UNIT Perineum

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					UNIT 17. ELIMINATION                                                              Name:
                                                                                  Period:
Objectives, Key points and Procedures

UNIT 17. STUDENT OBJECTIVES:
1. Describe the changes in urinary function associated with aging.
2. Describe and/or demonstrate skill in the care of indwelling urinary catheters.
3. State observations about urinary elimination that should be reported to the charge nurse.
4. Describe the changes in bowel function associated with aging.
5. Discuss measures to help prevent constipation.
6. Discuss ways to identify fecal impaction.
7. State observations about bowel elimination that should be reported to the charge nurse.
8. Discuss the important role of the nurse aide in regular and prompt toileting of residents.
9. Discuss the important role of the nurse aide in the bowel and/or bladder retraining program in your facility.
10. Describe and/or demonstrate skill in collecting:
    a) Routine or clean-catch urine specimens
    b) Routine stool specimens

Assignment
Read Chapter 19 (p.397-418) and worksheet
Practice procedural guidelines 41, 42, 43

KEY POINTS
A Urinary elimination
1. Normal function of urinary system - Review the urinary system

2. Changes in urinary function associated with aging

3. Urinary infection (UTI) any where in the urinary tract.
        Bladder or kidney infection or the whole tract
       s/s oliguria, urgency, dysuria, cloudy foul
           smelling urine, pyuria, hematuria, and
           sometimes for elderly increased confusion
4. Kidney failure –
        Output
        Dialysis – definition
                   Key points to KNOW

5. Role of the nurse aide in preventing urinary problems
         a.
         b.
         c.
6. Indwelling Urinary Catheter Care (Procedural Guideline #41)
         a.
         b.
         c.
         d.
7. Observing and reporting urinary elimination




CONTINUED
UNIT 17. ELIMINATION                                                      Name:
                                                                          Period:
Objectives, Key points and Procedures

B. Bowel elimination
1. Normal bowel function
2. Changes in bowel function associated with aging

3. Common problems of bowel elimination
   (a) Constipation
   (b) Diarrhea
   (c) Incontinence

4. Role of the nurse aide in preventing constipation
        a. Causes
        b. Prevention
        c.
        d.
        e.
5. Role of nurse aide in identifying fecal impaction
        a. fecal impaction is
        b. s/s –
        c. difference between constipation and impaction –

        d. causes
        e. Removal (OUCH!!!)
6. Role of nurse aide in managing diarrhea
        a.
        b.
        c.
7.Observing and reporting bowel elimination

 C. BLADDER AND/OR BOWEL INCONTINENCE
1. Definition and causes
   a. Bladder

    b. Bowel
2. Avoiding incontinence
    (a) Incontinence is not a normal part of aging.
    (b)
3. Use of incontinent pads and briefs
4. Use of external catheters for
5. Incontinent care

6. Bowel and bladder retraining programs
   (a) Description
   b. Role of the nurse aide in bowel and/or bladder retraining program
       1. Bladder training >
       2. Bowel training>


D. COLLECTING SPECIMENS
1. Urine Specimen Collection (Procedural Guideline #42)
2. Stool Specimen Collection (Procedural Guideline #43)
Texas Nurse Aide Skills Exam
Texas Department of Human Services Texas Curriculum for Nurse Aides in 03/01/2001 143 of 227 Long Term Care Facilities

PROCEDURAL GUIDELINE #41– INDWELLING URINARY CATHETER CARE
A. Purpose
    1. To maintain the indwelling urinary drainage system.
    2. To help avoid urinary tract infections.
B. Guidelines for Maintaining the Urinary Drainage System
    1. Wash hands. Wear gloves and follow Standard Precautions (Procedural Guideline #9A)
        if contact with blood or body fluids is likely.
    2. Check that the catheter remains secured with tape or leg strap following facility policy,
        to reduce friction and movement at the insertion site.
    3. Check that catheter is positioned over (not under) the leg.
    4. Check that there is no disconnection or leaking of urine from the system (except into
        the drainage bag).
    5. Check that urine is draining freely through the system.
    6. Keep the catheter and drainage tubing free of kinks or obstructions.
    7. Keep the urine-collecting bag below the level of the bladder at all times to prevent
       backflow of old urine into the bladder.
    8. Keep the drainage tubing and bag off the floor at all times to prevent contamination
        and damage.
    9. Never disconnect the catheter drainage system.
    10. When the resident is in bed, attach the collection bag to the bed frame--never to the
          side-rail.
C. Procedure for Emptying the Urinary Drainage Bag
    1. The catheter drainage bag is emptied at least every 8 hours or more often as needed
        to keep the bag from becoming full.
    2. Empty one urinary drainage bag at a time using a clean and separate graduate for each
       resident, washing hands and changing gloves between residents.
    3. Remember to knock on door, introduce self, greet resident, identify resident, explain
        procedure and provide privacy.
    4. Obtain a clean graduate container. Use a separate container for each individual resident
        to prevent cross contamination. The graduate may be labeled with resident’s name to
        reserve it for a single resident.
    5. Wash hands and put on gloves prior to contact with urine.
    6. Position the graduate to collect the urine.
    7. Open the clamp on the drain located at the bottom of the drainage bag.
    8. Empty urine into graduate touching only the clamp and using aseptic technique.
         a. Note that the drain spout should not come in contact with the collecting graduate,
             hands or other objects.
         b. If accidental contamination occurs, wipe drain spout with antiseptic wipe.
    9. Close clamp
    10. Measures output and discard urine following facility policy.
    11. Clean container and store for use for same resident following facility policy.
    12. Remove and discard gloves following facility policy promptly after use to avoid
          environmental contamination. Wash hands.
    13. Record urinary output.
Texas Nurse Aide Skills Exam
Texas Department of Human Services Texas Curriculum for Nurse Aides in 03/01/2001 144 of 227 Long Term Care Facilities

