exam 2 Flashcards
1
Q
what is the epidermis?
A
top layer of the skin
includes stratum corneum, lucidum, granulosum, spinosum. basele and melanocytes
2
Q
what is the dermis?
A
inner layer of the skin
where collagen is
includes papillae, papillary region, and reticular region
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.
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
5
Q
what is shear force?
A
the sliding movement of skin and subcutaneous tissue while the
underlying muscle and bone are stationary
6
Q
how do you avoid shear force?
A
using friction-relief devices
7
Q
where does shear force damage occur?
A
at the deeper fascial level of the tissues over the bony prominence
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
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
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
11
Q
what are the 6 risk factors for pressure ulcer development?
A
- inability to perceive pressure
- incontinence/moisture
- decreased activity level
- inability to reposition
- poor nutritional intake
- friction and shear
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
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
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
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
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)
17
Q
what is an MDRPI?
A
- a medical device-related pressure injury
- occurs from sustained pressure or shear from medical equiment
18
Q
who is most vulnerable to an MDRPI?
A
critically ill patients and neonates
19
Q
what is MARSI?
A
medical adhesive–related skin injury
- when redness or other abnormalities occur 30 minutes after tape removal
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
21
Q
what are the 2 major types of wounds?
A
- open
- closed
22
Q
what are examples of closed wounds?
A
contusions, hematomas, or stage 1 pressure injuries
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
24
Q
what is the definition of a wound?
A
a disruption of the integrity and function of tissues in the body
25
what layers of skin are lost in a partial loss wound?
epidermis and superficial dermal layers
26
what layers of skin are involved in a full-thickness wound?
epidermis and dermis
27
how does a partial-thickness wound heal?
regeneration
28
how does a full-thickness wound heal?
by forming new tissue, which takes longer
29
what is a primary intention wound?
- 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
30
what is a secondary intention wound?
- 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
31
what is a tertiary intention wound?
- 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
32
what is the best environment for a wound to heal?
moist and free of necrotic tissue and infection
33
what do you clean a wound with?
sterile water or saline
34
how do you clean a wound that is contaminated with debris, necrotic tissue, or
heavy drainage?
with a cleaner that is noncytotoxic to healthy tissue
35
do full-thickness wounds extend into the dermis and heal by
scar formation because deeper structures do not regenerate?
yes
36
what occurs in the inflammatory stage of wound healing? (2)
- 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
37
what are the 4 stages of wound healing?
1. hemostasis
2. inflammation
3. proliferation
4. remodeling
38
what is the goal of the homeostasis phase? (1)
control blood loss, establish bacterial control, and seal the defect that occurs when there is
an injury
39
what is the goal of the proliferation phase? (3)
3-4 days after injury, can last 2 weeks
- wound contracts to reduce area of healing
40
what is the goal of the remodeling phase? (4)
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
41
how do you detect a hemorrhage?
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
42
when is the risk of hemorrhage the greatest?
24 to 48 hours after surgery or injury
43
what are local signs of wound infection?
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)
44
what is dihiscence?
partial or total separation of wound layers
(can occur 5-12 days after suturing) (risk factors include poor nutrition, diabetes, infection, underlying disease)
45
what is evisceration?
extrusion of viscera or intestine through a surgical wound
- requires surgical repair
46
what do you do when eviceration occurs?
- place sterile gauze soaked
in sterile saline over the extruding tissues
- contact provider
- NPO
- observe S/S of shock
47
what is the Braden Scale used for?
assessing pressure injuries
total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure injury development
48
what are the 6 subscales in the Braden scale?
sensory perception
moisture
activity
mobility
nutrition
friction/shear
49
what nutrients are crucial to wound healing?
protein, vitamins (especially A and C), and the trace minerals zinc and copper
50
what are 3 things that clients with any type of wound require?
1. nutritional support
2. proper positioning
3. skin care
51
what are 3 major areas of nursing interventions for prevention of pressure injuries?
(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.
52
what should you use to clean the skin for patients with risk factors for pressure injuries?
- avoid soap and hot water as they increase skin dryness
- use cleaners with nonionic surfactants that are gentle to the skin
- apply moisturizer
53
what are first aid interventions when the client suffers a traumatic wound
stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury
54
with wounds that heal by primary intention when do you remove the dressing?
as soon as drainage stops
55
with wounds that heal by secondary intention when do you remove the dressing?
not until wound begins to heal more, the dressing material becomes a means for providing moisture to the wound or assisting in debridement
56
how much protein is recommended for healing?
