Fundamentals Exam #3 Study Guide - Hygiene - PDF

Fundamentals Exam \#3 -- Study Guide **Chapter 32 -- Hygiene** [Factors Affecting Hygiene] - **[Culture]** -- bathing habits, behaviors; use of various hygiene-related products. May influence whether bathing is a private or communal activity. - **[Socioeconomic Status]** -- often def...

Fundamentals Exam \#3 -- Study Guide **Chapter 32 -- Hygiene** [Factors Affecting Hygiene] - **[Culture]** -- bathing habits, behaviors; use of various hygiene-related products. May influence whether bathing is a private or communal activity. - **[Socioeconomic Status]** -- often define the hygiene options available to that person. - **[Spiritual Practices]** -- may dictate ceremonial washings and purifications, sometimes as a prelude to prayer or eating - Ex: Orthodox Jewish tradition calls for ritual baths for women after childbirth & menstruation - Some religions state that contact with a deceased person or a deceased animal may make a person "unclean." - Some religions dictate that no modern facilities be installed in homes - **[Developmental Level]** -- children learn practices from family members. Bathing frequency commonly decreases as a person ages - **[Health State]** -- disease, surgery, or injury may reduce a person's ability to perform hygiene measures or motivation to follow usual hygiene habits. Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash the lower extremities. Pain with an acute condition or chronic pain can affect a person's ability to perform and/or tolerate personal hygiene measures. - **[Personal Preferences]** -- taking a shower versus a tub bath, using bar soap versus liquid soap, and washing to wake oneself or to relax before sleep. **[Documentation of morning care]** Morning care is categorized [as self-care, partial care, or complete care.] - **[Self-Care]** - can manage their personal hygiene independently. - **[Partial Care]** - most often receive morning hygiene care at the bedside or seated near the sink in the bathroom. - **[Complete Care]** - the nursing assist with all aspects of personal hygiene. **[Patients at risk for alterations in hygiene]** - [Seriously ill] - increased vomiting acid in vomiting can eat away at the oral cavity.​ - [Comatose] - can't provide own oral are, will need frequent mouth care.  ​ - [Confused] - they may be unable to provide their on oral care.​ - [Depressed] -sometime they have no energy to complete Activity of Daily living. ​ - [Paralyzed] - will need assistance with oral care.​ - [Mental health issues] - depending on how severe, may need guidance or assistance with oral care. ​ - [Mouth breathers] - will have a dry mouth ​ - [NPO] - NPO means nothing by mouth, no food, ice chips or   ​ - [NG tubes] - Nasal gastric tube​ - [Oral airways] - patient may be on a vent, this will cause issues with the oral cavity. ​ - [Oral surgery] - can affect the oral cavity.  - [Bariatric Patients] - Increased risk for skin integrity issues, including increased risk for alterations in skin integrity and therefore require focused nursing care to prevent skin issues **[Steps for occupied bed making -- NEED TO KNOW]** **[Principles of bathing (soap and water, disposable bath systems)]** - Assess the patient's skin at least daily and after every episode of incontinence. - Cleanse the skin when indicated, such as when soiled, using a no-rinse, pH-balanced skin cleanser. - Avoid using soap and hot water; avoid excessive friction and scrubbing. - Minimize skin exposure to moisture (incontinence, wound leakage); use a skin barrier product as necessary. - Use skin emollients after bathing and as needed. **[Principles of oral care]** **[Oral Cavity]** Examine the following: - [Lips]: color, moisture, lumps, ulcers, lesions, and edema - [Buccal mucosa]: color, moisture, lesions, nodules, and bleeding - [Gums]: Color, lesions, bleeding, and edema - [Teeth]: any loose, missing, or carious (decayed) teeth. Note the presence and condition of dentures or other orthodontic devices - [Tongue]: color, symmetry, movement, texture, and lesions - [Hard and soft palates]: intactness, color, patches, lesions, and petechiae (pinpoint round, red, purple, or brown spots that result from bleeding) - [Oropharynx]: movement of the uvula and condition of tonsils, if present Note unusual mouth odors and assess the adequacy of mastication and swallowing. [Caries] -- is the decay of teeth with the formation of cavities Caries result from failure to remove plaque [Plaque] -- an invisible, destructive, bacterial film that builds up on everyone's teeth and eventually leads to the destruction of tooth enamel. [Periodontal Disease] -- result of infections and inflammation of the gums and bone that surround and support the teeth. [Gingivitis] is an inflammation of the gingiva, the tissue that surrounds the teeth [Periodontitis] -- aka periodontal disease & is marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. [Tarter] -- is a hard deposit that is made from plaque build & dead bacteria that Is formed at the gum lines [Halitosis] -- a strong mouth odor or a persistent bad taste in the mouth [Stomatitis] -- is an inflammation of the oral mucosa. Symptoms may include heat, pain, increased flow of saliva, and halitosis. [Glossitis] -- is