HESI Final Blueprint Fundamentals
Ventrogluteal NSG122.07.02.04
The ventrogluteal is an intramuscular injection site that
involves the luteus medius and guteus minimus muscles in
the hip area. This site offers a large muscle mass that is
relatively free from major nerves and blood vessels, the area
is clean (fecal contamination is rare at this site), and the
patient can be on the back, abdomen, or side for the injection.
To relax the gluteal muscle, the patient may flex
the knees while lying on the back, point the toes inward
while lying in the prone position, and flex the upper leg in
front of the lower leg in the side-lying position. Although
any of these three positions may be used when injecting
into the ventrogluteal site, nurses increasingly prefer the
side-lying position.
To locate the ventrogluteal site, place the palm of your
hand over the greater trochanter, with your fingers facing
the patient’s head. The right hand is used for the patient’s
left hip, or the left hand for the right hip, to identify landmarks.
Place the index finger on the anterosuperior iliac
spine and extend the middle finger dorsally, palpating the
iliac crest. A triangle is formed, and the injection is given
in the center of the triangle.
Sleep and Exercise NSG.122.11.01.03
When a sleep disturbance is noted, ask about the following when obtaining the history:
• The nature of the problem
• The cause of the problem
• The related signs and symptoms
• When the problem began and how often it occurs
• How the problem affects everyday living
• The severity of the problem and whether it can be treated independently by nurses or needs to be referred to another health care
professional
• How the patient is coping with the problem and the success of any treatments attempted
Safety-assistive devices NSG122.03.01.02 Topic not listed in RealizeIt under the node
MAINTAINING SAFETY
Assessing
Page 1 of 37
,When performing a safety assessment, the nurse focuses on three categories: the person, the environment, and specific risk factors.
Assessing the Person
Assessment of the person consists of a nursing history and a physical examination.
NURSING HISTORY
Be alert to any history of falls or accidents, because a person with a history of falling is likely to fall again. Note whether the patient uses any
assistive devices such as a wheelchair, brace, cane, walker, or crutches to aid in ambulation. Also, determine whether the assistive device is meeting
the patient’s needs, if it is required for mobility, and if it is being used safely. Be alert to any history of drug or alcohol abuse. Family members and
significant others are often valuable resources. Knowledge of family support systems
and the home environment is crucial for the nurse to plan protective health measures. The initial assessment performed by the nurse upon admission
to a health care facility summarizes all of this information (refer to Nursing History in Chapter 11).
Some people seem more likely than others to
Elderly falls‐family NSG122.03.01.03 Topic not listed in RealizeIt under the node
A person is considered at high risk for a fall if he or she has any of the following characteristics:
�� Age older than 65 years
�� Documented history of falls
�� Impaired vision or sense of balance
�� Altered gait or posture
�� A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics
�� Postural hypotension
�� Slowed reaction time
�� Confusion or disorientation
�� Impaired mobility
�� Weakness and physical frailty
�� Unfamiliar environment
Falls in the older adult can be prevented if they can be predicted. Therefore, continuous surveillance for environmental hazards is crucial in the health
care facility and the home environment and of patients who are at risk for falls. Family members are an invaluable resource in assessing a patient’s
risk for a fall. They can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls.
Home fall risk prevention‐GERI NSG122.03.01.03 Topic not listed in RealizeIt under the node
PREVENTING FALLS IN THE HOME
Major causes of falls in the home include slippery surfaces, poor lighting, clutter, and improperly fitting clothing or slippers. Common traffic
pathways in the home, the bathroom, and access areas to and from the home are hazardous areas for older adults. Measures as simple as installing
hand rails in bathrooms and on stairs, ensuring good lighting, and discarding or repairing broken equipment around the home help prevent accidents
(see Box 26-1, p. 694). Assessments by the nurse can play a vital role in promoting safety in the home. Home health care nurses frequently use the
acronym DAME to assess the risk for falling in older adults at home. The assessment, as summarized by Kulik (2011), includes consideration of:
�� D – Drug and alcohol use
�� A – Age-related physiologic status
�� M – Medical problems
�� E – Environment
Research appears to support the positive role that calcium supplementation and vitamin D play in promoting skeletal health and reducing fall risk for
this population. Regular exercise has a positive effect on bone and muscle strength, balance, and flexibility of joints. Women who participate in a
regular walking regimen plus other leisure activities are 55% less likely to suffer a hip fracture than sedentary women (Ponce, 2012). The martial art
of tai chi is another exercise routine that has proved particularly effective. It involves slow, deliberate movements that can be practiced almost
anywhere. Tai chi helps to prevent falls by developing balance control and stability in older adults.
