Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Comps > Ostomy, Enema, Glucose, IV, Foley, NGT > Flashcards

Ostomy, Enema, Glucose, IV, Foley, NGT Flashcards

0
Q

What is a stoma?

A

Piece of intestine brought out of the patients abdomen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

What is an Ostomy?

A

Opening in abdominal wall for elimination of feces/urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the stoma’s purpose?

A

To divert/drain fecal/urine material

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Name the type of ostomies?

A

Gastrostomy: through abd wall into stomach (feeding)
Jejunostomy: through abd wall into jejunum (feeding)
Colostomy: opens into colon
Urostomy: urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How are ostomies classified?

A

Permanent/temporary
Anatomic location
Construction of stoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Why do you need temporary colostomies?

A

for traumatic injuries/inflammation condition of bowel.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Why do you need permanent colostomies?

A

to provide means of elimination when rectum/anus is nonfunctional.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What do you assess with periostomal skin?

A

Maceration, redness, itching, rash, excoriation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Types of colostomies and their effluent

A

Ileostomy: liquid effluent, minimal odor
Ascending: liquid, odor
Transverse: mushy, odor
Descending: solid odor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How much output for ileostomy drainage?

A

initially 500-1500 ml/day then decreased to 500-800 ml/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How do you manage a colostomy bag?

A

change ostomy appliance Q7days/pouch leaks, empty pouch 1/3-1/2 full, rinse pouch with tap water only, ensure pouch connected to drainage bag (urostomy), below kidney level, appliances @ bedside

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How often do you change stoma/dura adhesive?

A

stoma: 5-6 days
dura: 10-14 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How big do you cut wafer/skin barrier?

A

1/16”-1/8” larger than the stoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What so you assess first 48 hours post op?

A

Stoma color and excessive bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How do you prevent premature leaking?

A

Dont wear tight garments, dont extra pouch, dont empty too late

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What do you assess every 8 hours? (ostomy)

A

Color, itchiness/cleanliness of pouch, bowel/stoma function, ostomy output, periostomal skin, S/S UTI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

When should you notify the MD?

A

necrotic stoma, hemorrhage, skin breakdown, change in appearance of output, rash

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What do you document? (ostomy)

A

color, shape, size, output, condition of skin.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Dietary considerations for ileostomies?

A

chew food well, drink 8 glasses fluid/day, avoid high fiber

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Showering techniques?

A

Leave bag on, water hit back, limit shower time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is an enema?

A

instillation of solution into rectum and large intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is its purpose? (enema)

A

Dx test prep, fecal removal (impaction/constipation), stimulate peristalsis, lubrication regulate habits, pre-op prevent escape of feces, expel flatus.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Name the 4 different types of enemas?

A

Cleansing: Hypertonic (fleet enema, exert osmotic pressure), Hypotonic (tap water; distends/stimulates peristalsis/softens feces), Isotonic (NS; safest; equal osmotic pressure), Soapsuds (castile soap; distends/irrigates mucosa), Oil (lubricates feces), return flow (relieves abdominal distention).
Carminative: expel fluids
Retention: lubricates rectum and anal canal
Return flow: relieve abd distention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How long is oil retention enema retained for?

A

1-3 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are the times the enemas take effect?

A

Hyper: 5-10 mins
Hypo: 5-20 mins
Iso: 15-20 mins
Soap: 10-15 mins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Enema is given in what position?

A

L lateral sims with R knee flexed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Enema bag is how many inches above anus?

A

12” above anus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Enema bag is how many inches above mattress?

A

18”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What do you assess prior to administration?

A

MD orders, Pts last BM, Abd distention, Sphincter control, If pt uses toilet/bedpan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

How do you prepare patient? (enema)

A

explain reason for enema, relaxation-breathing techniques, use of call light, provide privacy, may feel full

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Why and how much do you lubricate?

A

3-4”, to prevent trauma and facilitate insertion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What should you do after lube and why?

A

Run some solution through tube to expel any air in the tubing b/c causes unnecessary distention.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Why do you place patient in left lateral position?

A

this side facilitates flow of solution by gravity into the sigmoid/descending colon on the L side

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

How do you insert enema tube?

A

Smoothly, slowly, toward the umbilicus bc it follows the natural contour of the rectum. Slow prevents spasms of the sphincter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Insert tube how much total?

A

7-10 cm= 3-4 inch past sphincter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Insert tube how high?

A

The higher the solution container above rectum, the faster flow and greater force in rectum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What if patient complains of fullness or pain?

A

lower container, stop flow for 30 se, and restart slower

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What position should patient be after instillation?

A

Laying down because easier to retain enema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Adverse effects to enema?

