NUR141_3flshcards.txt

• • Culture: americans bathe too much according to some
• Communal bathing
• • Socioeconomic Class: where are poor and homeless going to bathe?
• • Spiritual Practices: Orthodx jews weird bathing rituals for women
• • Developmental and Knowledge Level: advanced age can hinder good hygiene, mentally disabled, young kids
• • Health State-dementia, or physically unable to bathePersonal Preferences-

• o helps patient to relax
• o promotes circulation
• o provides sensory input
• o improves self- image
• o builds nurse/patient relationship
• o back rubs increase venous return, two hands up center of back, across the shoulders and down with palms
• o touch
• ask about bathing habits, normal hygiene practices, past surgeries ( note scars), note bruises

• • Patient wishes
• • Ability to assist-Do not do for a patient what they can do for themselves. Walk them into the shower and check.
• • Privacy-always knock if door is closed
• • Warmth-do not leave people uncovered as you bathe them.
• Your attitude! Be pleasant
• Safety-suggest family put up safety bars, shower chairs, non skid mat with plastic bench.

• • Bed – usual. Partial-patient can help, complete care-you are doing it, self-care-patient is doing it
• • Bag bath-filled with premoistened towelettes with lotion. Bag is in a warmer and then used in place of regular bath. Do not leave pee or poop on skin.
• • Shower or Tub - need doctor’s order

• Oral care- first thing in a.m., chemo therapy might require oral care every two hours to combat infections, thrush, yeast infection. Poor oral care= heart disease
• Hair care-wet and dry shampoos available
• –Shaving, if on blood thinners do not let use safety razors, instead use electric razor
• • Eyes, ears and nose
• • Nail and foot- do not cut nails, podiatrists do it. You can file the nails with an emory board.
• • Perineal - vaginal care, uncircumcised male, perfect for bacterial growth. Females: wash front to back
• Males: uncircumcised males need flap washer SMEGMA-odor that occurs on accumulation

• existing skin breakdown
• poor hygiene
• poor nutrition
• incontinent-remove poop and pee please
• patients on bed rest-will start to breakdown from simply being in bed

• • Privacy- do you really want to pee and poop in public?
• • Position- sitting up right for better use of abdominal muscles.
• • Hygiene- wipe well, if they can’t you can.
• • Schedule-first thing in a.m., after a meal, nocturia=night time voiding kidney function starts to decline at 40.

• · Beside commode
• · Bedpan-regular/fracture or slipper; fracture pans are small and for hip fracture patients
• · Urinal
• · Diapers- “attends”, incontinence pads for undies,
• · Pads
• · Pull-upsExternal catheters-“condom catheters” or “Texas catheters” 2.5 cm into head of penis, change every 24 hours
• Bathroom

If patient can assist – Elevate head of bed 30 degrees, instruct patient to bend knees and raise hips to sit on bedpan. Raise head of bed to highest sitting position the patient can tolerate.


If patient is unable to assist – Keep head of bed flat, roll patient to side, place bedpan against patient’s buttocks and roll patient onto bedpan. Raise head of bed to highest sitting position the patient can tolerate.

• ANURIA-no urine
• DYSURIA-
• FREQUENCY
• GLYCOSURIA
• NOCTURIA
• OLIGURIA-less the 30 mL/hr
• POLYURIA
• PROTEINURIA
• PYURIA-

• · URGE- can’t make it to bathroom
• · MIXED-both stressed and urge
• · OVERFLOW-retention of urine in the bladder and then it leaks, neurological problem
• · FUNCTIONAL-dementia or cognitive problem, body gives signal but it is not recognized by impaired
• · TRANSIENT-incontinence issues for less than six months e.g. stint taken out of urethra
• · REFLEX-quadrapalgia or parapalegia
• · TOTAL-due to some kind of trauma to the area, sometimes bladder is nicked in surger.
• · STRESS-increase of abdominal pressure, (sneeze, cough) 80-85% women

• • Pharmacologic Treatment- deterol and ditropan
• • Prosthetic Supports for the Bladder Neck- pessaries, a prosthetic support, a hard ring of rubber. Put in vagina and supports bottom of bladder, NIH.gov
• Behavioral Techniques-transducer in rectum of male or vagina of female. Isolates certain muscles that they can then perform exercises. Consistency is vital.

