1. anuria
It means that the 24-hour urine output is less than 100ml or 12h without urine.
2. oliguria
It means that the 24-hour urine volume is less than 400ml or the hourly urine volume is less than 17ml.
3. polyuria
It means that the urine output in 24 hours exceeds 2500ml.
4. Urinary incontinence
Refers to the loss of conscious control or uncontrolled urination, urine involuntary outflow.
5. Urinary retention
It means that a large amount of urine stays in the bladder and cannot be excreted spontaneously.
6. urethral catheterization
Under strict aseptic operation, the catheter is inserted into the bladder through the urethra to drain urine.
7. constipation
Refers to the normal change of defecation form, the reduction of defecation times, the discharge of excessively dry feces, and the poor and difficult defecation.
8. Diarrhea
It refers to the change of normal defecation form, frequent discharge of loose and thin feces, and even watery stool.
9. fecal incontinence
Refers to the involuntary defecation unconsciously controlled by anal sphincter.
10. Enema
It means that a certain amount of liquid is poured into the colon through the anus and rectum to help patients clean their intestines, defecate, exhaust or administer drugs through the intestines, so as to achieve the purpose of diagnosis and treatment.
1 1. Bladder irritation
The main manifestations are frequent urination, urgency and dysuria.
12. indwelling catheterization
Guide the method of retaining catheter in bladder to drain urine after urine.
13. Bladder irrigation
It is a method of pouring solution into bladder by using three-way catheter, and then discharging the injected liquid by using siphon principle.
14. fecal impaction
Refers to the continuous accumulation of feces in the rectum, which is hard and cannot be discharged, and is more common in patients with chronic constipation.
15. grandiose
It means that too much gas accumulates in the gastrointestinal tract and cannot be discharged.
16.1.2,3 enema
50% magnesium sulfate 30 ml glycerin 60 ml, warm water 90 ml.
17. Retention enema
The liquid medicine is poured into rectum or colon and absorbed by intestinal mucosa to achieve the therapeutic purpose.
Second, fill in the blanks
1. The fresh urine of patients with urinary tract infection has odor, and the urine of patients with diabetic ketoacidosis has odor.
Ammonia stinks rotten apples.
2. Urinary incontinence can be divided into,,.
True urinary incontinence, false urinary incontinence and stress urinary incontinence.
3.
When urinary retention occurs, the bladder capacity increases, and the patient complains. Physical examination shows that pubic swelling can be touched.
Abdominal pain, dysuria, cystic mass and solid voice
4. The urethral length of female patients is cm, and the intubation length of male patients is cm.
4~5 4~6 18~20 20~22
5. The order of disinfection of vulva for female patients before opening urethral catheterization bag is as follows. After opening the urethral catheterization bag, the order of vulva disinfection is.
From outside to inside, from top to bottom, from inside to outside to inside, from top to bottom.
6. The two bends of male urethra are. Three strictness is.
Pubic downward curvature and pubic forward curvature, internal urethral orifice, membranous part and external urethral orifice.
7. For female patients with urethral catheterization, if they mistakenly enter the vagina, they should.
Replace the sterile catheter and reinsert it.
8. When indwelling catheter, in order to prevent retrograde infection, female patients should use benzalkonium bromide tincture cotton ball to wipe vulva and urethral orifice once a day. Replace the catheter once a day.
1~2 1
9. It is a common disease that the stool is often mushy or watery.
Have or.
Dyspepsia acute enteritis
10. The stool is dry and hard as chestnuts.
constipation
1 1. The stool is sour, rancid or fishy.
Dyspepsia, lower gastrointestinal ulcer, malignant tumor, upper gastrointestinal bleeding.
12. A large number of commonly used solutions for unreserved enema are, and adult doses.
It is milliliter, the temperature of the solution is℃, and the cooling temperature is.
It's degrees Celsius, and the temperature used by heatstroke patients is degrees Celsius.
