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deck_2218207 Flashcards

1
Q

what are some constipation foods?

A

cheese, lean meats, eggs, pasta

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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.

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3
Q

Clients with what conditions should avoid straining during BM

A

Cardiovascular diseaseglaucomaincreased intracranial pressuresurgical woundsincreased blood pressure

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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

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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.

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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

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7
Q

Promoting regular bowel habits

A

Timing: after meals and exercisePositioning: bedside commode or toilet vs. bedpanPrivacyNutrition: fluids, fiber, fruits, and veggiesExercise

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8
Q

Rectal suppositories

A

Some soften, lubricate, stimulate, for pain or symptom management, lubricant, insertion, retention, retention. Glycerin suppositories for infants and children.

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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.

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10
Q

Name two complications associated with diarrhea?

A

A.contamination and risk for skin ulcerationB.fluid and electrolyte or acid-base imbalances

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11
Q

An Enema is

A

Instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.

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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.

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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

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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

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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.

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16
Q

what are the 3 levels of critical thinking?

A

1) Basic critical thinking 2) Complex critical thinking 3) Commitment

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17
Q

Why is it essential to be a critical thinker?

A

NAME?

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18
Q

What is concept mapping?

A

A visual representation of client problems and interventions that illustrates an interrelationship

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19
Q

Reflection/Reflective journaling?

A

A tool used to clarify concepts through reflection by thinking back or recalling situations.

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20
Q

What are the five components of critical thinking?

A

NAME?

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21
Q

A rise in temperature of 1 F may cause an increase in pulse rate of _____ beats per minute

A

4

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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.

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23
Q

Factors affecting bowel elimination

A
  1. 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)
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24
Q

Normal characteristics of stool

A
  1. Volume2. Color3. Odor4. Consistency5. Shape6. Constituents
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25
Q

Constipation in the older adult is usually the result of

A

decreased fiber & fluid.

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26
Q

nursing intervention for constipation

A

add fiber, establish routine time for defacation

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27
Q

for an adult patient who will receive an enema, the nurse recognizes the tube should be inserted

A

3-4 inches and the height of the bag for a regular enema should be 12 inches above the anus

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28
Q

Temperature

A

the difference between heat produced by bodily functions and heat lost to the environment. -normal 96.8 to 100.4 F

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29
Q

Pyrexia (Fever)

A

-An alteration in the hypothalamic set point.-actually a body defense; it will destroy invading bacteria and viruses.

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30
Q

signs and symptoms of a fever

A

Hot dry, flushed skin, headachethirstloss of appetitemalaise

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31
Q

Critical signs and symptoms of a fever

A

Rapid heart rate dehydration decreased urinary output seizures.

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32
Q

What are the effects of fever?

A

Increased oxygen demandincreased HR and cardiac outputuntreated may lead to: dehydration acid-base & electrolyte imbalancescardiac dysrhythmia neurological damage.

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33
Q

Pulse

A

NAME?

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34
Q

stroke volume

A

Amount of blood ejected with each contraction of left ventricle

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35
Q

Cardiac output

A

Pulse rate X stroke volume

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36
Q

Tachycardia

A

Pulse faster than 100 beats per minute

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37
Q

Bradycardia

A

Pulse slower than 60 beast per minute.

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38
Q

Dysrhythmia

A

Any disturbance or abnormal in a normal rhythmic pattern, specially irregularity in the normal rhythm of the heart

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39
Q

Pulse Strength

A

0 Absent 1+ Thready 2+ normal 3+full 4+bounding

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40
Q

Tachypnea

A

Rapid respiration rate; exercise and fever increase respiratory rate.

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41
Q

Bradypnea

A

A slow respiratory rate, below 12 per minute

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42
Q

Dyspnea

A

Difficulty breathing

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43
Q

Apnea

A

A lack of spontaneous respirations

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44
Q

Cheyne-stokes respirations

A

An abnormal pattern of respiration; alternating patterns of apnea and deep, rapid breathing

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45
Q

Blood Pressure

A

The pressure exerted by the circulating volume of blood on the arterial walls, veins and chambers of the heart.