• · Timing- do not ignore the signal, dementia patients sometimes ignore this signal
• · Positioning-upright is preferable
• · Privacy
• · Nutrition-fiber
• · Exercise-abdominal strength is critical

• · Constipation-hard dry stool
• · Organic Changes (innervation of the rectum)-this area may be damaged
• · Local Causes- hemorrhoids, rectal surgery,
• · Extreme debilitation
• · Cognitive Impairment

• · Constipation- some patients misunderstand what it is-it isn’t not pooping
• · Risk for constipation-no fiber, not enough water, hereditary,
• · Perceived constipation-misinformation about constipation
• · Diarrhea-several liquid stools during the course of the day. Accompanied by intestinal cramps. Have patient describe diarrhea. Frequent watery stools.
• · Diarrhea is the body’s way of getting rid of something bad.

Pedialyte for children

STOMA-rosebud looking, moist mucus membrane

ILEOSTOMY-stool that comes out of here is always liquid, removal of large intestine would require this procedure. Must wear bag, always danger of skin breakdown

• Sigmoid-done in the area of the of the sigmoid
• Descending- to the patients left side. Fecal material is actually formed stool
• Transverse- Top of intestine, watery stool, patient must wear bag
• Ascending-patient’s right side, watery stool

• keep the patient as odor free as possible
• inspect the patient’s stoma regularly – dark red color and moist, if not, report it.
• note the size of the stoma
• keep the skin around the stoma clean and dry because many of the secretions break down the skin
• measure patient’s Intake and output
• Explain each aspect of care and teach the patient to care for the ostomy
• Encourage participation in care

• Protect the skin
• Collect the fecal drainage
• Control Odor
• Empty ostomy pouch when 1/3 full
• Replace pouch every 3-7 days and prn
• Rinse with tepid water and wipe distal 2 inches with tissue before closing
• Colostomy-perstalsis returns in 2-5 days after surgery

• –Stool
• –Sputum
• –Urine

• Routine Urinalysis-no sterile technique
• • Clean-Catch or Midstream- pee a second, then wipe, then pee again in jar
• • Sterile Specimen for Indwelling Catheter
• • 24-Hour- on ice in patient’s bathroom. All pee is saved til the next morning in the jar.

• Fecal Occult Blood-
• Feces (general)

• – Saliva
• – Nasal and Sinus Secretions
• – Dead Cells
• – Bacteria

• Administer oral hygiene q2hours
• - Keep nares clean
• - Help control local irritation
• - Tape tube securely to nose, pin to gown
• - Encourage patient to verbalize concerns
• - Document skin care

• Cylinders
• Wall Outlets

• Usually at 50 to 60 pounds per square inch (psi) of pressure
• Specially designed flow meter is attached to the outlet
• A valve regulates the oxygen flow

• Regulator is used with two gauges
• The one nearest the the tank shows the pressure or amount of oxygen in the tank
• The other gauge indicates the number of liters per minute of oxygen being released

• Measured as liters per min
• Example: 2L/min

• • Nasal Cannula
• Low flow- 1-6L/min 24-44%
• • Mask
• • Simple mask
• – Low Flow 6-10L/min 35-60% (never use below 5 L/min)
• • Partial Rebreather
• – Low Flow 6-15 L/min 70-90%
• • Nonrebreather
• – Low Flow 6-15 L/min 60-100%
• • Venturi mask
• – High Flow 4-10 L/min 24-55%

• skin care
• dry mucous membranes
• humidification with masks
• comfort
• correct positioning of oxygen appliance

• • Avoid open flames
• • No smoking
• • Check electrical equipment
• • Avoid synthetic fabrics, no polyester, cotton is good! No petroleum products.
• • Avoid oils