NCLEX Key Concepts

Clinical care notes covering bladder irrigation, assistive ambulation devices (crutches, canes, walkers), dumping syndrome, Crohn’s disease, and ulcerative colitis—key interventions, symptoms, and patient education in concise bullet points.

Alice Edwards

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1IMPORTANT NOTESBladder Irrigation•Continuous Bladder irrigation done mostly in HJRP•This is a three way catheter that keeps blood from accumulating•This is done with normal saline•Color of the urine should slowly progress to an amber colorOThe initial voidingfollowing removal may be uncomfortable, red in collorand contain dots. Thecolor of the urine should progress toward amber in 2 to 3 days.0On the fourth day the urine should be clear -4t-day if you see blood thisis NOT a good thing0If bright-red or ketchup-appearing (arterial) bleeding with clots is observed, the nurse shouldincrease the rate•If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow),turn offthe CBI andirrigate with 50 mL of irrigation solution using a large piston syringe.0Contact the primary care provider if unable to dislodge the clot.•Record the amount of irrigating solution instilled {generally very large volumes) and the amount ofreturn. The difference equals urine output•Instruct the client to not try to push pee0The catheter has a large balloon (30 to 45 mL) that is taped tightly to the leg. creating tractionso that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. Thismakes the client feel a continuous need to urinate.OTell patient not to push (muscle spasms) can cause more bleeding■Once an obstruction is ruled out administer an antispasmodic to stop spasms•Expected output 150-200ml q2-3hr (normal is 30ml/hr)OInstruct the client that expected output is 150 to 200 mL every 3 to 4hr. The client shouldcontact the provider if unable to void.•Need to watch out for blockage•Sodiumcan be absorbed through bladder irrigation•Avoid kinks in the tubing.•ComplicationsUrethral trauma, urinary retention, bleeding, and infection are complicationsassociated with TURP. Other complications include re-growth of prostate tissue and reoccurrence ofbladder neck obstruction.Crutches•Withcrutches elbows should be flexed 30 degrees•Do not alter crutches after proper fit has been determined. Follow the prescribed crutch gait.•Support body weight at the hand grip with theelbows flexed at 30°.•Position the crutches on the unaffectedside when sittingor risingfrom a chair.Climbing the Stairs with Crutches•Upstairs-Good foot {good up to heaven)•Downstairs Bad (bad go down hell)

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NCLEX Key Concepts

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