NCLEX RN GUIDE the best of NCLEX

Basic Care and Comfort Part 2

Elimination
1. Promotion of normal elimination
  1. Urination
    1. adequate fluid intake
    2. normal adult urinary output - 30 ml/hour
    3. alternative methods to promote client voiding, such as running water
  2. Bowel elimination
    1. adequate fluid intake
    2. regular exercise
    3. regulate fruit juices, raw fruits and vegetables as needed
    4. normal bowel evacuation: varies in healthy individuals; no more than 3 movements per day to 3 times a week
2. Urinary incontinence: involuntary release of urine
  1. Types
    1. stress incontinence - sudden increase in intra-abdominal pressure (such as sneezing, coughing) causes urine to leak from bladder
    2. overflow (reflex) incontinence - bladder empties incompletely, so urine dribbles constantly
    3. urge incontinence - uncontrolled contraction of the bladder results in leakage of urine before one reaches the bathroom
    4. functional incontinence - incontinence not due to organic reasons; for instance, impaired mobility may prevent the client from reaching the bathroom in time.

Diagnosis of urinary incontinence
1. history and physical examination
2. urinalysis - tells whether blood or infection present
3. cystoscopy - tells whether abnormalities are present
4. post-void residual - measures amount of urine remaining in bladder after voiding
5. stress test - determines if urine leaks after bladder is stressed due to coughing, lifting etc.
Treatment
1. drug therapy
  1. antispasmodics and anticholinergics - relax and increase capacity of bladder
  2. alpha-adrenergic agonists - increase urethral resistance
2. kegel exercises - strengthen weak muscles around the bladder
3. behavioral training - client learns different way to control urge to urinate
4. bladder retraining
5. surgery - repair of weakened or damaged pelvic muscles or urethra
Nursing interventions -
1. provide skin care, protective undergarments
2. establish toileting schedule - provide easy access to bathroom and privacy
3. teach client Kegel exercises:
  1. stop and start urinary stream while voiding
  2. hold contraction for 10 seconds and relax for 10 seconds
  3. work up to 25 repetitions three times a day
4. prevent infection
  1. cleanse urethral meatus after each void
  2. acidify urine
  3. increase daily intake of fluids

Catheterization
1. Purposes
  1. relieve acute urinary retention
  2. relieve chronic urinary retention
  3. drain urine preoperatively and postoperatively
  4. determine amount of post-void residual
  5. accurately measure output in the critically ill
  6. obtain sterile urine specimen
  7. continuous or intermittent bladder irrigation (illustration )
2. Types of catheters and general guidelines
  1. indwelling catheter
    1. use a closed drainage system
    2. advance catheter almost to bifurcation of catheter, especially in male patients (illustration )
    3. inflate balloon within guidelines of manufacturer only after urine is draining properly, then slightly withdraw catheter
    4. secure catheter to patient's thigh, allowing for some slack to accommodate movement and to lessen drag on patient
    5. ensure tubing is over patient's leg
    6. care of indwelling catheter:
      - cleanse around area where catheter enters urethral meatus.
      - do this with soap and water during the daily bathing routine and after defecation
      - do not pull on catheter while cleansing
      - do not use powder or spray around perineal area
      - do not open the drainage system
      - avoid raising the drainage bag above the level of the bladder
      - avoid clamping the drainage tubing
      - catheter is only irrigated when an obstruction, usually following prostate or bladder surgery (e.g., potential blood clots) is anticipated

suprapubic catheter
1. placed to drain the bladder
2. achieved via a percutaneous catheter or by way of an incision through the abdominal wall
intermittent self-catheterization
1. purpose: to drain the bladder
2. employed by the client with Spina Bifida and other neuromuscular diseases; can be taught to children ages 6 to 8
3. procedure:
  - gather equipment: catheter, water-soluble lubricant, soap, water, urine collection container
  - wash hands
  - cleanse urethral meatus and surrounding area
  - lubricate tip of catheter
  - insert catheter until urine flows
  - withdraw catheter when urine flow stops
  - clean off residual lubricant from meatus
  - dispose of urine
  - wash hands

