Nurse Assisting SkillsDiversified Health Occupations

Chapter 20

pg. 617-737

Nurse Assisting OBJECTIVES

Upon completion of this unit, the student should be able to…

Admit, transfer, or discharge a patient, demonstrating proper care of pts belongings.

Administer personal hygiene Measure and record intake and output Assist a patient with eating, feed a patient Collect stool specimens Ostomy care Catheter care

ADMITTING, DISCHARGING, AND TRANSFERRING A PATIENT

This may be one of your responsibilities. Alleviating anxiety and fear

Admission can cause anxiety and fear for many pts and their families

Even a transfer from one room to another can cause anxiety because the individual will have to adjust to another environment

Essential for health care provider to create a positive first impression

Assistant can do much to alleviate fear by being courteous, supportive, and kind.

ADMITTING, DISCHARGING, AND TRANSFERRING A PATIENT

Alleviating anxiety and fear Help patient become familiar with the unit

Provide clear instructions on how to operate equipment

Explain the type of routine to expect, such as times for meals

Do not hurry or rush Allow the pt to ask questions and to express

concerns If you do not know the answers to specific

questions, refer to your immediate supervisor

ADMISSION FORMS Forms list the procedures that must be performed Will vary slightly from facility to facility Important for health care worker to become familiar

with required information on the form Much of the information on the admission form is

used as a basis for the nursing care plan Must be complete and accurate! It the pt is unable to answer the questions, a relative

or the person responsible for the pt is usually able to provide the information

PROCEDURES PERFORMED UPON ADMISSION

Vital signs Height and weight measurements Collection of a routine urine specimen Protect patient’s possessions

Make a list of clothing, valuables, and personal items

In a hospital a family member will frequently take clothing home

Any personal items left in a room should be noted on a list, and the list should be signed by the pt and the assistant

At the time of transfer or discharge, the list of items is checked to make sure all of the belongings are returned

If the family member does not take items home, the items should be placed in a safe

FOLLOW CORRECT TECHNIQUE WHILE PERFORMING THESE PROCEDURES!!

PROCEDURES PERFORMED UPON ADMISSION

Orient patient to facility Provide instructions on how to operate the bed, call light,

remote control for TV, etc. Explain visiting hours, location of lounges, smoking

regulations, availability of services, times for meals, and other rules and regulations

Many facilities have a pamphlet or paper listing this information, which is given to the patient and family members.

FOLLOW CORRECT TECHNIQUE WHILE PERFORMING THESE PROCEDURES!!

TRANSFERS Done for a variety of reasons

Change in the patient’s condition Per patient request

Agency policy must be followed during any transfer Reason for transfer should be explained to patient

and family by the appropriate personnel New room or unit must be ready to receive the

patient All personal items must be moved with patient Organized and efficient transfer will help prevent

fear and anxiety for the patient

DISCHARGE Doctor’s order usually required If an individual plans to leave a facility without

permission, report this immediately to your supervisor

Facilities have special policies that must be followed when a patient leaves against medical advice (AMA)

When an order for discharge is received, assistant must check and pack the patient’s belongings

Check the unit, including any drawers, closets, and storage areas carefully to find all items

DISCHARGE Most agencies require a staff member to

accompany the individual to the car If a patient is transferred by ambulance, the

ambulance attendants will bring a stretcher to the room

Most agencies have forms or checklists that are used during a discharge to ensure that all procedures have been followed.

ADMITTING Obtain orders Prepare the room for the admission Greet and identify the patient Introduce yourself Ask the family to wait in the lounge or lobby Close the door and screen the unit Ask the patient to change into a gown Position the patient comfortably in the bed

ADMITTING Complete the admission form or checklist Measure and record vital signs Weigh and measure the patient Complete the clothing list and make sure patient or

family member checks the list Obtain a urine specimen, if ordered Orient the patient to the facility and explain all

routines Fill the water pitcher if patient is allowed to have

liquids

ADMITTING Observe all checkpoints

Patient is comfortable and in good alignment S/R x 4 bed is at lowest position Call light and supplies within reach Area is neat and clean

When admission is complete, allow family members to return and answer any questions they have