Soap water and physiological saline 500 ~1000 39 ~ 4128 ~ 324
13. The insertion length of anal canal is large enema cm, small enema cm and enema cm.
7~ 10 7~ 10 15~20
14. When keeping enema, the hip pad is cm high, the distance between the liquid surface and anus is less than cm, the retention time of the liquid medicine in the intestine is longer than hours, and the amount of enema solution is greater than ml.
10 30 1 200
15. When the anal canal is exhausted, the anal canal is inserted into the rectum about cm, which generally does not exceed the retention time.
Minutes later, if the anal canal is kept for too long, it will lead to anal sphincter.
15 ~ 1820 permanent relaxation
Third, multiple choice questions
1. Nursing patients with fecal incontinence should pay special attention to D.
A. Observe the nature of stool B. Record the amount of stool C. Dehydrate D. Prevent pressure ulcers
2. Except which of the following is the purpose of large-scale non-reserved enema C?
A. relieve constipation B. prepare for delivery. C. Take stool for test. D. Reduce the body temperature of patients with high fever.
3. when enema, the inflow of enema is blocked, and the first move is a.
A. turn the anal canal B. raise the enema tube C. stop lavage D. ask the patient to relax the abdominal muscles.
D is the person who doesn't need indwelling catheter.
A. Shock B. Coma C. Urethral injury D. Cystitis
5. Which is wrong in nursing indwelling catheterization patient B?
A. If the urine is turbid or precipitated, it should be handled in time. B. change the urine collection bag of the drainage tube every day.
C. replace the catheter once a week. D keep the urethral orifice clean to prevent infection.
6. Description of abnormal defecation, which one is wrong b
A. Upper gastrointestinal bleeding is tar. B. when the biliary tract is completely blocked, the feces are jam-colored.
C. People with indigestion have acid stools. D. Most people who drop blood after defecation are bleeding from hemorrhoids.
7. The pressure of enema refers to.
A. the distance from the liquid surface to the anus B. the distance from the bottom of the bucket to the anus
C. Distance between liquid level and bed edge D. Distance between upper edge of cylinder and bed
8. Which retention enema method is wrong?
A. Before enema, let the patient urinate. B. Hip pad height 10cm.
C. the anal canal is inserted into the rectum10cm-15cm D. the enema pressure should not exceed 30cm.
9. A large number of heatstroke patients keep enema to cool down, and the retention time of enema in intestinal cavity is C.
A.5- 10 minutes B. 10 minutes C. 30 minutes D.20 minutes
10. Patient Li, female, 30 years old, was ashamed to refuse because of preoperative catheterization for "hysteromyoma". After analyzing her mentality, the nurse should take C.
A. let the patient urinate by himself. B. Ask his family to help persuade him.
C patiently explain the purpose of intubation and cover the screen by the bed.
D. explain the indwelling time of catheter to patients.
1 1.c is not suitable for cleaning enema.
A. before x-ray examination of colon. Before rectal surgery
C. Pregnant women with abortion protection measures before rectal X-ray examination
12. 1 a patient with hepatic coma, whose clinical manifestations were vague consciousness and abnormal behavior, used acid solution enema to control symptoms, and the reason why soapy water enema was forbidden was D.
A. it will cause electrolyte imbalance. B. it is very irritating to intestinal mucosa.
C. Easily bloating D. Reduce the production and absorption of ammonia.
13. Which of the following is wrong when doing anal exhaust?
A, keep the anal canal 1 hour
B. the anal canal is inserted into the rectum 17cm.
C, insert one end of the rubber tube connected with the anal canal into the water bottle.
D, performing centrifugal massage according to the anatomical position of the colon.
14. polyuria means that the urine volume exceeds c day and night.
A, 2000ml b, 2300ml c, 2500ml d, 2800ml.
15. Help patients with indwelling catheter to exercise bladder reflex function, and the nursing measure is C.
A. Wash vulva with warm water twice a day. Replace the catheter every week.
C. Intermittent tube clamping D. Turn the patient over regularly.
16. Mr. Li, 60 years old, complained privately 12 hours without urinating, abdominal distension and pain, and vocal percussion. The following nursing methods are wrong: a.