1.8 g/kg/day
57
what does vitamin c promote?
collagen synthesis, capillary wall integrity, fibroblast function, and immunological function
58
what does protein promote?
the rebuilding of epidermal tissue
59
what does an increased caloric intake promote?
the replacement of subcutaneous tissue
60
what is debridement?
the removal of nonviable, necrotic tissue
61
why is the removal of necrotic tissue necessary?
to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing
62
what does a moist environment provide for a wound?
facilitates wound closure and supports movement of epithelial cells
63
what is NPWT?
negative pressure wound therapy
64
what is the first step in packing a wound?
assess size, depth, shape
65
does wound cleaning require aseptic technique?
yes
66
what is granulation tissue?
red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing
67
what is slough?
stringy substance attached to wound bed, white or yellow
68
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
Reduction of stress on the abdominal incision
Provision of support to abdominal tissues when coughing or walking
69
what are the steps for performing a wound irrigation in bed?
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.
70
what is a cystectomy?
bladder removal
usually due to cancer or significant bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent UTI
71
how are urinary diversions made?
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
72
where is an upper tract vs lower tract UT!?
kidneys is upper
lower is bladder and urethral
73
when does the neurological system become well-developed?
not until 2-3 years old
74
how does pregnancy change the urinary tract?
increases frequency
75
how does urine appear in children and infants?
can't effectively concentrate
light yellow or clear in color
in relation to body size they excrete large volumes of later
76
does age cause bladder dysfunction?
no, but it does increase risk and incidence
77
what are the components of a urinary assessment?
physical assessment including kidneys, bladder, external genitalia, urethral meatus, and perineal skin. Fluid intake, voiding pattern and amounts provide additional objective data
78
what will urine look like after several minutes of standing?
cloudy
79
what will urine look like in clients with kidney disease?
freshly voided urine appears cloudy because of protein concentration
80
what is hematuria?
blood in the urine
81
what odor does urine have?
ammonia
82
what do all lab specimen collections need to be labeled with?
patient’s name, date, time, and type of
collection
83
why might urine appear thick and cloudy?
bacteria and white blood cells
84
what is the normal range of urine production per day?
1 - 2L/ day (2300 ml)
85
how often do patients generally void urine?
6-8 hours
86
what are key interventions to prevent UTIs?
adequate fluid intake
promoting perineal hygiene
having clients void at regular intervals
87
what is a key intervention to prevent infection when using catheters?
to maintain a closed urinary drainage system
prevention of backflow, keeping urine bag below bladder
88
what should you do if a catheter becomes occluded?
change it rather than flushing to prevent infection (risk of debris going into bladder w flushing)
89
what are bladder instillations used for?
to instill medication into the bladder
90
how do you maintain the patency of indwelling urinary catheters?
irrigate or flush w sterile solution
91
what risk does irrigation pose?
risk of infection, debris into bladder
92
what is an indwelling catheter?
catheter that remains in place over period of time
short term is 2 weeks or less
long term is more than one month
93
what sizes of indwelling catheters are normal for adults?
14 to 16 Fr for short-term use
20 to 24 Fr if there is hematuria or clots
94
what is the range of balloon sizes for indwelling catheters?
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
what are single-lumen catheters used for?
intermittent/straight catheterization
96
what are double-lumen catheters used for?
designed for indwelling catheters
one lumen for urinary drainage
second lumen is used to inflate a balloon that keeps the catheter in place
97
what are triple-lumen catheters used for?
continuous bladder irrigation or when meds need to be instilled into bladder
98
what is a suprapubic catheter?
urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis
(for urinary drainage)
99
what type of medications are used to treat urinary urgency?
antimuscarinics such as oxybutynin
works by relaxing bladder
100
what are lifestyle changes to teach clients about to restore urinary continence?
avoid common irritants such as artificial sweeteners, spicy foods, citrus products, and
especially caffeine
101
what are components of the evaluation process of a patient who has urinary problems?
the client’s self-image, social interactions, sexuality, and emotional status as impacted by the urinary
problem
102
what is the Crede's method?
involves putting pressure on the suprapubic area and is used for the relief of urinary retention
103
what is the main source of energy in the diet?
Carbohydrates, composed of carbon, hydrogen, and oxygen
104
what are carbohydrates?
source of fuel (glucose) for brain and skeletal muscles, fuels exercise, erythrocyte and leukocyte production, and cell function of the renal
medulla
105
what do blood clotting, fluid regulation, and acid-base balance require?
protein
106
what does protein do in the body?
- 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
what transports nutrients and many drugs in the blood?
proteins
108
what do fats (lipids) do in the body?
- most calorie dense
- composed of triglycerides & fatty acids
- fatty acids are significant in health and incidence of disease
109
what does cell function depend on?
a fluid environment (water!!)
110
how much body weight is water?
60-70%
111
what are fat soluble vitamins?
vitamins (A, D, E, and K), stored in fatty compartments. body has high storage capacity for these
112
what are water soluble vitamins?
vitamin C and B complex
body does not store these so we need these in daily food intake
113
what are minerals?
inorganic elements that the body needs. they work as catalysts in biochemical reactions in the body
114
where is the primary absorption site for nutrients?
the villi in the small intestine
- villi increases surface area
115
how does the body absorb nutrients? through what processes?
by means of passive diffusion, osmosis, active transport, and pinocytosis
116
what is anabolism?
building of more complex biochemical substances by synthesis of nutrients
117
what is catabolism?
breakdown of biochemical substances into smaller substances
118
through what process does the body convert nutrients into needed substances?
metabolism
119
how does chyme move?
by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces
120
where is water absorbed in the large intestine?
in the mucose as feces move toward rectum
121
what does the pancreas do?
hormones regulate blood glucose levels
bicarbonates neutralize stomach acid
122
what does the liver do?
stores vitamins and iron
destroys old blood cells and poisons
produces bile to aid digestion
123
what does the gallbladder do?
stores and concentrates bile
124
what does the small intestine do?
completes digestion
mucus protects gut wall
absorbs nutrients, mostly water
125
what does the large intestine do?
reabsorbs some water, ions, vitamins
forms and stores feces
126
what marks the developmental stage of infancy?
rapid growth and high protein, vitamin, mineral, and energy requirements
127
what does the growth rate do during toddler years (1-3)? what diet changes happen?
growth rate slows
need fewer calories but increased protein in relation to body weight
128
what is the best guide to the nutritional needs of an adolescent?
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
how many more calories a day do lactating mothers need?
500 kcal/day more
130
do vitamin and mineral requirements change from middle adulthood onwards?
no
131
what are examples of clinical findings to assess for a client's nutrition?
dietary intake
weight changes
skin integrity
signs of malnutrition (e.g., muscle wasting, edema).
132
what are diagnostic studies to use to assess nutrition?
dietary recall
food diaries
anthropometric measurements (e.g., BMI, waist circumference)
laboratory tests (e.g., albumin, prealbumin)
133
A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions?
Monitoring for constipation
Fall prevention interventions
134
what is dysphagia?
difficulty swallowing
135
what are complications of dysphagia?
aspiration pneumonia, dehydration,
decreased nutritional status, and weight loss
136
what can dysphagia lead to?
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
what is the preferred site of gastric feedings for the risk of gastric reflex?
jejunal feeding is preferred
138
what does aspiration of enteral formula into the lungs cause?
irritates the bronchial mucosa, resulting in decreased blood supply to affected pulmonary tissue
139
who are good candidates for total parenteral nutrition (TPN)?
Clients in highly stressed physiological states such as sepsis, head injury, or burns
140
what does a TPN with greater than 10% dextrose require?
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
how is bowel elimination different in infants?
smaller stomach capacity, less secretion of digestive enzymes, more rapid intestinal peristalsis
142
how is bowel elimination different in adolescents?
- rapid growth of large intestine
- an increased secretion of gastric acids to digest food fibers
143
how is bowel elimination different in older adults?
- decreased chewing ability
- partially food is not digested as easily
- peristalsis declines
- esophageal emptying slows
144
how does diet impact bowel elimination?
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
how does fluid intake impact bowel elimination?
- 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
how does physical activity impact bowel elimination?
Physical activity promotes peristalsis, whereas immobilization
slows it
147
how do physiological factors impact bowel elimination?
Prolonged emotional stress impairs the function of almost all body systems. During emotional stress, the digestive process is accelerated, and peristalsis is increased.
148
how does pregnancy impact elimination?
- 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
what is ileus?
the condition of constipation caused by surgery that involves direct manipulation of the bowel. lasts 24-48 hours
150
what are signs of constipation?
infrequent bowel movements, fewer than three per
week, and hard, dry stools that are difficult to pass
151
what happens with diarrhea?
Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients
152
what is flatulence?
accumulated gas in the lumen of the intestines, the bowel wall stretches and distends
common cause of abdominal fullness, pain,
and cramping
153
what are the frequent causes of hemorrhoids?
straining at defecation, pregnancy, heart failure, and chronic liver disease
154
what is an ileoanal pouch anastomosis?
a surgical procedure for clients who need
to have a colectomy for treatment of ulcerative colitis or other conditions
155
are there blood tests for GI disorders?
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
what is the proper position for the client on a bedpan?
- 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
what are Cathartics and laxatives used for?
- empty bowel
- cathartics are stronger and more rapid
158
what are potential harmful effects of overusing laxatives?
impaired bowel motility and decreased response to sensory stimulus
159
what is in a solution for an enema?
- tap water, normal saline, soapsuds solution, and low-volume hypertonic saline
- each solution has a diff. osmotic effect
160
why is normal saline the safest solution to use?
because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel.
The volume of infused saline stimulates peristalsis
161
what do hypertonic solutions do to the bowel?
exert osmotic pressure that pulls fluids out of interstitial spaces.
- colon fills with fluid, and the resultant
distention promotes defecation
162
why do you add soapsuds to tapwater or saline?
to create the effect of intestinal
irritation to stimulate peristalsis
163
what is a levin tube?
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
what is a salem sump tube?
preferable for stomach decompression. The tube has two lumina: one for removal of gastric contents and one to provide an air vent
165
are enemas and NG tubes sterile procedures?
no, but wear gloves
166
what and when is mass peristalsis?
Mass peristalsis pushes undigested
food toward the rectum
occur only three or four times daily, with the strongest during the hour after
mealtime
167
what does sodium do in the body?
- 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
what is the normal range of sodium?
135-145 mEq/L
169
what does potassium do in the body? K+
- "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
what is the normal range of potassium in the body?
3.5-5 meq/L
171
what does calcium do in the body?
- bone and teeth health
- facilitates muscle contraction, including cardiac muscle contraction
- plays role in blood clotting
172
what is the normal range of calcium in the body?
8.5-10.5 milligrams per deciliter (mg/dL)
173
what is the normal range of magnesium in the body?
1.5-2.5 milligrams per deciliter (mg/dL)
174
what is the normal range of chloride?
95-105 milliequivalents per liter (mEq/L)
175
what is the normal range of phosphate?
2.5-4.5 milligrams per deciliter (mg/dL)
176
what does magnesium do for the body?
- bone health and structure
- facilitates muscle contraction and relaxation
- has role in energy metabolism
- regulates nerve function
177
what does chloride do in the body?
- maintains fluid balance and osmotic pressure
maintains proper hydration and electrolyte balance in cells
- helps acid base balance, forms hydrochloric acid in stomach
178
what does phosphate do in the body?
- 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
what is osmosis?
movement of water molecules across a selectively permeable membrane from an area of lower solute concentration to an area of higher solute concentration
180
what is filtration?
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
what is the Renin-angiotensin-aldosterone system?
hormonal cascade that plays a crucial role in regulating blood pressure, electrolyte balance, and fluid volume
182
what is renin?
enzyme produced and released by the kidneys in response to low blood pressure or decreased blood flow to the kidneys
183
what is Angiotensin I?
- 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
what is angiotensin II?
- 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
what is aldosterone?
- 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
what can dysfunction of the renin-angiotensin-aldosterone system (RAAS) lead to?
hypertension, electrolyte imbalances, and other cardiovascular disorders
187
what is the atrial natriuretic peptide?
- 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
what is hypovolemia?
- decreased volume of extracellular fluid in body, which leads to reduction in circulating blood volume
- can occur bc of fluid loss
189
what are S/S of hypovolemia?
S/S: thirst, dry mucous membranes, decreased urine output, tachycardia, hypotension, and dizziness
190
what is hypernatremia?
- elevated serum sodium levels (>145 mEq/L)
- when sodium intake is greater than water intake
191
S/S of hypernatremia?
