Exam (elaborations)
Foundations UNITEK LVN Elimination, Enema Administration & foley insertion Questions and Answers 2024
Foundations UNITEK LVN Elimination, Enema Administration & foley insertion
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Foundations UNITEK LVN Elimination,Enema Administration & foley insertion
Standard steps for all nursing procedures - answerBefore 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 - answerthe most common type of indwelling catheter. Should be
removed as soon as possible to avoid infection
stress incontinence - answerwhen urine leaks when coughing, laughing, during exercise
and certain movements that cause pressure on the bladder
urge incontinence - answerthe loss of urine in response to a sudden, urgent need to
void; the person cannot get to a toilet in time
urologist - answera 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 - answerApply 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 - answeris 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 - answera series of pelvic muscle exercises used to strengthen the
muscles of the pelvic floor
habit training - answerattempts to keep clients dry by having them void at regular
intervals; also referred to as timed voiding or scheduled toileting
documenting bowel movements - answerAmount - moderate, Color - normally brown
but affected by dietary changes, consistency - normally soft and formed
,frequency 1-3 days (individual)
Nursing interventions to avoid constipation - answerdiet high in Fiber, fruit and veg
fluid 2000-3000 mL
daily exercise
milk magnesia - answergive if constipated after 2 days - 30 mL
enema - answerthe 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 - answersoapsuds, 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 - answerlubricates 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 - answerpartial bowel obstruction
impacted feces - answerhardened stools, diarrhea can also be a consequence of
impaction
fecal incontinence - answerinvoluntary or inappropriate passing of stool or flatus
urinary retention - answerabnormal accumulation of urine in the bladder because of an
inability to urinate
, suppository - answera 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 - answerthe 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 - answerbowel 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 - answeropening - should be red and moist and protrudes (this means bag will fit
properly when attached)
nomeostasis - answerins and outs - daily water 2,500 mL (30 mL per hour)
No bowel movement for 3 days - answerNurse would need to address
As nurse should - answeridentifer 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 - answerchanged oncer per month
volume 30 mL / hr of urine for effective elimination
color - pale straw to amber
clarity - clear
odor - faintly aromatic
residual urine - 50 mL of urine that remains in bladder after voiding can lead to infection
Coude catheter - answercurved and has a rounded or bulbous tip that is easier to insert
into the male urethra when the prostate is enlarged. (usually inserted by urologist)
check for allergies - answeriodine / shell fish
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