Ostomies
1. Types of ostomies
  1. ileostomy
    1. liquid to semi-formed stool, dependent upon amount of bowel removed
    2. may skew fluid and electrolyte balance, especially potassium and sodium
    3. digestive enzymes in stool irritate skin
    4. do not give laxatives
    5. ileostomy lavage may be done if needed to clear food blockage
    6. may not require appliance; if continent ileal reservoir or Kock pouch
  2. colostomy
    1. ascending - must wear appliance - semi-liquid stool
    2. transverse - wear appliance - semi-formed stool
    3. loop stoma
      - proximal end - functioning stoma
      - distal end - drains mucous
      - plastic rod used to keep loop out
      - usually temporary
    4. double barrel
      - 2 stomas
      - similar to loop but bowel is surgically severed
    5. sigmoid
      - formed stool
      - bowel can be regulated so appliance not needed
      - may be irrigated
2. Stoma assessment
  1. color - should be same color as mucous membranes
  2. edema - common after surgery
  3. bleeding - slight bleeding common after surgery
3. Psychological reation to ostomy
  1. disturbed body image
  2. anxiety related to feared rejection
  3. ineffective coping related to ostomy care

Sleep
1. Factors affecting sleep
  1. Physical illness
  2. Drugs
  3. Lifestyle
  4. Excessive daytime sleep
  5. Emotional stress
  6. Environment
  7. Exercise/fatigue
  8. Food intake
2. Sleep disorders
  1. Bruxism: tooth grinding during sleep
  2. Insomnia: chronic difficulty with sleep patterns
    1. initial insomnia: difficulty falling asleep
    2. intermittent insomnia: difficulty remaining asleep
    3. terminal insomnia: difficulty going back to sleep
  3. Narcolepsy: fall asleep without warning
  4. Sleep apnea: intermittent periods of not breathing while asleep; usually due to problems with upper airway; can be treated with CPAP (continuous positive airway pressure) at bedtime
  5. Sleep deprivation: decrease in the amount and quality of sleep
  6. Somnambulism: sleepwalking, night terrors, or nightmares
  7. Depression
    1. secondary to disease process
    2. can occur with any sleep disorder
3. General nursing interventions for promoting restorative sleep
  1. Comfort measures
  2. Medications: sedatives, hypnotics
  3. Sleep routine
  4. Encourage daytime activity
  5. Eliminate naps
  6. Relaxation techniques
  7. Environmental control
  8. Limit alcohol, caffeine, and nicotine in evening

Pain
1. Theories of pain
  1. Specificity theory proposes that pain can be initiated only by painful stimuli.
  2. Pattern theory - stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and muscles to respond.
  3. Gate control theory - pain impulses can be altered or regulated by gating mechanisms along nerve pathways. This theory explains how past and present experiences can influence the perception of pain.
2. Variables influencing the perception of pain
  1. Culture and social groups shape attitude towards pain
  2. Religious beliefs regarding reasons for pain
  3. Previous experience with pain
  4. Age
  5. Sex
  6. Coping style
  7. Family support
3. Types of pain
  1. Acute - pain episode lasting up to 6 months
  2. Chronic - pain lasting longer than 6 months. May be intermittent or constant.

Medical treatment
1. Pharmacologic intervention (discussed in Lesson 6: Pharmacological and Parenteral Therapies)
2. Nonpharmacologic intervention
  1. acupuncture
    1. oriental method: insert fine needles at specified body sites
    2. unknown how acupuncture works physiologically
  2. relaxation techniques - biofeedback, visualization, meditation and hypnosis, to help client control anxiety
  3. electronic stimulation such as transcutaneous electric nerve stimulation (TENS) - electrodes applied over the painful area or along nerve pathway
  4. distraction - focusing client's attention on something other than pain
  5. massage - generalized cutaneous stimulation of the body. Makes the client more comfortable due to muscle relaxation
  6. ice and heat therapies - effective in some circumstances. Ice may decrease prostaglandins which intensify the sensitivity of pain receptors
  7. guided imagery - using one's imagination in a guided manner to achieve a specific positive effect
3. Nursing interventions in pain
  1. assess pain using pain assessment scale
  2. assess client's coping strategies and factors that produce ineffective coping
  3. teach client appropriate strategies to deal with pain

Communication
1. Cross-cultural communication - guidelines
  1. Findings of a lack of effective communication
    1. efforts to change the subject - client may not understand what the nurse is saying
    2. lack of questions - client may not understand what was said
    3. nonverbal cues such as blank expression, lack of eye contact
  2. Nursing interventions
    1. use simple sentence structure and pantomime while talking
    2. use visual aids
    3. discuss one topic at a time
    4. use any words you know in the client's language
    5. ask among the client's family and friends if anyone could serve as interpreter
    6. obtain phrase books or use flash cards
  3. Cultural interpretations
    1. silence
    2. touch
    3. eye contact
2. Client with hearing loss
  1. Findings of hearing loss
    1. speech deterioration
    2. indifference
    3. social withdrawal
    4. suspicion
    5. tendency to dominate conversation
  2. Nursing interventions
    1. speak slowly and distinctly; do not shout
    2. face client directly
    3. make sure your face is clearly visible
    4. before the discussion, tell client the topic you are going to discuss
    5. insure that client has access to hearing aid and that it is functional
    6. keep sentences short and simple
    7. use written information to enhance spoken word

