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Foundations Unitek LVN Elimination, Enema Administration & foley insertion
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Foundations Unitek LVN Elimination, Enema Administration & foley insertion
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FOUNDATIONS UNITEK LVNELIMINATION, ENEMA ADMINISTRATION
& FOLEY INSERTION
h Standard steps for all nursing procedures - Before skill - refer to medical record, care plan/kardex for
special interventions
hand hygiene, introduce yourself (yr name and title) privacy, ask pt to state name and DOB, check wrist
band, check Dr. orders, explain procedure and answer questions - Be reassuring
bed at proper height
Foley catheter - the most common type of indwelling catheter. Should be removed as soon as possible to
avoid infection
stress incontinence - when urine leaks when coughing, laughing, during exercise and certain movements
that cause pressure on the bladder
urge incontinence - the loss of urine in response to a sudden, urgent need to void; the person cannot get
to a toilet in time
urologist - a physician who specializes in diagnosing and treating diseases and disorders of the urinary
system of females and the genitourinary system of males
Crede's method - Apply pressure to suprapubic region with fingers while bearing down & holding our
breath. Massage to push out urine eg. paralysed patient.
Do NOT perform on spinal cord injury clients. This can cause autonomic dysreflexia which is a medical
emergency of increasing blood pressure.
bladder training - is a behavioral modification treatment technique for urinary incontinence that Involves
placing a patient on a toileting schedule. Bladder after use of catheter. Clamp tube 2 hours to allow
bladder to feel sensation of having urine fill again (under Dr.'s orders)
kegal exercises - a series of pelvic muscle exercises used to strengthen the muscles of the pelvic floor
habit training - attempts to keep clients dry by having them void at regular intervals; also referred to as
timed voiding or scheduled toileting
,documenting bowel movements - Amount - moderate, Color - normally brown but affected by dietary
changes, consistency - normally soft and formed
frequency 1-3 days (individual)
Nursing interventions to avoid constipation - diet high in Fiber, fruit and veg
fluid 2000-3000 mL
daily exercise
milk magnesia - give if constipated after 2 days - 30 mL
enema - the placement of a solution into the rectum and colon to empty the lower intestine through
bowel activity. Must get Dr.'s orders. Listen for bowel sounds
Patients should not rely on enemas to maintain bowel regularity because enemas do not treat the cause
frequent enemas disrupt normal defecation reflexes, resulting in dependency on enemas for elimination
and constipation
enemas should not be given to pts with appendicitis because rupture of the appendix may occur
room temperature to avoid cramping
if resistance is met when inserting enema tubing into the rectum pull back on tubing and reposition
before trying to reinsert.
cleansing enema - soapsuds, stimulates peristalsis thorugh distention and irritation of colon and rectum,
average adult is 500-1000ml. Usually prep before surgery - colonostomy or before GI diagnostic
procedure
Most common type of enema
stimulates peristalsis by instilling large volume of fluid into distal bowel
helps to completely empty the colon of feces completely
oil enema - lubricates stool and intestinal mucosa. Place pt in left side sims and ask to hold for 30
minutes (make sure to document volume and size of bowl movement, hard stool/blood/mucus
secondary consequence of constipation - partial bowel obstruction
, impacted feces - hardened stools, diarrhea can also be a consequence of impaction
fecal incontinence - involuntary or inappropriate passing of stool or flatus
urinary retention - abnormal accumulation of urine in the bladder because of an inability to urinate
suppository - a cone-shaped, solid drug that is inserted into a body opening; it melts at body
temperature. MUST check label before inserting as not always for bowel. Should be inserted whole
length of finger.
colostomy - the surgical creation of an artificial excretory opening between the colon and the body
surface. Stool depends where placed on colon - different bags empty into toilet. can take bags on and off.
MUST keep skin very clean to prevent breakdown. If not stuck properly feces will seep out.
ileostomy - bowel diversion which processes liquid fecal content from the small intestine to be
eliminated via the stoma. Nutrition different to colostomy. Needs to drink more fluid and more frequent
emptying of bag.
stoma - opening - should be red and moist and protrudes (this means bag will fit properly when
attached)
nomeostasis - ins and outs - daily water 2,500 mL (30 mL per hour)
No bowel movement for 3 days - Nurse would need to address
As nurse should - identifer x 2
know prior diagnosis, careplan, kardex
special inteventions
educate and promote patient's invovement
involve family and friends - keep updated
assess patient's tolerance
be alert for signs and symptoms of discomfort and fatigue
be transparent in your care - gain trust
call bell always within reach
bed in low position as you leave the room
clean up supplies hand hygiene
document
report unexpected outcomes
Foley catheter - changed oncer per month
volume 30 mL / hr of urine for effective elimination
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