Fish oil NSG122.07.01.01
In 2012, the CHA most commonly used by U.S. adults in the past 12 months were nonvitamin, nonmineral, natural products (17.7%); deep breathing
exercises (10.9%); yoga (9.5%); chiropractic or osteopathic manipulation (8.4%); meditation (8%); and massage (6.9%) (Clarke et al., 2015). Among
U.S. adults, the use of some mind–body therapies involving gentle physical activity, specifically yoga, tai chi, and qi gong, increased between 2007
and 2012. Of all the natural products, fish oil and glucosamine, chondroitin, or a combination supplement were the products most commonly used by
adults in 2012 (Clarke et al.).
Functional assessment NSG122.03.01.02 Topic not listed in RealizeIt under the node
Page 2 of 37
,Functional assessment measures an individual’s level of function and ability to perform specific tasks on a safe and dependable basis over a defined
period. A detailed assessment should include a pertinent clinical history, a neurologic and musculoskeletal evaluation, a physical effort
determination, and a comprehensive evaluation of behaviors that might impact physical performance.2 Assessments must be valid, reliable, and
reproducible. They can be self-administered questionnaires or clinician-administered.
Erikson‐older adult NSG122.03.01.02 Topic not listed in RealizeIt under the node
Erikson’s Theory
Ego Integrity vs Despair and Disgust
Erikson (1963) identified ego integrity versus despair and disgust as the last stage of human development, which begins at about 60 years of age.
Older adults continue to look forward but now also look back and begin to reflect on their life. It is a time for realization of a “wholeness”
perspective, with an inner search for meaning and order in the life cycle. Older adults search for emotional integration and acceptance of the past and
present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon,
called life review or reminiscence, has been identified worldwide. In a sense, this is a way for an older adult to relive and restructure life experiences
and is part of achieving
ego integrity (Klever, 2013; Fig. 19-4). Nurses can also use reminiscence as a therapy to facilitate adaptation to present circumstances.
Sterile dressing change NSG122.04.01.04
Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the
nurse at the patient's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable
medication are examples of surgical asepsis techniques.
Multiple steps involving application of PPE for use of sterile technique are used in the operating room in this order: applying a mask, protective
eyewear, and a cap; performing a surgical scrub; and applying a sterile gown and gloves. In contrast, performing a sterile dressing change at a
patient’s bedside requires only hand hygiene, applying a clean gown if splashing of fluid is likely, and applying sterile gloves (Box14.16). It is
important for you to refer to agency policy and procedure whenever there is a question about a procedure requiring sterile technique. Regardless of
the procedures followed in different settings, the use of surgical asepsis depends on developing an aseptic conscience. Always recognize the
importance of strict adherence to aseptic principles. In addition, be an excellent role model and patient advocate, reinforcing proper practice for other
caregivers (AORN, 2016).
Preparation for Sterile Procedures. In treatment rooms and at the bedside it is important to have a patient’s full cooperation in maintaining aseptic
technique. Therefore assess the patient’s understanding of sterile procedure and the reasons for not moving or interfering with the procedure. Special
precautions such as masking the patient or changing his or her position are sometimes necessary to prevent contamination during procedures.
Determine whether a patient has undergone a sterile procedure in the past. Explain how you will perform the procedure
and what the patient can do to avoid contaminating sterile objects:
1. Avoid sudden movements of body parts covered by sterile drapes.
2. Do not touch sterile supplies, drapes, or your sterile gloves and gown.
3. Avoid coughing, sneezing, or talking over a sterile area.
Certain sterile procedures last for an extended time. Assess each patient’s needs (e.g., pain control or elimination) in advance and anticipate factors
that will disrupt a procedure. If a patient is in pain, administer prescribed analgesics no more than 30 minutes before a sterile procedure begins.
Patients often are placed in relatively uncomfortable positions during sterile procedures. Help the patient assume the most comfortable position
possible. Finally, the patient’s condition sometimes results in events that contaminate a sterile field. For example, a patient with a respiratory
infection coughs, transmitting organisms that contaminate the sterile field. Anticipate such a problem and offer a mask to the patient before the
procedure begins.