Record required information on patient’s chart

DISCHARGING Obtain orders Check with patient to determine when relatives will

arrive for discharge Close the door or screen the room Help the patient dress, if needed Assemble all the patient’s personal belongings Assemble any equipment that is given to the patient,

such as the admission kit Check to make sure patient has received d/c orders

and instructions from the nurse or physician

DISCHARGING Obtain the patient’s valuables if they are in a safe Complete a d/c checklist Place all patient’s belongings on a cart Assist the patient into a w/c Transport patient to exit area and help patient into

the car Observe all safety factors while transporting patient Say good-byeSay good-bye

DISCHARGING Return to the unit, strip the bed, remove any

equipment and follow agency policy for cleaning the room

Record all required information on the patient’s chart

WORDS TO THE WISE!!! TALK WITH YOUR PATIENTS AT ALL

TIMES WATCH WHAT YOU SAY!! UNCONSCIOUS AND SEMI-CONSCIOUS

PATIENTS MAY BE ABLE TO HEAR YOU

ALWAYS BE KIND!!!!!!!!!!

Positioning, Turning, Moving, and Transferring Patients ALIGNMENT “positioning body parts in

relation to each other in order to maintain correct body posture”

PREVENTS Fatigue Pressure ulcers (decubitus ulcers) Contractures

FOOT DROP

Decubitus Ulcers

STAGE I STAGE II

STAGE III STAGE IV

PREVENTION PROVIDING GOOD SKIN CARE PROMPT CLEANING OF URINE AND FECES FROM

SKIN MASSAGING IN A CIRCULAR MOTION AROUND A

REDDENED AREA FREQUENT TURNING POSITIONING TO AVOID PRESSURE ON IRRITATED

AREAS KEEPING LINEN CLEAN, DRY, AND WRINKLE FREE APPLYING PROTECTORS TO BONY PROMINENCES

(HEELS & ELBOWS) EGG CRATE, ALTERNATING PRESSURE

MATTRESSES OR WATER/GEL FILLED MATTRESSES

TURNING AT LEAST q 2 hr IF PERMITTED BY MD PROVIDES EXERCISE FOR MUSCLES STIMULATES CIRCULATION PREVENTS DECUBITUS ULCERS AND

CONTRACTURES PROVIDES COMFORT TO PATIENT

DANGLING FOR PATIENTS WHO HAVE BEEN

CONFINED TO THE BED FOR A PERIOD OF TIME DONE PRIOR TO PATIENT BEING

TRANSFERRED FROM THE BED SITTING WITH THE LEGS HANGING

DOWN OVER THE SIDE OF THE BED PULSE CHECKED AT LEAST 3 TIMES

DURING THIS PROCEDURE!!!

DANGLING PULSE CHECKED BEFORE—used as control, or resting rate DURING—immediately after positioning the patient in the

dangling position AFTER—returning the patient to the supine position ALSO NOTE RESPIRATIONS, BALANCE, COLOR,

PERSPIRATION, COLOR, OTHER CHARACTERISTICS RETURN PATIENT TO SUPINE POSITION

IMMEDIATELY IF DANGLING IS NOT TOLERATED!! FOLLOW PROPER CHARTING AND NOTIFICATION

TO SUPERVISOR

TRANSFERS BED TO WHEELCHAIR OR CHAIR WHEELCHAIR OR CHAIR TO BED BED TO STRETCHER MECHANICAL LIFT NEVER TRANSFER WITHOUT PROPER

AUTHORIZATION OBSERVE PATIENT CLOSELY FOR CHANGES

IN PULSE RATE, RESPIRATIONS, AND COLOR, DIZZINESS, INCREASED PERSPIRATION, OR DISCOMFORT

ADMINISTERING PERSONAL HYGIENE

Usually includes the bath, back care, perineal care, oral hygiene, hair care, nail care, and shaving when necessary.

Must be sensitive to the patient’s needs and respect the patient’s right to privacy while personal care is administered.