an inflammation of the tongue. Caused by deficiencies of vitamin B12, folic acid, & iron Cheilosis -- ulceration & dry scaling of the lips with fissures at the angles of the mouth **Chapter 34 -- Activity** **[Principles of body mechanics]** [Functions of Skeletal System:] - Supporting the soft tissues of the body (maintains body form and posture) - Protecting crucial components of the body (brain, lung, heart, spinal cord) - Furnishing surfaces for the attachments of muscles, tendons, and ligaments, which, in turn, pull on the individual bones and produce movement - Providing storage areas for minerals (such as calcium) and fat - Producing blood cells (hematopoiesis) Functions of the Muscular System: - [Motion]: muscle contractions pull on tendons and move the bones, creating movements - [Maintenance of posture]: muscle contractions hold the body in stationary positions. - [Support]: muscles support soft tissues in the abdominal wall and floor of the pelvic cavity. - [Heat production]: contractions produce heat & help maintain body temperature Connective Tissues: Connect bones and muscles. 3 Types: - Ligaments = Bone to Bone ; tough & fibrous - Tendons = Muscle to Bone; strong & flexible - Cartilage = Hard, non-vascular ; functions as a shock absorber & reduces friction [Nervous System] - Nerve impulses stimulate muscles to contract - The skeletal and muscular systems rely on a functioning nervous system. - The afferent nervous system conveys information from receptors to the CNS. - The efferent system conveys a response from the CNS to skeletal muscles via the somatic nervous system. ANS \> CNS \> Skeletal muscles (via somatic nervous system) **[Prevention of DVT]** - Constantly move patient -- every 2 hours - Compression socks. - Being active **[Types of exercises]** - [Muscle Contraction] - exercises are classified by the type of muscle contraction that is involved - **[Isotonic]** involves muscle shortening and active movement (ADLs, ROMs, swimming, jogging, bicycling are some examples. Benefits are muscle toning, strength and mass; increased cardiac and respiratory benefits; increased circulatory and bone building benefits. - **[Isometric]** involves muscle contraction without shortening such as yoga poses; contraction of the gluteal or quads. Benefits are increased muscle mass, tone, strength to the exercised body part. - **[Isokinetic]** involves muscle contraction with resistance by use of an external device such as weights, bands, CPM (continuous passive motion) devices. - Body Movement - **[Aerobic]** refers to sustained or rhythmic muscle movement that increase blood flow, heart rate and metabolic demand for Oxygen. Promotes cardio conditioning. Examples include jogging, swimming, walking, aerobic dancing, bicycling, jumping rope. There are high and low impact aerobic exercises. - **[Stretching]** exercises involves movements that allow muscles and joints to be stretched gently through there full ROM. Benefits are range of joint movement, improved circulation, and posture. - **[Strength and endurance exercises]** are components of a variety of muscle building programs. Can be weight training or specific isometric exercises. **[Assessment of pt with alterations in mobility]** - Keeping in my patient individual problems and conducting a care plan for specific patient - ADLs = Eating, bathing, dressing, and toileting - IADLs = Housekeeping, meal preparation, management of finances, and transportation - Missing limb - Injured body part/bone/joint - Arthritis - Trauma (sprain/dislocation) - Rest is essential for the healing process, immobility associated with bed rest may cause its own problems. - When assessing a patient's response to a mobility deficit, work to: - Encourage attempts at behaviors that promote self-care activities despite limitations - Reinforce behaviors that promote healthy functioning - Correct behaviors that compound the mobility deficit over time **[Pt. education r/t mechanical aids for ambulation]** - Mechanical Aids: - Walkers - Canes - Crutches - Braces - Walkers - Patients who require a larger base of support and do not rely on the walker to bear weight can use walker with wheels on all four legs. - Wheeled walkers are best for patients who need minimal weight bearing from the walker - Instruct a patient using a **[walker]** to do the following: - Wear nonskid shoes or slippers. - When rising from a seated position, use the chair arms for support. Once standing, place one hand at a time on the walker and move forward into it. - Begin by gripping the top of the walker at the grips, then lift and position or push the walker forward, about one step ahead, keeping the back upright---do not hunch over the walker (MFMER, 2019d). Place one leg inside the walker, keeping the walker in place. Do not step all the way to the front (AAOS, 2015). Push straight down on the grips of the walker and then step forward with the remaining leg into the walker, keeping the walker still. Repeat the process by moving the walker forward again. - If the patient has an injured or weaker leg, the injured/weaker leg should be moved into the walker first, followed by the stronger or unaffected leg (American Academy of Orthopedic Surgeons, 2015; MFMER, 2019d). - Caution