Nursing 105

Essentials of Nursing Study Guide

Combating Infection Everyday care of catheter and drainage bag is important to reduce the risk of infection. Such precautions include: • Cleansing the urethral area (area where catheter exits body) and the catheter itself; disconnect the drainage bag from catheter only with clean hands • Disconnect the drainage bag as seldom as possible • Keep the drainage bag connector as clean as possible and cleansing the drainage bag periodically • Use a thin catheter where possible to reduce risk of harming the urethra during insertion • Have the patient drink sufficient liquid to produce at least two liters of urine daily • Sexual activity is very high risk for urinary infections, especially for catheterized women Nursing Procedures • Interventions : The nurse must take into account the ethical and legal considerations for elimination and respect the patient’s privacy. For some, privacy during defecation/urination is very important and the nurse should try to provide as much privacy while administering nursing care. Ensure appropriate fiber intake for sufficient bulknecessary to produce fecal volume. Encourage client to have a daily fluid intake of 2,000-3,000 mL to promote healthy fecal elimination. Encourage activity, as tolerated, to stimulate peristalsis, promoting the passage of chyme through the colon and to elicit properurinary control. The nurse needs to promote normal voiding habits for a patient on bed rest. This is accomplished by assisting the patient to a Fowler’s position with a small pillow or towel placed to support the small of the back, warm the bedpan, powder the dry bedpan, provide for privacy, run water for “sound” cue, and run warm water over the perineum if needed. The nurse should make appropriate referrals to home care, community care, or social services to secure proper resources (raised toilet seats, toileting aides, stoma care/supplies, home health aide). • Diagnosis: Check for impaired urinary elimination related to weak pelvic floor muscles secondary to childbirth (aging or obesity) . Check for stress incontinence related to weak pelvic muscles and those at risk for urinary tract infection related to improper hygiene. • Evaluation : Reassess, document and report patient’s response to nursing interventions. Revise patient’s care plan based on reassessment of the patient and determine the patient’s response to care provided by other members of the health care team.

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