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IRRIGATING CYSTOCLYSIS
CYSTOCLYSIS- “continuous bladder irrigation”- instilling sterile irrigation solution into the
bladder, then allowing fluid to drain out.
Purpose:
- To prevent urinary tract obstruction by flushing out small blood clots that form after prostate or bladder surgery.-To dissolve certain bladder calculi with chemolytic agents.
Indications:- after prostate or bladder surgery- Acute urinary retention
Contraindications:- presence of traumatic injury to the lower
urinary tract- not for long term treatment
Scientific Principles:
Anatomy and PhysiologyThe urinary bladder is a hollow muscular
organ shaped like a balloon, located in the anterior pelvis. Chemistry
Solutions like normal saline solution are introduced into the bladder.
PhysicsSolution flows in the urinary bladder by
the force of gravity. The IV bag should be placed higher than the patient for the fluid to drip through the IV line.
MicrobiologyStrict asepsis must be maintained
throughout the procedure because it is an invasive procedure and to prevent infections.
Psychology Explain the procedure to the patient to
reduce his/her anxiety about the procedure.
Time and Energy Prepare all materials needed for the procedure and do the procedure in a short period of time if possible.
Identify the types of cystoclysis:
Open System, the bladder is drained using a 60 ml syringe
- also called manual irrigation which is performed by the nurse
Closed System, the bladder drains directly into the Foley Bag
Complications:- Infection- Bladder Distention- Bladder rupture
Guidelines:- Sterility and patency is maintained to
avoid infection - NSS for infusion should be stored and
infused at room temperature to avoid bladder spasms.
- Strict Intake & Output is recommended for all patients receiving CBI
- Empty the drainage bag about every 4 hours, or as often as needed. Use sterile technique to avoid the risk of contamination.
- Monitor vital signs at least every 4 hours during irrigation; increase the frequency if the patient becomes unstable.
CAST CARE
Cast – a rigid device that immobilizes the affected body part while allowing other body part to move.
Fixator – a device that provides rigid immobilization of a fractured bone by means of rods attatched to pins that are placed in or through the bone.
Trabecular – (an open cell porous network also called cancellous or spongy bone) which is composed of a network of rod- and plate-like elements that make the overall organ lighter and allowing room for blood vessels and marrow.
Close reduction – most common nonsurgical method for managing a simple fracture.
Open reduction – allows the surgeon direct visualization of the fracture site
PURPOSES OF CASTING
-To maintain the integrity of the cast
-To prevent possible infections brought about by unsanitation.
TYPES OF FRACTURES :
TYPES OF CAST
I. UPPER EXTREMITY CAST1. Short arm cast (SAC) – extend
from below the elbow to part of the hand
USE: stable fractures of wrist (metacarpals, carpals, distal radius)
2. Long arm cast (LAC) – includes upper arm to part of the hand
USE: unstable fracture of wrist (distal humerus, radius, ulna)
3. Hanging-arm cast
USE: fractures in humerus that cant be aligned by LAC
4. Thumb spica cast –similar to SAC with thumb casted in abduction
USE: fractures of thumb
5. Shoulder spica cast – shoulder is casted in abduction with elbow flexed
USE: Unstable fracture of shoulder girdle or humerus, dislocation of shoulder
II. LOWER EXTREMITY 1. Short leg cast (SLC)– from
below the knee to base of toes
USE: Fractures of ankle, metatarsals or foot
2. Long leg cast (LLC) – from mid-upper thigh to base of toes
USE: unstable fractures of tibia, fibula or ankle
3. Walking cast – a walking
device on bottom of SLC or LLC
4. Leg cylinder - similar to SLC, but the ankle and foot are not casted
USE: Stable fractures of distal femur, proximal tibia or knee
5. Long leg cylinder- similar to LLC, but ankle and foot are not castedUSE: midshaft or distal sharf fractures of the femur
III. CAST BRACES
1. Patellar weight-bearing cast- similar to SLC or leg cylinder
2. External polycentric knee hinge cast- a hinge connects lower and upper leg and allow 90 degrees of flexion
IV. BODY CAST
1. Hip spica- extend from below the nipple line down the affected leg [single], down the leg and half of the unaffected leg [1/2], or down both legs [double]
2. Risser’s cast – body jacket extends from the shoulders to beyond the iliac crest and hips, with a larged opening over the anterior chest
