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fundamentals > exam 2 > Flashcards

exam 2 Flashcards

1
Q

You need an intact _______ system and functioning organs in order to void

A

neurological

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2
Q

Spinal Cord Injury above the level of the_____ region can result in loss of voluntary control of urination

A

sacral

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3
Q

Avg. Volume per voiding:

A

200-500mL

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4
Q

Normal urine Output per 24 Hours:

A

1200 mL-1500 mL

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5
Q

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

A

Timed Urine Specimen

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6
Q

What are the 7 factors that influence urinary elimination?

A
  • Developmental Factors
  • Disease Conditions
  • Muscle Tone
  • Psychosocial Factors
  • Fluid Balance
  • Surgical and Diagnostic Procedures
  • Medications
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7
Q

What information can you get from a urine analysis (U/A)?

5 things

A
  • PH
  • Protein
  • Glucose
  • Ketones
  • Specific gravity
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8
Q

normal pH for urine

A

4.6-8.0

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9
Q

Specific gravity for urine

A

(1.0053-1.030),

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10
Q

Urine is collected after voiding is initiated (midstream) and before voiding is completed

A

Midstream urine specimen

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11
Q

This is required for tests of renal function and urine composition.

A

24-Hour Urine Specimen

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12
Q

The entire volume of urine from a 24-hour period is collected.

If urine is accidentally discarded or contaminated or the patient is incontinent, restart the time period.

A

24-Hour Urine Specimen

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13
Q

Inability to empty the bladder

Retention of urine in the bladder; condition frequently caused by a temporary loss of muscle function.

A

urinary retention

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14
Q

Involuntary loss of urine

A

Urinary incontinence

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15
Q

Surgical diversion of the drainage of urine such as a ureterostomy.

A

urinary diversion

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16
Q

Can be caused by obstruction of the urinary tract or by nerve problems

A

Urinary Retention

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17
Q

inability to void or voiding frequently in small amounts often with sense of incomplete emptying,

bladder distention & tenderness, pain

A

Urinary Retention

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18
Q

Urinary Retention Interventions: treat the problem, may need to ________ the client

A

catheterize

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19
Q

Affects 50% of men over age 60 and 90% of men over age 70

Common signs and symptoms: voiding in small amounts, frequency, urgency, hesitancy, weak stream

A

Benign Prostatic Hypertrophy(BPH

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20
Q

They are the most common health-care associated infection in the United States

A

Urinary Tract Infections(UTIs)

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21
Q 
infection where Common signs and symptoms: 
Urgency
Burning on urination
Fever
Chills
WBC’s in the urine sample
A

Urinary Tract Infections(UTIs)

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22
Q

Adequate fluid intake per day

A

(2000-2500mL)

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23
Q

6 ways to prevent UTI

A 
Adequate fluid intake
Frequent voiding upon urge
Promote Complete Emptying-Double voiding
Proper perineal care- 
Avoid using feminine hygiene products
Acidify the urine
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24
Q

Sometimes the first sign of a bladder infection or UTI in the elderly is_____________

A

confusion

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25
Q

involuntary loss of urine associated with effort or exertion on sneezing or coughing

A

Stress Incontinence

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26
Q

Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction

A

Urge Incontinence

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27
Q

Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2

A

Reflex Incontinence

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28
Q

Loss of continence because of causes outside the urinary tract. Usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, poor motivation, or environmental barriers

A

Functional Incontinence

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29
Q

Incontinence caused by medical conditions that in many cases are treatable and reversible

A

Transient Incontinence

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30
Q

this is the remedy for what type of Incontinence

pelvic muscle exercises

A

Stress Incontinence

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31
Q

this is the remedy for what type of Incontinence

Avoid bladder irritants (e.g., caffeine, artificial sweeteners, alcohol).

instruct patient in pelvic muscle exercises, in , urge-inhibition exercises, and/or in bladder training

A

Urge Incontinence

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32
Q

this is the remedy for what type of Incontinence

Follow the prescribed schedule for emptying the bladder either through voiding or by intermittent catheterization.

Supply urine-containment products: condom catheter, undergarments, pads, briefs. Monitor for signs and symptoms of urinary retention and UTI.