- thirst, dry mucous membranes, restlessness, weakness, irritability, and altered mental status
- severe: neurological like coma or seizures
192
what is hyponatremia?
- low serum sodium levels (<135 mEq/L)
- too much water relative to sodium levels
193
S/S of hyponatremia?
headache, nausea, vomiting, confusion, lethargy, seizures, and coma
194
what is hypokalemia?
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
what are S/S of hypokalemia?
muscle weakness, fatigue, muscle cramps, constipation, palpitations, and cardiac dysrhythmias. Severe: cardiac arrhythmias
196
what is hyperkalemia?
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
S/S of hyperkalemia?
muscle weakness, paresthesias, palpitations, bradycardia, cardiac dysrhythmias, and potentially cardiac arrest.
Severe: ventricular fibrillation or asystole.
198
what is hypocalcemia?
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
what is hypercalcemia?
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
S/S of hypocalcemia?
muscle cramps, numbness and tingling in the extremities (paresthesias), tetany, seizures, and abnormal heart rhythms
201
S/S of hypercalcemia?
fatigue, weakness, constipation, abdominal pain, confusion, bone pain, kidney stones, and cardiac arrhythmias.
Severe hypercalcemia can lead to coma or cardiac arrest.
202
what is hypomagnesemia?
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
S/S of hypomagnesemia?
muscle cramps, tremors, weakness, cardiac arrhythmias, seizures, and neuromuscular irritability
204
what is hypermagnesemia?
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)
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S/S of hypermagnesemia?
lethargy, drowsiness, weakness, nausea, vomiting, respiratory depression, cardiac arrhythmias, and hypotension.
Severe: respiratory arrest and cardiac arrest
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what are ovolactovegetarians?
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
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what are urinary diversions?
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
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what is ileoanal pouch anastomosis?
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
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what is metabolic acidosis?
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)
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what are symptoms of metabolic acidosis? what is treatment?
S: rapid breathing (Kussmaul respirations), confusion, lethargy, and nausea.
treatment aims to address underlying cause, may involve administration of bicarbonate
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what is metabolic alkalosis?
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)
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what are causes of metabolic alkalosis?
Loss of acids (e.g., vomiting, excessive use of diuretics)
Excessive intake of bicarbonate-containing meds
Hypokalemia (low potassium levels)
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how do you treat metabolic alkalosis?
correcting the underlying cause, such as restoring fluid and electrolyte balance and addressing potassium deficiency
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what is oncotic pressure? aka colloid osmotic pressure
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
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what phlebitis?
inflammation of a vein
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what is respiratory acidosis?
an excess of carbon dioxide (CO2) in the bloodstream due to inadequate ventilation or impaired gas exchange in the lungs
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what is cystitis?
inflammation of the bladder
- more common in women due to shorter urethra
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what is dysuria?
symptom characterized by painful or uncomfortable urination.
manifests as a burning, stinging, or itching sensation during urination
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what is hematuria?
refers to the presence of blood in the urine
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what is a nephrostomy?
surgical procedure in which a tube (nephrostomy tube) is inserted through the skin and into the kidney to drain urine from the renal pelvis
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what is a colonoscopy?
diagnostic procedure that allows direct visualization of the entire colon (large intestine) using a flexible, lighted instrument called a colonoscope
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what is a colostomy?
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
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what is effluent?
refers to the output or discharge from an ostomy, such as a colostomy or ileostomy, into an external collection device (ostomy pouch)
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what is Fecal Immunochemical Test (FIT)?
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
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what is flatulence?
passing gas
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what is ileus?
refers to a temporary cessation or impairment of normal intestinal motility and peristalsis, leading to a functional obstruction of the bowel
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what is dehiscence?
partial or complete separation of the layers of a surgical incision or wound, typically occurring along the surgical suture line
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what is induration?
abnormal hardening or thickening of tissue, often characterized by firmness or palpable nodules
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what is reactive hyperemia?
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
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what is the International Classification for Nursing Practice (ICNP®)?
standardized terminology system developed by the International Council of Nurses (ICN) to support the documentation, communication, and analysis of nursing practice worldwide
- promotes consistency
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what is NANDA International (NANDA-I)?
professional nursing organization that develops and maintains standardized nursing diagnostic terminologies, known as NANDA-I Nursing Diagnoses