Reasons for providing personal hygiene Promotes good habits of personal hygiene Provides comfort and stimulates circulation Provides health care worker an opportunity to develop a

good and caring relationship with the patient

BATHS Type of bath depends on the patient’s condition and

ability to help. Complete bed bath (CBB)

Health assistant bathes all parts of the body; which includes oral hygiene

Partial bed bath (PB) Health assistant bathes some parts of the body and also

gathers supplies needed by the patient Tub bath or shower

Assistant helps by providing towels and supplies, preparing tub or shower area

ORAL HYGIENE Refers to the care of the mouth and teeth Should be done at least 3 times a day and more often

if patient’s condition requires frequent oral care PURPOSES

Prevents disease, caries, and halitosis. Stimulates appetite and provides comfort

ROUTINE ORAL HYGIENE Refers to regular tooth brushing and flossing Patient can often do self care, but assistant can help when

needed

ORAL HYGIENE Denture care

Many patients sensitive about dentures Assistant must provide privacy and reassure the patient Extreme care must be taken while handling dentures

NPO Patients Special oral hygiene

Care provided to unconscious or semiconscious patient Care must be taken to clean all parts of the mouth Special supplies may be used for this procedure

HAIR CARE Important aspect of personal care that is often

neglected Brushing will stimulate circulation to scalp

and help prevent scalp disease Shampooing must be approved by the doctor

Various types of dry or fluid shampoos are available for pts confined to bed

Special devices are available for use while giving a shampoo to a pt confined to bed

NAIL CARE Should be done as part of daily hygiene and

patient care Often neglected area in personal care of the pt Nails harbor dirt and can lead to infection and

disease Never cut the toenails!

SHAVING Normal daily routine for most men Important to provide when pt unable to shave Both regular and electric razors may be used Correct technique must be used to prevent injury to

patient Females usually appreciate shaving of legs and

underarms BE SURE YOU HAVE SPECIFIC ORDERS FROM

DOCTOR OR IMMEDIATE SUPERVISOR

BED BATHS As with any procedure—obtain proper authorization,

assemble equipment, knock, introduce yourself, identify the patient, screen the unit, eliminate drafts, adjust the thermostat, wash hands (you will need gloves for part of a complete bed bath), lock wheels on bed, & elevate bed to proper level

As you bathe patient, take special care to expose ONLY the area of the body you are washing at the time

Keep patient warm and covered

BED BATHS Lower side rail on side you are working Replace top linen with bed blanket Provide oral hygiene Shave male patient or after face is washed Fill basin 2/3 full with warm, not hot water

(105°-110°)

BED BATHS Help patient move to side of bed nearest you Remove bedclothes keeping patient covered

with bath blanket Place towel over upper edge of bath blanket With washcloth, form mitten around hand,

tucking in edges (see figure 20-41, page 668)

BED BATHS Wet washcloth, squeezing out extra water Wash patient’s eyes, starting at inner area,

moving to outside Use different part of cloth for other eye Rinse cloth Wash face, neck, and ears, using soap on face

if patient desires Rinse and pat dry

BED BATHS Towel lengthwise under arm on ***far side Hand and nails in basin Wash, rinse, and pat arm dry from axilla to

hand Nail care

BED BATHS Bath towel over chest Fold bath blanket down from under towel Wash, rinse, and dry the chest and breasts Pay particular attention to area under female’s

breasts Dry thoroughly—apply lotion as desired

BED BATHS Turn towel lengthwise to cover chest and

abdomen Fold bath blanket down to pubic area Wash, rinse, and dry abdomen Replace bath blanket Remove towel

BED BATHS Fold bath blanket to expose patient’s far leg Place towel lengthwise under leg and foot Place foot in basin by flexing the knee Wash and rinse leg and foot Remove basin Dry leg and foot Repeat for other leg

BED BATHS Provide nail care as needed NEVER cut toenails File straight across Apply lotion to feet Observe for any color changes or irritated

areas that may signify problems

BED BATHS ELEVATE SIDERAIL CHANGE WATER IN BASIN ALWAYS CHANGE WATER AT THIS

TIME WATER MAY BE CHANGED AT OTHER

TIMES IF IT BECOMES TOO COOL, DIRTY, OR SOAPY

BED BATHS Lower siderail Turn patient onto side or prone Place towel lengthwise on the bed along patient’s

back Wash, rinse, dry entire back thoroughly with towel Observe for changes that may signify problems,

especially bony areas Give backrub

BACK RUBS

RUB SMALL AMOUNT OF LOTION INTO HANDS TO WARM A.—REPEAT 4 TIMES B.—REPEAT 4 TIMES C.—REPEAT 1 TIME D. –USE FIRST MOTION FOR 3-5 MINUTES E. –REPEAT FOR 1-2 MINUTES (RELAXATION AFTER STIMULATION)