Client with aphasia
1. Injured cerebral cortex blocks some language-related functions
2. Nursing interventions
  1. face client and establish eye contact
  2. avoid completing client's statements
  3. use gestures, pictures, and communication boards
  4. limit conversation to practical matters
  5. use the same words and gestures for objects
  6. keep background noise to a minimum
  7. do not shout or speak loudly
  8. give the client time to understand and respond
  9. if client has problems speaking ask "yes" or "no" questions
Client with stroke
1. Approach client from side of intact field of vision
2. Remind client to turn head in direction of visual loss to compensate for loss of visual field
3. Explain location of object when placing it near the client
4. Always put client care items in same places
5. Put objects within client's reach, and on unaffected side
6. Encourage client to repeat sounds of the alphabet
7. Speak slowly and clearly
8. Use simple sentences with gestures or pictures
9. Reorient client to time, place, and situation
10. Provide familiar objects
11. Minimize distractions
12. Repeat and reinforce instructions
Client with dementia
1. Be calm and unhurried
2. Keep conversations short and focused
3. Do not ask the client to make decisions
4. Be consistent
5. Avoid distractions
6. Use reality orientation techniques

Alternative and Complementary Medicine
1. Herbal therapy
  1. Used as dried herbs in capsules or tablets, tinctures, teas, ointments
  2. Use only products standardized with a specific amount of active ingredients
  3. Some may interfere with medications
2. Chiropractic treatment
  1. Effective by manipulating the musculosketal system
  2. Manipulation to put the vertebrae in proper alignment
3. Acupuncture and acupressure
  1. Based on belief that channels of energy are blocked causing diseases or discomfort
  2. Acupuncture is primary treatment used by physicians of Chinese medicine
    1. insert fine needles at specific points to open channels of energy (meridians)
    2. used to decrease pain and to treat or prevent illness
  3. Acupressure
    1. uses gentle pressure at specific points
    2. used for prevention and relief of muscle tension

Therapeutic massage
1. Manipulates the soft tissue of the body and assists with healing
2. Can be either relaxing or energizing
3. Is contraindicated for a client with phlebitis, thrombosis, or infectious skin diseases
Aromatherapy
1. Uses oils produced by plants for inhalation or topical application
2. Different scents are thought to produce different responses in the body
Reflexology applies pressure to specific areas of the feet thought to correspond with all the different parts of the body
Relaxation therapy
1. Rhythmic breathing
2. Progressive relaxation
Yoga
1. Treatment of the mind-body connection
2. Can tone the muscles that balance all parts of the body and control the emotions and mind through correct posture and breathing

All individuals require the same nutrients, but the amounts vary according to factors such as age, weight, activity level, and health state.
The energy value of foods is defined in calories; only proteins, fats and carbohydrates provide calories.
The average adult drinks 2 to 3 liters of water per day.
The normal thirst mechanism in the elderly may be diminished and they may need encouragement to drink sufficient water to prevent dehydration.
Discontinue ROM exercises at point of pain.
Use rubber suction tips on crutches and canes to prevent slipping.
Prevent deformities and complications such as contractures, thrombophlebitis, and pressure ulcers by turning and positioning the client in good alignment.
There should be at least two inches between axilla and top of arm piece of crutch to prevent pressure on the brachial plexus.
The majority of residents in nursing homes are incontinent.
Incontinence is not a normal sequela of aging.
Initiate pain relief before the pain becomes unbearable.
Essential amino acids cannot be synthesized. They must be ingested daily.

Weight is maintained when daily food intake equals energy expenditure.
Age affects daily requirements: young, old, pregnancy, lactation.
Weight loss is a long-term process and patients need long-term support.
Reconstructive surgery may be required after large amount of weight loss.
Support groups are available for patients losing weight.
Increased fiber in the diet may cause flatulence.
In constipation, increase fluid to 3000 cc/day (unless contraindicated).
Small frequent loose stools or seepage of stool are often indicative of a fecal impaction.
Use transparent drainage bag initially for assessment of stoma and drainage.
Avoid foods that cause odor, gas, diarrhea, or may block ileostomy.
Allow the client to rate his degree of pain and the degree of relief from pain relief measures.
Self-control methods to manage pain: distraction, massage, guided imagery, relaxation, biofeedback, hypnosis.
Change ostomy appliance as needed.

Login form

Search

Nursing links

Statistics

Total online: 1

Guests: 1

Users: 0