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IMPORTANT NOTES
Bladder 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 color
O The initial voidingfollowing removal may be uncomfortable, red in collorand contain dots. The
color of the urine should progress toward amber in 2 to 3 days.
0 On the fourth day the urine should be clear -4 t- day if you see blood this is NOT a good thing
0 If bright-red or ketchup-appearing (arterial) bleeding with clots is observed, the nurse should
increase the rate
• If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow), turn off the CBI and
irrigate with 50 mL of irrigation solution using a large piston syringe.
0 Contact the primary care provider if unable to dislodge the clot.
• Record the amount of irrigating solution instilled {generally very large volumes) and the amount of
return. The difference equals urine output
• Instruct the client to not try to push pee
0 The catheter has a large balloon (30 to 45 mL) that is taped tightly to the leg. creating traction
so that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. This
makes the client feel a continuous need to urinate.
O Tell 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)
O Instruct the client that expected output is 150 to 200 mL every 3 to 4hr. The client should
contact the provider if unable to void.
• Need to watch out for blockage
• Sodium can be absorbed through bladder irrigation
• Avoid kinks in the tubing.
• Complications Urethral trauma, urinary retention, bleeding, and infection are complications
associated with TURP. Other complications include re-growth of prostate tissue and reoccurrence of
bladder neck obstruction.
Crutches
• With crutches 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 the elbows flexed at 30°.
• Position the crutches on the unaffected side when sitting or rising from a chair.
Climbing the Stairs with Crutches
• Upstairs - Good foot {good up to heaven)
• Downstairs Bad (bad go down hell)

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Cane
■ Important to always have TWO CONTACT POINTS touching at all times - two points of support
■ Keep the cane on the STRONG SIDE of the body
■ When moving with the cane: support body weight on both legs, move the cane forward 6 to 10
inches, then move the weaker leg forward toward the cane. Next, advance the stronger leg.
Ambulating w/ devices
■ Cane: When ambulating with the cane- have client keep the cane on the strong side of the body. Move
cane up to 4 inches, ther WEAK LEG- strong leg.
0 Upstairs with Cane: (UP-STRONG/DOWN- STRONG)
. Take first step with the strong leg
Move the affected leg to the same step
0 Downsta irs with Cane:
Take first step by placing cane and unaffected(strong) legon the step
, Lower the affected leg to the same step
• Walker: Adjust walker to client s height. Allow 20 to 30 degree flexion of the elbows when grasping
the hand grips
0 Move walker up 6 to 8 inches & move the WEAK LEG & then bring the strong leg equal with the
weak leg. WWS!
• Crutches: Axillary crutch is more commonly used and must be measured to fit an individual. Crutch
should be 2 fingers width from the axilla and 15 cm lateral to client's heel ■ The basic crutch stand is
thetripod position the crutch is placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of
each foot. It improves a person's balance. The axilla should not bear weightand client assumes tripod
position before crutch walking.
Types of Crutch Gaits:
• Four-point gait- {Alternating Gait) gives stability to client- requires weight bearing on both legs. Each
eg is moved alternatively with each opposing crutch.
• Three-point gait- requires the client to bear all of the weight on one foot. Client will bear all the
weight on both crutches and then on the uninvolved leg- affected leg does not touch the ground.
• Two- point gait- requires partial weight bearing on each foot. The client moves the crutch at the same
time as the opposing leg.
■ Swing-through gait- (paraplegics wear weight supporting braces use this gait)With weight placed on
both legs, the client will place the crutches one stride in front and then swings through the crutches.
Dumping Syndrome
• After bariatric surgery observe pt for S/S of dumping syndrome.
■ Dumping syndrome is a complication of gastric surgery that consists of vasomotor symptoms occurring
in response to food ingestion. Symptoms result from the rapid emptying of gastric contents into the
small intestine.