3. Halo cast – body jacket contains a halo brace
Principles
1. Anatomy and Physiology – the health provider should know the different pressure points
2. Physics - friction may cause skin irritation, dryness and skin damage.
3. Microbiology – a clean environment (cast) will prevent further complications and decreasing the chances of growth of microorganisms
4. Body mechanics – proper positioning will help hasten the drying of the cast
Complications1. Impaired blood flow
- This is due to pressure in casted extremity
- Possible symptoms :Pulselessness ,Inadequate capillary refill in nail beds,Pallor or cyanosis of kin,Pain,Coldness of skin,swelling
2. Nerve damage
- This is due to pressure on a nerve as it passess over a bony prominence
- Possible symptoms include :Pain, increasing, persistent and localizedNumbnessFeeling of deep pressureMotor weakness
3. Infection
- This is due to skin breakdown- Possible symptoms :
Musty, unpleasant odor over cast or at ends of castSudden unexplained body temperature elevation
4. Compartment syndrome - A compartment syndrome develops
when the space within a compartment is reduced. During exercise, the muscle swells, fluid accumulates and cannot escape immediately, pressing on structures which become tense and painful
- Possible symptomsPainParesthesiaParalysis of the limb is usually a late finding
Assessment of Neurovascular Status in Clients with Musculoskelatal Injury
Assessment technique Normal findingsSkin color
- Inspect the area distal to the injury
Skin temperature
- palpate the area distal to the injury (the dorsum of the hands is most sensitive to temperature).
Movement
- ask the client to move the affected area or the area distal to the injury (active motion).
- move the area distal to the injury (passive motion).
Sensation
No change in pigmentation compared wit other parts of the body
The skin is warm
The client can move without discomfort
No difference in comfort compared with active movement
No numbness or tingling
- ask the client if numbness or tingling is present (paresthesia)
- palpate with a paper clip (especially the web space between the first second toes or the web space between the thumb and forefinger).
Pulses
- palpate the pulses distal to the injury.
Capillary refill (least reliable)
- press the nail beds distal to the injury until blanching occurs (or the skin near the nail if nails are thick and brittle).
Pain
- ask the client about the location, nature and frequency of the pain
No difference in sensation in the affected and unaffedted extremities. (loss of sensation in these areas indicates perineal nerve or median damage).
Pulses are strong and easily palpated; no difference in the affected and unaffected extremities.
Blood returns (return to usual color) within 3 sec ( 5 sec for other clients)
Pain is usually localized and is often described as stabbing or throbbing. (pain out of proportion to the injury and unrelieved by analgesics might indicate compartment syndrome.)
Handling new cast- keep cast dry and clean
- Dont lean on or push on the cast because it may break.
- Don’t put anything inside the cast
- Do not trim the cast or break off any rough edges because this may weaken or break the cast
- Wear cast boot if walking is ok. The boot is to keep the cast from wearing out on the bottom and has a tread to keep people in casts from falling.
- If the cast is on the foot or leg, do not walk on or put any weight on the injured leg,
Skin care
- Keep bed free of wrinkles and crumbs
- Support leg with pillow to prevent constant pressure on the heel
- Fingers or toes should be bathed, lightly oiled and massaged at least once daily
- Frequent active exercise is encouraged
Turning- Turn patient from front to back and vice
versa every 2 hours
- help in moving and turning a casted patient
- Never use cast braces to lift a casted patient
- Always turn a casted patient away from the injured or operated side; keep weight off the fractured or operated side
Toileting and Bathing- Cover the cast with a plastic bag or wrap the cast to bathe (and check the bag for holes before using the bag a second time). - Avoid showers; use the bathtub and hang the covered cast or injured body part outside of the tub while you bathe. - Do not lower the cast down into the water.
Prevention of Complications- Perform cast care at least once a day or
as prescribed
- Prevent cast from getting wet
- Promote ROM exercises
- Report if cast is too tight or loosened
CARE OF PATIENTS WITH TRACTION
Traction- is the application of a pulling force to an injured part of the body or extremity to provide reduction, alignment and rest.Countertraction- pulling force equal and opposite the traction weightsFixator- metallic plate or screw placed on the bone to provide support.Trapeze- an overhead patient helping device to promote mobility in bed
PURPOSES :
A. TRACTION
immobilize a reduce fracture to treat an unstable fracture
to prevent or correct deformities
B. FIXATOR
1. EXTERNAL
manage open fractures with soft tissue damage.
tprovide stable support for severe comminuted fractures
to facilitate patient's comfort, early mobility and active exercise or alignment of a joint.
to minimize complications related to immobility.
