deck_2218207 Flashcards
1
Q
what are some constipation foods?
A
cheese, lean meats, eggs, pasta
2
Q
What is constipation?
A
Having a bowel movement fewer than every 3 days, hard, dry stool; difficult to eliminate, excessive straining, bloating, and the sensation of a full bowel.
3
Q
Clients with what conditions should avoid straining during BM
A
Cardiovascular diseaseglaucomaincreased intracranial pressuresurgical woundsincreased blood pressure
4
Q
What are some causes of constipation?
A
not enough fiber in the diet, lack of physical activity, some medications, milk, cheese, irritable bowel syndrome, changes in life or routine such as pregnancy, aging, and travel. Laxative misuse, ignoring the urge to have a bowel movement, dehydration, specific diseases or conditions such as stroke, problems with colon and rectum
5
Q
complications of constipation?
A
Hemorrhoids: dilated veins in rectum from straining, painful; itchy. can be internal or external.Impaction: feces/stool obstruction. liquid stool may ooze or leak around hardened stool.Flatulence: Excess or trapped gas. Can result from slowed mobility.Incontinence.
6
Q
Individuals at high risk for constipation?
A
Patients on bed rest taking constipating medicinesPatients with reduced fluids or bulk in their dietPatients who are depressedPatients with central nervous system disease or local lesions that cause painPatients on NARCOTICS
7
Q
Promoting regular bowel habits
A
Timing: after meals and exercisePositioning: bedside commode or toilet vs. bedpanPrivacyNutrition: fluids, fiber, fruits, and veggiesExercise
8
Q
Rectal suppositories
A
Some soften, lubricate, stimulate, for pain or symptom management, lubricant, insertion, retention, retention. Glycerin suppositories for infants and children.
9
Q
What is diarrhea?
A
An increased number of stools and the passage of liquid, unformed feces, associated with disorders affecting digestion, absorption, and secretion.
10
Q
Name two complications associated with diarrhea?
A
A.contamination and risk for skin ulcerationB.fluid and electrolyte or acid-base imbalances
11
Q
An Enema is
A
Instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.
12
Q
Types of Enemas
A
Cleansing: to relieve constipation or impaction to empty for surgery, to clear out for exams, to establish bowel function during training.
13
Q
Diarrhea causes & prevention
A
Viruses and bacteria from people or surfacesC-diff infections now highly contagious and has become health care associated infection.Wash your hands and those of the patients.Prevention:Hand-washing
14
Q
Treatment of Diarrhea
A
Acute diarrhea-hours to daysRehydration is most important skin careantidiarrheal meds usually after bacteria R/OChronic Diarrhea-3-4 weeks or moremany causes and treatments*immodium, lomotil, kaopectate, peptobismol
15
Q
What is the definition of critical thinking?
A
-An active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others. -Also recognizing an issue exist, analyzing information, evaluating information, and making conclusions.
16
Q
what are the 3 levels of critical thinking?
A
1) Basic critical thinking 2) Complex critical thinking 3) Commitment
17
Q
Why is it essential to be a critical thinker?
A
NAME?
18
Q
What is concept mapping?
A
A visual representation of client problems and interventions that illustrates an interrelationship
19
Q
Reflection/Reflective journaling?
A
A tool used to clarify concepts through reflection by thinking back or recalling situations.
20
Q
What are the five components of critical thinking?
A
NAME?
21
Q
A rise in temperature of 1 F may cause an increase in pulse rate of _____ beats per minute
A
4
22
Q
The most appropriate goal for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection is?
A
once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern.
23
Q
Factors affecting bowel elimination
A
- Interference with normal functioning2. Developmental stage3. Daily patterns4. Amount or quality of fluid/food intake5. Level of activity6. Lifestyle7. Emotional states8. Pathological processes9. Medications10. Procedures (diagnostic procedures/ surgeries)
24
Q
Normal characteristics of stool
A
- Volume2. Color3. Odor4. Consistency5. Shape6. Constituents
25
Constipation in the older adult is usually the result of
decreased fiber & fluid.
