Clients needing temporary restraints include: Those who are at risk for falls Those who are confused

used Those who wander Those who are disruptive and agitated and at risk for self-injury or violence to self and/or others

Restraints are also used to prevent interruption of therapy such as: An IV catheter Urinary or surgical drains Nasogastric tube Traction Life support equipment

The use of restraints is associated with serious complications, including: Pressure ulcers Constipation Urinary and/or fecal incontinence Urinary retention

In some cases, death has resulted because of strangulation or asphyxiation. Loss of self-esteem, humiliation, fear, and anger are additional serious concerns. The least-restrictive type of restraint should be ordered. Orders are never on an asneeded (prn) basis. The physician's order must specify:

The type of behavior requiring restraint The type of restraint The time limitations

Assessment

Assess the need for restraint when all other measures have failed to prevent interruption of therapy or injury to the client or others. Review agency policies regarding restraints. Review the manufacturer's instructions for restraint application and determine the most appropriate size restraint. Inspect the area where the restraint is to be placed, including the condition of the skin and the adequacy of circulation.

PlanningExpected Outcomes

The client will be free of injury.

The prescribed therapies will be continued without interruption. The client's self-esteem and dignity will be maintained.

Evaluation

Observe the area of restraint for signs of injury, pressure, or other hazards of immobility. Verify that prescribed therapies are continued without interruption. Reassess the client's need for restraint at least every 24 hours, with the intent of discontinuing restraint at the earliest possible time.

2.15 Unexpected Outcomes

Unexpected Outcome The client experiences impaired skin integrity.

Intervention

Assess the skin and provide appropriate therapy. Notify the physician and reassess the need for continued use of restraint. Consider whether alternatives to restraint can be used. Ensure the correct application of the restraint, pad the skin under restraints, and remove restraints more frequently.

Unexpected Outcome The client has altered neurovascular status to an extremity (cyanosis, pallor, coldness of the skin, or complaints of tingling, pain, or numbness). Unexpected Outcome The client exhibits increased confusion, disorientation, or agitation. Unexpected Outcome The client escapes from the restraint device and suffers a fall or injury.

Intervention

Remove the restraint immediately. Stay with the client. Notify the physician.

Intervention

Identify the reason for the behavior change and attempt to eliminate the cause. Attempt restraint alternatives.

Intervention

Attend to the client's immediate physical needs and inform the physician. Reassess the type of restraint used, then verify the correct application and whether alternatives can be used.

When assisting the client with feeding, you should encourage the client to ingest an adequate volume of food at a comfortable pace.

Clients with neuromuscular diseases involving the brain, brain stem, cranial nerves, or muscles of swallowing should be assessed for swallowing difficulties before feeding. Clients with dysphagia (impaired swallowing) require special precautions to prevent aspiration. Maintaining an upright position to enhance the effects of gravity is important. When feeding the client, you place food on the unaffected side of the mouth (as in clients with hemiparesis) and observe the adequacy of the client's swallowing and any delayed swallowing. Food that is the consistency of mashed potatoes is easiest for dysphagic clients to swallow.

Assessment

Assess the level of consciousness, the ability to cooperate, mobility/activity orders, and physical limitations. Assess the need for toileting, hand hygiene, and oral care before feeding. Assess food tolerance, cultural and religious preferences, and food likes and dislikes. Assess the client's lung sounds, ability to cough on request, and the presence of gagging or involuntary coughing when the back of the throat is tickled with a tongue depressor or wet cotton swab. Assess the client's swallowing reflex before feeding by placing fingers on the client's throat at the level of the larynx, then ask the client to swallow.

For a client with dysphagia, include the following:

Thickener (if ordered) Suction equipment Oxygen

PlanningExpected Outcomes

The client's body weight remains stable or trends toward the normal level. The client's nutrition-related laboratory values trend toward normal. The client demonstrates increased ability to feed himself or herself or open items on the tray. The client coughs appropriately when eating, with an absence of signs of aspiration or new respiratory compromise. The client demonstrates the use of adaptive utensils as appropriate. The client's intake improves in the quality of nutrients ingested.

In addition, for the client with dysphagia, expected outcomes may include:

The client swallows without retaining food in the mouth. The client demonstrates a complete, effective swallowing event.

you should perform the following evaluation measures:

Monitor body weight daily or weekly. Monitor laboratory values as ordered. Observe the client's technique for self-feeding (certain items, part or all of the meal). Observe the client during eating for choking, coughing, gagging, or food left in the mouth. Observe the use of adaptive utensils. Observe the amount of food on the tray after the meal.

Additional evaluation measures for the client with dysphagia:

Unexpected Outcomes

Observe the contents of the client's mouth during the meal for food pocketing. Observe the client for a continuous swallowing event that occurs without delay.

Unexpected Outcome The client refuses to eat the food offered.

Intervention

Try to identify and resolve possible problems. Determine whether the client has other food preferences, cultural influences, or religious restrictions. Determine whether different times of the day are better for eating. Determine whether discomfort or anxiety should be treated before eating. Determine whether the client is mentally incapable of cooperating.

Unexpected Outcome The client chokes on food.

Intervention

Use suction equipment if necessary to clear food from the airway. Position the client in the high-Fowler's position or, if unable to do this, position the client on the side. If choking occurs repeatedly, stop the feeding and notify the physician. Provide oxygen as ordered by physician if the client remains in respiratory distress, the airway remains compromised, or the color has failed to return to normal.

Unexpected Outcome Food sits on the side or back of mouth. Unexpected Outcome Food and/or fluids drain out of the client's nose during the meal.

Intervention Teach the client to use the tongue or to massage the cheek externally to move food to a more functional area of the mouth. Intervention

Stop feeding the client. Suction the nasopharyngeal area. Resume feeding with increased head flexion.

Laboratory analysis aids in identifying:

A client's diagnosis The level or stage of a client's disease process A client's response(s) to treatment

When asking for urine, stool, vaginal, or other excretory specimens, ensure client privacy and provide an environment that is accepting and nonjudgmental. Each requisition must include: Date and time specimen is obtained Client name Client ID number Name of the test Source of specimen/culture Specimens need to be delivered promptly to the laboratory because when some specimens are left at room temperature, false abnormal findings may result. A culture and sensitivity (C&S) of urine is a test performed to identify urinary tract infections (UTIs) and to determine the most effective antibiotic for treatment. Specimens for C&S may be collected either as a clean-voided midstream specimen or under sterile conditions from a urinary catheter.

Characteristics of Urine

Urine should appear clear yellow to amber in color and without a foul or strong odor. Regardless of the method of collection, a routine urinalysis includes the following measurements:

Measurement pH Protein Glucose Ketones

Normal 4.6 to 8 0 0 0

Function Indicates acid-base balance Presence suggests renal disease and/or damage Elevated in diabetes Present during dehydration, starvation, and poorly controlled diabetes

Measurement Blood Specific gravity

Normal

Function

Less than 2 red blood cell Elevated with kidney disease and/or damage, (RBC) count infection, trauma, and surgery 1.010 to 1.025

Reflects urine concentration Increased with dehydration; decreased with overhydration

White blood cells (WBC) 0 to 4 Bacteria Casts 0 0

Elevated with UTI Presence indicates UTI Presence indicates kidney abnormality

To report the presence of: Blood Mucus, cloudiness, or excess sediment Foul odors Assess for indications of UTI. The most common signs and symptoms of a UTI include:
o o o o o o o o o o o o

PlanningExpected Outcomes

Frequency Urgency Dysuria (burning with urination) Changes in the color of the urine The presence of blood Flank or lower back pain The presence of fever The presence of odor Changes in the characteristics of the urine: cloudy versus clear, the presence of sediment, mucus, etc.

Evaluation

Client produces midstream urine specimen that is not contaminated with feces or toilet tissue. Urine has normal characteristics and is negative for bacterial growth. Client will discuss purpose of midstream urine collection.

Ask the client to identify the steps in the specimen collection procedure and the purpose of specimen collection. Observe the specimen for contaminants such as toilet paper or feces. Review the client's urine culture and sensitivity report for bacterial growth. Routine cultures identify organism(s), and the sensitivity study identifies antimicrobial medications that may be effective against pathogen(s).

Unexpected Outcomes

Outcome The sample of urine is contaminated with feces or toilet paper. Outcome The urine specimen is accidentally discarded. Outcome The client is unable to urinate on demand.

Intervention

Repeat the client instructions and obtain a new specimen. If you are unable to obtain an acceptable specimen through clean voiding, the client may require catheterization.

Intervention Obtain another specimen.

Intervention

Offer the client fluids (if permitted) and allow more time for urine to accumulate in the bladder. Try to collect a specimen after 30 minutes have elapsed.

Outcome

Intervention

The urine culture reveals bacterial Report the findings to the provider and continue to monitor your growth (designated by colony count client for fever and dysuria. of more than 10,000 organisms per milliliter).

A urinary catheter is a plastic or rubber tube inserted into the urinary bladder under strict aseptic (sterile) conditions. It is used to drain urine from the bladder and may be inserted for single or long-term use. In some instances, it may be inserted surgically through the abdominal wall into the bladder. This last procedure is called suprapubic catheterization. However, the desire to urinate can be sensed when the bladder contains a smaller amount of urine (150 to 200 mL in an adult and 50 to 100 mL in a child). Adult urinary output averages 1000 to 2400 mL in 24 hours. Minimum average hourly output is 30 mL. Normal urine is clear, straw-colored, and slightly acidic.

Factors Influencing Urinary Elimination

Age Sociocultural Psychological Muscle tone Fluid intake Disease conditions Surgical Medications Diagnostics

Preventing Infection

E. coli, a common strain of bacteria found in feces, causes many UTIs. Hospitalacquired UTIs are often related to:

Poor hand hygiene Improper catheter care Faulty catheterization technique

Sites at risk are: The site of catheter insertion The drainage bag The spigot The tube junction The junction of the tube and the bag If this urine flows back into the client's bladder, an infection will probably develop.

Tips for Preventing Infection in Catheterized Clients

Follow good hand hygiene techniques. Never allow the spigot on the drainage system to touch a contaminated surface. Use only sterile technique to collect specimens from a closed drainage system. If the drainage tube becomes disconnected, refrain from touching the ends of the catheter or tubing. Ensure that each client has a separate receptacle for measuring urine to prevent cross-contamination. Prevent pooling of urine in the tubing and reflux of urine into the bladder. Avoid raising the drainage bag above the level of the bladder. If it becomes necessary to raise the bag during transfer of the client to a bed or stretcher, clamp the tubing or empty the tubing contents into the drainage bag first. Provide for drainage of urine from the tubing to the bag by positioning the tubing above the drainage bag. Before exercise or ambulation, drain all urine from the tubing into the drainage bag. Avoid prolonged kinking or clamping of the tubing. Empty the drainage bag at least every 8 hours. If large outputs are noted, empty more frequently. Encourage fluid intake unless contraindicated Remove the catheter as soon as clinically warranted. Tape or secure the catheter appropriately for the client. Perform routine perineal hygiene per agency policy and after defecation and/or bowel incontinence. Male clients experiencing urinary incontinence because of neurologic deficits that cause complete and spontaneous bladder emptying benefit from the use of a condom catheter.

It may be worn continuously or at night only, depending on the client's needs. Typically you should change a condom catheter every 24 hours. However, close monitoring every 4 hours to detect potential problems is necessary.

Occasionally you will care for a male client with a retracted penis. A retracted penis pouch is available for these clients.