2. INTERNAL
hold the bone fragments in position until solid bone healing occurs.
facilitate faster mobilization than external fixator.
INDICATIONS:
1. TRACTION:
fractures muscle contracture
2. EXTERNAL FIXATOR:
complicated fractures of the forearm, femur tibia and pelvis
fracture fragment immobilization.
bony non-union
3. INTERNAL FIXATOR:
fractures associated with complex soft tissue injury.
damaged nerves or blood vessels.
CONTRAINDICATIONS
1. TRACTION
hypersensitive skin severe osteoporosis
osteomyelitis
2. FIXATOR
open fracture with large fragments and is massively contaminated
systematically ill patients
TYPES OF TRACTION:
1. RUNNING TRACTION- is a pulled in one direction against the long axis of the body or bone
2. BALANCED TRACTION- is a combination of a running traction plus a countertraction source other than the body.
APPLICATION OF TRACTION :
1. SKIN TRACTION – pull is applied to client’s skin which transmitted the pull to the musculoskeletal structures.
TYPES OF SKIN TRACTION
BUCK’S TRACTION- is a running skin traction used temporarily to immobilize a fracture of the hip/femur until possible to do surgery.
CERVICAL HEAD HALTER TRACTION – for neck pain, neck strain and whiplash, traction can be applied to the cervical spine by means of a head halter.
RUSSELL’S TRACTION (balanced traction) - downward pull, as in Buck's traction, may be applied to the leg, but an additional overhead pulley system is
incorporated into the traction apparatus with the leg supported by a sling.
PELVIC TRACTION – used in pelvic fractures to support separated bones. It is usually applied intermittently, on 2 hrs, off 2 hours, while the client ia awake.
BRYANT’S TRACTION- immobilize a fracture of the femur in children weighing <40 lbs. A running traction in which legs are raised at 90° angle to the body.
2. SKELETAL TRACTION- applied directly to the bone with wires and pins surgically
TYPES OF SKELETAL TRACTION
SKULL/HEAD TRACTION- by inserting a points of a skull tong device (such as Vinke or Crutchfield tongs) into the skull bone. It is used reduced a fracture of the cervical vertebrae. This type traction is often used only temporarily until a halo device can be placed.
BALANCED SUSPENSION TRACTION – treat displacement or comminuted femoral fractures.
TYPES OF FIXATOR
EXTERNAL FIXATOR-is the device is used to manage complex fractures that associated with soft tissue damage or with open wounds in the fractures area
INTERNAL FIXATOR- done through open reduction, the surgeon places a pin, wire, screw, plate, nail or rod into or onto the bone to keep it reduced (properly aligned), immobilized, or both. (ORIF)
COMPLICATIONS OF TRACTION
1. Over distraction
2. Loss of position
3. Pressure sores
4. Pin track infection
PREVENTING COMPLICATIONS-perform neurocirculatory checks every hour for the first 24-48 hours
-maintain elevation of area affected on bed
GENERAL CARE OF PATIENTS WITH TRACTION
1. ASSESSMENT - assess the patients neuromuscular status.- observe skin for irritation and breakdown.
2. HANDLING NEW TRACTION- inspect traction apparatus frequently to ensure the ropes are running straight and through the middle of the pulleys; the weights are hanging free- check ropes frequently to be sure they are not frayed.
- Avoid releasing weights from or altering the line of pull of the traction.- Avoid adding weight to the traction - Avoid bumping into the bed or traction equipment- Be sure that weights are securely fastened to their ropes- Avoid manipulation of pins 3. SKIN CARE- encourage the patient to turn slightly from side to side and to lift hip up on the trapeze to relieve pressure on the skin on the sacrum and scapulae- inspect skin frequently - keep skin areas around the pin sites clean and dry
4. TURNING- turning to any position as long as the integrity of the traction is not compromised and the patient is comfortable.
5. TOILETING- use a fracture pan with blanket roll or padding as support under the back- protect the Thomas ring splint with water proof material when female patients are using the bed pan.