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46
Q

Systolic

A

The higher number, represents the pressure when the ventricles are contracting

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47
Q

Diastolic

A

The second number, represents the pressure within the artery between beats

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48
Q

Pulse Pressure

A

Difference between the systolic and diastolic pressures

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49
Q

HAI’S

A

Health care associated infections

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50
Q

Asepsis

A

absence of disease-producing microorganisms

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51
Q

Standard precautions

A

NAME?

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52
Q

Airborne precautions

A

used for pts who have infections that spread through the air, such as TB-place PT in private room that has negative pressure

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53
Q

Contact precautions

A

NAME?

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54
Q

Sterile Field

A

NAME?

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55
Q

Personal Hygiene

A

The self care which involves bathing, toileting, general and grooming. it is highly personal.

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56
Q

factors that influence urinary elimination

A

anxiety; increased fluid intake; diabetes mellitus; narcotic analgesics; long term use of indwelling catheters

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57
Q

characteristics of normal urine

A

pale, straw to amber color; transparent; characteristic odor

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58
Q

urine output measurement

A

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

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59
Q

midstream specimen

A

a clean-voided specimen

60
Q

types of urinary incontinence

A

functional; stress; urge; mixed; overflow; hyperactive/overactive bladder

61
Q

functional

A

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
Q

stress

A

involuntary leakage of urine during increased abdominal pressure in the absence of bladder muscle contraction

63
Q

urge

A

involuntary passage of urine after a strong sense of urgency to void

64
Q

mixed

A

combination of urge and stress signs and symptoms

65
Q

appropriate measures for prompting pt’s normal urinary elimination

A

maintain elimination habits; maintain adequate intake of food; promote complete bladder emptying; stimulate micturition reflex

66
Q

evidence-based practices to avoid CAUTI

A

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
Q

nasal canula

A

28%-44% O2up to 6Lat 4L, add water for humidity

68
Q

Suctioning

A

Removal of secretions by a catheter connected to suctionSterile techniqueTypes-Pharyngeal- Oral, Nasal-Nasotracheal-Endotracheal-Trach

69
Q

Artificial AirwaysOropharyngeal=

A

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
Q

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?

A

Nasal Cannula

71
Q

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

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
Q

Removing indwelling catheters

A

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
Q

Enema administration

A

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
Q

what are the methods of bathing?

A

-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
Q

what are the bathing guidelines?

A

NAME?

76
Q

Key principles of bathing a client

A

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
Q

Common bed positions?

A

FowlerSemi-fowlertrendelnburgReverse trendlenburg flat

78
Q

Bed-making

A

Infection controlPreserve skin integritycomfortclient safety your safety

79
Q

Safety while making bed

A

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
Q

Basic needs

A

OxygenNutrition

81
Q

components of a safe environment

A

Meets basic needsreduces physical hazardsreduces transmission of pathogenscontrols pollution prevents or minimizes terrorism

82
Q

What is the most important a nurse can do to prevent the transmission of pathogens

A

HANDWASHING

83
Q

Restraints

A

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
Q

Physiologic hazards associated with restraints

A

NAME?

85
Q

seizure precautions

A

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
Q

fire safety

A

-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
Q

Factors that contribute to falls

A

NAME?

88
Q

8 rights of medication

A

Right medication right patient right dosage right route right time right documentation right reason right education

89
Q

nurses’ six right’s for safe medication admiration. The right to:

A

NAME?

90
Q

Oral medication

A

Solid form: tablets, capsules pills.-Scored -enteric -extended releaseLiquid forms: elixirs, suspensions, syrups May be water based or alcohol-based.

91
Q

Oral route

A

Stay with pt while they swallow medication do not leave it at the bedside.

92
Q

Enteral route

A

Administering drug through an enteral tube

93
Q

Sublingual administration

A

placing drug under the tongue should not be swallowed offer drink of water or oral care prior to administration

94
Q

Buccal administration

A

Placing drug between tongue and check should not swallowedoffer drink of water or oral care prior to administration.

95
Q

Intradermal Injections

A

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
Q

Intramuscular injections

A

Vastus lateralis ventrogluteal deltoid dorsogluteal

97
Q

Vastus lateralis

A

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
Q

Ventrogluteal site

A

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
Q

Giving IM injections

A

Stretch skin tautdart to insertaspirate inject slowly and withdraw gentle pressure over sitedo not massage alternate sites

100
Q

Body mechanics

A

Using alignment, posture, and balance in a purposeful and coordinated effort during activity to prevent injury

101
Q

Principles of safe client transfer and positioning

A

NAME?