A. oral diuretic B. gently massage the lower abdomen
C. Let the patient listen to the sound of running water. D. Acupuncture at Zhongwan and Sanyinjiao points.
17. the measures to reduce intestinal gas production after operation do not include B.
A, tell patients not to eat beans as much as possible; b, let patients stay in bed and minimize activities.
C, eating speed should not be too fast D, drink less carbonated drinks.
18. Congestive heart failure enema is the best
A, 0. 1% soapy water b, normal saline c,1.2,3 enema d, oil agent.
19. The specific gravity of normal urine is C.
a、 1.00 1- 1.002 B、 1.020- 1.030
c、 1.0 15- 1.025 D、 1.030- 1.040
20. The indwelling catheter should be replaced 1 time every week for the purpose of B ..
A, training bladder reflex function B, preventing retrograde infection
C, keep the drainage unobstructed d, let the patient rest.
2 1. Patients with amebic dysentery should be enema and take B.
A, left lateral position, retention enema B, right lateral position, retention enema.
C, left lateral position, clean enema D, right lateral position, clean enema.
22. The ingredient of "1, 2,3 enema" used in a small amount of non-reserved enema is A.
A 30 ml of 50% magnesium sulfate, 60 ml of glycerol and 90 ml of warm water.
B 60ml of 50% magnesium sulfate, 30ml of glycerol and 90ml of warm water.
C 60ml of 50% magnesium sulfate, 90ml of glycerol and 30ml of warm water.
D 90ml of 50% magnesium sulfate, 60ml of glycerol and 30ml of warm water.
E 30 ml of 50% magnesium sulfate, 90 ml of glycerol and 60 ml of warm water.
23. Oliguria means that the amount of urine per day and night is less than D.
A, 1000 ml b, 800 ml c, 600 ml d, 400 ml.
24. What's wrong with nursing patients with urinary incontinence?
A, control the patient's drinking water, and reduce urine output; B, use a urine receiver to receive urine.
C, depending on the condition of indwelling catheter D, E, strengthen skin care, prevent pressure ulcers.
25. The following patients don't need indwelling catheter after catheterization is A.
A, taking urine culture specimen B, perineal injury
C urinary retention caused by paraplegia before pelvic organ surgery
26. Patient Li suffered from heatstroke and cooled down with enema. The following error is D.
A, enema with isotonic saline B, enema temperature 4℃
C, enema liquid volume is 500- 1000ml D, and the patient lies on the right side during enema.
27. Liu, a patient with flatulence after pelvic surgery, did not keep a small amount of enema. The following error is D.
A, enema with 1, 2,3 enema b, patient lying on the left side.
C, anal canal inserted 7- 10 cm d, liquid level 50 cm away from the anus.
28. Patient Lu Mou, with jaundice due to biliary obstruction, has bilirubin in his urine, and his urine color is C.
A, red B, light yellow C, yellowish brown D, soy sauce color
28. the stool of intussusception children is type a.
A, jam color B, asphalt sample C, clay color D, light yellow
29. Which of the following enemas is prohibited for patients with hepatic coma?
A
A, soap solution B, clear water C, 1, 2, 3 enema solution D and normal saline
29. the PH value of normal urine is d.
A, weakly acidic b, alkaline c, neutral d, alkaline
30. Patients with highly inflated bladder and extremely weak bladder should not urinate more than C for the first time.
A, 500ml of b, 800ml of c,1000ml of d,1500ml.
3 1. When conducting urethral catheterization for male patients, lift the penis at an angle of 600 with the abdominal wall, that is, make one.
A, pubic bone leans forward and disappears; B, pubic retroversion disappears.
C, pubic kyphosis disappeared D, bladder neck muscle relaxation
32. which of the following patients' urine smells like rotten apples B.