Cath insertion technique NSG122.09.01.04
PATIENT PREPARATION
Before the catheterization, explain to the patient the procedure and the reason for it. Tell the patient that catheter insertion produces a sensation of
pressure and some discomfort. Explain that measures will be taken to avoid exposure and embarrassment. The more relaxed the patient is, the easier
it will be to insert the catheter.
The most common patient position for catheter insertion is the dorsal recumbent position, with the patient preferably on a solid surface, such as a firm
mattress or a treatment table. Catheterizing a patient in a bed with a soft mattress, especially a female patient, is not as satisfactory because the
patient's pelvic surfaces are not firmly supported and visualization of the meatus is difficult. Also, the patient may sink into the bed, causing the
bladder to be lower than the outlet of the catheter. If the patient is in bed, supporting the buttocks on a firm cushion is helpful.
Page 3 of 37
, The Sims’, or lateral, position is an alternate position for catheter insertion in female patients. This position may allow better visualization and be
more comfortable for the patient, especially if hip and knee movements are difficult. The smaller area of exposure is also less stressful for the patient.
Allow the patient to lie on either side, depending on which position is easiest for the nurse and best for the patient's comfort. Place the patient's
buttocks near the edge of the bed with her shoulders at the opposite edge and her knees drawn toward her chest. Lift the upper buttock and labia to
expose the urinary meatus.
Urethral Catheter Insertion
Nurses are often responsible for performing urinary catheterization, inserting indwelling catheters and caring for the patient. Adhering to surgical
asepsis is of utmost importance to help prevent UTIs. An inflated balloon holds the indwelling catheter in position in the bladder. The prefilled
syringe included in the catheter kit contains the amount of sterile water needed to inflate the balloon to the desired spherical shape. It is important to
use the entire amount provided by the manufacturer to avoid underinflation of the catheter balloon. A balloon that is only partially inflated could
cause irritation and erosion to the mucosa in the bladder.
FIGURE 37-13. Demonstration of the side-lying position (A) and of how to expose the urinary meatus when catheterizing a female patient in the
side-lying position (B).
Most of the lubricant applied externally on the catheter may remain at the meatus, essentially allowing an unlubricated catheter to cause trauma to the
lining of the urethra. As a result, the recommended procedure for urinary catheterization in male patients includes retrograde injection of a water-
soluble lubricant before inserting the catheter (SUNA, 2015c). Some institutions use 2% lidocaine hydrochloride jelly for lubrication before insertion
of the catheter. The jelly comes prepackaged in a sterile syringe and serves a dual purpose of lubricating and numbing the urethra. A medical order is
necessary for the use of lidocaine jelly (SUNA, 2015c). Insert indwelling catheters for male patients to the catheter bifurcation (the “Y” level created
by the balloon filling and urinary drainage ports) to assure the balloon is within the bladder and to avoid inadvertent inflation of the balloon in the
urethra (ANA, 2014; SUNA, 2015c).
Properly secure an indwelling catheter to the thigh or abdomen to prevent movement and excessive force on the bladder neck or urethra, which leads
to irritation or injury (ANA, 2014; SUNA, 2015a; Yates, 2016). The indwelling catheter is connected to a drainage and collection system that must
be properly positioned and secured to minimize the risk for infection. The following techniques should be used to complete the closed urinary
drainage system:
• Maintain a constant downward flow of urine. Check tubing frequently to ensure kinks and dependent loops (low points) are not present in
the tubing (Wuthier, Sublett, & Riehl, 2016). Check to see that the patient is not lying on the drainage tubing and compressing it.
• Keep the catheter drainage bag below the level of the bladder at all times.
• Keep the drainage bag off the floor at all times to reduce the risk of infection. The floor is grossly contaminated.
• Check that all connections are secure and that no leakage is occurring.
• Maintain the closed drainage system.
See the accompanying Through the Eyes of a Student for a student's account of her experience with urinary catheterization.
