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300 final > BLADDER/BOWEL ELIMINATION & PROFESSIONALISM > Flashcards

BLADDER/BOWEL ELIMINATION & PROFESSIONALISM Flashcards

1
Q

cystoscopy - pt teaching

A
  1. direct visualization of urethra & bladder

2. burning, frequency, dysuria, blood in urine after exam

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2
Q

hemorrhoids - assessment & interventions

A

when veins become distended, apply repeated pressure

take Hx, PE, feces inspection, assess for pain

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3
Q

factors affecting a pt’s elimination needs

A
  1. poor fluid intake
  2. medication
  3. feeding tube
  4. laxative
  5. no fiber
  6. cognitive impairment
  7. immobility
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4
Q

pt teaching R/T promotion of proper elimination

A
  1. maintain proper food and fluid intake
  2. promote regular exercise
  3. promote regular bowel habits
  4. facilitate normal defecation
  5. promote comfort (skin care, hemorrhoids, ostomy)
  6. maintain skin integrity
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5
Q

professional boundaries - nsg actions to avoid crossing boundaries

A
  1. effectiveness & to safety

2. stay in the middle of the continuum between too involved and negligent

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6
Q

most important legal document for a nurse & why

A

State Nurse Practice Act

single most important piece of legislation for nursing

affects all facets of nursing practice

it is the law with in the state

scope of nursing practice (what we can and cannot do)

-regulated by State Board of Nursing

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7
Q

definition of subjective data

A

“S”
-stated
what the pt tells you

SYMPTOMS

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8
Q

definition of objective data

A

“O”
-observed
everything else

SIGNS

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9
Q

Nursing Process steps

A
  1. assessment
  2. diagnosis/analysis
  3. planning
  4. implementation
  5. evaluation
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10
Q

Ns Process: assessment

A

collection and verification of data
-establishing a database

bedside assessment, hx, records, obtain temp & vital signs, PE

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11
Q

Ns Process: diagnosis/analysis

A

ID pt strengths & problems

ID problem R/T cause 2º med dx

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12
Q

Ns Process: planning

A

developing POC

individualized or routine?

  • goals
  • orders
  • actions taken

Nsg orders

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13
Q

Ns Process: Implementation

A

performs activities necessary for achieving pt’s health goals

-bathing and other actions

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14
Q

Ns Process: Evaluation

A

judging the quality, value, or worth by comparing to previous desired outcomes
-modify or terminate?

look at coccygeal area, conclude goal not met, change Dx and order, 2 days later

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15
Q

goal evaluation format

A 
Specific
Measurable
Action-oriented
Realistic
Timely

effectiveness:

  • goal met
  • partially met
  • not met
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16
Q

How to phrase Nsg Dx

A

related to: R/T

problem R/T etiology 2º med Dx

17
Q

definitions of NANDA labels: O2 needs

A
  1. ineffective airway clearance
  2. ineffective breathing pattern
  3. impaired gas exchange
  4. activity intolerance
18
Q

definitions of NANDA labels: comfort/pains

A

acute pain: signs of discomfort and change in vital signs <6mo

chronic pain: >6mo impaired comfort

readiness for enhanced comfort

19
Q

definitions of NANDA labels: self-care

A
  1. self-care, readiness for enhanced
  2. self-care deficit, bathing
  3. self-care deficit, dressing
  4. self-care deficit, feeding
  5. self-care deficit, toileting
20
Q

definitions of NANDA labels: mobility

A
  1. mobility, impaired bed
  2. mobility, impaired physical
  3. mobility, impaired wheelchair
21
Q

Critique of nursing interventions

A

are they

  • clear?
  • specific?
  • have a time frame?
  • begin with a verb?
22
Q

physiological manifestations of stress in pts

A
  1. increased V/S
  2. behavior
  3. appetite
  4. activity
  5. thought processes
  6. feelings of hopelessness
  7. continual frustration/worry
  8. cold hands/feet
  9. neck/shoulder tension
  10. clenched jaw
  11. constant fatigue
  12. nervous laughter
23
Q

stages of GAS

A

General Adaptation Syndrome (Seyle)

  1. alarm reaction: SNS
  2. resistance: PNS
  3. stage of exhaustion
24
Q

GAS: alarm reaction

A
  1. stressor perceived (fight or flight)
  2. increased HR, BP, RR
  3. decreased nonessential functions
  4. dilated pupils
  5. death if prolonged or severe
  6. can last from 1 min-24 hours
25
Q

GAS: resistance

A
  1. re-stabalization
  2. attempts to cope w stressor (parasympathetic takes over)
  3. amount of resistance depends on level of functioning in all dimensions as well as number/intensity of stressors

300 final (5 decks)

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