the patient to avoid pushing the walker out too far in front and leaning over it. Patients should always step into the walker, rather than walking behind it, staying upright as they move (MFMER, 2019d). - Never attempt to use a walker on stairs or an escalator. - Canes - Cane should fit so that when the patient stands with the cane's tip 4 inches to the side of the foot, the cane extends from the floor to the crease in the patient's wrist. The elbow should be bent slightly, flexed 15 degrees when holding the cane - Cane Patient Instruction - The patient stands with weight evenly distributed between the feet and the cane. - The cane is held on the patient's stronger side and is advanced one small stride ahead (AAOS, 2015). - Supporting weight on the stronger leg and the cane, the patient advances the weaker foot forward, parallel with the cane. - Supporting weight on the weaker leg and the cane, the patient brings the stronger leg forward to finish the step (AAOS, 2015). - Teach patients to position their canes within easy reach when they sit down so that they can rise easily. - Crutches - Axillary crutches & forearm crutches - Axillary crutches -- support of body weight should come on the hands and arms while using the crutches, not in the axillary area - Positioning - Prevent pressure on the axillae. When standing ,crutches should be about 1 to 2 inches below the armpits. Weight should rest on the hands. - Keep elbows close to sides. Handgrips should be even with hips - Prevent crutches from getting closer than 12 inches to feet. - Home Instructions - [Rise from a chair] -- Slide forward to the edge of the chair. Extend the injured leg to prevent any weight bearing. Place crutches on unaffected side, lean forward, and push off using the crutches. - [Climb stairs] -- Advance unaffected leg past crutches, then place weight on unaffected leg. Advance affected leg and then crutches to the step. Continue with this order until top of stairs is reached. - [Descend Stairs] -- Move crutches and affected leg first, followed by the unaffected leg **[Patient positions]** Fowler's A person lying on a pillow Description automatically generated Sims  Modified Side-lateral (30-degree lateral tilt of hips A person\'s legs on a bed Description automatically generated **[ROM exercises]** Range of motion is the maximum degree of movement of which a joint is normally capable. When assessing joint mobility, note the following: - Size, shape, color, and symmetry of joints: note any masses, deformities, or muscle atrophy - Range of motion of each joint - Any limitation in the normal range of motion or any unusual increase in the mobility of a joint (instability); range of motion varies among people and decreases with aging - Muscle strength when performing range-of-motion exercises against resistance - Any swelling, heat, tenderness, pain, nodules, or crepitation (palpable or audible crunching or grating sensation produced by motion of the joint) - Comparison of findings in one joint with those of the opposite joint In active exercise, the patient independently moves joints through their full range of motion (isotonic exercise) In passive exercise, the patient is unable to move independently, and the nurse moves the joint through its range of motion The following are basic guidelines to follow when helping to put the patient's joints through range of motion: - Teach the patient what exercise is being undertaken, why, and how it will be done. - Avoid overexertion. - Start gradually and work slowly. - Move each joint until there is resistance but not pain. - Keep friction at a minimum when moving extremities to avoid injuring the skin. - Use range-of-motion exercises twice a day The goal of range-of-motion exercises is to keep the patient in the best possible physical state when bed rest is necessary or movement is restricted. **Chapter 31 -- Perioperative** **[Classifications of surgery ]** Surgical procedures usually are classified according to urgency, risk, and purpose These are then broken down into further subcategories - Urgency - Elective -- preplanned & delay of surgery has no ill effects - Tonsillectomy, hernia repair, cataract extraction and lens implantation, hemorrhoidectomy, hip prosthesis (may also be urgent), scar revision, facelift, mammoplasty - Urgent -- not an emergency but normally done within 24--48 hours - Removal of gallbladder, coronary artery bypass graft (CABG), surgical removal of a malignant tumor, colon resection, amputation - Emergency -- done immediately to preserve life, a body part or function - Ex: Control of hemorrhage; repair of trauma, perforated ulcer, intestinal obstruction; tracheostomy - Risk - Major -- may be elective, urgent, or emergency; requires hospitalization & specialized care. - Ex: Carotid endarterectomy, cholecystectomy, nephrectomy, colostomy, hysterectomy, radical mastectomy, amputation, trauma repair, CABG - Minor -- primarily elective; outpatient clinic, or same-day surgery. - Ex: Tooth extraction, removal of warts, skin biopsy, dilation and curettage, laparoscopy, cataract extraction, arthroscopy - Purpose - Diagnostic - Breast biopsy, laparoscopy, exploratory laparotomy - Ablative - Appendectomy, subtotal thyroidectomy, partial gastrectomy, colon