Enemas NSG122.09.02.04
An enema is the introduction of a solution into the large intestine, usually to remove feces. It can also be used to administer certain medications. The
instilled solution distends the intestine and irritates the intestinal mucosa, thus increasing peristalsis. Enemas are generally classified as cleansing or
Page 4 of 37
Ventrogluteal NSG122.07.02.04
The ventrogluteal is an intramuscular injection site that
involves the luteus medius and guteus minimus muscles in
the hip area. This site offers a large muscle mass that is
relatively free from major nerves and blood vessels, the area
is clean (fecal contamination is rare at this site), and the
patient can be on the back, abdomen, or side for the injection.
To relax the gluteal muscle, the patient may flex
the knees while lying on the back, point the toes inward
while lying in the prone position, and flex the upper leg in
front of the lower leg in the side-lying position. Although
any of these three positions may be used when injecting
into the ventrogluteal site, nurses increasingly prefer the
side-lying position.
To locate the ventrogluteal site, place the palm of your
hand over the greater trochanter, with your fingers facing
the patient’s head. The right hand is used for the patient’s
left hip, or the left hand for the right hip, to identify landmarks.
Place the index finger on the anterosuperior iliac
spine and extend the middle finger dorsally, palpating the
iliac crest. A triangle is formed, and the injection is given
in the center of the triangle.
Sleep and Exercise NSG.122.11.01.03
When a sleep disturbance is noted, ask about the following when obtaining the history:
• The nature of the problem
• The cause of the problem
• The related signs and symptoms
• When the problem began and how often it occurs
• How the problem affects everyday living
• The severity of the problem and whether it can be treated independently by nurses or needs to be referred to another health care
professional
• How the patient is coping with the problem and the success of any treatments attempted
Safety-assistive devices NSG122.03.01.02 Topic not listed in RealizeIt under the node
MAINTAINING SAFETY
Assessing
Page 1 of 37
,When performing a safety assessment, the nurse focuses on three categories: the person, the environment, and specific risk factors.
Assessing the Person
Assessment of the person consists of a nursing history and a physical examination.
NURSING HISTORY
Be alert to any history of falls or accidents, because a person with a history of falling is likely to fall again. Note whether the patient uses any
assistive devices such as a wheelchair, brace, cane, walker, or crutches to aid in ambulation. Also, determine whether the assistive device is meeting
the patient’s needs, if it is required for mobility, and if it is being used safely. Be alert to any history of drug or alcohol abuse. Family members and
significant others are often valuable resources. Knowledge of family support systems
and the home environment is crucial for the nurse to plan protective health measures. The initial assessment performed by the nurse upon admission
to a health care facility summarizes all of this information (refer to Nursing History in Chapter 11).
Some people seem more likely than others to
Elderly falls‐family NSG122.03.01.03 Topic not listed in RealizeIt under the node
A person is considered at high risk for a fall if he or she has any of the following characteristics:
�� Age older than 65 years
�� Documented history of falls
�� Impaired vision or sense of balance
�� Altered gait or posture
�� A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics
�� Postural hypotension
�� Slowed reaction time
�� Confusion or disorientation
�� Impaired mobility
�� Weakness and physical frailty
�� Unfamiliar environment
Falls in the older adult can be prevented if they can be predicted. Therefore, continuous surveillance for environmental hazards is crucial in the health
care facility and the home environment and of patients who are at risk for falls. Family members are an invaluable resource in assessing a patient’s
risk for a fall. They can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls.
Home fall risk prevention‐GERI NSG122.03.01.03 Topic not listed in RealizeIt under the node
PREVENTING FALLS IN THE HOME
Major causes of falls in the home include slippery surfaces, poor lighting, clutter, and improperly fitting clothing or slippers. Common traffic
pathways in the home, the bathroom, and access areas to and from the home are hazardous areas for older adults. Measures as simple as installing
hand rails in bathrooms and on stairs, ensuring good lighting, and discarding or repairing broken equipment around the home help prevent accidents
(see Box 26-1, p. 694). Assessments by the nurse can play a vital role in promoting safety in the home. Home health care nurses frequently use the
acronym DAME to assess the risk for falling in older adults at home. The assessment, as summarized by Kulik (2011), includes consideration of:
�� D – Drug and alcohol use
�� A – Age-related physiologic status
�� M – Medical problems
�� E – Environment
Research appears to support the positive role that calcium supplementation and vitamin D play in promoting skeletal health and reducing fall risk for
this population. Regular exercise has a positive effect on bone and muscle strength, balance, and flexibility of joints. Women who participate in a
regular walking regimen plus other leisure activities are 55% less likely to suffer a hip fracture than sedentary women (Ponce, 2012). The martial art
of tai chi is another exercise routine that has proved particularly effective. It involves slow, deliberate movements that can be practiced almost
anywhere. Tai chi helps to prevent falls by developing balance control and stability in older adults.