A

Fluid overload and F/E imbalance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What should enema temp be?

A

37.7 cel or 100 far

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Volume instilled by age

A

18 months: 30-150 mL
18mo-5yrs: 160-300 mL
5-12yrs: 300-500 mL
12yrs+: 500-1000mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What should you document? (Enema)

A

response to enema, adverse effects, type of enema/solution/size of tubing, volume given

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

State the purpose of glucose monitoring

A

ID trends in glucose levels, enables pt to make self-management decisions regarding diet/exercise/meds, detect hyper/hypoglycemia, ID where changes in tx should be made

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What is the purpose of insulin?

A

provide glyoemic control for nutritional needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Name types of Insulin used

A

Rapid: lispro “Humalog,” aspart (onset 5-15 mins//peak 30-90//duration 2-4hrs)
Short acting: Regular (CZI) (onset 30mins//peak 2-4hrs//duration 6-8hrs)
Intermediate: NPH, Lente (onset 1-2 hrs//peak 6-12 hrs//duration 18-24 hrs)
Long acting: Ultra lente (onset 6-8hrs//peak 12-16 hrs//duration 20-30hrs)
Very long acting: Lantis “glargine” (onset 1 hr//No peak//duration 24 hours)

45
Q

When should BG be checked for RISS (regular insulin sliding scale)?

A

Immediately before insulin dose admin

46
Q

What kind of pts have RISS?

A

Pts whose baseline insulin requirements are hard to predict, NPO pts, high than desired GLU level before meals

47
Q

When is BG measured?

A

Qac and Qhs

48
Q

QC means?

A

quality control

49
Q

What do you assess for insulin preparation?

A

color, clarity, expiration date, drug compatability

50
Q

Which insulin is only one you can give IV and cont?

A

Regular insulin

51
Q

Name the supplies you need for insulin prep

A

alcohol pad, insulin syringe, insulin vial

52
Q

What is independent double check?

A

another RN/LVN verify amount aspirated. Vial still attached

53
Q

Which one do you withdraw first?

A

clear then cloudy

54
Q

When should insulin be given?

A

Qday at a chosen site x1 week

55
Q

How far apart should injections be?

A

1.5” apart at a site area each day

56
Q

Injection sites?

A

butt, love handles, stomach, arms, thighs

57
Q

Where should you avoid injecting?

A

2” from umbilicus, atrophied, hypertrophied, reddened, scarred or edematous tissue

58
Q

Complications of same needle/site

A

lipoatrophy, lipohypertrophy, lipodystrophy

59
Q

How long can you store insulin?

A

OK for 1 month after opening, not to exceed 86 degrees (room temp)

60
Q

How long can you store insulin with refridgeration?

A

1 month, 36-46 degrees

61
Q

Hypoglycemic S/S

A

dizzy, diaphoresis, deceased LOC, trembling, HA, tachycardia, seizures

62
Q

Hyperglycemia S/S (gradual onset)

A

dehydration, polydipsia, polyphagia, polyuria, N/V, fruity breath increased breathing

63
Q

State purpose of IV therapy

A

fluid restriction, electrolyte replacement, titrated meds, access to vein.

64
Q

How do you prepare medication?

A

MD order/Kardex/MAR
Gather supplies from the supply room
3 checks (at time of pulling, prior to spiking, before infusion)
date/time/initial label

65
Q

What do you inspect IV bag at onset of shift/bag change for?

A

type of solution, additives, cloudiness/precipitation, label

66
Q

Complications of IV maintenance

A

Infiltration (stop infusion, remove catheter, restart at another site)
Phlebitis (stop infusion, warm compress, restart at another site)
Extravasation of vesicant drug is considered a medical emergency (stop infusion, disconnect tubing from cath and aspirate any fluid left in hub, elevate arm, cold/hot, take picture)

67
Q

Why would the alarm trigger?

A

IV solution low, occlusion, air in tubing, tubing not high enough

68
Q

Which med do you run first?

A

shirt first, longest med last

69
Q

What to do if drug is not in dictionary of pump?

A

basic secondary screen to add drug to IV pump

70
Q

How often do you change bag?

A

IV bag: 24 hours

71
Q

How often do you change tubing?

A

Q96H if cont, Q24H if intermittent

72
Q

How ofter do you check IV site?

A

Q2H for redness, swelling, dressing intact

73
Q

Categorize solutions (IV)

A

Hypertonic: D5NS, D51/2NS, D10NS, D20W, D50W
Hypo: 1/2NS
Iso: NS, D5W, LR

74
Q

What are some nursing responsibilities for foley?