BED BATHS Turn patient onto back Keep patient draped with bath blanket If patient can wash perineal area, place basin

with water, soap, washcloth, towel, and call signal within easy reach

Raise siderail and wait outside for patient to complete procedure

BED BATHS STRAIGHTEN BED LINEN CHANGE GOWN AS NEEDED

BED BATHS If patient cannot wash perineal area: Put on gloves Drape and position the female patient in

dorsal recumbent position, male patient in horizontal recumbent position

Towel or disposable underpad under patient

PERINEAL CARE--FEMALE Always wash from front to back (or rectal

area) Separate the labia, or lips Cleanse area thoroughly with front to back

motion Use clean area of washcloth or rinse cloth

between each wipe Wash rectal area

PERINEAL CARE--MALE Cleanse the tip of penis using a circular motion

starting at urinary meatus working outward Cleanse penis from top to bottom If not circumcised, gently draw the foreskin back to

wash the area After rinsing and drying the area, gently return

foreskin to normal position Wash scrotum and scrotal area Turn male patient on his side to wash rectal area

BED BATHS When perineal area is rinsed, clean, and dry,

reposition patient on his/her back Remove towel or underpad Remove gloves Wash hands Provide clean bedclothes Provide hair care Make bed—occupied bed

BED BATHS Observe all checkpoints Clean and replace all equipment Proper charting procedures

TUB BATHS OR SHOWERS MAKE SURE THE TIME IS APPROPRIATE FOR

A SHOWER OR BATH TAKE SUPPLIES TO BATH OR SHOWER AREA TUBS SHOULD BE CLEANED BEFORE AND

AFTER USE NON SKID STRIPS OR RUBBER MAT IN TUB

OR SHOWER FILL TUB ½ FULL OF WARM WATER (105°)

OR ADJUST SHOWER TEMPERATURE

TUB BATHS OR SHOWERS ASSIST PATIENT WITH ROBE AND

SLIPPERS ASSIST PATIENT TO TUB/SHOWER

AREA USING WHEELCHAIR AS NEEDED

IF NECESSARY, OR IN ACCORDANCE WITH FACILITY POLICY, REMAIN WITH PATIENT OR INSTRUCT PATIENT ON USE OF EMERGENCY CALL LIGHT

TUB BATHS OR SHOWERS CHECK ON PATIENT FREQUENTLY IF PATIENT SHOWS SIGNS OF WEAKNESS OR

DIZZINESS, USE CALL BUTTON TO GET HELP ASSIST TO WHEELCHAIR/CHAIR FROM

SHOWER EMPTY TUB KEEP PATIENT COVERED WITH TOWEL OR

BATH BLANKET TO PREVENT CHILLING

TUB BATHS OR SHOWERS HELP AS NEEDED AFTER TUB OR

SHOWER HELP WITH CLEAN BED CLOTHES ADMINISTER BACK RUB, HAIR, OR

NAIL CARE OBSERVE ALL CHECKPOINTS BEFORE

LEAVING PATIENT

TUB BATHS OR SHOWERS REPLACE ALL EQUIPMENT AND

SUPPLIES CLEAN BATH/SHOWER AREA USING

GLOVES WASH HANDS CHART ACCORDING TO POLICY

FEEDING A PATIENT Good nutrition is an important part of patient’s

treatment Important to make mealtimes as pleasant as possible

Mealtimes are social times Most people prefer to eat with others People who eat alone often have poor appetites and poor

nutrition In LTCF, patients are encouraged to eat in the dining

room and interact socially with others If patient is confined to bed—important to talk while

serving or feeding

FEEDING A PATIENT--Preparation Patient should be ready to eat when tray arrives Offer bedpan/urinal or assist to bathroom Clear room of offensive odors Allow patient to wash hands & face Provide oral hygiene Position patient comfortably, in sitting position, if

able Clear overbed table & position it for meal tray Remove objects such as emesis basin & urinal from

patient’s view

FEEDING A PATIENT If patient’s tray is delayed due to tests, etc., explain

this to patient Check food tray carefully before serving Check patient’s name, room number, & type of diet Note anything that seems out of place, such as:

Salt shaker on low salt diet Sugar on diabetic diet

Inform supervisor of any problems Never add any food to tray without checking diet

order

FEEDING A PATIENT ALWAYS allow patient to feed him/herself if

possible Assist by cutting meat, opening milk cartons,

buttering bread If patient is blind or visually impaired;

Tell patient what food is on plate by comparing it to clock face

Ex: Swiss steak at 12; peas and carrots at 4, mashed potatoes at 9

Make sure all utensils are conveniently placed Position towel or napkin under the patient’s chin

FEEDING A PATIENT Test temperature of hot foods before feeding

patient Place small amount on your wrist (NOT the

patient’s!!) to check temperature NEVER blow on hot food to cool it!!!!

