscle strength and tone • Decalcification of bones • Degeneration of joints ▪ Genitourinary • Decreased bladder capacity • Prostate hypertrophy in males • Decline in estrogen or testosterone production • Atrophy of breast tissue in females ▪ Endocrine • Decline in triiodothyronine (T3) production, yet overall function remains effective • Decreased sensitivity of tissue cells to insulin ▪ Immune • Decreased production of antibodies by B cells • Increased production of autoantibodies (antibodies against the host’s body) with increased autoimmune response • Decreased core body temperature • Decreased T-cell function • Decreased stress response • Decreased response to immunizations • Review functional changes in older adults (Basic and Instrumental ADLs) ▪ Include day to day (ADL’s) involving activities within physical, psychological, cognitive, and social domains ▪ Performance of ADL’s is a sensitive indicator of health or illness. Two types • Basic ADLS o Eating, hygiene, grooming, bathing, mouth care, dressing and toileting • Instrumental ADLs o Managing money, grocery shopping, cooking, house cleaning, laundry, managing meds, using phone, accessing transportation ▪ Changes are usually linked to illness or to disease and degree of chronicity ▪ Performance of ADLs is a sensitive indicator of health or illness ▪ Occupational and physical therapists are your best resources for a comprehensive assessment • Know the symptoms of cognitive impairment that are not a normal part of aging o Cognitive disorders (3 D’s) ▪ Delirium • Acute confusional state • Potentially reversible • Often has physiological cause ▪ Dementia • Overall term for conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person’s ability to perform everyday activities • Gradual, progressive, irreversible cerebral dysfunction ▪ Depression • Mood disturbance is characterized by feelings of sadness and despair • Treatable • Review nursing management of dementia o Nursing management of dementia ▪ Consider the safety and physical and psychosocial needs of the older adult and the family ▪ These needs change as the progressive nature of dementia leads to increased cognitive deterioration ▪ Changes as they further decline ▪ Individualize nursing care to enhance quality of life, maximize functional performance by improving cognition, mood, and behavior • Review the psychosocial changes of aging and strategies/nursing interventions used to meet the older adult’s psychosocial needs. o Psychosocial Changes ▪ Stage: Integrity vs Despair ▪ Isolation ▪ Sexuality • Love, warmth, sharing ▪ Housing and environment ▪ Death • Loved ones and friends • Review physiological health concerns and health promotion for the older adult o Health promotion and maintenance ▪ Physiological health concerns • Heart disease and cancer are leading causes of death • COPD • Stroke • Tobacco use/Alcohol use (affects) • Dental problems • Review psychosocial health intervention for the older adult (therapeutic communication, touch, reality orientation, validation therapy, reminiscence, body-image interventions) o Psychosocial Health Concern: Elder Mistreatment o Interventions supporting psychosocial health of the older adult include: ▪ Therapeutic Communication ▪ Touch ▪ Reality Orientation ▪ Validation Therapy ▪ Reminiscence ▪ Body-Image Interventions • Review all reading assignments, powerpoint slides, notes from class • Review the following ATI resources: o ATI Content Mastery Series Fundamentals for Nursing book/ebook Chapter 23, 24, 25, 16 o Your completed Active Learning Templates for Young, Middle and Older Adult Development ▪ Minimize noise, extreme temperature, and light during sleep • Know the normal sleep requirements across the lifespan o Neonates ▪ 14-17 hours o Infants ▪ 8-10 hours at night for a total of 12-15 hours per day o Toddlers ▪ 11-14 hours o Preschoolers ▪ 10-13 hours o School Age ▪ 9-11 hours o Adolescents ▪ 8-10 hours o Young Adults ▪ 7-9 hours o Middle and Older Adults ▪ Total number of hours declines • Know health promotion for good SLEEP HYGIENE o Factors influencing sleep ▪ Physical illness • Hypertension, respiratory, musculoskeletal, chronic illness ▪ Lifestyle • Work schedule, social activities, routines ▪ Emotion stress/Mental Illness • Worries, physical health, death, losses ▪ Exercise and fatigue • Moderate exercise and fat • igue cause a restful sleep ▪ Drugs • Nicotine, caffeine, alcohol ▪ Usual sleep patterns • May be disrupted by social activity