resection, amputation - Palliative - Colostomy, nerve root resection, debridement of necrotic tissue, tumor debulking, arthroscopy - Reconstructive - Scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction - Constructive - Cleft palate repair, closure of atrial--septal defect - Transplantation - Kidney, liver, cornea, heart, joints **[Effects of anesthesia ]** Anesthetic agents can be administered systemically (general) or regionally to block nerve conduction. [General] -- a balance of loss of consciousness, analgesia, relaxation, & loss of reflexes - combination of both IV and inhalation anesthetics - The desired actions of general anesthesia are loss of consciousness, amnesia, analgesia, relaxed skeletal muscles, and depressed reflexes. [Regionally] -- does not cause narcosis, but results in analgesia and reflex loss. - Occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. - Patient receiving regional anesthesia remains awake but loses sensation in a specific area or region of the body. [Moderate sedation/analgesia (conscious or procedural sedation)] -- used for short-term and minimally invasive procedures. - The patient maintains cardiorespiratory function and can respond to verbal commands. Produces decrease in anxiety & discomfort/pain with some degree of amnesia [Local Anesthesia] -- injection of an anesthetic agent such as bupivacaine, lidocaine, or tetracaine to a specific area of the body [Topical anesthesia] -- primarily applied to intact skin but may be used with mucous membranes and in some cases of wound care. **[Informed consent ]** Reflects a process of effective communication that results in the patient's voluntary agreement to undergo a particular procedure or treatment Provider should provide the following information in everyday language that considers the patient's health literacy level and is culturally sensitive: - Description of the procedure or treatment (its name, site, and side if applicable), potential alternative therapies, and the option of nontreatment - Underlying disease process and its natural course - Name and qualifications of the health care provider performing the procedure or treatment---provide an emphasis on shared decision making between the patient and provider(s) - Explanation of the risks (nature, magnitude, probability of the risks) and benefits - Explanation that the patient has the right to refuse treatment and that consent can be withdrawn - Explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course Informed consent protects the patient, the health care providers, and the health care facility. Nurse can act as witness but not give informed consent to patient. **[Nursing interventions in the pre-operative setting ]** Patients intervention can be a wide variety of situations, ranging from essentially healthy people who have planned elective procedures to emergency admissions for treatment of trauma or serious illness. Interventions are designed to meet the patient's physical and psychological needs and facilitate recovery as the patient progresses through the perioperative period. - Review past health history and documents for evidence of existing or previous medical and nursing diagnoses and treatments. - Initiate referrals to health care personnel and/or agencies, as appropriate. - Determine availability and quality of resources - Determine status of basic living needs. - Use mutual goal setting as appropriate. **[Physiologic factors that affect nursing care for the pt undergoing a procedure ]** - [Developmental level] - [Medical & Surgical History] - [Medication History] - [Nutritional Status] - [Use of Alcohol, Illicit Drugs, or Nicotine] - [Activities of Daily Living & Occupation] - [Coping Patterns & Support Systems] - [Sociocultural Needs] **[Post-operative assessment ]** - Divided into 2 stages - immediate care (provided in PACU in both in-hospital & outpatient centers) - ongoing postoperative care (lasting from return to the unit through convalescence) - Nursing assessments & interventions are consistent with those in the preoperative & intraoperative phases - carried out to maintain function, promote recovery, and facilitate coping with alterations in structure or function. - **Postoperative vital signs are high priority -- Every 10-15 minutes** - Respiratory status - Cardiovascular status - Temperature - CNS status - Fluid status (skin turgor, vital signs, urine output, wound drainage, and IV fluid/blood product administration) - Gastrointestinal status - Wound status **Chapter 33 -- Skin Integrity** **[Types of drainage ]** The inflammatory response results in the formation of exudate which then drains from the wound. The exudate may contain fluid/serum, cellular debris, bacteria, and leukocytes. This exudate is called wound drainage and is described as serous, sanguineous, serosanguineous, or purulent. - [Serous drainage] = clear, serous portion of the blood. Serous drainage is clear and watery. - [Sanguineous drainage] = large numbers of RBC and looks like blood. - [Serosanguineous drainage] = a mixture of serum and red blood cells. Light pink to blood tinged. - [Purulent drainage] = WBC , liquefied dead tissue debris with both dead and live bacteria. Is thick, often has a musty or foul odor, and