26
nursing intervention for constipation
add fiber, establish routine time for defacation
27
for an adult patient who will receive an enema, the nurse recognizes the tube should be inserted
3-4 inches and the height of the bag for a regular enema should be 12 inches above the anus
28
Temperature
the difference between heat produced by bodily functions and heat lost to the environment. -normal 96.8 to 100.4 F
29
Pyrexia (Fever)
-An alteration in the hypothalamic set point.-actually a body defense; it will destroy invading bacteria and viruses.
30
signs and symptoms of a fever
Hot dry, flushed skin, headachethirstloss of appetitemalaise
31
Critical signs and symptoms of a fever
Rapid heart rate dehydration decreased urinary output seizures.
32
What are the effects of fever?
Increased oxygen demandincreased HR and cardiac outputuntreated may lead to: dehydration acid-base & electrolyte imbalancescardiac dysrhythmia neurological damage.
33
Pulse
#NAME?
34
stroke volume
Amount of blood ejected with each contraction of left ventricle
35
Cardiac output
Pulse rate X stroke volume
36
Tachycardia
Pulse faster than 100 beats per minute
37
Bradycardia
Pulse slower than 60 beast per minute.
38
Dysrhythmia
Any disturbance or abnormal in a normal rhythmic pattern, specially irregularity in the normal rhythm of the heart
39
Pulse Strength
0 Absent 1+ Thready 2+ normal 3+full 4+bounding
40
Tachypnea
Rapid respiration rate; exercise and fever increase respiratory rate.
41
Bradypnea
A slow respiratory rate, below 12 per minute
42
Dyspnea
Difficulty breathing
43
Apnea
A lack of spontaneous respirations
44
Cheyne-stokes respirations
An abnormal pattern of respiration; alternating patterns of apnea and deep, rapid breathing
45
Blood Pressure
The pressure exerted by the circulating volume of blood on the arterial walls, veins and chambers of the heart.
46
Systolic
The higher number, represents the pressure when the ventricles are contracting
47
Diastolic
The second number, represents the pressure within the artery between beats
48
Pulse Pressure
Difference between the systolic and diastolic pressures
49
HAI'S
Health care associated infections
50
Asepsis
absence of disease-producing microorganisms
51
Standard precautions
#NAME?
52
Airborne precautions
used for pts who have infections that spread through the air, such as TB-place PT in private room that has negative pressure
53
Contact precautions
#NAME?
54
Sterile Field
#NAME?
55
Personal Hygiene
The self care which involves bathing, toileting, general and grooming. it is highly personal.
56
factors that influence urinary elimination
anxiety; increased fluid intake; diabetes mellitus; narcotic analgesics; long term use of indwelling catheters
57
characteristics of normal urine
pale, straw to amber color; transparent; characteristic odor
58
urine output measurement
use a graduated receptacle to accurately measure up to 100-200 ml of urine; use of a separate plastic graduated measuring receptacle obtains a more precise urine measurement from a drainage bag
59
midstream specimen
a clean-voided specimen
60
types of urinary incontinence
functional; stress; urge; mixed; overflow; hyperactive/overactive bladder
61
functional
loss of urine caused by factors outside the urinary tract that interfere with the ability to respond in a socially appropriate way (environmental barriers, sensory, cognitive, mobility issues)
62
stress
involuntary leakage of urine during increased abdominal pressure in the absence of bladder muscle contraction
63
urge
involuntary passage of urine after a strong sense of urgency to void
64
mixed
combination of urge and stress signs and symptoms
65
appropriate measures for prompting pt's normal urinary elimination
maintain elimination habits; maintain adequate intake of food; promote complete bladder emptying; stimulate micturition reflex
66
evidence-based practices to avoid CAUTI
insert indwelling urinary cath (according to established evidence-based guidelines that address) limiting use & duration to situations necessary for pt care and using aseptic technique for site prep, equip, supplies; manage indwelling caths (according...) securing caths for unobstructed urine flow & drainage, maintaining the sterility of the urine collection system, replacing the urine collection system when required, & collecting urine samples; measure and monitor cath-associated uti prevention processes and outcomes in high-vol areas by selecting measures using evidence-based guidelines or best practices, monitoring compliance with evidence-based guidelines or best practices, and evaluating the effectiveness of prevention efforts.