102
Q

mobility

A

the ability to engage in activity and move about freely

103
Q

Exercise

A

is a type of physical activity defined as a planned, structured and repetitive bodily movement performed to improve or maintain physical fitness

104
Q

Physical Activity

A

is bodily movement produced by skeletal muscle contraction that increases energy expenditure

105
Q

ROM

A

is the ability to move a joint through the full extent of intended function

106
Q

Activity Tolerance

A

Is the type and amount of exercise or work that a person is able to perform

107
Q

Gait

A

the style or character of a person’s walk

108
Q

Pressure Ulcer

A

Localized injury to skin or underlying tissue, usually over a body prominence.

109
Q

What are the three pressure-related factors which contribute to pressure ulcer development

A

Intensity duration tissue tolerance

110
Q

Collecting a Timed Urine Specimen

A

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
Q

Guidelines for Appropriate Catheter Selection

A

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
Q

Routine indwelling catheter care

A

Secure the catheterPerineal 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
Q

Timed Urine Specimen

A

begins after discarding first specimen and ends with a final voiding at the end of the time period

114
Q

Collecting a midstream urine specimen

A

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
Q

Nonrebreather Mask

A

60-95% concentration of oxygen 6-10 L/minuteHighest concentration of oxygen

116
Q

ASPIRATION PRECAUTIONS

A

30 minute rest before/after eatingSit upright, slightly flex head to chin down positionTry different consistencies of food/fluidsFour levels of dysphagiadiet:Puree, Mechanically altered, advanced, regularFour levels of liquid:*Thin, Nectarlike, Honeylike, Spoon-thickADDITIONAL: Utensil placement, verbal coaching

117
Q

Clear Liquid

A

Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles

118
Q

Full Liquid

A

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
Q

Enteral Tube Feeding

A

Deliver nutrients through GI tract via:Nasogastric tubeNasointestinal tube*Gastrotomy tubeJejunostomy TubePEG/PEJ Tube

120
Q

Parenteral Tubes

A

Deliver nutrients intravenously Used when enteral feedings can’t be absorbed e.g.-sepsis-head injury-burns

121
Q

Cognitive

A

Includes all intellectual behaviors and requires thinking

122
Q

Affective

A

Deals with expression of feelings and acceptance, opinions or values

123
Q

Psychomotor

A

Involves acquiring skills that require integration of mental and muscular activity

124
Q

Cognitive Domain Teaching methods

A

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
Q

Affective Domain Teaching Method

A

• 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
Q

Psychomotor Domain Teaching

A

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
Q

Password Safety

A

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
Q

HIPPA

A

First federal legislation to protect automated patient records

129
Q

what are the contributing factors to ulcer development

A

NAME?

130
Q

what are the risk factors for pressure ulcers

A

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
Q

Classification of pressure ulcers

A

Stage I, Stage II, Stage III, stage IV, unstageable

132
Q

Stage I ulcer

A

Intact skin with nonblancable rednedd of a localized area usually over a bony prominence

133
Q

Stage II ulcer

A

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
Q

Stage III ulcer

A

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
Q

Stage IV ulcer

A

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
Q

unstageable

A

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
Q

Slough

A

Yellow, tan, gray, green or brown

138
Q

Eschar

A

Tan, brown or black in the wound bed.

139
Q

Granulation

A

red, moist tissue indicated progressing toward healing

140
Q

Exudate

A

amount, color, odor, consistency, of wound drainage.

141
Q

Serous

A

clear, watery

142
Q

Purulent

A

yellow, green, tan, or brown

143
Q

Serosanguineous

A

pale, red, watery, mixture of clear and red fluid

144
Q

Sanguineous

A

Active bleeding

145
Q

Dressings

A

-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
Q

Primary intention

A

surgical wounds, skin edges are approximated and risk of infection low

147
Q

Secondary Intention

A

Involves loss tissue such as burn or pressure ulcer. heals by secondary intention.

fundamentals 3 (8 decks)

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