varies in color (dark yellow or green) **[Types of drainage systems ]** Open drainage does not have a collection device. It empties into absorptive dressing material. Promotes drainage passively. It is not sutured in place. - Gauze -- allows healing from base - Infected wounds - Penrose -- drains blood & fluid - After incision & drainage in abdominal surgery Closed drainage systems consist of a drainage tube that may be connected to an electrical suction device or have a portable built-in reservoir to maintain constant low suction. - Blake -- drains blood & fluid - Used in cardiac surgeryinstead of chest tube or JP drain - Chest Tube -- drains blood - Cardiac surgery - Hemovac -- drains blood & fluid - Abdominal & orthopedic surgery - Jackson-Pratt (JP) -- drains blood & fluid - Breast surgery & abdominal surgery - T-tube -- collects bile - Gallbladder surgery **[Nursing interventions to prevent skin breakdown ]** - Ongoing evaluation of skin integrity is needed to determine needs and the effectiveness of any interventions, including heat and cold therapy. - Assessing risk factors: Braden scale to estimate the risk of pressure injuries. Braden scale considers factors like sensory perception, moisture, activity, mobility, nutrition, friction, and shear risk.  - Relieving pressure: Reposition patients every 2 hours.  - Maintaining skin hygiene  - Promoting wound healing - Educating patients and families about skin breakdown & wound care **[Pressure injury staging ]** Pressure injuries classified as: - Stage 1 -- non-blanchable erythema of intact skin - Stage 2 -- partial thickness skin loss with exposed dermis - Stage 3 -- full-thickness skin loss; adipose tissue visible - Stage 4 -- full-thickness skin and tissue loss with exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle - Unstageable -- unable to visualize the extent of tissue damage due to slough or eschar - Deep Tissue Pressure Injury (DTPI) -- persistent non-blanchable deep red, maroon, or purple discoloration **[Nursing interventions for an eviscerated wound ]** Dehiscence & evisceration are the most serious postoperative wound complications. Dehiscence is the partial or total separation of wound layers because of excessive stress on wounds that are not healed. Evisceration is the most serious complication of dehiscence. Occurs primarily with abdominal incisions. In evisceration, the abdominal wound completely separates, with protrusion of viscera (internal organs). Patients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining Dehiscence with evisceration of an abdominal incision is a medical emergency. 1. Place the patient in the low Fowler's position 2. Cover the exposed abdominal contents keep the exposed viscera moist. 3. Do not leave the patient alone & provide reassurance & pain meds 4. Notify the primary care provider immediately. \*\*This situation is an emergency that requires prompt surgical repair, so the patient should be kept NPO **[Steps for wound change ]** The goal of wound care is to promote tissue repair and regeneration so that skin integrity is restored. Wounds can be treated by leaving them open to air. Wounds left open to air heal more slowly because wound drying produces a dried eschar or scab. Closed wound care uses dressings to keep the wound moist, promoting healing. A moist environment is best for wound healing. An ideal dressing should maintain a moist environment, be absorbent, provide thermal insulation, act as a bacterial barrier, reduce or eliminate pain at the wound site, and allow for pain-free removal There is no standard frequency for how often dressings should be changed. Prepare the patient for the dressing change before starting the procedure by explaining what will be done. - If wound care is uncomfortable, administer a prescribed analgesic 30 to 45 minutes before changing the dressing. - Provide privacy by properly screening the patient; close the room door and curtain. - Expose only the area necessary to perform the wound care while maintaining proper draping. - Surgical wounds that have dehisced require the use of sterile technique. - Remove, Clean, Apply new dressing [Removing a Dressing] - Use standard precautions; use appropriate transmission-based precautions when indicated. - Perform hand hygiene and put on clean (nonsterile) gloves. - Remove tape and dressings in the direction of hair growth to minimize trauma to the skin. - Carefully lift the adhesive barrier from the surrounding skin to prevent medical adhesive--related skin injury. Remove the sides/edges first, then the center. - Slowly remove the dressing, noting the amount, type, color, and odor of the drainage. - Discard the dressing according to facility policy. - Remove gloves and perform hand hygiene. [Applying a New Dressing] - Perform hand hygiene. - Use standard precautions; use appropriate transmission-based precautions when indicated. - Check the patient's identification. - Explain what you are going to do to the patient. - Provide privacy - Put on gloves. - Cleanse the wound - Apply a skin barrier, such as Skin Prep, to the areas of skin where the dressing adhesive or tape will be placed and to areas around the wound where drainage may come in contact with skin. - Apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; - Gently