EYE
EYE INSTILLATION- administration of sterile ophthalmic therapeutic agents
GUIDELINES- offer patient tissue paper to remove
sol’n during the procedure- clean the eye of any drainage- tilt the patients head slightly (sitting),
place a pillow (lying down)- let the patient look up- hold dropper 1-2 cm above conjunctival
sac- ask the patient to blink- apply gentle pressure over the inner
canthus for 1min.- instruct patient not to rub eyes
PURPOSE- dilate or contract the pupil when
examining the eye- relieve pain, discomfort, itching and
inflammation- to clean or lubricate the eye
INDICATION- glaucoma- ophthalmic infection- eye discomfort
CONTRAINDICATION- hypersensitivity to drug
NURSING RESPONSIBILITIES
(BEFORE)- verify physician’s order- place drape to protect clothes- assess for redness, location and nature
of discharges, complaints- clean the eyelids and lashes
(DURING)- double check ophthalmic preparation- hold dropper 1-2 cm above conjunctival
sac- ask the patient to blink- apply gentle pressure over the inner
canthus for 1min.(AFTER)
- instruct not to rub eyes- assess and document
EYE IRRIGATION- flushing of irritant out of the eye
PURPOSE- irrigate or remove foreign bodies of the
eye- remove secretions, itching, pain- provide moisture- preparation for surgical procedure
INDICATION- allergic conjunctivitis- bacterial eye infection
CONTRAINDICATION- hypersensitivity- who just had eye surgery
COMPLICATION- stinging and burning sensation- scarring- visual impairment
GUIDELINES- direct irrigating fluid from inner to outer
canthus- avoid touching the eye
- place kidney basin at the side of the patient’s face to collect fluid
- dry the surrounding area with sterile cotton ball
- avoid rubbing
NURSING RESPONSIBILITIES
(BEFORE)- position patient properly- instruct patient to hold kidney basin
beside the eye(DURING)
- instruct patient to look up- irrigate from inner to outer canthus
along conjunctival sac- let patient close his eyes periodically
(AFTER)- dry the surrounding area - let patient close and open his eyes- note patient’s reaction and response
COMMON OCULAR MEDS
1. TOPICAL ANESTHETIC (Proparacaine Hcl)
- anesthetic for severe eye pain
2. MYDRIATICS (dilate) & CYCLOPLEGICS ( paralyze iris sphincter)
- instruct pt. to wear sunglasses
3. ANTI-INFECTIVE (Gentamicin sulfate)- treat ocular infxn
4. CORTICOSTROID/NSAID- for inflammatory conditions
5. OCULAR IRRIGANT (Decroise)- clean / irrigate external eye, eliminate
debris
6. OCULAR LUBRICANT (eye mo)- for dry eyes Keratoconjunctivitis sicca
EAR
EAR INSTILLATION- introduction of medication to the ear
PURPOSE- relieve pain- reduction of inflammation or destroy
infective organism
INDICATION- hardened earwax- pain / inflammation of ear canal- otitis media / externa
CONTRAINDICATION- ruptured/perforated tympanic memb.- Pregnancy / breastfeeding (meds
contraindicated to pregnant women)- Hypersensitivity
COMPLICATION- allergic rxn- permanent hearing loss- worsening of pain
GUIDELINES- wash hands before and after- clean external ear with cotton balls b4
instilling med- position patient by tilting head to the
side so that the affected area is uppermost
- wait for 5-15 mins b4 instilling to the other side
NURSING RESPONSIBILITIES
(BEFORE)- check medication- warm the eardrop to body temp (rolling
bottle in the hands)(DURING)
- let pt. lie on his side w/ the affected ear- pull lobe up and back (adults) or down
and back (children)- instill 1cm away and avoid touching the
ear with the dropper- let pt. remain in his position for 5-10
mins(AFTER)- dry the surrounding area- place cotton ball for 15 mins to absorb
excess med.
EYE IRRIGATION- flushing of external ear canal with NSS or water.