Fish oil NSG122.07.01.01
In 2012, the CHA most commonly used by U.S. adults in the past 12 months were nonvitamin, nonmineral, natural products (17.7%); deep breathing
exercises (10.9%); yoga (9.5%); chiropractic or osteopathic manipulation (8.4%); meditation (8%); and massage (6.9%) (Clarke et al., 2015). Among
U.S. adults, the use of some mind–body therapies involving gentle physical activity, specifically yoga, tai chi, and qi gong, increased between 2007
and 2012. Of all the natural products, fish oil and glucosamine, chondroitin, or a combination supplement were the products most commonly used by
adults in 2012 (Clarke et al.).
Functional assessment NSG122.03.01.02 Topic not listed in RealizeIt under the node
Page 2 of 37
,Functional assessment measures an individual’s level of function and ability to perform specific tasks on a safe and dependable basis over a defined
period. A detailed assessment should include a pertinent clinical history, a neurologic and musculoskeletal evaluation, a physical effort
determination, and a comprehensive evaluation of behaviors that might impact physical performance.2 Assessments must be valid, reliable, and
reproducible. They can be self-administered questionnaires or clinician-administered.
Erikson‐older adult NSG122.03.01.02 Topic not listed in RealizeIt under the node
Erikson’s Theory
Ego Integrity vs Despair and Disgust
Erikson (1963) identified ego integrity versus despair and disgust as the last stage of human development, which begins at about 60 years of age.
Older adults continue to look forward but now also look back and begin to reflect on their life. It is a time for realization of a “wholeness”
perspective, with an inner search for meaning and order in the life cycle. Older adults search for emotional integration and acceptance of the past and
present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon,
called life review or reminiscence, has been identified worldwide. In a sense, this is a way for an older adult to relive and restructure life experiences
and is part of achieving
ego integrity (Klever, 2013; Fig. 19-4). Nurses can also use reminiscence as a therapy to facilitate adaptation to present circumstances.
Sterile dressing change NSG122.04.01.04
Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the
nurse at the patient's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable
medication are examples of surgical asepsis techniques.
Multiple steps involving application of PPE for use of sterile technique are used in the operating room in this order: applying a mask, protective
eyewear, and a cap; performing a surgical scrub; and applying a sterile gown and gloves. In contrast, performing a sterile dressing change at a
patient’s bedside requires only hand hygiene, applying a clean gown if splashing of fluid is likely, and applying sterile gloves (Box14.16). It is
important for you to refer to agency policy and procedure whenever there is a question about a procedure requiring sterile technique. Regardless of
the procedures followed in different settings, the use of surgical asepsis depends on developing an aseptic conscience. Always recognize the
importance of strict adherence to aseptic principles. In addition, be an excellent role model and patient advocate, reinforcing proper practice for other
caregivers (AORN, 2016).
Preparation for Sterile Procedures. In treatment rooms and at the bedside it is important to have a patient’s full cooperation in maintaining aseptic
technique. Therefore assess the patient’s understanding of sterile procedure and the reasons for not moving or interfering with the procedure. Special
precautions such as masking the patient or changing his or her position are sometimes necessary to prevent contamination during procedures.
Determine whether a patient has undergone a sterile procedure in the past. Explain how you will perform the procedure
and what the patient can do to avoid contaminating sterile objects:
1. Avoid sudden movements of body parts covered by sterile drapes.
2. Do not touch sterile supplies, drapes, or your sterile gloves and gown.
3. Avoid coughing, sneezing, or talking over a sterile area.
Certain sterile procedures last for an extended time. Assess each patient’s needs (e.g., pain control or elimination) in advance and anticipate factors
that will disrupt a procedure. If a patient is in pain, administer prescribed analgesics no more than 30 minutes before a sterile procedure begins.
Patients often are placed in relatively uncomfortable positions during sterile procedures. Help the patient assume the most comfortable position
possible. Finally, the patient’s condition sometimes results in events that contaminate a sterile field. For example, a patient with a respiratory
infection coughs, transmitting organisms that contaminate the sterile field. Anticipate such a problem and offer a mask to the patient before the
procedure begins.