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■ Client Education- Dumping Syndrome
Q Lay down after meal - because it will slow the movement of food within the intestines
O Limit the amount of fluids ingested at one time
■ Eliminate liquids with meals and for 1 hr prior to and following a meal
O Consume a high fat, high proteins, low to moderate carbs diet
O Avoid milk, sweets, and sugars - because these can cause diarrhea
O Small frequent meals rather than large meals
O Pernicious anemia is common here- Give Vit B12
Crohn's Disease
• Intermittent involvem ent of throughout the entire lower Gl tract, most commonly in the small intestine
and the terminal ileum.
• Inflammation and ulceration throughout the Gl tract - see sporadic lesions and fistulas are common
• Diarrhea and colicky abdominal pain
• Monitor for Megaloblastic (pernicious Janemia - Give VITAMIN B12 injection monthly for life
• UTI - first sign in bowel/bladder fistula (Feces times seen in urine and vagina)
• S/S: Abdominal pain/cramping: Often right-lower quadrant pain
O Anorexia and weight loss, fever, diarrhea, high-pitched bowel sounds, steatorrhea
• Acute treatment is fluid and bowel rest
• More difficult to cure and manage- Commonly in small intestines
• Perineal abscess and fistulas- common in Crohn's disease
■ Low fibe r diet or NP O (seve re inflammation)
• Long term treatment is low fiber diet and medication
Ulcerative colitis
• TOXIN MEGACOLON - common in ulcerative colitis
• More acute - see blood and mucus
• Bloody a nd frequ ent dla rrhea and abd o minal pa in, te nesmus & rectaI bIeeding
• See in the DESCENDING COLON
• Common to see joint pain/ arthritis (inflammation)
• Antiinflammatory med:
o Give sulfasalazine (Azulfidine)
1 May cause yellowish orange discoloration of skin and urine
■ Avoid sun exposure - wear sun blocked
• Low fiber diet or NPO (severe inflammation)
Ulcerative Colitis Interventions
• Priority Intervention: NPO (they will have 20 to 25 stools a day)
• Diaper & bowel rest/ colitis can lead to TOXIC MEGA COLON
• Only in the rectum/TREAT WITH SITZ BATH OF WITCH HAZEL COMPRESSION
• Medication- antibiotics: SULFASALAZINE (AZULFIDINE) - decrease inflammation of intestinal mucosa
(can be given recta lly)

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Ulcerative Colitis and Crohn s Disease Nursing Care
■ Educate the client in eating foods that are high in protein and calories, and low in fiber.
• Instruct the client to avoid caffeine and alcohol, and take a multivitamin that contains iron.
■ Advise the client that small frequent meals may reduce the occurrence of symptoms.
• Inform the client that dietary supplements that are high in protein and low in fiber may be used.
• Monitor for an electrolyte imbalance, especially potassium. Diarrhea can cause a loss of fluids and
electrolytes.
■ Monitor fluids and assess for dehydration.
• Educate the client regarding the use of vitamin supplements and B12 injections, if needed.
• Assist the client in identifying foods that trigger symptoms.
Diverticulitis
• Saccular Dilations or Outpunching of the Diverticula
■ Abdominal pain - SIGMOID COLON LLQ. abd. distension, bloating, flatulence & bowel changes
• Increase-High fiber diet & increase fluids- is very important in preventing future diverticulitis attacks
but during EXACERBATION OF DIVERTICULITIS put patient on LOW fiber diet
• Encourage walk daily for 30mins (for no constipation)- No strenuous exercises
Acute Diverticulitis
• Priority interven tion: NPO-BoweI rest.
Example Q: Which of the following comments made by the patient indicates that additional instruction about
the care of a new ileostomy is needed?
1. "I should change the appliance daily to prevent odors.
2. "When I change the appliance. I should check the skin for irritation."
3. "I should clean around the stoma with mild soap and water and pat dry."
4. "I'll need to alter the appliance opening when the stoma becomes smaller as the area heals."
Rationale: The appliance is changed every 4 to 7 days unless leakage occurs
Heat and Cold Therapy
• First 24hrs -cold
0 Prevents swelling, decreases inflammation, reduces bleeding, reduces fever, diminishes muscle
spasms decreases pain by decreasing the velocity of nerve conduction
• After 24 hrs - heat
• Heat increases blood flow
0 Increases tissue metabolism
0 Relaxes muscles
0 Do not take long showers
0 Eases joint stiffness and pain
• Avoid heat application over metal devices to avoid deep tissue burns
■ Heat-Monitor bony prominences carefully as they are more sensitive to heat applications.
0 Avoid the use of heat applications over metal devices (pacemakers, prosthetic joints) to prevent
deep tissue burns.
0 Do not apply heat to the abdomen of a pregnant woman to prevent harm to the fetus.
0 Do not place a heat application under an immobile client as this may increase the risk of burns