PURPOSE- clean external ear canal- remove discharges or foreign objects- soften cerumen- destroy organism or insects lodging the
canal
INDICATION- cerumen impaction- local inflammation- presence of foreign body
CONTRAINDICATION- ruptured/perforated tympanic memb.- Recent ear or head trauma
COMPLICATION- dizziness, n/v- pain- tinnitus
GUIDELINES- warm sol’n 40°C / 105°F- straighten auditory canal
NURSING RESPONSIBILITIES
(BEFORE)- position patient properly- position protective towel
(DURING)- use cotton applicator to remove
discharges- place kidney basin close to patient’s
head(AFTER)
- dry external ear with cotton ball
OTIC AGENTS
1. ACETIC ACID (Vosol)- antibacterial and drying; eliminate and
prevent susceptible organism
2. BENZOCAINE (Otocain, Auralgan)- otic anesthetic- a/e: respiratory distress, cyanosis
3. HYDROCARTISONE, NEOMYCIN SULFATE
- decrease inflammation
4. CHLORAMPHENICOL OTIC (Chloromycetin)
- antibiotic; bacteriostatic effect
5. TROLAMINE POLYPEPTIDE + OLEATE-CONDENSATE (Cerumenex)
- soften cerumen
NOSE
NASAL INSTILLATION- administering medication by spray or drops into nasal cavity
SINUSES:- ETHMOID – around bridge of the nose- MAXILLARY – around area of cheeks- FRONTAL- area of forehead- SPHENOID – deep in the face behind
nose. Sinus develops during adolescence
PURPOSE- loosen secretion, facilitate drainage- shrink swollen mucous memb- treat infxn
INDICATION- nasal congestion- sinusitis - rhinitis, allergy
CONTRAINDICATION- neck and spine injury- hpn- increase ICP
COMPLICATION- epistaxis- inflammation
POSITIONING1. PROETZ – ethmoid and sphenoid- place pt in flat supine w/ shoulders
supported w/ pillow to hyperextend neck
2. PARKINSON’S – maxillary and frontal- pt. flat w/ shoulder supported w/ pillow
and head hyperextended and turned toward affected side
GUIDELINES- position patient properly depending on
the affected side- avoid touching the nose with dropper, it
may cause patient to sneeze- don’t share nasal instillation prep to
other patients- let pt. remain in a supine position for 5-
10 mins.
COMMON NASAL MEDS
1. BACLOMETHASONE DIPROPRINATE- dec. nasal inflammation
2. EPINEPHRINE HCL (Adrenaline chloride)
- adrenergic
3. SODIUM CHLORIDE (Muconase)- nasal decongestant
4. NAPHOZALINE HCL - local constriction of dilated arterioles
5. AZELASTINE HCL - exhibits histamine release
NURSING RESPONSIBILITIES
(BEFORE)- check medication- inspect/ assess nose with penlight- instruct patient to blow/ clear his nose
with tissue unless contraindicated- position patient
(DURING)- instruct pt to breathe through mouth and
not to speak or swallow
- avoid touching dropper to nose (1cm away)
- instill drops toward midline of ethmoid bone
(AFTER) - let pt remain in position for 5-10 mins.
MOUTH
MOUTHWASH – an fluoride compound antiseptic added to drinking water
SALIVA - water (99.5%)- digestive enzyme- lysozyme (enzyme that kills bacteria)- proteins- antibodies (IgA)- various ions
Function: - lubricates mouth - moistens food during chewing- protects mouth against pathogens- chemical digestion
PURPOSE- freshen mouth and prevent halitosis- keep teeth, mouth and gums in good
condition- provides comfort and improve appetite
INDICATIONS- halitosis- pt. w/ periodontal dse.
CONTRAINDICATION- hypersensitivity to mouthwash
GOALS - removal of excess secretion - stimulate salivary gland
GUIDELINES- encourage client to establish regular
routine
- enc. client to visit the dentist - use dental hygiene products of pts.
choice COMMON MOUTHWASH SOL’N
1. BACTIDOL (Hexetidine)-anti-infective and antiseptic
2. LISTERINE (Benzoic acid)-anti-infective and antiseptic
3. BETADIBE GARGLE (Povidine-iodine)- antiseptic used in throat preparation
4. PERIDEX-dec. redness, swelling and bleeding gums
NURSING RESPONSIBILITIES
(BEFORE)- determine type and amount of
sol’n to be used- perform handwashing and don
glove(DURING)
[conscious] - position pt. in sitting position - place a towel on pts. chest and
kidney basin under his chin[unconscious]
- position pt. with head tilted towards the nurse
- place a towel on pts. chest and kidney basin under his chin
- use padded tongue depressor to open mouth and rinse w/ diluted sol’n
(AFTER) - return pt. to comfortable position - Record unusual bleeding or
inflammation
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