Monitor for autonomic dysreflexia

A

Reflex Incontinence

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33
Q

this is the remedy for what type of Incontinence

Adequate lighting in the bathroom

Individualized toileting program

Mobility aides (e.g., raised toilet seats, toilet grab bars)

Toilet area cleared to allow access for a walker or wheelchair

Elastic-waist pants without buttons or zippers

Call bell always within reach

A

Functional Incontinence

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34
Q

this is the remedy for what type of Incontinence

With new-onset or increased incontinence look for reversible causes. Notify health care provider of any suspected reversible causes

A

Transient Incontinence

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35
Q

Severe skin breakdown from urine constantly in contact with skin

A

Incontinence Associated Dermatitis

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36
Q

6 Nursing Care of Client with Urinary Diversion:

A 
Provide emotional support
Maintain intact skin around stoma
Referral to WOCN, Provide client education
Maintain fluid intake
Monitor I & O
Monitor for signs of infection
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37
Q

Estimated ___% loss of nephrons by age 80

A

30

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38
Q

Try to ________ to see if urinary retention is present before proceeding with an invasive procedure (urinary catheterization)- Decrease the risk of infection!

A

bladder scan

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39
Q

Drainage system must be _______ the level of the bladder.

A

below

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40
Q

after Catheter removal, client should void within ____ hours

A

6-8

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41
Q

This device is not a catheter but a drainage system connected to the external male genitalia.

It is used for the incontinent male to minimize skin irritation from urine.

A

Condom Catheter

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42
Q

Secure with care, follow equipment instructions: leave 1-2 inches from end of penis to tip of the catheter, only use elastic tape and apply in a spiral fashion or self securing catheter

Critical to assess circulation at least 30 minutes after applying

A

Condom Catheter

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43
Q

Voiding excessive amounts of urine

A

Polyuria

44
Q

Diminished urinary output in relation to fluid intake

A

Oliguria:

45
Q

failure of kidneys to produce urine

A

Anuria:

46
Q

Awakened from sleep because of the urge to void

A

Nocturia

47
Q

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity

Wound edges are clean and intact.

A

Acute

48
Q

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity

Continued exposure to insult impedes wound healing.

A

Chronic

49
Q

Wound that is closed

A

Primary Intention

50
Q

Wound edges not approximated

A

Secondary Intention

51
Q

Wound that is left open for several days; then wound edges are approximated

A

Tertiary Intention

52
Q

_________ wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers)

A

Partial-thickness

53
Q

________ wounds that involve total loss of the skin layers (epidermis and dermis).

A

full-thickness

54
Q

________ wounds are shallow in depth, moist, and painful; and the wound base generally appears red

A

Partial-thickness

55
Q

_______ wound extends into the subcutaneous layer, and the depth and tissue type varies, depending on body location

A

A full-thickness

56
Q

________ wound heals by regeneration;

A

A partial-thickness

57
Q

____________ heals by forming new tissue, a process that can take longer

A

full-thickness wound

58
Q

is localized injury to the skin and other underlying tissue, usually over a bony prominence

A

A pressure ulcer

59
Q

6 types of people at risk for a pressure ulcer

A
  • Older adults, those who have experienced trauma
  • Those with spinal-cord injuries (SCI)
  • Those who have sustained a fractured hip
  • Those in long-term homes or community care, the acutely ill
  • Individuals with diabetes
  • Patients in critical care settings
60
Q

A _____________ is an example of a wound with little tissue loss. Heals by primary intention

A

clean surgical incision

61
Q

5 Factors Affecting Wound Healing

A 
Desiccation
Maceration
Edema
Infection
Necrosis
62
Q

Scraping or rubbing away of epidermis; may result in localized bleeding and later weeping of serous fluid.

A

Abrasion

63
Q

The action of pulling or tearing away

A

Avulsion

64
Q

State of extreme dryness, or the process of extreme drying

A

desiccation

65
Q

Softening and breaking down of skin from prolonged exposure to moisture.

A

maceration

66
Q

Termination of bleeding by mechanical or chemical means or the coagulation process of the body.

A

hemostasis

67
Q

damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and white blood cells into the damaged tissues.

4 to 6 days

A

inflammatory stage

68
Q

begins and lasts from 3 to 24 days. The main activities during this phase are the filling of a wound with granulation tissue, wound contraction, and wound resurfacing by epithelialization

A

proliferative phase

69
Q

the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound

A

Maturation

70
Q

: Shallow. Involves epithelialization.

A

Partial thickness

71
Q

: Extend into dermis. Involves granulation

A

Full-thickness

72
Q

Closing a wound
Edges touch— APPROXIMATED
Heals more quickly, makes less of a scar

A

Primary intention:

73
Q

Wound is left open to heal “from the ground up”—as in a contaminated wound

Takes longer time to heal, leaves bigger scar, greater risk for infection, can be more difficult for patient both physically and psychologically

A

Secondary intention:

74
Q

Wound is not sutured or stapled closed

A

Secondary Intention Healing

75
Q

Heals from bottom and sides

Takes time, but does work with right factors in place

A

Secondary Intention Healing

76
Q

4 Wound Complications

A

Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation

77
Q

__________, or bleeding from a wound site, is normal during and immediately after initial trauma

A

Hemorrhage

78
Q

wound drainage that is

Clear, watery plasma

A

Serous

79
Q

wound drainage that is

Thick, yellow, green, tan, or brown

A

Purulent

80
Q

wound drainage that is

Pale, pink, watery; mixture of clear and red fluid

A

Serosanguineous

81
Q

wound drainage that is

Bright red; indicates active bleeding

A

Sanguineous

82
Q

When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury).

A

Dehiscence

83
Q

(protrusion of visceral organs through a wound opening) occurs.

A

Evisceration.

84
Q

4 risk factors for Wound Dehiscence and Evisceration

A

Obesity

Abdominal

Radiological or chemotherapeutic treament

Increased intraabdominal pressure (coughing,sneezing, laughing)

85
Q

6 things that are on the Braden scale for prediction of PU Development

A 
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
86
Q

part of Braden scale where

Ability to respond meaningfully to pressure-related discomfort

A

Sensory Perception

87
Q

part of Braden scale where

Degree to which skin is exposed to moisture

A

Moisture

88
Q

part of Braden scale where

Degree of physical activity

A

Moisture

89
Q

part of Braden scale where

Ability to change and control body position

A

Mobility

90
Q

part of Braden scale where

Usual food intake pattern

A

Nutrition

91
Q

Worst possible score = __
Best possible score = __

braden scale

A

6

23

92
Q

stage of pressure ulcer where

nonblanchable erythema of intact skin

A

1

93
Q

stage of pressure ulcer where

partial-thickness skin loss

A

2

94
Q

stage of pressure ulcer where

full-thickness tissue loss; not involving underlying fascia. SC fat may be visible. May include tunneling and undermining.

A

3

95
Q

stage of pressure ulcer where

full-thickness tissue loss with extensive destruction. Exposed bone, tendon or muscle.

A

4

96
Q

______ determines if there is actual tissue damage v. reactive hyperemia.

A

Blanch test

97
Q

If the skin does not blanch, then tissue damage or ________ (Ineffective tissue perfusion)

A

Stage I pressure ulcer

98
Q

Soft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention.

Red and moist, viable

A

granulation tissue

99
Q

Soft white or yellow, stringy

wound

A

Slough

100
Q

Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed.

Black or brown; hard,necrotic

A

eschar

101
Q

4 things to lok for when assesing a pressure ulcer

A

Size of wound
Depth of wound
undermining,
tunneling, or sinus tract

102
Q

_______- wound debridement would be necessary in order to get down to the granulating surface

A

Necrotic tissue

103
Q

______ need to be cultured to determine what is growing in the wound bed and what we need to give the patient (antibiotics) to eliminate the bioburden.

A

Infected wounds

104
Q

______ is the cleanser of choice for most wounds

A

Normal Saline

105
Q

3 things in nutrition to help woh wound healing

A

Protein, Vitamin C, Zinc

106
Q

Decrease pressure times- limit pressure every___ hours whether sitting in a chair, lying in bed, laying on a bony prominence

A

2

fundamentals (6 decks)

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