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Cold- Decreases inflammation
• Prevents swelling
• Reduces bleeding
• Reduces fever
• Diminishes muscle spasms
• Decreases pain by decreasing the velocity of nerve conduction
Avoid cold application for cold intolerance
• Hyperthyroidism
• Peripheral arterial disease
• Raynaud s phenomenon
Hot compress causes vasodilation and delivers more blood to the site.
• If a patient is in pain, you could apply a hot compress to direct blood, which carries oxygen and
nutrients to the area, which will alleviate pain.
Cold compresses cause vasoconstriction in the area and divert blood flow.
Cognitive Disord ers/Alzheimer's
• How do you promote hygiene/p roper care in pt with Alzheimer's?
• Alzheimer's disease (AD) is a nonreversible type of dementia that progressively develops through
seven stages over many years
• AD is a type of dementia. Dementia is defined as multiple cognitive deficits that impair memory and
can affect language, motor skills, and/or abstract thinking
Nursing Care for Alzheimer
• Assess cognitive status, memory, judgment, and personality changes.
• Initiate bowel and bladder program with the client based on a set schedule.
• Encourage the client and family to participate in an AD support group.
■ Provide a safe environment.
• Keep the client on a sleeping schedule and monitor for irregular sleeping patterns.
• Provide verbal and nonverbal ways to communicate with the client.
• Offer snacks or finger foods if the client is unable to sit for long periods of time.
• Check the client's skin weekly for breakdown.
• Provide cognitive stimulation: f a m j|y pj C S i t i m e place and p e r s o n
• Offer varied environmental stimulations such as walks, music, or craft activities.
• Keep a structured environment and introduce change gradually (client's daily routine or a room
change}.
• Use a ca le ndar to assist with o rientatio n.
• Use short directions when explaining an activity or care the client needs, such as a bath.
• Use therapeutic touch
• Place stop signs on the door. Have the client wear ID, Have client walk with supervision. Apply physical
restraints only as a last resort.
Provide Memory Training!
• Reminisce with the client about the past.

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■ Use memory techniques such as making lists and rehearsing.
• Stimulate the client's memory by repeating the client's last statement.
• Avoid overstimulation (keep noise and clutter to a minimum and avoid crowds).
• Promote consistency by placing commonly used objects in the same location and using a routine
schedule.
■ Reality orientation (early stages)
• Easily viewed clock and single day calendar
• Pictures of fa mily an d pets
• Frequent reorientation to time, place, and person
• Validation therapy (later stages)
• Acknowledge the client’s feelings.
• Don't argue with the client; this will lead to the client becoming upset.
■ Reinforce and use repetitive actions or ideas cautiously.
• Promote self-care as long as possible. Assist the client with activities of daily living appropriate.
■ Speak directly to the client in short, concise sentences.
• Reduce agitation (use calm, redirecting statements: provide a diversion).
■ Provide a routine toileting schedule.
If patient has CHOLECYSTITIS. What kind of diet restrictions should be on?
■ Cholecystitis is an inflammation of the gallbladder wall, it is most often caused by gallstones
(cholelithiasis) obstructing the cystic and/or common bile ducts (bile flow from the gallbladder to the
duodenum) causing bile to back up and the gall bladder to become inflamed.
• Sharp pain in the RightUpper Quadrant of the abdomen, often radiating to the right shoulder.
• Pain with deep inspiration during right subcostal palpation (Murphy s sign)
• Jaundice, clay-colored stools, steatorrhea (fatty stools), dark urine, and pruritus (accumulation of
bile salts in the skin) may be seen in clients with chronic cholecystitis (due to biliary obstruction).
Diagnostic Procedures:
• A right-upper quadrant (RUQ) ultrasound visualizes gall stones and a dilated common bile duct.
■ An abdominal x-ray or CT scan can visualize calcified gallstones and an enlarged gall bladder.
•

