Question

Joanne is a 40 Y.O. woman admitted under your care after a stroke. Joanne has a R) sided facial droop and dysphagia. She has a supra-pubic catheter insitu. Joanne has a history of DMT2 and was on oral hypoglycaemic agents; however, her medications have been withheld since coming to hospital. The following are ordered:

DVT prophylaxisIV AntibioticsRest in BedPassive exercises4/24 neurological observationsIDC and 2/24 urine measurementNasogastric tube and commencement of feeds via tubeAllied health referral

If the urine had sediment in it what actions would you need to complete?

Prepare a Nursing Care Plan for Joanne

Student to state the safety checks that they would take before administration of feeding solution via the nasogastric tube.

List the equipment that you would use for SPC care

Answer 1

Some of the actions which has to be taken in case sediments are found in urine

• Assess the patient for any signs of infection (fever )
• Inform to the concerned provider for initiating next step like sending a urine routine or culture to rule out the presence of bacteria or microorganisms in the urine
• Bladder wash can be done to clear out the sediments as per order

●Nursing care plan

Imbalanced nutrition less than body requirement related to stroke as evidenced by difficulty in swallowing, ,facial droop ,presence of NG tube

Goal:To maintain normal nutritional status

Assessment

Objective data:

• inability to eat
• Loss of gag function of oral cavity due to facial droop or paralysis
• NG tube

Subjective :

• Having difficulty to swallow food

Nursing intervention and rationale

• Assess the patient's nutritional status to get the baseline data and plan for care
• Plan for a timely fluid diet as per order
• Maintain intake and output chart to rule out any loss or excess in intake
• Assess the patients blood glucose level as the patient is not on hypoglycemic drugs ,unplanned diet can further runs the blood sugar level
• Provide a propped up position to avoid aspiration

Evaluation:

Patient should be able to eat maintain a normal nutritional status

Safety checks before administering feeding solution via nasogastruc tube are

• Check the position of the NG tube (marking on the external site, 70cm indicates the tube is in position )
• Aspirate with a syringe before initiating feed,residual content indicates the tube is in stomach
• Assess for any abdominal pain,bloating ,vomiting to ruleout any obstruction
• Assess the patient vitals to ensure patient is not in respiratory distress

The equipment required for a suprapubic catheter care are

• For self cleaning (soap ,water,hand sanitizer, gauze )
  • Perform hand hygiene
  • Remove any previous dressing
  • Apply mild soap and water around the site
  • Pat it dry
  • Apply a sterile gauze around the catheter
  • Wash hands
• By a medical professional
  • sterile gloves(to prevent infection)
  • sterile gauze (to reduce the transmission of microorganisms and protect the site)
  • normal saline ,providine  solution (to clean the site)
  • spirit(to cleanbthe site)
  • kidney tray(to collect the waste)
  • artery forceps (to hold the gauze)