FINAL Flashcards
(39 cards)
indications for a CBI
- to prevent formation & to remove blood clots in patients bladder
- to instill medication
- to prevent venous hemorrhage following genitourinary surgery
what is the patient at risk for with a CBI?
Over-distension of the Bladder – Due to clot formation and obstruction of drainage system. May lead to increased bleeding/pain/rupture of bladder
Bleeding and Hemorrhage – Related to surgical process. Can be caused by over-distension of bladder
Pain – Meatal trauma due to tension on catheter. Bladder spasm related to over-distension
Infection – Nosocomial infections
TUR syndrome??? syndrome is fluid overload and iso-osmolar hyponatraemia during TURP from large volumes of irrigation fluid being absorbed through venous sinuses
Nursing Actions for over-distended bladder:
What goes in MUST come out (+ plus renal output)
Assess bladder for distention q1-2H
Adjust rate to obtain clear returns and so you can see your fingers through the tubing:
May run wide open at first
Red returns=active bleeding
Old red=irrigation likely needed
Irrigate PRN as ordered
DO NOT let the drainage bags fill completely - empty often (when ¾ full)
what is TUR syndrome?
- fluid may be absorbed through the open surgical side & retained, increasing the risk for fluid retention, fluid imbalance and water intoxication.
- urine I&O and fluid used for irrigation must be monitored closely
- patient is also monitored for electrolyte imbalances, hyponatermia, rising bp, confusion & respiratory distress. these signs & symptoms must be reported to the surgeon immediately
TUR syndrome S&S:
Uneasy/vague apprehension Headache & dizziness N & V, abdominal distension Hypertension Bradycardia Lethargic Later S & S: Hypotension, Angina, Dyspnea, Hypoxia, Cardiovascular collapse, Neuromuscular disturbances, transient blindness, cerebral edema & coma.
Febrile non-hemolytic reaction
-happens in 30mins -6hrs
-(HLA-human leukocyte antigen)
-S&S: fever, headache, flu-like symptoms
WHAT TO DO:
-Stop
-VS
-call
-anticipate dr will give Tylenol (anti-pyretic)
Acute Hemolytic reaction
-major HLA response
-Time usually 5-15 mins (rapid, starts happening right away)
-S&S: very high fever, spikes @ 41 degrees, sweating, tachycardia, Increased Resp rate, first BP increases then BP decreases,
-want to avoid DIC
WHAT TO DO:
-Stop
-NS/VS
-CALL
(this pt will be going to ICU for dialysis)
transfusion reaction form filled out
Blood & tubing to blood bank
why do you want to make pt pee or empty their foley before you start a blood transfusion
if they are having a hemolytic reaction there will be hemolysis in their urine
Mild Allergy
-IGF
-ithcy, rash
-antihistamin (diphenhydramine - benadryl)
WHAT TO DO:
-stop
(hx of allergy - previous allergic rx)
Severe allergy ananphylaxis
-IGA
-S&S: SOB, respiratory distress/collapse
WHAT TO DO:
STOP
O2
VS
CALL
anticipate Epi (epinephrine-corticosteriods) (vasopresssion) (intubate if airway closed)
TACO (transfusion acquired cardiac overload)
S&S: JVD, SOB, crackles, cahnges in VS (increase HR, Increase RR, increase BP) WHAT TO DO: -stop -lasix (pee out volume) - may anticipate run infusion slowly
TRALI (transfusion related acute lung injury)
- agglutination in microvessels of lungs
- anticipate pt will go to ICU
What is the difference in care for a subrapubic catheter compared to a urinary one?
-catheter care is the same as a regular foley but there is a sterile dressing that needs to be changed at the site with NS
what assessments should a nurse do prior to inserting a catheter?
- check I&O’s
- last time client voided (any return’s expected, may use bladder scanner)
- understanding of procedure and medical/surgical hx, cognitive ability
- trauma informed practice
- possible obstructions eg. prostate enlargment
- mobility issues for positioning
- genitals
- reason for catheter (size of catheter to be used)
- allergies (latex)
What are some indications for urinary catherization?
Relieve urinary retention Comfort in palliative care Instillation of medication, e.g. administration of urinary radiographic contrast to aid in patient diagnosis, or chemotherapy Determine residual volume in the bladder Strict intake & output monitoring in critically ill patients Risk reduction perioperatively Gentiourinary Surgery Stage III to IV pressure ulcer
what is urinary retention?
-inability of the bladder to empty partially or completely during voiding
what are some causes of urinary retention?
- obstructions
- structural abnormalites
- medications
- neurological problems
- tissue trauma
- pregnancy
- emotional & psychological problems
- MOST common cause in men (manifestation of another problem BPH)
Complications of urinary retention
- urinary tract infection
- pyelonephritis
- stone formation
- structural damage
- ruptured bladder
- loss of bladder tone
- renal failure
Assessing the client for urinary retention
- bladder discomfort/pain
- urge to void
- restlessness, sweating, anxiety
- feeling of not emptying completely
- may void small amounts frequently
- palpation for bladder distention
- gentle percussion for dullness
- bladder scanner
- post voiding residual (greater than 100ml)
Suprapubic catheter, what is it?
- inserted through the abdominal wall (above the pubis)
- surgically inserted
- may be sutured to skin, secured with adhesive or retained with fluid-filled ballon
- may be temporary measure until urethral route passable
- continuously drains urine
Catheter inserted urinary tract prevention practices
Aseptically inserting urinary catheters Limiting use of indwelling catheters Using smallest catheter possible Cleansing urethral meatus daily Maintaining closed drainage system Maintaining free flow of urine Avoiding urethral trauma
where is a tracheostomy tube inserted?
-just below second & third tracheal ring, bypassing the epiglottis
indications for a trach?
- obstruction/edema
- respiratory nerve damage
- to protect the airway from aspiration
- as a route for suctioning
- for long term mechanical ventilation
- post laryngectomy
what are the purposes of a cuffed trach?
- allows for mechanical ventilation (there must be a cuff so it creates seal and so air can go in)
- to prevent aspiration
- pressure placed on bleeding site post-operatively after neck & throat surgery