A

insertion, irrigation, removal, change per MD order

75
Q

State the purpose of indwelling catheter

A

provide continuous bladder drainage/irrigation, prevent urine from contracting infection (skin breakdown) post perineal surgery, relieve discomfort from bladder distention, assess residual urine, manage incontinence, accurate I&O

76
Q

State purpose of external catheter

A

collect urine/control urinary incontinence, permit physical activity while controlling UI, prevent skin irritation as a result of UI

77
Q

State purpose of straight catheter

A

obtain sterile urine sample, measure residual urine, empty bladder before surgery

78
Q

What should you assess prior to catheterization?

A

MD orders, allergies, ID patient

79
Q

How much can you drain at once and why?

A

700-1000 mL d/t hypovolemic shock

80
Q

What is the commonly sized balloon?

A

10mL

81
Q

Name your equipment (foley)

A

sterile gloves, syringe, foley cath, cotton balls, drape, tape, benadine, forceps, collection bag, lubricant

82
Q

How much do you go in M/F?

A

6-9” for males 3-4” for females

83
Q

How much do you lubricate the catheter?

A

5-6” males 1-2” females

84
Q

Why do you advance the catheter 2” farther after urine?

A

to be sure it is fully in the bladder

85
Q

How much urine do you collect for specimen?

A

3 mL for culture, 30 mL for UA

86
Q

Where do you tape the catheter?

A

upper thigh males, inner thigh females

87
Q

Instructions on foley catheter

A

never pull on it, below bladder, shower than bath, ensure no kinks/twists, S/S UTI

88
Q

What do you assess Q4H?

A

bladder distention, UO, leakage, S/S UTI, cath secured, tubing not looped, bag below bladder

89
Q

What are unusual orders after d/c?

A

Monitor I&Os Q8H for 24 hours after D/C

90
Q

How much do you irrigate with?

A

30-50 mL NS for cath irrigation, 100-200 mL for bladder irrigation

91
Q

Extra information (foley)

A

document french size, peri care, UO. Clean with soap and water Q8H. Empty bag when 3/4 full

92
Q

State 4 reasons for NGT insertion

A

decompression, feeding, lavage, gastric analysis

93
Q

When do you use vented tubes? (salem sump)

A

continuos suction. Vent lumen allows in flow of air to prevent vacuum of gastric tube adheres to stomach, so stomach irritation avoided.

94
Q

When do you use non vented tubes? (levine)

A

gravity drainage or low intermittent suction

95
Q

Complications from insertion

A

aggravated esophagus, esophageal ulcer, encephalitis

96
Q

What position will patient be placed?

A

high fowlers. easier to swallow and gravity helps

97
Q

Why does patient need gag reflex/cough reflex?

A

accidental placement into lungs is much higher

98
Q

Why do you need water soluble lubricant?

A

it dissolves. Oil based doesnt and can cause respiratory problems

99
Q

Nam the supplies you need (NGT)

A

safety pin, lopez valve, cup of water, rubber band, tape, emesis basin, lube, salem sump, stethoscope, 60 mL syringe, gloves, penlight, towel

100
Q

How much do you flush with (NGT)

A

10-30mL

101
Q

What do you assess for (NGT)

A

abd distention, BS, N/V, drainage color, patency

102
Q

Why do you tilt your head forward

A

helps tube into esophagus and not into airway

103
Q

when do you check residuals

A

prior to med/feedings, Q4H for cont feeding, Q8H if pt is NPO

104
Q

When collecting specimens, what are some nursing responsibilities?

A

check MD order, standard precautions, label specimen, timely, C&S to lab ASAP or refrigerated, documented

105
Q

Urine Speciemen

A

test glucose, SG, pH, albumin C&S culture for bacteria growth and sensitivity to antibiotics, protein ketones
Collection (clean: midstream specimen; sterile: catheter/indwelling cath- clamp 30 min prior, gloves, clean port with alcohol)

106
Q

Stool Specimen

A

analyze for tumors, hemorrhage, infection
tests for pus, OB, ova and parasites
Guaiac test (FOBT): colorectal screening test, Hct slide test (repeat x3times)
collection (chemical preservatives, aseptic tech, label, lab on time, document)

107
Q

Sputum

A

ordered to ID organisms growing

3 types: C&S, acid fast bacilli (AFB) x3 days, cytology to ID cancer cells x3days.

108
Q

Throat swabs

A

AC meals or 1 hr prior, tilt head back “AHH”- use tongue depressor if pharynx isnt visible, swab tonsils or exudate

109
Q

Nose culture

A

blow nose, check nostril patency, swab inflamed mucosa or exudate and advance into nasopharynx.

Comps (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions