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exam 2 Flashcards

1
Q

what is the epidermis?

A

top layer of the skin
includes stratum corneum, lucidum, granulosum, spinosum. basele and melanocytes

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2
Q

what is the dermis?

A

inner layer of the skin
where collagen is
includes papillae, papillary region, and reticular region

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3
Q

what is pathogenesis?

A

the process by which an infection leads to disease
(1) implantation of virus at the portal of entry
(2) local replication
(3) spread to target organs (disease sites)
(4) spread to sites of shedding of virus into the environment.

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4
Q

who is more at risk for impaired skin integrity?

A

clients with:
- altered sensory perception
- immobile
- comatose
- confused/disoriented
- expressive aphasia
- inability to verbalize

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5
Q

what is shear force?

A

the sliding movement of skin and subcutaneous tissue while the
underlying muscle and bone are stationary

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6
Q

how do you avoid shear force?

A

using friction-relief devices

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7
Q

where does shear force damage occur?

A

at the deeper fascial level of the tissues over the bony prominence

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8
Q

what happens when shear is present?

A

the skin and subcutaneous layers
adhere to the surface of the bed, and the layers of muscle and the bones slide in the direction of body movement

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9
Q

what is friction?

A

force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens

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10
Q

what part of the skin do friction injuries affect?

A

epidermis or top layer of the
skin also known as superficial skin loss

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11
Q

what are the 6 risk factors for pressure ulcer development?

A
  1. inability to perceive pressure
  2. incontinence/moisture
  3. decreased activity level
  4. inability to reposition
  5. poor nutritional intake
  6. friction and shear
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12
Q

what is a stage 1 pressure injury?

A

nonblanchable erythema of intact skin
- color does not include purple or maroon discoloration this is a sign of deep tissue pressure injury
- changes in sensation, temperature, or
firmness may precede visual changes

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13
Q

what is a stage 2 pressure injury?

A

partial thickness skin loss with exposed dermis, fat layer is not visable. granulation tissue, slough, and eschar are not present

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14
Q

what is a stage 3 pressure injury?

A

full thickness skin loss, fat and granulation tissue and epibole (rolled wound edges) present
- fascia, muscle, tendon, ligament, cartilage, and/or bone are not
exposed
- if slough or eschar is present its unstageable

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15
Q

what is a stage 4 pressure injury?

A

full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone

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16
Q

what is a deep tissue pressure injury?

A

intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister
(pain and temp is altered)

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17
Q

what is an MDRPI?

A
  • a medical device-related pressure injury
  • occurs from sustained pressure or shear from medical equiment
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18
Q

who is most vulnerable to an MDRPI?

A

critically ill patients and neonates

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19
Q

what is MARSI?

A

medical adhesive–related skin injury
- when redness or other abnormalities occur 30 minutes after tape removal

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20
Q

what is the goal of wound classification systems?

A

to describe onset and duration of healing process such as the status of skin integrity, the cause of the wound, or severity or extent of tissue injury, loss, or damage

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21
Q

what are the 2 major types of wounds?

A
  1. open
  2. closed
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22
Q

what are examples of closed wounds?

A

contusions, hematomas, or stage 1 pressure injuries

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23
Q

how does an open wound look?

A

skin is split, incised, or cracked, and the underlying tissues are
exposed to the outside environment

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24
Q

what is the definition of a wound?

A

a disruption of the integrity and function of tissues in the body

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25
Q

what layers of skin are lost in a partial loss wound?

A

epidermis and superficial dermal layers

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26
Q

what layers of skin are involved in a full-thickness wound?

A

epidermis and dermis

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27
Q

how does a partial-thickness wound heal?

A

regeneration

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28
Q

how does a full-thickness wound heal?

A

by forming new tissue, which takes longer

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29
Q

what is a primary intention wound?

A
  • surgical incision, skin edges are approximated or closed, risk of infection is low
  • healing occurs quickly with minimal scar formation if infection and secondary breakdown are prevented
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30
Q

what is a secondary intention wound?

A
  • wound involving loss of tissue such as a burn, Stage 2 pressure injury, or severe laceration
    longer to heal, higher chance of infection
    -epithelial cells and scar tissue form scar
    -if scarring is severe, loss of tissue infection is often permanent
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31
Q

what is a tertiary intention wound?

A
  • wound that’s left open for several days, edges are approximated
  • seen in wounds that are contaminated, require observation for signs of inflammation before closing them
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32
Q

what is the best environment for a wound to heal?

A

moist and free of necrotic tissue and infection

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33
Q

what do you clean a wound with?

A

sterile water or saline

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34
Q

how do you clean a wound that is contaminated with debris, necrotic tissue, or
heavy drainage?

A

with a cleaner that is noncytotoxic to healthy tissue

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35
Q

do full-thickness wounds extend into the dermis and heal by
scar formation because deeper structures do not regenerate?

A

yes

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36
Q

what occurs in the inflammatory stage of wound healing? (2)

A
  • damaged tissue and mast cells secrete histamine,
  • vasodilation of surrounding capillaries
  • movement or migration
    of serum and white blood cells (WBCs) into the damaged tissues.
  • results in localized redness, edema, warmth, and throbbing
  • form new blood vessels
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37
Q

what are the 4 stages of wound healing?

A
  1. hemostasis
  2. inflammation
  3. proliferation
  4. remodeling
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38
Q

what is the goal of the homeostasis phase? (1)

A

control blood loss, establish bacterial control, and seal the defect that occurs when there is
an injury

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39
Q

what is the goal of the proliferation phase? (3)

A

3-4 days after injury, can last 2 weeks
- wound contracts to reduce area of healing

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40
Q

what is the goal of the remodeling phase? (4)

A

several weeks after injury
- collagen scar reorganizes and gains strength
- scar tissue contains pigmented cells or melanocytes and lighter color than normal skin
- darker skin with have darker scars

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41
Q

how do you detect a hemorrhage?

A

by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock

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42
Q

when is the risk of hemorrhage the greatest?

A

24 to 48 hours after surgery or injury

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43
Q

what are local signs of wound infection?

A

erythema
increased amount of wound drainage
change in
appearance of a wound drainage including increase thickness, color change,
presence of odor
periwound warmth, pain, or edema
(fever and increased WBC)

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44
Q

what is dihiscence?

A

partial or total separation of wound layers
(can occur 5-12 days after suturing) (risk factors include poor nutrition, diabetes, infection, underlying disease)

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45
Q

what is evisceration?

A

extrusion of viscera or intestine through a surgical wound
- requires surgical repair

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46
Q

what do you do when eviceration occurs?

A
  • place sterile gauze soaked
    in sterile saline over the extruding tissues
  • contact provider
  • NPO
  • observe S/S of shock
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47
Q

what is the Braden Scale used for?

A

assessing pressure injuries
total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure injury development

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48
Q

what are the 6 subscales in the Braden scale?

A

sensory perception
moisture
activity
mobility
nutrition
friction/shear

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49
Q

what nutrients are crucial to wound healing?

A

protein, vitamins (especially A and C), and the trace minerals zinc and copper

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50
Q

what are 3 things that clients with any type of wound require?

A
  1. nutritional support
  2. proper positioning
  3. skin care
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51
Q

what are 3 major areas of nursing interventions for prevention of pressure injuries?

A

(1) skin care and management of incontinence
(2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces
(3) education.

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52
Q

what should you use to clean the skin for patients with risk factors for pressure injuries?

A
  • avoid soap and hot water as they increase skin dryness
  • use cleaners with nonionic surfactants that are gentle to the skin
  • apply moisturizer
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53
Q

what are first aid interventions when the client suffers a traumatic wound

A

stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury

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54
Q

with wounds that heal by primary intention when do you remove the dressing?

A

as soon as drainage stops

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55
Q

with wounds that heal by secondary intention when do you remove the dressing?

A

not until wound begins to heal more, the dressing material becomes a means for providing moisture to the wound or assisting in debridement

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56
Q

how much protein is recommended for healing?

A

1.8 g/kg/day

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57
Q

what does vitamin c promote?

A

collagen synthesis, capillary wall integrity, fibroblast function, and immunological function

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58
Q

what does protein promote?

A

the rebuilding of epidermal tissue

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59
Q

what does an increased caloric intake promote?

A

the replacement of subcutaneous tissue

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60
Q

what is debridement?

A

the removal of nonviable, necrotic tissue

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61
Q

why is the removal of necrotic tissue necessary?

A

to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing

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62
Q

what does a moist environment provide for a wound?

A

facilitates wound closure and supports movement of epithelial cells

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63
Q

what is NPWT?

A

negative pressure wound therapy

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64
Q

what is the first step in packing a wound?

A

assess size, depth, shape

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65
Q

does wound cleaning require aseptic technique?

A

yes

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66
Q

what is granulation tissue?

A

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing

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67
Q

what is slough?

A

stringy substance attached to wound bed, white or yellow

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68
Q

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

A

Reduction of stress on the abdominal incision

Provision of support to abdominal tissues when coughing or walking

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69
Q

what are the steps for performing a wound irrigation in bed?

A

Organized steps ensure a safe, effective irrigation of the wound.

Form cuff on waterproof biohazard bag and place near bed.

Fill 35-mL syringe with irrigation solution.

Attach 19-gauge angiocatheter.

Using continuous pressure, flush wound.

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70
Q

what is a cystectomy?

A

bladder removal
usually due to cancer or significant bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent UTI

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71
Q

how are urinary diversions made?

A

constructed from a section of intestine to create a storage reservoir or conduit for urine, through an opening in the abdominal wall called a stoma

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72
Q

where is an upper tract vs lower tract UT!?

A

kidneys is upper
lower is bladder and urethral

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73
Q

when does the neurological system become well-developed?

A

not until 2-3 years old

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74
Q

how does pregnancy change the urinary tract?

A

increases frequency

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75
Q

how does urine appear in children and infants?

A

can’t effectively concentrate
light yellow or clear in color
in relation to body size they excrete large volumes of later

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76
Q

does age cause bladder dysfunction?

A

no, but it does increase risk and incidence

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77
Q

what are the components of a urinary assessment?

A

physical assessment including kidneys, bladder, external genitalia, urethral meatus, and perineal skin. Fluid intake, voiding pattern and amounts provide additional objective data

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78
Q

what will urine look like after several minutes of standing?

A

cloudy

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79
Q

what will urine look like in clients with kidney disease?

A

freshly voided urine appears cloudy because of protein concentration

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80
Q

what is hematuria?

A

blood in the urine

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81
Q

what odor does urine have?

A

ammonia

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82
Q

what do all lab specimen collections need to be labeled with?

A

patient’s name, date, time, and type of
collection

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83
Q

why might urine appear thick and cloudy?

A

bacteria and white blood cells

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84
Q

what is the normal range of urine production per day?

A

1 - 2L/ day (2300 ml)

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85
Q

how often do patients generally void urine?

A

6-8 hours

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86
Q

what are key interventions to prevent UTIs?

A

adequate fluid intake
promoting perineal hygiene
having clients void at regular intervals

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87
Q

what is a key intervention to prevent infection when using catheters?

A

to maintain a closed urinary drainage system
prevention of backflow, keeping urine bag below bladder

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88
Q

what should you do if a catheter becomes occluded?

A

change it rather than flushing to prevent infection (risk of debris going into bladder w flushing)

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89
Q

what are bladder instillations used for?

A

to instill medication into the bladder

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90
Q

how do you maintain the patency of indwelling urinary catheters?

A

irrigate or flush w sterile solution

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91
Q

what risk does irrigation pose?

A

risk of infection, debris into bladder

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92
Q

what is an indwelling catheter?

A

catheter that remains in place over period of time
short term is 2 weeks or less
long term is more than one month

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93
Q

what sizes of indwelling catheters are normal for adults?

A

14 to 16 Fr for short-term use
20 to 24 Fr if there is hematuria or clots

94
Q

what is the range of balloon sizes for indwelling catheters?

A

from 3 mL (for a child)
for an adult is a 5mL balloon (the balloon is 5 mL and requires 10 mL to fill completely)
to 30 mL for continuous bladder irrigation

95
Q

what are single-lumen catheters used for?

A

intermittent/straight catheterization

96
Q

what are double-lumen catheters used for?

A

designed for indwelling catheters
one lumen for urinary drainage
second lumen is used to inflate a balloon that keeps the catheter in place

97
Q

what are triple-lumen catheters used for?

A

continuous bladder irrigation or when meds need to be instilled into bladder

98
Q

what is a suprapubic catheter?

A

urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis
(for urinary drainage)

99
Q

what type of medications are used to treat urinary urgency?

A

antimuscarinics such as oxybutynin
works by relaxing bladder

100
Q

what are lifestyle changes to teach clients about to restore urinary continence?

A

avoid common irritants such as artificial sweeteners, spicy foods, citrus products, and
especially caffeine

101
Q

what are components of the evaluation process of a patient who has urinary problems?

A

the client’s self-image, social interactions, sexuality, and emotional status as impacted by the urinary
problem

102
Q

what is the Crede’s method?

A

involves putting pressure on the suprapubic area and is used for the relief of urinary retention

103
Q

what is the main source of energy in the diet?

A

Carbohydrates, composed of carbon, hydrogen, and oxygen

104
Q

what are carbohydrates?

A

source of fuel (glucose) for brain and skeletal muscles, fuels exercise, erythrocyte and leukocyte production, and cell function of the renal
medulla

105
Q

what do blood clotting, fluid regulation, and acid-base balance require?

A

protein

106
Q

what does protein do in the body?

A
  • source of energy
  • essential for growth, maintenance, repair of body tissues
    Collagen, hormones, enzymes, immune cells,
    deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein
107
Q

what transports nutrients and many drugs in the blood?

A

proteins

108
Q

what do fats (lipids) do in the body?

A
  • most calorie dense
  • composed of triglycerides & fatty acids
  • fatty acids are significant in health and incidence of disease
109
Q

what does cell function depend on?

A

a fluid environment (water!!)

110
Q

how much body weight is water?

A

60-70%

111
Q

what are fat soluble vitamins?

A

vitamins (A, D, E, and K), stored in fatty compartments. body has high storage capacity for these

112
Q

what are water soluble vitamins?

A

vitamin C and B complex
body does not store these so we need these in daily food intake

113
Q

what are minerals?

A

inorganic elements that the body needs. they work as catalysts in biochemical reactions in the body

114
Q

where is the primary absorption site for nutrients?

A

the villi in the small intestine
- villi increases surface area

115
Q

how does the body absorb nutrients? through what processes?

A

by means of passive diffusion, osmosis, active transport, and pinocytosis

116
Q

what is anabolism?

A

building of more complex biochemical substances by synthesis of nutrients

117
Q

what is catabolism?

A

breakdown of biochemical substances into smaller substances

118
Q

through what process does the body convert nutrients into needed substances?

A

metabolism

119
Q

how does chyme move?

A

by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces

120
Q

where is water absorbed in the large intestine?

A

in the mucose as feces move toward rectum

121
Q

what does the pancreas do?

A

hormones regulate blood glucose levels
bicarbonates neutralize stomach acid

122
Q

what does the liver do?

A

stores vitamins and iron
destroys old blood cells and poisons
produces bile to aid digestion

123
Q

what does the gallbladder do?

A

stores and concentrates bile

124
Q

what does the small intestine do?

A

completes digestion
mucus protects gut wall
absorbs nutrients, mostly water

125
Q

what does the large intestine do?

A

reabsorbs some water, ions, vitamins
forms and stores feces

126
Q

what marks the developmental stage of infancy?

A

rapid growth and high protein, vitamin, mineral, and energy requirements

127
Q

what does the growth rate do during toddler years (1-3)? what diet changes happen?

A

growth rate slows
need fewer calories but increased protein in relation to body weight

128
Q

what is the best guide to the nutritional needs of an adolescent?

A

their physiological age, not actual age
- 6-12 grows at slower steady rate
- gradual decline in energy requirements per unit of body weight
- energy needs will increase to meet greater metabolic needs of growth

129
Q

how many more calories a day do lactating mothers need?

A

500 kcal/day more

130
Q

do vitamin and mineral requirements change from middle adulthood onwards?

A

no

131
Q

what are examples of clinical findings to assess for a client’s nutrition?

A

dietary intake
weight changes
skin integrity
signs of malnutrition (e.g., muscle wasting, edema).

132
Q

what are diagnostic studies to use to assess nutrition?

A

dietary recall
food diaries
anthropometric measurements (e.g., BMI, waist circumference)
laboratory tests (e.g., albumin, prealbumin)

133
Q

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions?

A

Monitoring for constipation
Fall prevention interventions

134
Q

what is dysphagia?

A

difficulty swallowing

135
Q

what are complications of dysphagia?

A

aspiration pneumonia, dehydration,
decreased nutritional status, and weight loss

136
Q

what can dysphagia lead to?

A

leads to disability or decreased functional status, increased length of stay and health care costs, increased likelihood of discharge to institutionalized care, and increased mortality, malnutrition

137
Q

what is the preferred site of gastric feedings for the risk of gastric reflex?

A

jejunal feeding is preferred

138
Q

what does aspiration of enteral formula into the lungs cause?

A

irritates the bronchial mucosa, resulting in decreased blood supply to affected pulmonary tissue

139
Q

who are good candidates for total parenteral nutrition (TPN)?

A

Clients in highly stressed physiological states such as sepsis, head injury, or burns

140
Q

what does a TPN with greater than 10% dextrose require?

A

a central venous catheter that a health care provider places into a high-flow central vein such as the superior vena cava under sterile conditions

141
Q

how is bowel elimination different in infants?

A

smaller stomach capacity, less secretion of digestive enzymes, more rapid intestinal peristalsis

142
Q

how is bowel elimination different in adolescents?

A
  • rapid growth of large intestine
  • an increased secretion of gastric acids to digest food fibers
143
Q

how is bowel elimination different in older adults?

A
  • decreased chewing ability
  • partially food is not digested as easily
  • peristalsis declines
  • esophageal emptying slows
144
Q

how does diet impact bowel elimination?

A

Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber in the diet provides the bulk in the fecal material

145
Q

how does fluid intake impact bowel elimination?

A
  • a fluid intake of 3.7 L per day for men and 2.7 L per day for women is recommended
  • fiber absorbs fluid which liquefies intestinal contents creating larger and softer stool
  • increased peristalsis
  • promotes movement
146
Q

how does physical activity impact bowel elimination?

A

Physical activity promotes peristalsis, whereas immobilization
slows it

147
Q

how do physiological factors impact bowel elimination?

A

Prolonged emotional stress impairs the function of almost all body systems. During emotional stress, the digestive process is accelerated, and peristalsis is increased.

148
Q

how does pregnancy impact elimination?

A
  • pressure is exerted on the rectum
  • temporary obstruction created by the fetus impairs passage of feces
  • Slowing of peristalsis during the third trimester often leads to constipation
149
Q

what is ileus?

A

the condition of constipation caused by surgery that involves direct manipulation of the bowel. lasts 24-48 hours

150
Q

what are signs of constipation?

A

infrequent bowel movements, fewer than three per
week, and hard, dry stools that are difficult to pass

151
Q

what happens with diarrhea?

A

Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients

152
Q

what is flatulence?

A

accumulated gas in the lumen of the intestines, the bowel wall stretches and distends
common cause of abdominal fullness, pain,
and cramping

153
Q

what are the frequent causes of hemorrhoids?

A

straining at defecation, pregnancy, heart failure, and chronic liver disease

154
Q

what is an ileoanal pouch anastomosis?

A

a surgical procedure for clients who need
to have a colectomy for treatment of ulcerative colitis or other conditions

155
Q

are there blood tests for GI disorders?

A

There are no blood tests to specifically diagnose most GI disorders, but hemoglobin and hematocrit help 9 determine whether anemia from GI bleeding is present

156
Q

what is the proper position for the client on a bedpan?

A
  • elevate the head of the bed 30 to 45
    degrees
  • never lift client on bedpan
  • never place client on bedpan and leave with bed flat
157
Q

what are Cathartics and laxatives used for?

A
  • empty bowel
  • cathartics are stronger and more rapid
158
Q

what are potential harmful effects of overusing laxatives?

A

impaired bowel motility and decreased response to sensory stimulus

159
Q

what is in a solution for an enema?

A
  • tap water, normal saline, soapsuds solution, and low-volume hypertonic saline
  • each solution has a diff. osmotic effect
160
Q

why is normal saline the safest solution to use?

A

because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel.
The volume of infused saline stimulates peristalsis

161
Q

what do hypertonic solutions do to the bowel?

A

exert osmotic pressure that pulls fluids out of interstitial spaces.
- colon fills with fluid, and the resultant
distention promotes defecation

162
Q

why do you add soapsuds to tapwater or saline?

A

to create the effect of intestinal
irritation to stimulate peristalsis

163
Q

what is a levin tube?

A

single-lumen tube with holes near the tip. It is connected to a drainage bag or an intermittent suction device to drain stomach secretions

164
Q

what is a salem sump tube?

A

preferable for stomach decompression. The tube has two lumina: one for removal of gastric contents and one to provide an air vent

165
Q

are enemas and NG tubes sterile procedures?

A

no, but wear gloves

166
Q

what and when is mass peristalsis?

A

Mass peristalsis pushes undigested
food toward the rectum
occur only three or four times daily, with the strongest during the hour after
mealtime

167
Q

what does sodium do in the body?

A
  • maintains fluid
  • helps regulate blood pressure and volume
  • obtained through canned food, processed meats and cheeses
  • Regulated by ADH hormone (holds water in bod) and aldosterone hormone (holds salt in body)
168
Q

what is the normal range of sodium?

A

135-145 mEq/L

169
Q

what does potassium do in the body? K+

A
  • “moving and grooving”
  • Action and contraction of heart and skeletal muscle
  • Keeps each muscle cell charged via sodium potassium channels
    Obtained: through diet- fruits and green leafy veggies
    Excreted: by kidneys and bowels
170
Q

what is the normal range of potassium in the body?

A

3.5-5 meq/L

171
Q

what does calcium do in the body?

A
  • bone and teeth health
  • facilitates muscle contraction, including cardiac muscle contraction
  • plays role in blood clotting
172
Q

what is the normal range of calcium in the body?

A

8.5-10.5 milligrams per deciliter (mg/dL)

173
Q

what is the normal range of magnesium in the body?

A

1.5-2.5 milligrams per deciliter (mg/dL)

174
Q

what is the normal range of chloride?

A

95-105 milliequivalents per liter (mEq/L)

175
Q

what is the normal range of phosphate?

A

2.5-4.5 milligrams per deciliter (mg/dL)

176
Q

what does magnesium do for the body?

A
  • bone health and structure
  • facilitates muscle contraction and relaxation
  • has role in energy metabolism
  • regulates nerve function
177
Q

what does chloride do in the body?

A
  • maintains fluid balance and osmotic pressure
    maintains proper hydration and electrolyte balance in cells
  • helps acid base balance, forms hydrochloric acid in stomach
178
Q

what does phosphate do in the body?

A
  • bone health and mineralization
  • regulates acid-base balance by acting as buffer in the blood
  • role in energy metabolism and cell function as a component of ATP
179
Q

what is osmosis?

A

movement of water molecules across a selectively permeable membrane from an area of lower solute concentration to an area of higher solute concentration

180
Q

what is filtration?

A

movement of water and solutes across a membrane due to hydrostatic pressure differences

example: renal filtration- blood pressure forces water and small solutes through capillary walls into the renal tubules

181
Q

what is the Renin-angiotensin-aldosterone system?

A

hormonal cascade that plays a crucial role in regulating blood pressure, electrolyte balance, and fluid volume

182
Q

what is renin?

A

enzyme produced and released by the kidneys in response to low blood pressure or decreased blood flow to the kidneys

183
Q

what is Angiotensin I?

A
  • an inactive peptide formed from angiotensinogen by renin
  • converted into angiotensin II by an enzyme called angiotensin-converting enzyme (ACE), primarily found in the lungs
184
Q

what is angiotensin II?

A
  • the active hormone in the RAAS cascade
  • vasoconstriction of blood vessels, leading to an increase in blood pressure
  • stimulates the release of aldosterone from the adrenal glands
  • triggers the sensation of thirst
  • stimulates the release of antidiuretic hormone (ADH) from the posterior pituitary gland, promoting water reabsorption in the kidneys
185
Q

what is aldosterone?

A
  • hormone produced by adrenal glands (on top of kidneys)
  • acts on kidneys to increase reabsorption of sodium ions and water from urine, back into bloodstream
  • promotes excretion of potassium ions
  • leads to increase in blood volume and pressure
186
Q

what can dysfunction of the renin-angiotensin-aldosterone system (RAAS) lead to?

A

hypertension, electrolyte imbalances, and other cardiovascular disorders

187
Q

what is the atrial natriuretic peptide?

A
  • hormone primarily secreted by cells in the atria of the heart in response to increased blood volume and pressure
  • promotes excretion of sodium ions, reduced blood volume and pressure which leads to increased urine output
  • causes relaxation of blood vessels, which results in lower blood pressure
188
Q

what is hypovolemia?

A
  • decreased volume of extracellular fluid in body, which leads to reduction in circulating blood volume
  • can occur bc of fluid loss
189
Q

what are S/S of hypovolemia?

A

S/S: thirst, dry mucous membranes, decreased urine output, tachycardia, hypotension, and dizziness

190
Q

what is hypernatremia?

A
  • elevated serum sodium levels (>145 mEq/L)
  • when sodium intake is greater than water intake
191
Q

S/S of hypernatremia?

A
  • thirst, dry mucous membranes, restlessness, weakness, irritability, and altered mental status
  • severe: neurological like coma or seizures
192
Q

what is hyponatremia?

A
  • low serum sodium levels (<135 mEq/L)
  • too much water relative to sodium levels
193
Q

S/S of hyponatremia?

A

headache, nausea, vomiting, confusion, lethargy, seizures, and coma

194
Q

what is hypokalemia?

A

low serum potassium levels (<3.5 mEq/L)
- can occur due to various factors such as inadequate potassium intake, excessive potassium loss through conditions like vomiting, diarrhea, diuretic use, or renal disorders

195
Q

what are S/S of hypokalemia?

A

muscle weakness, fatigue, muscle cramps, constipation, palpitations, and cardiac dysrhythmias. Severe: cardiac arrhythmias

196
Q

what is hyperkalemia?

A

high serum potassium levels (>5.0 mEq/L)
- can result from impaired renal excretion of potassium, excessive potassium intake, or shifts of potassium from intracellular to extracellular compartments

197
Q

S/S of hyperkalemia?

A

muscle weakness, paresthesias, palpitations, bradycardia, cardiac dysrhythmias, and potentially cardiac arrest.
Severe: ventricular fibrillation or asystole.

198
Q

what is hypocalcemia?

A

low levels of calcium in the blood, typically below 8.5 mg/dL

  • can occur w low calcium intake, vitamin D deficiency, renal failure, loop diuretics
199
Q

what is hypercalcemia?

A

high levels of calcium in the blood, typically above 10.5 mg/dL

  • can occur w hyperparathyroidism, malignancy (especially involving the bone), excessive intake of calcium or vitamin D supplements, prolonged immobilization, or certain medications like thiazide diuretics
200
Q

S/S of hypocalcemia?

A

muscle cramps, numbness and tingling in the extremities (paresthesias), tetany, seizures, and abnormal heart rhythms

201
Q

S/S of hypercalcemia?

A

fatigue, weakness, constipation, abdominal pain, confusion, bone pain, kidney stones, and cardiac arrhythmias.
Severe hypercalcemia can lead to coma or cardiac arrest.

202
Q

what is hypomagnesemia?

A

low levels of magnesium in the blood, typically below 1.8 mg/dL

  • can occur due to inadequate dietary intake of magnesium, gastrointestinal losses (e.g., diarrhea), renal losses (e.g., diuretic use, renal tubular dysfunction), or certain medical conditions like malabsorption syndromes or alcoholism
203
Q

S/S of hypomagnesemia?

A

muscle cramps, tremors, weakness, cardiac arrhythmias, seizures, and neuromuscular irritability

204
Q

what is hypermagnesemia?

A

high levels of magnesium in the blood, typically above 2.6 mg/dL

  • can be caused by excessive magnesium intake (e.g., magnesium-containing antacids or laxatives), impaired renal excretion of magnesium (e.g., renal insufficiency), or excessive administration of magnesium-containing medications (e.g., magnesium sulfate therapy)
205
Q

S/S of hypermagnesemia?

A

lethargy, drowsiness, weakness, nausea, vomiting, respiratory depression, cardiac arrhythmias, and hypotension.

Severe: respiratory arrest and cardiac arrest

206
Q

what are ovolactovegetarians?

A

consume plant-based foods along with eggs and dairy products. They abstain from consuming meat, poultry, and fish but include eggs and dairy in their diet

207
Q

what are urinary diversions?

A

surgical procedures that redirect the flow of urine from its normal pathway due to conditions like bladder cancer, trauma, or birth defects

examples:
- ileal conduit: w a stoma and urine pouch
- continent urinary reservoir
- neobladder

208
Q

what is ileoanal pouch anastomosis?

A

surgical procedure performed to treat ulcerative colitis and familial adenomatous polyposis (FAP) by removing the colon and rectum and creating a reservoir or pouch from the end of the small intestine (ileum)

  • avoids stoma and ostomy bag
209
Q

what is metabolic acidosis?

A

occurs when there is an accumulation of acid in the body or a loss of bicarbonate ions, leading to a decrease in blood pH below the normal range (pH < 7.35)

210
Q

what are symptoms of metabolic acidosis? what is treatment?

A

S: rapid breathing (Kussmaul respirations), confusion, lethargy, and nausea.

treatment aims to address underlying cause, may involve administration of bicarbonate

211
Q

what is metabolic alkalosis?

A

occurs when there is an excess of bicarbonate ions in the blood, leading to an increase in blood pH above the normal range (pH > 7.45)

212
Q

what are causes of metabolic alkalosis?

A

Loss of acids (e.g., vomiting, excessive use of diuretics)
Excessive intake of bicarbonate-containing meds
Hypokalemia (low potassium levels)

213
Q

how do you treat metabolic alkalosis?

A

correcting the underlying cause, such as restoring fluid and electrolyte balance and addressing potassium deficiency

214
Q

what is oncotic pressure? aka colloid osmotic pressure

A

the osmotic pressure exerted by proteins, particularly albumin, in the blood vessels
- a decrease in oncotic pressure leads to fluid shifting out of blood vessels, leading to edema

215
Q

what phlebitis?

A

inflammation of a vein

216
Q

what is respiratory acidosis?

A

an excess of carbon dioxide (CO2) in the bloodstream due to inadequate ventilation or impaired gas exchange in the lungs

217
Q

what is cystitis?

A

inflammation of the bladder
- more common in women due to shorter urethra

218
Q

what is dysuria?

A

symptom characterized by painful or uncomfortable urination.
manifests as a burning, stinging, or itching sensation during urination

219
Q

what is hematuria?

A

refers to the presence of blood in the urine

220
Q

what is a nephrostomy?

A

surgical procedure in which a tube (nephrostomy tube) is inserted through the skin and into the kidney to drain urine from the renal pelvis

221
Q

what is a colonoscopy?

A

diagnostic procedure that allows direct visualization of the entire colon (large intestine) using a flexible, lighted instrument called a colonoscope

222
Q

what is a colostomy?

A

surgical procedure that involves creating an artificial opening (stoma) in the abdominal wall and connecting a portion of the colon (large intestine) to the skin surface

223
Q

what is effluent?

A

refers to the output or discharge from an ostomy, such as a colostomy or ileostomy, into an external collection device (ostomy pouch)

224
Q

what is Fecal Immunochemical Test (FIT)?

A

screening test used to detect hidden (occult) blood in the stool, which may indicate gastrointestinal bleeding from colorectal cancer or other sources
- tests for hemoglobin, the protein in blood

225
Q

what is flatulence?

A

passing gas

226
Q

what is ileus?

A

refers to a temporary cessation or impairment of normal intestinal motility and peristalsis, leading to a functional obstruction of the bowel

227
Q

what is dehiscence?

A

partial or complete separation of the layers of a surgical incision or wound, typically occurring along the surgical suture line

228
Q

what is induration?

A

abnormal hardening or thickening of tissue, often characterized by firmness or palpable nodules

229
Q

what is reactive hyperemia?

A

refers to the transient increase in blood flow to a tissue or organ following a period of reduced perfusion or ischemia

  • occurs as response to restore O2 and nutrient delivery to tissues
  • common after exercise
230
Q

what is the International Classification for Nursing Practice (ICNP®)?

A

standardized terminology system developed by the International Council of Nurses (ICN) to support the documentation, communication, and analysis of nursing practice worldwide

  • promotes consistency
231
Q

what is NANDA International (NANDA-I)?

A

professional nursing organization that develops and maintains standardized nursing diagnostic terminologies, known as NANDA-I Nursing Diagnoses

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