A, cystitis B, diabetic ketoacidosis
C, prostatitis D, acute nephritis
33. Patient Li, a 30-year-old male, needs to be indwelling catheter in advance because of traumatic paraplegia and urinary incontinence. Attention should be paid to D when inserting catheter for patients.
A, the intubation length should be 16 ~ 18 cm b, when inserting the catheter, the penis and the abdominal wall form an angle of 400.
C, pay attention to two urethral strictures, namely the internal urethral orifice and the external urethral orifice.
C, pay attention to the two bends of urethra, namely, pubic anterior bend and pubic inferior bend.
Fourth, multiple choice questions
1. contraindication The disease of enema is ABCD.
A. Acute abdomen B. Gastrointestinal bleeding C. Pregnancy D. Severe cardiovascular disease E. Hepatic coma
2. Which solution is suitable for retention enema?
A.2%% berberine B.0.5%~ 1% neomycin C. Glycerol and water
D. 10% chloral hydrate e. soapy water
3. The purpose of cleaning enema is Abe.
A. cleaning the intestine B. preparation before intestinal surgery C. giving sedatives
D. relieve constipation of pregnant women with abortion. E. Reducing poisoning
4.ACD is the correct method for nursing patients with indwelling catheterization.
A, regularly change the urine collection bag b every day and change the catheter twice a week.
C, encourage patients to drink more water d, found that urine turbidity, precipitation should be handled in time.
E, routine urine examination 1 time.
5. Measures for patients with urinary retention Which of the following is correct ABCDE?
A, intramuscular injection of carbaryl B, let patients listen to the sound of running water C, warm water to wash perineum.
D, hot compress the lower abdomen e, massage the bladder area
6. An intern nurse practiced catheterization for a female patient, but it was ABCDE that did not conform to the aseptic operation.
One, two vulva disinfection order is from outside to inside, from top to bottom.
B after opening the catheter, put a hole towel before wearing gloves.
C, content pollution should be immediately wiped with alcohol cotton ball disinfection.
Insert the catheter into the vagina, pull it out and reinsert it.
E, take 5 ml of urine in the front section as urine culture specimen.
7. Which of the following data should nurses collect before ABCDE catheterization?
A, patient's condition b, patient's conscious state c, patient's understanding and cooperation degree d, bladder filling degree e, patient's vital signs.
8. Which of the following is the cause of urinary incontinence ABCD?
A, coma B, paraplegia C, vesicovaginal fistula
D, abdominal muscle contraction, abdominal pressure increased E, urinary tract infection
9. The urine test includes ABCDE.
A, urine volume b, color c, smell
D, specific gravity e, transparency
10. The factors affecting normal urination are ABCDE.
A, culture and education B, disease influence C, liquid intake
D, climate change E, personal habits
Verb (abbreviation of verb) short answer questions
1. Briefly describe the nursing care of patients with urinary retention.
(1) Psychological nursing
(2) provide a hidden environment
(3) Adjust body position and posture
(4) inducing urination
(5) Hot compress and massage
(6) Health education, knowing that patients develop the habit of urinating regularly.
(7) Drug treatment: intramuscular injection of carbaryl according to the doctor's advice when necessary.
(8) If it cannot be relieved after the above treatment, catheterization can be used.
2. What factors are beneficial to the absorption of drugs by intestinal mucosa during retention enema?
(1) enema is suitable for intestinal infection at night, because the activity is reduced at this time, and the liquid medicine is easy to stay and absorb, thus achieving the therapeutic purpose.
(2) Choose a suitable lying position according to the condition: if chronic bacillary dysentery is mostly in rectum or sigmoid colon, use the left lying position; However, the pathological changes of amebic dysentery are mostly in ileocecum, and taking the right lateral position can improve the curative effect.
(3) Lift the buttocks 10 cm to prevent the liquid medicine from overflowing and facilitate absorption.
(4) The anal canal should be thin and inserted deeply (15 ~ 20cm), and the liquid injection should be slow, and the liquid level should not exceed 30cm from the anus, so as to keep and absorb it.