PRINCIPLES OF FEEDING A PATIENT Alternate the foods by giving sips of liquids

between solid foods, but don’t mix foods Use straws for liquids whenever possible

Do not use straws if patient has dysphagia or difficulty in swallowing

Straws can force liquids down the throat faster and cause choking

“Thick-It” solidifies liquids slightly to make easier to swallow, but must be ordered by MD or dietician

FEEDING A PATIENT Hold spoon or fork at right angles to patient’s

mouth so you are feeding them from the tip Place small amounts on the spoon—1/3 to ½

full Tell the patient what s/he is eating Encourage the patient to eat as much as

possible

FEEDING A PATIENT Provide relaxed, unhurried atmosphere Allow patient sufficient time to chew food Observe how much patient eats

Keep record of nutritional intake If patient does not like a certain food, check

with supervisor to see if substitutions can be made

Record the intake if patient is on I&O

FEEDING A PATIENT Always be alert to signs of choking while

feeding a patient Make every effort to prevent choking Feed small quantities Allow patient time to chew and swallow Provide liquids to keep the mouth moist and

make chewing and swallowing easier

FEEDING A PATIENT If patient has had a stroke, one side of mouth might

be affected As you feed the patient, direct the food to unaffected

side Watch patient’s throat to check swallowing Watch for food that may be lodged in the affected

side of the mouth If patient chokes, be prepared to proved abdominal

thrusts or Heimlich maneuver

FEEDING A PATIENT Allow patient to hold bread or help to extent the

patient is able Use towel or napkin to wipe mouth as necessary Be alert at all times to signs of dysphagia and or

choking When meal is complete, allow patient to wash hands

and face and provide oral hygiene Note amount of food eaten & record I&O

BEDPANS/URINALS

ELIMINATION TERMINOLOGY

URINATE, MICTURATE, VOID DEFECATE, BOWEL

MOVEMENTS (BM)

INTAKE AND OUTPUT A large part of the body is fluid, so there must be a

balance between the amount of fluid taken into the body and the amount lost from the body

Fluid balance may be abnormal in certain pts Heart or kidney disease Loss of fluid through diarrhea, vomiting, diarrhea,

excessive perspiration, or bleeding Swelling or edema occurs when excessive fluid is

retained

INTAKE AND OUTPUT Dehydration occurs if excessive fluid is lost Edema or dehydration can lead to death if not

treated I and O record used to record all fluids taken

in and discharged from the body Forms vary but most contain separate sections

for intake and output

INTAKE Oral Tube feeding or enteral feedings IV Irrigation

OUTPUT BM Emesis Urine Irrigation

INPUT AND OUTPUT Records must be accurate Care must be taken when adding or totaling

the columns Totals are calculated for 8 hour and 24 hours

periods Careful instruction must be given to patients

AND their families on I&O’s

Procedure for recording I&O Use a blue or black pen Find the correct time line and column to record the

information Note the number of cc’s or ml’s for standard

containers such as coffee cup, glass, and other containers at the top of the chart

Recheck all entries for accuracy Enter observations about colors, types, solutions

used, and other information in the remarks column

Procedure for recording I&O After all the information for an 8-hour time period is

recorded, total each column separately to calculate the 8-hour total

When all 8-hour time periods have been totaled, add the three 8-hour totals together for each separate column

On some charts, all 24-hour totals for intake are added together for a 24-hour intake total, and all 24-hour totals for output are added together for a 24-hour output total

Procedure for recording I&O If you make an error

Draw one line through the error Initial, and record the correct information

Do a final check of the I & O Make sure all entries are correct Make sure comments are noted in comment

section Make sure all additions are accurate and legible

CATHETER CARE Provided to keep urinary meatus clean and

free of secretions Helps prevent bladder and kidney infections Done AT LEAST once every 8 hours Careful observation of urine

Amount, color, presence of other substances Report unusual observations immediately