or work schedule ▪ Environment • Noise, routines ▪ Food and calorie intake • Time of day, heavy meals • Review all reading assignments, powerpoint slides, notes from class • Review the following ATI resources: o ATI Engage Fundamentals>Comfort, Rest, Sleep Module o ATI Content Mastery Series Fundamentals for Nursing book/ebook Chapter 38 Rest and Sleep Urinary Elimination: Casto (14 questions) • Know common problems/alterations associated with urinary elimination. o Urinary Incontinence ▪ Involuntary loss of urine ▪ Major types • Urge o Bladder oversensitivity and urgency • Stress o Relaxed pelvic floor, increased abdominal pressure- prego • Overflow o Caused by overdistended bladder, usually related to an outlet obstruction • Function o Problems with immobility • Reflex o Result of a problem with CNS o Urinary Retention ▪ Inability to partially or completely empty the bladder ▪ Can be acute or chronic ▪ Associated with • Obstructions • Inflammation • Ineffective neuromuscular activation o Discomfort ▪ Should be pain free ▪ Causes • UTI • Urinary Retention o UTI s/s ▪ Urgency, frequency, fever, burning or painful urination, flank pain/ suprapubic discomfort, cloudy, foul-smelling, blood-tinged urines ▪ Pyelonephritis • Serious infection of upper urinary tract (Kidney) ▪ Most common healthcare acquired infection, usually caused by foley catheter insertion ▪ ECOLI is most common organism o Neoplasms ▪ Benign and malignant neoplasms of the prostate ▪ Can lead to blockage of urinary flow in men o Organ Failure ▪ Renal (kidney) failure • Acute – can occur suddenly, usually associated with an injury to the kidney referred to AKI • Chronic – can be a slow process referred to as a CDK ▪ If kidney is not functioning properly then it cannot remove and produce urine ▪ Creates physiological challenge for the body ▪ What does kidney do • A WET BED • Acid base balance • Water Removal • Erythropoiesis • Toxin Removal • Blood pressure control • Electrolyte balance • Vitamin D activation ▪ Pt with CKD are prone to anemia, hypertension, fluid, and electrolyte imbalances, acid/base imbalances • Be able to analyze urinary elimination assessment information and apply it to a clinical situation. • Assessment o Nature of problem o S/S o Onset/duration o Severity o Predisposing Factors o Effect on pt • Physical assessment o Kidneys ▪ CVA tenderness o Bladder ▪ Distension ▪ Post Void Residual (PVR) o External genitalia and urethral meatus ▪ Drainage ▪ Inflammation ▪ Lesions o Perineal Skin ▪ Erythema ▪ Moisture, erosion ▪ Burning/itching pain • Identify factors that commonly affect urinary elimination. • Factors influencing urinary elimination o Age o Immobility o Surgical Procedures o Pregnancy o Psychosocial Factors o Medications o Diet ensure that the client’s genitals are wiped with a laboratory-approved sanitary wipe so that contaminates from the surrounding area do not contaminate the sterile urine specimen container. o Time urine specimen (24 hour urine) o urine is collected over a 24-hour period, placed in a special container, and refrigerated. o Begins after pt urinates and ends with final voiding at the end of the time period o DISCARD the first void o Void into clean receptable and then transfer to special collection container o Many require special preservatives o May need to be kept cool by setting in container of ice o Free of feces and toilet paper o Pt education • Know the procedure for measuring post-void residual with a bladder scanner. • Assessing abdomen for distension • Assessing patient’s ability to toilet before scan • Determining timing and frequency within 10 minutes of voiding • Interpret results • Hand hygiene, pt ID, go void, measure output, scan within 10 minute timeframe hysterectomy means male in the machine, palpate pubic bone, apply generous amount of ultrasound jelly, midline 1-1.5 inches above cubic bone, orient at 45 degree into bladder, apply a bit of pressure with scanner head pointed downward, press and wait for “bzzzz” then release, make sure scanner is in the center of cross-air • Can be delegated to AP according to policy • Know the medications related to the urinary system reviewed in class (Powerpoint slide, your notes from class will help and ATI Content Mastery Series book/ebook). • Medications o Antibiotics for UTIs o Phenazopyridine bladder analgesic to treat symptoms of UTI (pyridium) o Tricyclic antidepressants to relieve urinary incontinence (nortriptyline) o Anticholinergic