NI, Caths & Irrigation
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| Nursing Intervention Def | Specific nursing activities or actions that a nurse must perform to prevent complications, provide comfort & promote, maintain & restore health
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| How to determine interventions (2) | cause of problem; what can I do to fix problem
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| Guidelines for Intervention (8) | Interventions to reduce or eliminate problem, look at goal, identify strengths, individualize nursing actions, be realistic, consistent therapies & utilize other resources, teach whenever possible, scientific rationale - reason, expected affect & hazards
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| When writing NI's (5) | date, verb, subject, descriptive phrase, signature
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| Implementation (3) | put plan into action, record everything, when doing intervention, reaccess to see if plan is working. *no less than 2 or 3 interventions for every goal*
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| Interpersonal communication methods/processes (4) | reading, writing, speaking, listening
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| Social vs interpersonal | social is equal exchange; interpersonal/therapeutic is patient centered - meets needs and is unequal return
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| 3 steps involved in interpersonal communication | listening, understanding, supporting
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| Goals for interpersonal communication (3) | establish relationship, work w/ them, want to accomplish
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| Communication Process - 3 steps | Perception (receiving), Evaluation (sensory reaches brain where its evaluated), Transmission (give response)
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| Methods for communication (2) | verbal & nonverbal
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| Verbal def | written or spoken, least reliable form - doesnt include emotions
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| nonverbal def | not spoken or written - incorporates senses and emotions
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| Categories of nonverbal (senses)(5) | Vocal, action, object, space (amount), touch
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| Ineffective styles of communication (5) | giving advice, false reassurance, dont be judgmental or stereotypical, avoid being defensive,changing subject of conversation
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| Factors to improve communication(3) | Communicate empathy (understanding feelings, listening and conveying feelings), Communicate respect (dont argue/make fun of),Communicate warmth
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| respect def | belief in value and potential of person
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| Factors that encourage communication (6) | Acknowledging, offering of self, open ended questions, reflecting/restating/phrasing, silence - good thing along w/ touch, listening
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| Summary in roles of communication (5) | decrease pt anxiety, minimize nurses verbal participation, allow pts to express negative feelings, accepts pds of silence & remember nurses presnse can communicate alot more, dont talk down to pt
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| Cleveland Clinics Communication Technique (HEART) | Hear story, Empathy, Apologize, Respond to problem, Thank pt
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| Catheters def & size | long, slender, hollow tube used to w/drawl drain or inject fluid through a body opening - balloon inflats and thats how it stays in place available in 14,16,18 for normal adult
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| Catheterization def | removal of urine from urinary bladder by inserting a tube through the urthera
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| Categories of caths (2) and their sub categories (2,5) | Straight-robinson(no balloon),coude(curved tip used in pt w/enlarged prostate);Retention-foley (inflate balloon),3x lumin(for irrigating cath/continuous drainage),malecott(2-4wings,no balloon, nephrostomy in surgery) depezzer(surgery only cystomy), coude
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| potential complications for caths (3) | 50% or more pts develop UTI's, become septic, avoid caths to avoid problems
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| Indwell cath complications (5) | pain, bladder spasms, urtheral erotion, peri-uretheral absess, atrophy
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| Purposes for straight caths (4) | obtain sterile urine specimen, measure residual urine (amt left in bladder after voiding),used in short term surgery, relieve bladder distension & provide gradual decompression of over-extended bladder
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| Purposes for Retention Caths (5) | Keep incontinent pt dry, provide for continuous bladder irrigation, prevent urine from coming in contact w/ incision, spliint urethra after surgery, keep accurate measurement of output
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| Prep of Equipment for caths (3) | need order - mostly PRN, if pt retaining urine, never w/drawl great than 1000ml - cause hypovolemic shock & puts pressure on nerves, check order for size - check for infection & C&S
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| Charting for cath care | pt tolerance, color & amount; self pts can clean themselves w/clean gloves b/c its their own organisms
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| Different Aspects of Cath Care (3) | Proper drainage, Protect against accidental dislodgment, Prevent infection
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| Removing Cath | Need order to discontinue, make sure balloon size to ensure its all out - pull back on syringe to ensure all water out, empty bag & record output, afterwards can pts still void? - if greater than 8 hours then theres a problem
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| Irrigation def | Flushing/washing out using a specified solution - taken out immediately
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| Bladder irrigation def | When intro of fluid to bladder and its immediate removal
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| Bladder irrigation purposes (2) | maintain patency of cath, treat bladder infection or inflammation by irrigating w/ a medicated solution
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| Different option for irrigation (3) | open, closed, clamping with rubber band
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| Open irrigation def | open system & separate from cath
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| Closed irrigation def | Either continuous or intermittent, DR orders frequency; if intermittent temp close of line/bag - bladder irrigation - you need 200ml, irrigating cath - 30-50ml - remember to deduct & use syringe
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| Documentation of irrigation (3) | what solution used, amount, pt response, returns - clear,mucus,blood?
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| Bladder instillation (3) | Stays in place - ordered amount of time (usually 30-60 min), used in severe inflammation or infection, remember to deduct from output
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Created by:
breinard
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