67
nasal canula
28%-44% O2up to 6Lat 4L, add water for humidity
68
Suctioning
Removal of secretions by a catheter connected to suctionSterile techniqueTypes-Pharyngeal- Oral, Nasal-Nasotracheal-Endotracheal-Trach
69
Artificial AirwaysOropharyngeal=
Can suction along side the airwayOften seen post-op in post anesthesia care unitsStimulate gag reflex, will often spit outDo not tape in placeMouth care needed
70
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?
Nasal Cannula
71
A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?
A Disadvantage of this Therapy is that it Dislodges Easily; The Client Should Form a Habit of Checking its Position; Oxygen Toxicity is a Complication; Manifestations of Oxygen Therapy Are: Nonproductive Cough, Substernal Pain, Nasal Stiffness, Nausea, Vomiting, Fatigue, Headache, Sore Throat, and Hypoventilation
72
Removing indwelling catheters
clamping to strengthen bladder muscles, remove all the fluid in the balloon maybe even twice, clean the area after with soap and water, access for voiding afterwards
73
Enema administration
1.Not sterile, gloves, privacy, warmed solution as ordered, adult 750-1000 ml2.Assess for abdominal distention, bowel sounds*3.Left side, sim's position (follow natural curve of colon), insert lubricated tip, adult 3-4 inches4.Open clamp and allow to flow slowly, raise to appropriate height, can cause cramping if flow rate too rapid5.If order, "enemas until clear", repeat until fluid passed is clear, up to 3 total
74
what are the methods of bathing?
-Completed bed bath; totally dependent client in bed.-Partial bed bath -sponge bath at sink; client can perform a portion-tub bath: immersion/ may need assistance-shower; chair in shower-bag bath: travel bath
75
what are the bathing guidelines?
#NAME?
76
Key principles of bathing a client
Wash the face first: begin the bath at the cleanest area and work downward toward the feet.use long firm strokes from wrist to shoulder, to promote circulation by increasing venous return. while bathing assess skin for any redness or discolorations (possible pressure ulcers)
77
Common bed positions?
FowlerSemi-fowlertrendelnburgReverse trendlenburg flat
78
Bed-making
Infection controlPreserve skin integritycomfortclient safety your safety
79
Safety while making bed
Side rails as appropriate bed in low position walkways clear and free debris and are dry minimize clutter call light/bed control/ phone in client's reach.
80
Basic needs
OxygenNutrition
81
components of a safe environment
Meets basic needsreduces physical hazardsreduces transmission of pathogenscontrols pollution prevents or minimizes terrorism
82
What is the most important a nurse can do to prevent the transmission of pathogens
HANDWASHING
83
Restraints
must have physician order, based on a face-to-face assessment of the clientorder must have restraining type, location, time limit and specific client behavior cannot be order as prn restrains must ne periodically removed ans patient reassessed for need of restraint.
84
Physiologic hazards associated with restraints
#NAME?
85
seizure precautions
Protect the client from injury --pre-seizure: inspect for potential safety hazards in client's environment , have padding for bed rails and head boars.--During a seizure: place client in safe position, especially protecting head, and position for ventilation and oral secretion drainage
86
fire safety
-Leading cause of fire-related death is careless smoking-oxygen is combustible not explosive -use the mnemonic RACE to set priorities in case of fireR-RescueA-Activate the alarm C-confine the fire by closing doors and windows E-Extinguish the fire using a
87
Factors that contribute to falls
#NAME?
88
8 rights of medication
Right medication right patient right dosage right route right time right documentation right reason right education
89
nurses' six right's for safe medication admiration. The right to:
#NAME?
90
Oral medication
Solid form: tablets, capsules pills.-Scored -enteric -extended releaseLiquid forms: elixirs, suspensions, syrups May be water based or alcohol-based.
91
Oral route
Stay with pt while they swallow medication do not leave it at the bedside.
92
Enteral route
Administering drug through an enteral tube
93
Sublingual administration
placing drug under the tongue *should not be swallowed* offer drink of water or oral care prior to administration
94
Buccal administration
Placing drug between tongue and check should not swallowedoffer drink of water or oral care prior to administration.