D. Observe for and Report to Charge Nurse:
   1. Catheters that are not secured with tape or straps.
   2. Kinks in tubing that cannot be corrected by simple repositioning.
   3. Accidental disconnection of tubing.
   4. Leaking of urine from tubing.
   5. No evidence of drainage of urine through tubing.
   6. Accidental elevation of bag above level of bladder.
   7. Amount of urine output at time of emptying drainage bag.
   8. Appearance of urine such as dark, red, cloudy. Presence of unusual substances such
       as solid particles, blood, odor.
   9. Problems at catheter-meatal junction such as redness, irritation, swelling, crusting,
      drainage, bleeding, pain.
   10. Urinary complaints such as dysuria, burning, urgency, frequency, flank pain.
   11. Other significant observations.
Texas Nurse Aide Skills Exam
Texas Department of Human Services Texas Curriculum for Nurse Aides in 03/01/2001 145 of 227 Long Term Care Facilities

PROCEDURAL GUIDELINE #42 – URINE SPECIMEN COLLECTION
A. Purpose: To collect a routine or clean-catch urine specimen for testing.
B. Beginning Steps
    1. Wash hands. Wear gloves and follow Standard Precautions (Procedural Guideline #9A)
         if contact with blood or body fluids is likely.
    2. Gather needed supplies:
         a. Clean bedpan, urinal, commode or specimen pan.
         b. Appropriate urine specimen container with lid and transport bag if used.
         c. Label--filled out following facility policy.
         d. Laboratory request form--to be completed by nurse
         e. Clean, disposable examination gloves
         f. For clean-catch specimen: clean-catch kit or follow facility policy
    3. Knock on door and identify self by name and title.
    4. Greet resident by preferred name and identify resident per facility policy.
    5. Explain procedure and encourage resident's participation as appropriate.
    a. Explain that a urine specimen is needed. Offer a glass of water if allowed.
    b. Ask resident to notify you when ready to urinate.
    6. Provide privacy as appropriate such as close door/curtains, drape resident.
    7. Provide safety as appropriate such as use good body mechanics, adjust bed to
        proper working height.
    8. If side-rails are in use, lower them on working side, keep them up on opposite side
        and always put them up before you step away from bedside.
C. To Collect Routine Urine Specimen:
    1. If perineum is heavily soiled, wear gloves and give perineal care (Procedural
       Guidelines #24 or #25 as appropriate).
    2. Wash hands and put on gloves prior to contact with urine.
    3. When resident is able to urinate, assist with toileting as appropriate. Remind resident
        not to put tissue or to have bowel movement in specimen.
    4. Assist resident to clean and dry perineum.
    5. Pour approximately 60cc of urine into the specimen container without contaminating
        the outside of the container.
    6. If urine is accidently spilled on outside of container, wipe outside of container clean
        with disinfectant wipe.
    7. Measure urine volume if resident is on I & O.
    8. Empty, clean and replace bedpan or urinal following facility policy.
    9. Remove gloves and wash hands after contact with urine.
    10. Record urine output on I and O.
    11. Place lid securely on container, attach label, and place in transport bag if used.
    12. Take the specimen promptly to charge nurse or follow facility policy.
Texas Nurse Aide Skills Exam
Texas Department of Human Services Texas Curriculum for Nurse Aides in 03/01/2001 146 of 227 Long Term Care Facilities