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• Tighten pelvic muscles for a count of 10, relax slowly for a count of 10 . and repeat in sequences of 15
in the lying-down, sitting and standing position
0 Perform four times a day
• Keep abdominal muscles relaxed during contractions.
• Contract the circumvaginal and/or perirectal muscles.
Sleep Disorders
• Recognizing and reporting sleep disorders
• How does it affect medications (cholesterol meds work better during sleep)
• insomnia, the most common sleep disorder, is defined as the inability to get an adequate amount of
sleep and to feel rested. The person may have difficulty falling asleep, have difficulty staying asleep,
awaken too early, or not get refreshing sleep
Q Acute insomnia lasts for only a few days and may be due to personal stressors.
O Chronic insomnia lasts a month or more. Some people experience intermittent insomnia, where
they are able to sleep well for a few days and then experience insomnia for a few days. Women
and older adults are more likely to experience insomnia.
• Sleep apnea is a disorder in which there are more than five apneic occurrences lasting longer than 10
seconds/hr during sleep, resulting in decreased arterial oxygen saturation levels
• Narcolepsy - a disorder of the sleep and wake mechanism. The person may lose the ability to stay
awake. It often happens at inappropriate times and can put the person at risk for injury.
• Assessment/Data Collection:
O Ask the client about sleep patterns, history, and if any changes have occurred.
O Ask the client about sleep problems, which include
O Type of problem, symptoms, timing, seriousness, related factors, how the lack of sleep has
affected the client.
0 Use a linear scale or visual with "best sleep" on one end and "worst sleep" on the opposite end.
Also, the nurse could ask the client to rate sleep on a 0 to 10 scale.
O Assess for common factors that interfere with sleep, which include:
■ Illness - may require more sleep or disrupt sleep, such as nocturia
■ Current life events (traveling more, change in work hours).
■

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• Therapeutic Touch
• Pain Pathways - Gate Control Theory: The theory guided research toward the cognitive behavioral
approaches to pain management. This theory helps to explain how interventions based on
somatosensory (auditory, visual and tactile) stimulation such as friction, music therapy and distraction
provide pain relief.
0 Two receptors for opioids
o Nu and Kappa
• Distraction-Includes ambulation, deep breathing, visitors, television, and music
0 Distraction therapy works best with children
• Relaxation-Includes meditation, yoga, and progressive muscle relaxation
• Imagery- Focusing on a pleasant thought to divert focus
0 Requires an ability to concentrate
• Acupuncture - vibration or electrical stimulation via tiny needles inserted into the skin and
subcutaneous tissues at specific points
O Reduction of pain stimuli in the environment
• Elevation of edematous extremities to promote venous return and decrease swelling
Stump Pain after Amputation
• Elevation for edema
• Phantom pain
O Treated as real pain
O Patient says they have pain - give them pain meds
Acute and Chronic Glomerulonephritis
• Glomerulonephritis is an inflammation of the glomerular capillaries, usually following a Streptococcal
Infection. It is an immune complex disease, not an infection of the kidney
• Due to swelling and capillary cell death
0 Also get it from SLE, hypotension and diabetes mellitus
• Patient will have a spontaneous recovery
• Diet includes:
O Fluid restriction (24 hr output +500 mL).
0 LOW SODIUM, LOW PROTEIN AND LOW POTASSIUM DIET
O