95
Intradermal Injections
Into the dermislongest absorption time used for sensitivity test site: inner of forearm, upper back needle size: short and fine Small amt of fluid: less than 0.5 mlflat angle: 10-15 degrees
96
Intramuscular injections
Vastus lateralis ventrogluteal deltoid dorsogluteal
97
Vastus lateralis
Anterolateral aspect of thigh no large nerves or vessels does not cover a joint preferred site for infantsdivide thigh into thirds horizontally and vertically injection given in outer middle third
98
Ventrogluteal site
Gluteus medius and gluteus minimus large muscle mass no major nerves or blood vessels patient can be on back, abdomen or sidepalm of hand over greater trochanter index finger on the anterosuperior iliac spine injection given in the center of the triangle
99
Giving IM injections
Stretch skin tautdart to insertaspirate inject slowly and withdraw gentle pressure over sitedo not massage alternate sites
100
Body mechanics
Using alignment, posture, and balance in a purposeful and coordinated effort during activity to prevent injury
101
Principles of safe client transfer and positioning
#NAME?
102
mobility
the ability to engage in activity and move about freely
103
Exercise
is a type of physical activity defined as a planned, structured and repetitive bodily movement performed to improve or maintain physical fitness
104
Physical Activity
is bodily movement produced by skeletal muscle contraction that increases energy expenditure
105
ROM
is the ability to move a joint through the full extent of intended function
106
Activity Tolerance
Is the type and amount of exercise or work that a person is able to perform
107
Gait
the style or character of a person's walk
108
Pressure Ulcer
Localized injury to skin or underlying tissue, usually over a body prominence.
109
What are the three pressure-related factors which contribute to pressure ulcer development
Intensity duration tissue tolerance
110
Collecting a Timed Urine Specimen
This is required for tests of renal function and urine composition.The entire volume of urine from a designated time period is collected.Testing begins after discarding first specimen and ends with a final voiding at the end of the time period.If urine is accidentally discarded or contaminated or the patient is incontinent, restart the time period.
111
Guidelines for Appropriate Catheter Selection
*Size: Determined by size of client’s urethral canal, French scale=larger the number, the larger the catheter, children 8-10 Fr.,women 14-16 Fr.,men 16-18 Fr. (Box 45-8)*Catheter material selection: Plastic catheters are only used for intermittent. Silicone and teflon are best suited for long-term use.*Balloon size: Children, 3ml., Adults 5-10ml. (most common). 30ml may be used for prostatectomies to help with hemostasis.*Use only sterile water to inflate the balloon.*If leakage around the catheter, may need to insert larger size catheter.
112
Routine indwelling catheter care
*Secure the catheter*Perineal hygiene at least t.i.d. (3 times/day) with soap and water. With male client, always reposition the foreskin after care. *When cleansing the catheter, always stabilize the catheter and cleanse from the meatus down the catheter in a circular motion.*Maintain adequate intake of fluids.*Maintain closed system.*Prevent pooling of urine in the tubing and reflux of urine into the bladder.*Keep drainage bag below the level of the bladder. * Empty bag at least every 8 hours.
113
Timed Urine Specimen
begins after discarding first specimen and ends with a final voiding at the end of the time period
114
Collecting a midstream urine specimen
Patient needs to clean urethra meatus initiate stream into toilet and then pause to collect urine into an assessment container and then pause again to move container out of the way & proceed to empty their bladder into the commode.