Assessment

Client's normal elimination pattern Client's ability to voluntarily urinate and/or continence Client's mental status Condition of the skin on and surrounding the penis The client's level of understanding as to the purpose of the condom catheter Allergies to:
o

Latex and/or rubber products (Remember that allergies to some tropical fruits or a history of frequent exposure to latex products over time could suggest an allergy to latex.) Antiseptic solutions (Betadine) [Remember that an allergy to shellfish may be an indication of hypersensivity to iodine (Betadine).]

PlanningExpected Outcomes

The client will remain continent with the condom catheter in place. The foreskin, glans, and shaft of the penis will remain free of skin irritation or breakdown. The client can explain the purpose of the procedure and what to expect. After the condom catheter is applied, the client will be able to describe signs and symptoms that might indicate irritation and/or infection.

Monitor urinary output by checking: The amount The color The characteristics Within 30 minutes of applying the condom catheter, verify that the condom sheath is intact and working properly. Look for swelling and discoloration, and ask the client if there is any discomfort. Subsequently check the catheter every 4 hours. If a leg urinary collection bag is used, check circulation in the leg at least once every 8 hours. Replace the condom catheter daily. Inspect the penis for signs of redness, breaks in the skin, or edema. Provide and/or assist the client with hygiene and reapplying the device.

Unexpected Outcomes

Outcome Redness and excoriation around the penis:

Intervention

Check for allergy. Remove the condom catheter. Notify the physician.

Outcome

Intervention

Results from pressure of adhesive and/or contact with urine May suggest possible latex allergy

Reapply after penis and surrounding tissue are free from irritation. Some institutions apply a thin layer of plasticized skin spray to skin of penile shaft to protect skin from ulceration and irritation caused by rubber condom and adhesive holding it in place. Intervention

Outcome Inadequate amount of urine drainage

Check the system for kinks. Assess condom application 30 minutes after applying, and inspect every 4 hours to determine if the penis circulation is adequate.

Outcome Pooling at the tip of the condom

Intervention

Remove the sheath. Provide hygiene. Reapply a new condom catheter.

Outcome The penis is swollen or discolored.

Intervention

The catheter has been improperly applied or adhesive has been applied too snugly, resulting in impaired circulation. Remove the catheter.

Outcome The catheter falls off.

Intervention

Verify that the size of the condom sheath is appropriate for the client. Reapply a new condom catheter.

Outcome Venous circulation in leg is impaired from leg bag strap and the client complains of leg discomfort.

Intervention

Remove the leg collection bag and reapply. Assess the leg every 8 hours for circulatory impairment. Apply a large Foley bag at night or continuously for a bedridden client.

Perineal care and cleansing of the first 4 inches of the catheter as it exits the urinary meatus should be completed at least once every 8 hours. This is often referred to as "catheter care." Removal of an indwelling catheter is a skill requiring clean technique. When removing an indwelling catheter, you must prevent trauma to the urethra.

if the catheter was in place for several days, the client may experience dysuria (painful voiding) resulting from inflammation of the urethral canal. Because of decreased bladder muscle tone, the client may urinate frequently. One of your primary responsibilities after catheter removal is monitoring the client for the ability to voluntarily void in normal amounts.

Assessment
Determine how long catheter has been in place. Observe any discharge or encrustation around the urethral meatus. Assess for complaints of pain or discomfort. Assess for the presence of allergies (e.g., to antiseptic solution). Monitor the client's temperature. Determine the client's fluid intake. Lack of fluid intake reduces natural flushing of the urinary system and increases the chance of bacterial growth. Assess urine color, clarity (clear versus cloudy), odor, and amount. Deviations from the normal characteristics of urine could indicate a UTI.

PlanningExpected Outcomes
Expected outcomes after completion of the procedure include:

The urethral meatus is free of secretions and encrustation. The urine is clear, and volume is sufficient. The client is afebrile. The skin under the tape site is intact. The client will verbalize a feeling of comfort after the procedure is completed. After the catheter is removed, the client voids without discomfort and voids a minimum of 250 mL of urine with each voiding within 6 to 8 hours of catheter removal.