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* BUN (10-20)- increased
* Creatinine (0.8-1.2}- increased
* Anuria: non-passage of urine
End Stage Renal failure means hemodialysis for life
* DAILY weights-loss of 2 lbs in 24 hrs, little urine output, fever -sign of infection
* DM+HTN are the most risk factors
Diet Teaching Uric Acid- to prevent hyperuricemia
* Avoid -Red meat (beef, pork and lamb), fatty fish and seafood (tuna, shrimp, lobster and scallops
shellfish like scallop, lobster, oyster, clam, and shrimp will have more purine levels than normal fish.)
* Avoid beans and legumes
* Avoid dark green leafy vegetable, cauliflower, spinach, mushrooms and asparagus
* Limit or avoid alco hoi & sugar
* Choose low-fat o r f at-f ree dai ry prod ucts: Drinking skim o r low-fat miIk & yogurt
* Choose complex carbohydrates: whole grains and fruits and vegetables
Chronic Kidney Disease
* Which priority Intervention for CKD can be delegated to UAP? Monitor l&O
* Canned, pickled and smoked food is prohibited
* Know the im portance of mon ito r I £.0? LIM IT FLUID INTAKE
* Assess protenuria- teach patient toAVOID EXCESS PROTEIN because increased protein intake can
affect mental status £ cause confusion
Peritoneal dialysis
* Therapeutic procedure for CKD utilizes the patient's abdominal cavity lining as a natural filter
* Interventions: STERILE
* Cl oudy Urine dia lysis: IM MEDIATE INTERVENTION
* Abdominal cramping: SLOW THE INFUSION
* Assess for infection -clean the pins with HYDROGEN PEROXIDE AND NS
Kayexalate
■ Normal potassium level 3.5-5.0
* Therapy for elevated potassium (hyperkalemia)
* Kayexalate - never give it to patient with PARALYTIC ILEUS
AV Shunt
* Assess:thrill and bruit (thrill is palpated £ bruit is heard)
*

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eaten, the dishwashers or dishpans in which they are cleaned, the sponges with which they are
cleaned and the towels with which they are dried.
• A kosher household will have at least two sets of pots, pans and dishes: one for meat and one for
dairy. One must wait a significant amount of time between eating meat and dairy. Opinions differ, and
vary from three to six hours after meat. This is because fatty residuesand meat particles tend to cling
to the mouth. From dairy to meat, however, one need only rinse one's mouth and eat a neutral solid
like bread, unless the dairy product in question is also of a type that tends to stick in the mouth.
• All fruits and vegetables are kosher. However, bugs and worms that may be found in some fruits and
vegetables are not kosher.
Jehovah's Witnesses
• Jehovah's Witnesses do NOT accept blood transfusions.
• Clients avoid foods having or prepared with blood.
• Can recommend an AUTOLOGOUS blood transfusion
0 When the patient goes in a couple of days before and donates their own blood
Stoma Care
■ An ostomy is a surgical opening from the inside of the body to the outside. Ostomies can be permanent
or temporary and are located in various parts of the body.
• Jleostomy opening at the small intestine
0 See more fluids and more skin degeneration
■ Colostomy opening at the colon
o See more solid ...change bag more often-% to VS full- change it!
• Nursing Actions
0 Assess the type and fit of the ostomy appliance.
0 Monitor for leakage (risk to skin integrity).
0 Fit the ostomy appliance based on:
■ Type of ostomy.
■ Location of the ostomy.
■ Visual acuityandmanualdexterity of the client.
0 Visual acuity a

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