3. Briefly describe the nursing of diarrhea patients?
(1) Delete reason
(2) Stay in bed to reduce intestinal peristalsis and keep the abdomen warm.
(3) Diet conditioning: Encourage patients to drink water, and give a light liquid or semi-liquid diet as appropriate to avoid greasy, spicy and high-fiber foods. When diarrhea is severe, you should temporarily fast.
(4) Pay attention to replenish water and electrolyte to prevent water and electrolyte disorder.
(5) Keep the skin intact.
(6) Observe the condition closely, record the nature and frequency of defecation, and take samples for inspection when necessary.
(7) Psychological support
(8) Health education: explain the knowledge about diarrhea, guide patients to pay attention to food hygiene and develop good hygiene habits.
4. Briefly describe the nursing care of patients with flatulence.
(1) instruct patients to develop good eating habits of chewing slowly.
(2) remove the cause, such as not eating gas-producing food and actively treating intestinal diseases.
(3) Encourage patients to exercise properly.
(4) When there is slight flatulence, abdominal hot compress, abdominal massage and acupuncture can be used. In case of severe flatulence, medication or anal drainage should be given according to the doctor's advice.
5. What are the factors that affect defecation?
(1) psychological factors
(2) Cultural education
(3) Age
(4) Food and liquid intake
(5) Activities
(6) Personal defecation habits
(7) Diseases
(8) drugs
6. What are the factors that affect urination?
(1) psychological factors
(2) Personal habits
(3) Cultural education
(4) liquid and dietary intake
(5) Climate change
(6) Treatment and examination
(7) Diseases
(8) Other factors, such as the increased frequency of urination caused by uterine compression of bladder during pregnancy; The elderly have frequent urination due to decreased bladder muscle tension.
7. What are the common causes of urinary retention?
(1) Mechanical obstruction: such as prostatic hypertrophy or tumor pressing urethra, causing dysuria.
(2) Dynamic obstruction: If the activity of the primary micturition center of the spinal cord is disturbed or inhibited by trauma, disease or the use of anesthetics, micturition reflex cannot be formed.
(3) Other reasons: including psychological factors, such as anxiety and embarrassment, which make urination not timely; Urinary retention is caused by excessive urinary retention, excessive bladder filling and weak bladder contraction.
8. Briefly describe the contents of urine assessment.
(1) Urine volume and frequency
(2) Color
(3) Transparency
(4) Smell
(5) Acid-base reaction
(6) Specific gravity
9. Briefly describe the nursing care of patients with urinary incontinence.
(1) Psychological nursing
(2) Skin care
(3) external drainage
(4) reestablishing normal urination function.
Continuous bladder training
Ingestion of appropriate liquids
Muscle strength training
(5) urethral catheterization
10. Briefly describe how to help patients maintain normal urination activities.
(1) Establish normal urination habits.
(2) Ensure adequate liquid intake
(3) perineal muscle exercise
(4) Self-relaxation
(5) provide a hidden environment
(6) Listening to the sound of running water, cleaning perineum with warm water and other hints.
(7) Correct posture
(8) Health education: understand the importance of normal urination, the relationship between liquid intake and prevention of stones and infection, correct exercise and self-relaxation.
1 1. What is the purpose of catheterization?
(1) Drainage urine for patients with urinary retention to relieve pain.
(2) Auxiliary clinical diagnosis: for example, take uncontaminated urine samples for bacterial culture; Measure bladder volume, pressure and check residual urine; Perform urethrography or cystography
(3) Bladder chemotherapy for patients with bladder tumor.
12. Briefly describe the purpose of indwelling catheterization.
(1) to rescue the critically ill. Shock patients should correctly record the hourly urine volume and urine specific gravity, so as to closely observe the changes of their condition.
(2) Empty the bladder during pelvic surgery to keep the bladder empty continuously and avoid accidental injury during operation.
(3) The indwelling catheter after operation for some urinary system diseases is convenient for drainage and irrigation, which reduces the tension of the surgical incision and promotes the healing of the incision.