115
Nonrebreather Mask
60-95% concentration of oxygen 6-10 L/minuteHighest concentration of oxygen
116
ASPIRATION PRECAUTIONS
*30 minute rest before/after eating*Sit upright, slightly flex head to chin down position*Try different consistencies of food/fluids*Four levels of dysphagiadiet:*Puree, Mechanically altered, advanced, regular*Four levels of liquid:*Thin, Nectarlike, Honeylike, Spoon-thickADDITIONAL: Utensil placement, verbal coaching
117
Clear Liquid
Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles
118
Full Liquid
As for clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt
119
Enteral Tube Feeding
Deliver nutrients through GI tract via:*Nasogastric tube*Nasointestinal tube*Gastrotomy tubeJejunostomy TubePEG/PEJ Tube
120
Parenteral Tubes
Deliver nutrients intravenously Used when enteral feedings can't be absorbed e.g.-sepsis-head injury-burns
121
Cognitive
Includes all intellectual behaviors and requires thinking
122
Affective
Deals with expression of feelings and acceptance, opinions or values
123
Psychomotor
Involves acquiring skills that require integration of mental and muscular activity
124
Cognitive Domain Teaching methods
Discussion (one-on-one or group) •Involves nurse and one patient or a nurse with several patients •Promotes active participation and focuses on topics of interest to patient •Allows peer support •Enhances application and analysis of new information• Lecture Is more formal method of instruction because it is teacher controlled • Helps learner acquire new knowledge and gain comprehension• Question-and-answer session •Addresses patient's specific concerns •Assists patient in applying knowledge• Role play, discovery •Allows patient to actively apply knowledge in controlled situation •Promotes synthesis of information and problem solving• Independent project (computer-assisted instruction), field experience
125
Affective Domain Teaching Method
• Role play •Allows expression of values, feelings, and attitudes • Discussion (group) • Allows patient to receive support from others in group • Helps patient learn from others’ experiences • Promotes responding, valuing, and organization • Discussion (one-on-one) •Allows discussion of personal, sensitive topics of interest or concern
126
Psychomotor Domain Teaching
Demonstration •Provides presentation of procedures or skills by nurse •Permits patient to incorporate modeling of nurse's behavior •Allows nurse to control questioning during demonstration• Practice•Gives patient opportunity to perform skills using equipment in a controlled setting•Provides repetition• Return demonstration•Permits patient to perform skill as nurse observes •Provides excellent source of feedback and reinforcement• Independent projects, games • Requires teaching method that promotes adaptation and origination of psychomotor learning • Permits learner to use new skills
127
Password Safety
*Do not share your computer password with anyone under any circumstances.* A good system requires frequent and random changes in personal passwords to prevent unauthorized persons from tampering with records. *Most staff have access only to patients in their work area.* Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess.
128
HIPPA
First federal legislation to protect automated patient records
129
what are the contributing factors to ulcer development
#NAME?
130
what are the risk factors for pressure ulcers
Friction- the force of two surfaces moving across one another Shear-the force exerted parallel to the skin resulting from gravity pushing down on the body and resistance (friction) between the client and a surface Moisture- reduces the skin's resistance to other physical factors as pressure and shear force.
131
Classification of pressure ulcers
Stage I, Stage II, Stage III, stage IV, unstageable
132
Stage I ulcer
Intact skin with nonblancable rednedd of a localized area usually over a bony prominence
133
Stage II ulcer
Partial-thickness skin loss involving epidermis and/ or dermis presenting as a shallow open ulcer with a red pink would bed, without slough, abrasion, blister or shallow crater
134
Stage III ulcer
Full thickness tissue loss with visible fat involving damage or necrosis of subcutaneous tissue bone, tendon or muscle are not exposed. slough may be present by does not obscure the depth of the tissue loss. May be undermining and tunneling.
135
Stage IV ulcer
Full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed. often includes undermining and tunneling
136
unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough and eschar until enough slough and or eschar is removed to expose to the base of the wound, the true depth and therefore stage, cannot be determined.
137
Slough
Yellow, tan, gray, green or brown
138
Eschar
Tan, brown or black in the wound bed.
139
Granulation
red, moist tissue indicated progressing toward healing
140
Exudate
amount, color, odor, consistency, of wound drainage.
141
Serous
clear, watery
142
Purulent
yellow, green, tan, or brown
143
Serosanguineous
pale, red, watery, mixture of clear and red fluid
144
Sanguineous
Active bleeding
145
Dressings
-Dry to moist (gauze)-Hydrocolloid (protects the wound from surface contamination -Hydrogel (maintains a moist surface to support healing -Wound V.A.C (uses negative pressure to support healing)
146
Primary intention
surgical wounds, skin edges are approximated and risk of infection low
147
Secondary Intention
Involves loss tissue such as burn or pressure ulcer. heals by secondary intention.