D. To Collect a Clean-Catch (Clean Voided/Midstream) Urine Specimen:
    1. If perineum is heavily soiled, wear gloves and give perineal care (Procedural
        Guideline #24 or #25 as appropriate).
    2. When resident is able to urinate, open the clean-catch kit or needed supplies following
        facility policy.
    3. Position resident on bedpan, toilet or bedside commode as indicated.
    4. Wash hands and put on gloves prior to contact with urine, other body fluids or
         mucous membrane.
    5. Wipe the perineal area following instruction on kit or facility policy.
    6. If resident is able to control stream of urine:
         a. Instruct resident to start urinating, then stop the stream.
         b. Place clean-catch container in position to catch urine and instruct resident to
             start urination.
         c. Collect the required amount of urine (about 60cc).
         d. Instruct resident to stop the stream when the needed amount is collected.
    7. If resident is unable to control stream of urine:
         a. Ask resident to start urinating
         b. Place clean-catch container under the stream and collect the required amount of urine.
    8. Remove specimen container and instruct resident to finish voiding.
    9. Assist resident to clean and dry perineum.
    10. Wipe outside of container with disinfectant wipe.
    11. Follow steps C 7 thru 12 of this Procedural Guideline.
E. Closing Steps
    1. Clean and store reusable items and discard disposables per facility policy.
    2. If gloved, remove and discard gloves following facility policy at the appropriate time
       to avoid environmental contamination. Wash hands.
    3. Provide for resident's comfort and safety before leaving as appropriate such as
        straighten clothing/bedding, adjust bed/side-rails.
    4. Always replace call signal and needed items within resident's reach.
    5. Inform resident when finished and ask if anything is needed before you go.
F. Observe For and Report to Charge Nurse:
    1. Problems or complaints related to procedure.
    2. Time and type of specimen collected.
    3. Amount and appearance of urine such as dark, red, cloudy. Presence of unusual substances
        such as particles, blood, odor.
    4. Urinary complaints such as dysuria, burning, urgency, frequency, flank pain.
    5. Other significant observations.
Texas Nurse Aide Skills Exam
Texas Department of Human Services Texas Curriculum for Nurse Aides in 03/01/2001 147 of 227 Long Term Care Facilities

PROCEDURAL GUIDELINE #43 – STOOL SPECIMEN COLLECTION
A. Purpose: To collect a routine stool specimen for testing.
B. Procedural Guidelines
    1. Beginning steps
         a. Wash hands. Wear gloves and follow Standard Precautions (Procedural Guideline
            #9A) if contact with blood or body fluids is likely.
         b. Gather needed supplies:
              (1) Clean bedpan, commode or specimen pan
              (2) Appropriate stool specimen container with lid and transport bag if used
              (3) Tongue blade
              (4) Label--filled out following facility policy
              (5) Laboratory request form--to be completed by nurse
              (6) Clean, disposable examination gloves
         c. Knock on door and identify self by name and title.
         d. Greet resident by preferred name and identify resident per facility policy.
         e. Explain procedure and encourage resident's participation as appropriate.
              (1) Explain that a stool specimen is needed.
              (2) Ask resident to notify you when ready to have bowel movement, or make
                  other arrangements as appropriate.
         f. Provide privacy as appropriate such as close door/curtains, drape resident.
         g. Provide safety as appropriate such as use good body mechanics, adjust bed to
             proper working height.
         h. If side-rails are in use, lower them on working side, keep them up on opposite side
            and always put them up before you step away from bedside.
    2. Wash hands and put on gloves prior to contact with stool.
    3. When resident is ready to have bowel movement, assist with toileting as appropriate.
    4. When finished, assist resident to clean and dry the rectal area and buttocks.
    5. Using tongue blade, place requested amount of feces (usually about 2 tablespoons)
        into specimen container without contaminating outside of container.
    6. If outside of container is accidently contaminated with feces, wipe clean with
        disinfectant wipe.
    7. Empty, clean and replace bedpan following facility policy.
    8. Remove gloves and wash hands.
    9. Place lid securely on container, attach label and place in transport bag.
    10. Take specimen promptly to charge nurse or follow facility policy.
    11. Closing steps
         a. Clean and store reusable items and discard disposables per facility policy.
         b. If gloved, remove and discard gloves following facility policy at the appropriate
             time to avoid environmental contamination. Wash hands.
         c. Provide for resident's comfort and safety before leaving as appropriate such as
            straighten clothing/bedding, adjust bed/side-rails.
         d. Always replace call signal and needed items within resident's reach.
         e. Inform resident when finished and ask if anything is needed before you go.
    12. Observe for and report to charge nurse:
         a. Problems or complaints related to procedure.
         b. Time and type of specimen collected.
         c. Amount and appearance of stool. Presence of unusual substances such as blood, mucus.
         d. Bowel complaints such as pain, constipation, diarrhea, bleeding.
         e. Other significant observations.

				
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