Cath insertion technique NSG122.09.01.04
PATIENT PREPARATION
Before the catheterization, explain to the patient the procedure and the reason for it. Tell the patient that catheter insertion produces a sensation of
pressure and some discomfort. Explain that measures will be taken to avoid exposure and embarrassment. The more relaxed the patient is, the easier
it will be to insert the catheter.
The most common patient position for catheter insertion is the dorsal recumbent position, with the patient preferably on a solid surface, such as a firm
mattress or a treatment table. Catheterizing a patient in a bed with a soft mattress, especially a female patient, is not as satisfactory because the
patient's pelvic surfaces are not firmly supported and visualization of the meatus is difficult. Also, the patient may sink into the bed, causing the
bladder to be lower than the outlet of the catheter. If the patient is in bed, supporting the buttocks on a firm cushion is helpful.
Page 3 of 37
, The Sims’, or lateral, position is an alternate position for catheter insertion in female patients. This position may allow better visualization and be
more comfortable for the patient, especially if hip and knee movements are difficult. The smaller area of exposure is also less stressful for the patient.
Allow the patient to lie on either side, depending on which position is easiest for the nurse and best for the patient's comfort. Place the patient's
buttocks near the edge of the bed with her shoulders at the opposite edge and her knees drawn toward her chest. Lift the upper buttock and labia to
expose the urinary meatus.
Urethral Catheter Insertion
Nurses are often responsible for performing urinary catheterization, inserting indwelling catheters and caring for the patient. Adhering to surgical
asepsis is of utmost importance to help prevent UTIs. An inflated balloon holds the indwelling catheter in position in the bladder. The prefilled
syringe included in the catheter kit contains the amount of sterile water needed to inflate the balloon to the desired spherical shape. It is important to
use the entire amount provided by the manufacturer to avoid underinflation of the catheter balloon. A balloon that is only partially inflated could
cause irritation and erosion to the mucosa in the bladder.
FIGURE 37-13. Demonstration of the side-lying position (A) and of how to expose the urinary meatus when catheterizing a female patient in the
side-lying position (B).
Most of the lubricant applied externally on the catheter may remain at the meatus, essentially allowing an unlubricated catheter to cause trauma to the
lining of the urethra. As a result, the recommended procedure for urinary catheterization in male patients includes retrograde injection of a water-
soluble lubricant before inserting the catheter (SUNA, 2015c). Some institutions use 2% lidocaine hydrochloride jelly for lubrication before insertion
of the catheter. The jelly comes prepackaged in a sterile syringe and serves a dual purpose of lubricating and numbing the urethra. A medical order is
necessary for the use of lidocaine jelly (SUNA, 2015c). Insert indwelling catheters for male patients to the catheter bifurcation (the “Y” level created
by the balloon filling and urinary drainage ports) to assure the balloon is within the bladder and to avoid inadvertent inflation of the balloon in the
urethra (ANA, 2014; SUNA, 2015c).
Properly secure an indwelling catheter to the thigh or abdomen to prevent movement and excessive force on the bladder neck or urethra, which leads
to irritation or injury (ANA, 2014; SUNA, 2015a; Yates, 2016). The indwelling catheter is connected to a drainage and collection system that must
be properly positioned and secured to minimize the risk for infection. The following techniques should be used to complete the closed urinary
drainage system:
• Maintain a constant downward flow of urine. Check tubing frequently to ensure kinks and dependent loops (low points) are not present in
the tubing (Wuthier, Sublett, & Riehl, 2016). Check to see that the patient is not lying on the drainage tubing and compressing it.
• Keep the catheter drainage bag below the level of the bladder at all times.
• Keep the drainage bag off the floor at all times to reduce the risk of infection. The floor is grossly contaminated.
• Check that all connections are secure and that no leakage is occurring.
• Maintain the closed drainage system.
See the accompanying Through the Eyes of a Student for a student's account of her experience with urinary catheterization.
Enemas NSG122.09.02.04
An enema is the introduction of a solution into the large intestine, usually to remove feces. It can also be used to administer certain medications. The
instilled solution distends the intestine and irritates the intestinal mucosa, thus increasing peristalsis. Enemas are generally classified as cleansing or
Page 4 of 37
