U


U



6982


Ultrasonography: Limited Obstetric


Definition: Performance of ultrasound (U/S) exams to determine ovarian, uterine, or fetal status


Activities:



• Determine indication for ultrasound (U/S) imaging


• Set up equipment


• Instruct patient and family about exam indication(s) and procedure


• Prepare patient physically and emotionally for procedure


• Place transducer on abdomen or in vagina, as appropriate


• Obtain clear picture of anatomic structures on the monitor


• Identify uterine position, size, and endometrial thickness, as appropriate


• Identify ovarian location and size, as appropriate


• Monitor follicular growth throughout ovulation, as appropriate


• Monitor gestational sac growth and location


• Monitor fetal parameters, including number, size, cardiac activity, presentation, and position


• Identify placental location


• Observe for placental abnormalities, as appropriate


• Measure amniotic fluid indexes


• Monitor fetal breathing movements, gross movements, and tone


• Identify fetal structures to parents, as appropriate


• Provide picture of fetus(es), as appropriate


• Discuss test(s) results with primary practitioner, consultants, and patient, as appropriate


• Schedule additional tests or procedures, as necessary


• Clean equipment


• Document findings


2nd edition 1996



2760


Unilateral Neglect Management


Definition: Protecting and safely reintegrating the affected part of the body while helping the patient adapt to disturbed perceptual abilities


Activities:



• Monitor for abnormal responses to three primary types of stimuli: sensory, visual, and auditory


• Evaluate baseline mental status, comprehension, motor function, sensory function, attention span, and affective responses


• Provide realistic feedback about patient’s perceptual deficit


• Perform personal care in a consistent manner with thorough explanation


• Ensure that affected extremities are properly and safely positioned


• Adapt the environment to the deficit by focusing on the unaffected side during the acute period


• Supervise and/or assist in transferring and ambulating


• Touch unaffected shoulder when initiating conversation


• Place food and beverages within field of vision and turn plate, as necessary


• Rearrange the environment to use the right or left visual field, such as positioning personal items, television, or reading materials within view on unaffected side


• Give frequent reminders to redirect the patient’s attention, cueing the patient to the environment


• Avoid rapid movement in the room


• Avoid moving objects in the environment


• Position bed in room so that individuals approach and care for patient on unaffected side


• Keep side rail up on affected side, as appropriate


• Instruct patient to scan from left to right


• Provide range of motion and massage to affected side


• Encourage patient to touch and use affected body part


• Consult with occupational and physical therapists concerning timing and strategies to facilitate reintegration of neglected body parts and function


• Gradually focus patient’s attention to the affected side, as patient demonstrates an ability to compensate for neglect


• Gradually move personal items and activity to affected side, as patient demonstrates an ability to compensate for neglect


• Stand on affected side when ambulating with patient, as patient demonstrates an ability to compensate for neglect


• Assist patient with activities of daily living from affected side, as patient demonstrates an ability to compensate for neglect


• Assist patient to bathe and groom affected side first, as patient demonstrates an ability to compensate for neglect


• Focus tactile and verbal stimuli on affected side, as patient demonstrates an ability to compensate for neglect


• Instruct caregivers on the cause, mechanisms, and treatment of unilateral neglect


• Include family in rehabilitation process to support the patient’s efforts and assist with care, as appropriate


2nd edition 1996



0570


Urinary Bladder Training


Definition: Improving bladder function for those with urge incontinence by increasing the bladder’s ability to hold urine and the patient’s ability to suppress urination


Activities:



• Determine ability to recognize urge to void


• Encourage patient to keep a voiding diary


• Keep a continence specification record for 3 days to establish voiding pattern


• Assist patient to identify patterns of incontinence


• Review voiding diary with patient


• Establish interval of initial toileting schedule, based on voiding pattern


• Establish beginning and ending time for toileting schedule, if not for 24 hours


• Establish interval for toileting of not less than 1 hour and preferably not less than 2 hours


• Toilet patient or remind patient to void at prescribed intervals


• Provide privacy for toileting


• Use power of suggestion (e.g., running water or flushing toilet) to assist patient to void


• Avoid leaving patient on toilet for more than 5 minutes


• Reduce toileting interval by one half hour if more than three incontinence episodes occur in 24 hours


• Maintain toileting interval if three or less incontinence episodes occur in 24 hours


• Increase toileting interval by one half hour if patient is unable to void at two or more scheduled toileting times


• Increase the toileting interval by 1 hour if patient has no incontinence episodes for 3 days, until optimal 4-hour interval is achieved


• Express confidence that incontinence can be improved


• Teach the patient to consciously hold urine until the scheduled toileting time


• Discuss daily record of continence with patient to provide reinforcement


2nd edition 1996; revised 2004



0580


Urinary Catheterization


Definition: Insertion of a catheter into the bladder for temporary or permanent drainage of urine


Activities:



• Explain procedure and rationale for catheterization


• Assemble appropriate equipment


• Ensure privacy and proper draping of patient for modesty (i.e., only expose genitalia)


• Ensure correct lighting for proper visualization of anatomy


• Prefill catheter bulb to check patency and size


• Maintain strict aseptic technique


• Maintain proper hand hygiene before, during, and after catheter insertion or manipulation


• Position patient appropriately (e.g., female on back with legs apart or on side with upper leg flexed at hip and knee; male on back)


• Cleanse area around urethral meatus with antibacterial solution, sterile saline, or sterile water, per agency protocol


• Insert straight or retention catheter into the bladder, as appropriate


• Use smallest size catheter, as appropriate


• Assure that catheter is inserted far enough into bladder to prevent trauma to urethral tissues with inflation of balloon


• Fill catheter bulb for indwelling catheter, adhering to age and body size manufacturer recommendations (e.g., 10 cc adult, 5 cc child)


• Connect retention catheter to a bedside drainage bag or leg bag


• Secure catheter to skin, as appropriate


• Place drainage bag below level of bladder


• Maintain a closed and unobstructed urinary drainage system


• Monitor intake and output


• Perform or teach patient clean intermittent catheterization, when appropriate


• Perform postvoid residual catheterization, as needed


• Document care including catheter size, type, and bulb fill amount


• Assure catheter removal as soon as indicated by patient condition


• Teach patient and family proper catheter care

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Dec 3, 2016 | Posted by in NURSING | Comments Off on U

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