place the dressing at the wound center and extend it at least 1 in beyond the wound in each direction. - 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. **Chapter 38 -- Urinary Elimination** **[Risk factors for UTIs ]** - People who habitually urinate infrequently develop more urinary tract infections (UTIs) and kidney disorders than those who urinate at least every 3 to 4 hours. - Decreased bladder contractility may lead to urine retention and stasis - Sexually active people with female genitalia - People who use diaphragms for contraception - Postmenopausal people  - People with an indwelling urinary catheter in place   - People with diabetes - Older adults  Preventing UTI - Drink six to eight 8-oz glasses of non-caffeinated liquid daily - Do not postpone going to the bathroom; urinate when you feel the urge - Take enough time to fully empty the bladder when urinating - If you have female genitalia, dry from the front to the back - Take showers instead of baths. - Void before and after intercourse - If you use a diaphragm, unlubricated condoms, or spermicide, talk with your PCP about switching birth control methods; these methods can increase the chances of developing a bladder infection - Wear underwear with a cotton crotch and avoid clothing that is tight and restrictive on the lower half of the body **[Physiologic changes r/t urinary elimination ]** - Bladder capacity: The bladder\'s capacity to store urine decreases. - Medications: Certain medications can cause urinary problems.  - Dehydration: Inadequate fluid intake can lead to concentrated urine.  - Sodium Intake: High sodium intake decreases urine formation - Certain foods may affect the odor/color of urine - Activity: Regular exercise means increased metabolism and optimal urine production and elimination. - Immobility: During prolonged periods there is decreased bladder and sphincter tone & results in poor urinary control and urinary stasis. - Pregnancy and childbirth: Hormonal changes and the weight of the fetus can lead to stress incontinence.  - Menopause: Women produce less estrogen after menopause, which can impact urinary function.  - Enlarged prostate: In older men, an enlarged prostate gland can lead to incontinence.  - Neurological disorders: Multiple sclerosis, Parkinson\'s disease, a stroke, a brain tumor, or a spinal injury can impact bladder control.  - Tumors: A tumor in the urinary tract can block urine flow.  **[Types of urinary catheters and when they are used ]** - [Intermittent urethral catheter] -- aka straight catheters -- drain the bladder for short periods. - Preferred for patients with urinary retention and bladder-emptying dysfunctions and following surgical interventions - [Indwelling urethral catheter] -- remain in place for continuous drainage aka retention or Foley catheters. - Designed so that it does not slip out of the bladder. - Used in lab - In a double-lumen catheter, one lumen is connected directly to the balloon, which is inflated with sterile water; the other is the lumen through which the urine drains. The triple-lumen catheter provides an additional lumen for the instillation of irrigating solution. - [Suprapubic catheter] is a type of indwelling urinary catheter used for long-term continuous drainage. - Inserted surgically through a small incision above the pubic area - Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or gynecologic or abdominal surgery has compromised the flow of urine through the urethra - CAUTI = catheter-associated urinary tract infection (CAUTI) - increases health care costs and is associated with increased morbidity and mortality. CAUTIs are considered by the Centers for Medicare and Medicaid Services to represent a reasonably preventable complication of hospitalization **[Pt education r/t common medications r/t urinary elimination ]** Nephrotoxic = poisonous or damaging to the kidney. Abuse of analgesics & some antibiotics can cause nephrotoxicity Diuretics prevent the reabsorption of water and certain electrolytes in the tubules. May cause increase in production and excretion of dilute urine Cholinergic medications stimulate contraction of the detrusor muscle and produce urination. Analgesics & Tranquilizers suppress CNS, interfering with urination by diminishing the effectiveness of the neural reflex. [Urine Color Change Due to Medication] - Anticoagulants may cause Hematuria (blood in the urine), leading to a pink or red color. - Diuretics can lighten the color of urine to pale yellow. - Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine. - The antidepressant amitriptyline or B-complex vitamins can turn urine green or blue-green. - Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine. Explore patient's voiding duration, severity, and precipitating factors. Note the patient's perception of the problem and the adequacy of the patient's self-care behaviors. **[Collection of urine for diagnostic testing ]** Use of scheduled toileting (i.e. every 2 hours) can assist in obtaining urine. - A clean-catch urine specimen is collected during midstream voiding and minimizes bacterial contamination from adjacent anatomic areas - It is generally thought that urine voided at midstream is most characteristic of the