agents to decrease urgency of overactive bladder (oxybutynin) o Study nursing actions and client education • Management of urinary retention and urinary incontinence. • Acute Care o Catheterization o Urinary diversions o Medications ▪ Antibiotics for UTIs ▪ Phenazopyridine bladder analgesic to treat symptoms of UTI (pyridium) ▪ Tricyclic antidepressants to relieve urinary incontinence (nortriptyline) ▪ Anticholinergic agents to decrease urgency of overactive bladder (oxybutynin) ▪ Study nursing actions and client education • Continuing Restorative Care o Stress, urge, mixed incontinence ▪ Behavioral therapy • Lifestyle changes • Pelvic floor muscle training • Bladder retraining • Toileting schedules o Chronic urinary retention ▪ Intermittent catheterization o Risk for urine leakage ▪ Skin care • Know the procedure for inserting an indwelling catheter (skill reviewed in lecture, demonstration in lab, and ATI resources). • Female o Stand on client’s right side if right-handed; left side if left-handed o Spread labia with non-dominant hand (firm, but gentle) o Labia may not close back over the meatus o With cotton swab & sterile forceps, clean one side of labia majora then the other (anteroposterior motion) o Repeat procedure with labia minora o Clean the meatus o Insert catheter until urine received back o Once urine received insert another 2” o Inflate balloon o Gently pull back until resistance is felt • Male o Grasp the penis with non- dominant hand just below the glans o If uncircumcised, retract the foreskin o Hold penis upright to straighten the urethra o Using cotton ball and forceps clean from the center of the meatus out ▪ (3 times) o If the penis is dropped, the procedure must be restarted o Insert the catheter to the bifurcation of drainage and balloon inflation port. o Lower penis and hold catheter in non-dominant hand. o Inflate balloon with free hand o Pull back gently until you meet resistance • Removal of Indwelling Catheter o Check order o Gather supplies ▪ Disposable, waterproof pad, clean gloves, sterile syringe o Deflate the balloon and withdraw catheter o Document ▪ Date/Time; amount, color, & clarity of urine; intactness of catheter; education of client o Assess for 1st voiding & adequate voiding in first 6-8 hrs after D/C of cath • What measures should the nurse take in caring for a patient with an indwelling catheter to reduce the risk of catheter associated urinary tract infection (CAUTI)? • Regular perineal hygiene to reduce risk of CAUTI • What is the difference between a straight catheter, indwelling catheter, external catheter, suprapubic catheter, Coude’ catheter, and an irrigation catheter? ▪ Intermittent (Straight Catheter) • One time cath for bladder emptying or measurement of PVR when bladder scanner not available ▪ Indwelling • Remains in place over time • Appropriate indications for indwelling cath • Acute urinary retention or bladder outlet obstruction • Need for accurate measurements of urinary output in critically ill pt • Perioperative use for selected surgical pt o Urologic surgery or other surgery of genitourinary tract o Anticipated prolonged duration of surgery (should be removed In PACU) o Anticipated to receive large volume infusions or diuretics during surgery o Need for intraoperative monitoring of urinary output • To assist in healing of open sacral or perineal wounds in incontinent patients • Requires prolonged immobilization (unstable thoracic or lumbar spine, multiple traumatic injuries like pelvic fractures) • To improve comfort for end-of-life care if needed ▪ External catheter ▪ AKA condom catheter, Texas catheter, penile sheath ▪ Condom catheter ▪ Usually used for people with cognitive impairment and urinary incontinence ▪ Can not use it for urinary retention problems ▪ Female external catheter (purewick) ▪ Soft flexible wick connected to wall suction to pull tine into drainage cannister ▪ Suprapubic Catheterization • Urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis • Indications • Enlarged prostate • Urethral stricture • After urological surgery • In place of long term urethral catheter • Nursing care • Daily cleaning of insertion site and catheter • Same care for tubing and drainage bag as urethral catheter • Assess for s/s of inflammation/infection, monitor output ▪ Coude-tip catheter • Curvature at end that helps it maneuver through the prostatic urethra d/t large prostate • Special training to use this type ▪ Continuous bladder irrigation