CATHETER CARE Obtain proper authorization Knock, pause, introduce self, identify patient,

explain procedure, provide privacy Safety points & standard precautions Female patient in dorsal recumbent position Male patient in horizontal recumbent position Drape patient to expose only perineal area Sterile applicator moistened with antiseptic solution

or soap and water

CATHETER CARE--FEMALE Gently separate labia or lips to expose urinary

meatus Wipe from front to back with sterile

applicator Place used applicator in plastic waste bag Use clean, sterile applicator each time, and

continue to wipe from front to back until area is clean

CATHETER CARE--MALE Gently grasp penis and draw foreskin back Use circular motion to clean around meatus Use sterile applicator to wipe from meatus down the

shaft Place used applicator in plastic waste bag Use clean sterile applicator each time, and continue

to wipe from meatus down shaft until area clean After the area is clean, gently return the foreskin to

its normal position

CATHETER CARE Use sterile applicator to clean catheter from

meatus down about 4 inches Take care not to pull on catheter Place used applicator in plastic waste bag Use clean sterile applicator and repeat until

clean Observe area carefully for any signs of

irritation, abnormal discharges, or crusting

CATHETER CARE Reposition patient comfortably in correct

alignment Check all points on catheter and urinary

drainage unit Always check patient for safety and comfort

before leaving Record and/or report all required information

OSTOMY CARE OBJECTIVES DEFINE OSTOMY DIFFERENTIATE BETWEEN A

URETEROSTOMY, ILEOSTOMY, COLOSTOMY LIST BASIC PRINCIPLES FOR OSTOMY CARE IDENTIFY UNIVERSAL PRECAUTIONS

OBSERVED DURING OSTOMY CARE

OSTOMY CARE Ostomy

Surgical procedure in which an opening, called a stoma, is created in the abdominal wall

Allows wastes such as urine or stool (feces) to be expelled through the opening

Most often done due to tumors/cancers in urinary bladder or intestine

Birth defects, ulcerative colitis, bowel obstruction, injuries

Permanent or temporary

TYPES OF OSTOMIES Ureterostomy

Opening into one of the ureters Ureter is brought to the surface of abdomen to drain urine

Ileostomy Opening in ileum (small intestine), with loop brought to

abdomen Entire large intestine is bypassed Stool expelled—liquid and frequent Contains digestive enzymes that irritate skin

TYPES OF OSTOMIES Colostomy Opening into large intestine or colon Different kinds of colostomies depending on the area of

large intestine involved Stool expelled through an ascending colostomy is usually

more liquid Transverse or descending colostomy more solid and formed Sigmoid colostomy is similar to normal stool

Digestive products have moved through most of the intestine

Water and other substances have been reabsorbed

OSTOMY CARE Bags or pouches to collect urine or stool Held in place by belt or adhesive seal Problems include leakage, odor, irritation of skin

surrounding stoma Pouch must be emptied frequently Good stoma and skin care essential since these areas

are irritated by the urine or stool drainage Skin barriers

OSTOMY CARE New colostomies are cared for by RNs “older” ostomies may be cared for by trained

health care assistants Know facility policy and legal responsibilities Eventual self care of ostomy

OSTOMY CARE-Pyschological Loss of self worth and dignity Patient feels different even though clothes cover bag Sometimes difficulty maintaining normal sex life Anger, anxiety, depression, fear, hopelessness

(especially with CA diagnosis) Allow expression of feelings, verbalize fears Understanding Support groups

OSTOMY CARE--Observations Stoma is mucous membrane-no nerve endings Bright to dark red with wet appearance Rubbing or pressure can cause bleeding Report any abnormal appearance

Blue to black color indicates interference with blood supply

Pale or pink color can indicate low hemoglobin Dry or dull appearance signifies dehydration

OSTOMY CARE-Observations Profuse bleeding, ulceration or cuts, or

formation of crystals on the stoma indicate problems

Discharge in bag should be observed Note amount, color, type (liquid, semi-formed,

formed) REPORT and RECORD anything unusual

OSTOMY CARE Standard precautions Gloves, wash hands often, eye protection Discard pouch in biohazard bag If bedpan is used, it must be cleaned and

disinfected Any areas contaminated with urine or stool

must be cleaned with disinfectant

OSTOMY CARE Obtain proper authorization Knock, pause, introduce yourself, identify

patient, explain the procedure, provide privacy

Observe all safety points regarding body mechanics, siderails, height of bed, and patient safety