urine the body is producing. - Sterile urine specimens may be obtained by catheterizing the patient's bladder or by taking the specimen from an indwelling catheter already in place. - When it is necessary to collect a urine specimen from a patient with an indwelling catheter, the specimen should be obtained from the catheter itself using the special port for specimens because specimen from the collecting receptacle (drainage bag) may not be fresh & could result in an inaccurate analysis. - Clean urine specimens can be obtained from a urinary diversion appliance into a clean container for a routine urinalysis - Specimens for culture should never be obtained directly from an existing urostomy pouch or drainage bag **[Interventions for age-related incontinence ]** Nursing interventions focus on maintaining and promoting normal urinary patterns, improving or controlling urinary incontinence, preventing potential problems associated with bladder catheterization, and assisting with care of urinary diversions. - Noninvasive, low-risk behavioral interventions are the first line of therapy for urinary incontinence   - Indwelling urinary catheters are not recommended because of the associated risk of developing a UTI  - Absorbent products can provide protection for skin and clothing but should not be used in place of definitive interventions to decrease or eliminate urinary incontinence - Scheduled voiding/Prompted voiding/Bladder training - Patient keeps track of when voiding and leaking occur to plan when to void, with increasing length of voiding intervals.  - Urgency control is addressed using distraction and relaxation techniques.  - Prompting from a caregiver for patients who have impaired cognitive function. **[Nursing dx r/t altered urinary elimination ]** Examples of Signs & Symptoms (AEB) - Subjective - Urgency - Hesitancy - Dysuria - Nocturia - Objective - Bladder distention - Retention as detected through bladder scanning - Incontinence - Use of catheterization - Frequency [Example of Possible Expected Outcomes] - Patient will verbalize techniques to prevent urinary infection & retention. - Patient will demonstrate how to properly self-catheterize/clean indwelling catheter. - Patient will achieve a normal elimination pattern free from frequency and urgency. - Patient will verbalize diet changes to incorporate to improve urinary elimination. Nursing Interventions - Education patient on bladder training - Encourage water intake - Limit coffee & caffeine - Educate on supplements - Have patient demonstrate catheter techniques - Use bladder scanning - Educate on proper hygiene - Refer to urology - Educate on floor exercises - Educate on medications - Use incontinence supplies **Chapter 39 -- Bowel Elimination** **[Physiologic process of defection ]** The parasympathetic nervous system stimulates movement & the sympathetic system inhibits movement. The autonomic nervous system innervates the muscles of the colon. Diarrhea accompanies periods of high anxiety. Flight or fight responses the body mobilizes itself for intense action, blood is shunted away from the stomach and intestines, resulting in a slowing of GI motility People who chronically worry and those with certain personality types who tend to hold onto problems and negative feelings may experience frequent constipation. When parasympathetic stimulation occurs, the internal anal sphincter relaxes and the colon contracts, allowing the fecal mass to enter the rectum **[Assessment of stoma ]** Ostomy is a term for a surgically formed opening in an organ of the body Stoma, the part of the ostomy that is attached to the skin, is formed by suturing the mucosa to the skin. An Ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma. A Colostomy permits formed feces in the colon to exit through the stoma. [Removing bag] 1. Hand hygiene 2. Empty contents 3. Remove old bag 4. Clean stoma & area 5. Inspect Area 6. Place Gauze over Stoma [Applying New Bag] 1. Measure stoma 2. Cut adhesive to match 3. Apply Skin Protectant 4. Remove Gauze 5. Attach pouch 6. Ensure bag clamp is closed 7. Document Keep the patient as free of odors as possible. Empty an ostomy appliance before it is half-full to reduce the risk of separation from the skin and leakage. **[Pt education r/t ostomy ]** - Explain the reason for bowel diversion and the rationale for treatment. - Demonstrate self-care behaviors that effectively 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. - Demonstrate a positive body image. - During the first 6 to 8 weeks after surgery consume low-fiber foods - Drink at least 2.5 quarts of fluids daily - Ileostomy output is high in potassium and sodium -- monitor electrolytes. - Fiber blockages can cause cessation of gas and/or bowel movements, watery stools with bad odor, abdominal cramping and pain, and distention, along with nausea and vomiting - Foods that commonly cause blockage to occur include nuts, corn, popcorn, coconuts, mushrooms, stringy vegetables, and foods with skins and casings **[Assessment of patient s/p colonoscopy ]** - Esophagogastroduodenoscopy (EGD): visual examination of the esophagus, the stomach, and the duodenum - Colonoscopy: visual examination of the large intestine from the anus to the ileocecal valve - Sigmoidoscopy: visual examination of the sigmoid colon, the rectum, and the anal canal Colonoscopy - visual examination of the rectum, colon, and distal small bowel using a long, flexible, fiberoptic-lighted scope. **[Preparation]** Ensure that an informed consent is signed. Preparation prior to test may involve: - Low-residue diet (low fiber) should be followed several days before the procedure. A clear liquid diet is usually ordered for 48 to 72 hours before the procedure - Multiple types of bowel preps for this procedure. - The prep is usually given as a split dose, with half being given the night before and rest the morning of the procedure. - 2^nd^ dose to be given at least 5 hours and completed at least 2 hours before the study. - The prep may be better tolerated if a straw is used, and the liquid is chilled. Some prep solutions may come with a flavor pack. - Those who cannot tolerate the oral prep or have a contraindication to large volumes of fluid may have an enema prep. - May be NPO for at least 6 to 8 hours before the study with small sips of water for meds, and nothing for 2 hours before the study. - Explain to the patient they will be sedated during the test. **[Aftercare]** - The patient may experience flatulence or gas pains because air was used to distend the intestines for better visibility. - Usual diet may be resumed once patient recovers from the sedation. - Check vital signs according to facility protocol. - Observe for signs of bowel perforation: rectal bleeding, abdominal pain and distention, fever, malaise. Warning signs of Colorectal Cancer - Rectal bleeding - Persistent change in the bowel elimination pattern or consistence of the stool - Blood in the stool - Persistent cramping or pain in the lower abdomen or gas - A feeling that the bowel doesn't empty completely after having a bowel movement - Weakness or fatigue - Losing weight without trying **[Pt education r/t diet changes that affect bowel elimination ]** - Constipation may be the result inadequate fiber in the diet, a change in lifestyle (e.g., lack of exercise), poor fluid intake, and ignoring or delaying the urge to defecate. - Constipation may also occur because of metabolic, neurologic, or psychological disorders, such as diseases within the colon or rectum (e.g., tumors), IBS, and injury to, or degeneration of, the spinal cord.  - Medications, such as opioid analgesics and calcium-channel blockers, may also cause constipation. - Changes in color, contents, odor, and appearance of stool may be related to conditions that traumatize the stomach or intestines, or that interfere with normal digestion.  - A high-fiber diet of 25 to 38 g of fiber (USDA & USDHHS, 2020) and a daily fluid intake of at least 2,000 mL aid in bowel elimination - Regular exercise improves GI motility and muscle tone, whereas inactivity decreases both. **[Enema administration ]** - An Enema is the introduction of a solution into the large intestine, usually to remove feces.  - Can be used to administer certain medications - The instilled solution distends intestine and irritates mucosa, increasing peristalsis.  - Enemas should only be used occasionally. - Rectal agents should be avoided in patients at risk of thrombocytopenia, leukopenia, immunocompromised patients. - Enemas are also contraindicated for patients with bowel obstruction or paralytic ileus, and when administration could cause circulatory overload, mucosal damage, necrosis, perforation, hemorrhage after GI or gynecological surgery - Two classifications: cleansing or retention enemas [Cleansing enemas] -- are given to remove feces from the colon - Relieve constipation or fecal impaction - Evacuate the bowel before surgery to prevent involuntary escape of fecal material during surgical procedures - Promote visualization of the intestinal tract by radiographic or endoscopic examination - Common types of solutions used for cleansing enemas are tap water, normal saline solution, soap solution, and hypertonic solution [Retention enemas] -- are retained in the bowel for a prolonged period for different reasons: - *Oil-retention enemas*: soften the stool and lubricate the intestinal mucosa, making defecation easier. About 150 to 200 mL of solution is administered to adults. - *Carminative enemas*: expel flatus from the rectum & relief from gaseous distention. - *Medicated enemas*: medications that are absorbed through the rectal mucosa. A reclining position ---specifically left side--lying with the knees flexed and the upper thigh pulled toward the abdomen if possible, but if the patient has a difficulty breathing, elevate the head of the bed slightly. **Avoid Fowler position.** - Warm the enema solution to at or just above body - Elevate the solution so that it is no higher than 18 inches. - Direct it at an angle pointing toward the umbilicus, not the bladder - Give the solution slowly over a period of 5 to 10 minutes. - Assess for dizziness, lightheadedness, nausea, diaphoresis, & clammy skin - If the patient experiences any of these symptoms, stop the procedure **immediately**, monitor the patient's heart rate and blood pressure, and notify the health care team. - Encourage the patient to hold the solution until the urge to defecate is strong, in about 10 to 15 minutes.