(4) Drain urine for patients with urinary incontinence or perineal wound, and keep perineum clean and dry.
13. Briefly describe the nursing of patients with indwelling catheterization.
(1) Measures to prevent retrograde infection of urinary system
Keep the urethral orifice clean; Change the urine collection bag regularly every day, empty the urine collection bag in time and record the urine volume; Replace the catheter 1 time every week, and the silicone tube replacement cycle can be extended as appropriate.
(2) Encourage patients to drink plenty of water, so as to achieve the purpose of naturally flushing the urinary tract.
(3) To train bladder reflex function, intermittent tube clamping method can be used.
(4) Pay attention to the patient's chief complaint and observe the urination. If the urine is turbid, precipitated and crystallized, it should be treated in time and urine routine examination should be done once a week.
14. Briefly describe the purpose of bladder irrigation.
(1) For patients with indwelling catheter, keep the urine drainage unobstructed.
(2) Clean the bladder and remove blood clots, mucus, bacteria and other foreign bodies in the bladder to prevent infection.
(3) Treating some bladder diseases such as cystitis and bladder tumor.
15. What should be included in the observation of feces?
(1) defecation frequency (2) quantity (3) color (4) shape (5) content (6) smell
16. Briefly describe the nursing measures for constipation patients?
(1) Health education: Help patients and their families correctly understand the significance of maintaining normal defecation habits and acquire knowledge about defecation.
(2) Help patients rebuild their normal defecation habits.
(3) Reasonable arrangement of meals
(4) Encourage patients to take appropriate activities.
(5) Provide proper defecation environment
(6) Choose a proper defecation posture
(7) Abdominal circular massage
(8) Give oral laxatives according to the doctor's advice.
(9) Use simple laxatives
(10) The above methods are invalid, and enema should be performed according to the doctor's advice.
17. Briefly describe the nursing measures for patients with fecal impaction.
(1) Suppositories and oral laxatives can moisten the intestines and relieve constipation in the early stage.
(2) If necessary, conduct oil retention enema first, and then clean enema after 2 ~ 3h.
(3) artificial defecation.
(4) Health education: explain the knowledge about defecation and make a reasonable dietary structure. Assist patients to maintain normal defecation habits and prevent constipation.
18. Briefly describe the nursing measures for patients with fecal incontinence.
Answer: (1) Psychological nursing.
(2) Protect the skin
(3) Help patients rebuild their ability to control defecation.
(4) If there are no contraindications, ensure that patients consume enough liquid every day.
(5) Keep the mattress and clothes clean and the indoor air fresh. Change the dirty clothes, pants and sheets in time, and open the window regularly to ventilate and remove the odor.
19. what is the purpose of a large number of unreserved enemas?
Answer: (1) Relieve constipation and flatulence.
(2) clean the intestines to prepare for surgery, examination or delivery.
(3) Rare and remove harmful substances in the intestine to reduce poisoning.
(4) Inject low-temperature solution into patients with high fever to cool down.
Sixth, the essay questions
1. Patient Wang was unable to take care of himself because of femoral fracture and plaster fixation for a week. He complained that his abdomen was full and he had not defecated for five days. The patient has moderate development and nutrition, poor spirit and little food. Check at T 36.9℃, P 70 times/minute and R 20 times/minute. Excuse me:
1. What is the patient's health problem?
2. What is the first problem to be solved? Briefly describe its nursing contents.
Answer: 1. Constipation, self-care defect.
2. constipation
Nursing measures for constipation:
(1) Health education: Help patients and their families understand the significance of maintaining normal defecation habits and gain knowledge of defecation.
(2) Help patients rebuild their normal defecation habits.
(3) Reasonable diet: eat more crude fiber food and drink more water to promote intestinal peristalsis.
(4) Encourage patients to take appropriate activities.
(5) Provide proper defecation environment
(6) Choose a proper defecation posture
(7) Abdominal circular massage
(8) Give oral laxatives according to the doctor's advice.
(9) Use simple laxatives