Observe standard precautions

OSTOMY CARE Cover the patient with a bath blanket Place bed protector or underpad under the

patient’s hips on the side of the stoma Fill basin with water (105-110°F) Place the bedpan and plastic waste bag within

easy reach and put on gloves

OSTOMY CARE Open belt and carefully remove ostomy bag Be gentle when peeling bag away from stoma Note amount, color, and type of drainage in

the bag Place bag in bedpan or biohazard bag (if

ostomy bag is disposable)

OSTOMY CARE If bag is reusable

Drain the fecal material (or urine) by placing the clamp end of the bag over a bedpan

Release the clamp and allow the fecal material to empty into the bedpan

Wash the inside of the bag with soap and water and allow it to dry before reapplying the bag

Most people use a second bag while the first is drying Use toilet tissue to gently wipe around the stoma to

remove feces or drainage

OSTOMY CARE Look at the stoma and surrounding skin carefully

Check for irritated areas, bleeding, edema or swelling, or discharge

Report unusual observations Wash ostomy area gently with soap and water, using

a circular motion, working from the stoma outward Rinse entire area well to remove any soapy residue

and dry the area gently Use measuring chart to determine the correct size

barrier wafer

OSTOMY CARE If the wafer is not self-adhesive

Apply adhesive stoma paste to the skin around the stoma

Allow paste to dry if necessary Peel the paper backing from the wafer Position the wafer, adhesive side down, over the

adhesive paste Position the belt around the patient

OSTOMY CARE Place a clean ostomy bag in place over the wafer and seal bag

tightly to wafer to prevent leakage If the pouch has a drainage area, make sure the clip or clamp

is secure Remove underpad Reposition patient comfortably in correct alignment Check patient for comfort and safety before leaving Observe standard precautions while discarding the used

ostomy bag, drainage, and other contaminated equipment REPORT AND RECORD

URINE SPECIMENS SPECIMEN USUALLY COLLECTED

FROM FIRST URINE VOIDED IN AM URINE IS MORE CONCENTRATED MORE SHOW MORE ABNORMALITIES USUALLY HAS ACID pH, WHICH HELPS

PRESERVED CELL PRESENT IF TEST FOR GLUCOSE AND ACETONE,

SPECIMEN MUST BE FRESH AND COLLECTED JUST BEFORE TESTING

URINE SPECIMENS MAY BE COLLECTED IN BEDPAN/URINAL OR

SPECIAL URINE COLLECTOR AND POURED INTO SPECIMEN CONTAINER

MAY VOID DIRECTLY INTO CONTAINER USUALLY 120cc SUFFICIENT FOR TESTING PLACE IN BIOHAZARD BAG TO SEND TO LAB REFRIGERATE UNTIL TESTING

URINE SPECIMENS CLEAN CATCH OR MIDSTREAM

SPECIAL METHOD OF OBTAINING URINE SPECIMEN FREE FROM CONTAMINATION

STERILE URINE SPECIMEN CATHETERIZATION REQUIRED

URINE SPECIMENS 24 HOUR SPECIMEN

USED FOR KIDNEY FUNCTION & FOR COMPONENTS SUCH AS PROTEIN, CREATININE, UROBILINOGEN, HORMONES, CALCIUM

PT VOIDS, URINE DISCARDED-TIME NOTED BEGINNING 24 HOUR PERIOD ALL URINE VOIDED IN NEXT 24 HOURS SAVED LAST URINE VOIDED AT END OF 24 HOUR PERIOD

SAVED FOR FINAL COLLECTION

STOOL SPECIMENS Specimen of feces or stool examined by lab

personnel Usually done for ova and parasites (O&P)—eggs

and worms!! Specimen must be kept warm at body temperature Should be tested within 30 minutes for accurate

results Can be examined for presence of fats,

microorganisms, and other abnormal substances or OCCULT BLOOD

Special stool specimen container

STOOL SPECIMENS-Hemoccult Blood from intestinal tract in stool—occult (hidden)

blood Test requires very small amount of stool Special card with chemical Uses developing solution Color change indicates positive results=presence of

blood No requirements for immediate testing or special

temperature

PRACTICE & CHECK OFF PCA REQUIREMENTS!!!