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