Exam 2 Flashcards
SMART acronym for writing patient goals
Specific Measurable Attainable Realistic Timed
Independent nursing interventions
Actions that a nurse initiates w/out supervision or direction
Correctly written nursing interventions include?
Actions, frequency, quantity, method, and the person to perform them
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?
Patient will be turned every 2 hours within 24 hours.
Patient will have normal bowel function within 72 hours.
Patient’s skin integrity will remain intact through discharge.
Erythema of skin will be mild to none within 48 hours.
Erythema of skin will be mild to none within 48 hours.
Turning the patient every 2 hours in a 24-hour period is an intervention. Both “Patient will have normal bowel function within 72 hours” and “Patient’s skin integrity will remain intact through discharge” are goals.
Which of the following factors does a nurse consider in setting priorities for a patient’s nursing diagnoses? (Select all that apply.)
Numbered order of diagnosis on the basis of severity
Notion of urgency for nursing action
Symptom pattern recognition suggesting a problem
Mutually agreed on priorities set with patient
Time when a specific diagnosis was identified
Notion of urgency for nursing action
Symptom pattern recognition suggesting a problem Mutually agreed on priorities set with patient
These three factors are considered in setting priorities for a patient’s nursing diagnoses or collaborative problems. The other options are inappropriate because a numbering system and time of identification hold little meaning when a patient’s condition changes.
A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.)
Providing mouth care every 4 hours
Maintaining intravenous (IV) infusion at 100 mL/hr
Administering prochlorperazine (Compazine) via rectal suppository
Consulting with dietitian on initial foods to offer patient
Controlling aversive odors or unpleasant visual stimulation that triggers nausea
Maintaining intravenous (IV) infusion at 100 mL/hr Consulting with dietitian on initial foods to offer patient
Controlling aversive odors or unpleasant visual stimulation that triggers nausea
Providing mouth care every 4 hours and controlling aversive odors or unpleasant visual stimuli that triggers nausea are both independent nursing interventions. Administering prochlorperazine via suppository is a dependent intervention.
A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient’s room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse’s unit environment will affect her ability to set priorities? (Select all that apply.) Policy for conducting hourly rounds Staffing level Interruption by staff nurse colleague RN’s years of experience Competency of patient care technician
Policy for conducting hourly rounds
Staffing level
Interruption by staff nurse colleague
Many factors within the health care environment affect your ability to set priorities, including model for delivering care, the workflow routine and staffing levels of a nursing unit, and interruptions from other care providers. Available resources (e.g., policies and procedures) also affect priority setting. The nurse’s years of experience and the competency of the patient care technician are not part of the environment.
ACT OF URINATION
- Brain structures influence bladder function.
- Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxation
- Bladder wall stretching signals micturition center.
- Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.
- When a person is ready to void, the central nervous system sends a message to the micturition centers, the external sphincter relaxes and the bladder empties.
FACTORS INFLUENCING
URINATION
- Growth and development
- Sociocultural factors
- Psychological factors
- Personal habits
- Fluid intake
- Pathological conditions: diabetes mellitus, MS, stroke. Pt’s either have overactivity or deficient
- Surgical procedures
- Medications
- Diagnostic Examinations
COMMON URINARY ELIMINATION
PROBLEMS
• Urinary retention • An accumulation of urine due to the inability of the bladder to empty • Urinary tract infection • Results from catheterization or procedure • Urinary incontinence • Involuntary leakage of urine • Urinary diversion - Diversion of urine to external source
Function of kidneys
Filter waste products of metabolism from the blood
Function of ureters
Transport urine from the kidneys to the bladder
Function of the bladder
Holds urine until the volume in the bladder triggers a sensation of urge, indicating the need to pass urine
Define micturition
Occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra
Functional unit of the kidneys
Nephron, they remove waste products from the body and play a major role in the regulation of fluid and electrolyte balance.
-each nephron contains a cluster of capillaries called glomerulus which filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes
Erythropoietin
Produced by the kidneys, it stimulates RBC production and maturation in bone marrow
-pt’s w/chronic kidney conditions cannot produce sufficient quantities of this hormone; therefore they are prone to anema
How do kidneys play a role in BP control?
Via the renin-angiotensin system (i.e. release of aldosterone and prostacyclin)
- in times of renal ischemia (decreased blood supply), renin is released from juxtaglomerular cells
- Renin functions as an enzyme to convert antiotensinogen (a substance synthesized by the liver) into angiotensin I
- angiotensin I is converted to angiotensin II in the lungs.
- Angiotensin II causes vasoconstriction and stimulates aldosterone release from the adrenal cortex
- Aldosterone causes retention of water, which increases blood volume
- The kidneys also produce prostaglandin E2 and prostacyclin, which help maintain renal blood flow through vasodilation.
- These mechanisms, increase arterial BP and renal blood flow
Alcohol decreases?
The release of antidiuretic hormone, thus increasing urine production
Some drugs change the color of urine (e.g. phenazopyridine-orange, riboflavin-intense yellow)
.
Transient incontinence
- caused by medical conditions
- common reversible causes: delirium, inflammation, medications etc.
- Nursing interventions: look for reversible causes, notify health care provider of any suspected reversible causes
Functional incontinence
Loss of continence because of causes outside urinary tract, usually related to functional deficits such as altered mobility and manual dexterity
- toilet access restricted by: sensory impairments, cognitive impairments, altered mobility, etc.
- nursing interventions: adequate lighting in bathroom, individualized toileting program, mobility aids
Goal and outcome
Goal: broad statement that describes a desired change in a patient such as a patient will understand postop risks.
Outcome: is measurable change such as a pt will know s/s and symptoms of wound infection
Which of the following factors does a nurse consider in setting priorities for a patient’s nursing diagnosis (select all that apply)
1) numbered order of diagnosis on the basis of severity
2) Notion of urgency for nursing action
3) Symptom pattern recognition suggesting a problem
4) Mutually agreed on priorities set w/pt
5) Time when a specific diagnosis was identified
Factors influencing urinary elimination
Growth and development, sociocultural factors, psychological factors, personal habits, fluid intake, pathological conditions, surgical procedures, medications, diagnostic exams
Postvoid residual (PVR)
The amount of urine left in the bladder after voiding and is measured either by ultrasound (bladder scan) or straight catherterization
Characteristics of urine
Color, clarity, odor
Patient education for a healthy bladder
Maintain adequate hydration, keep good voiding habits, keep the bowels regular, prevent UTIs, stop smoking
An intravenous pyelogram (IVP) involves what?
Intravenous injection of an iodine based contrast media. Patients that have had a previous hypersensitivity reaction to contrast media in the past are at high risk for another reaction. Informed consent is required. There is no need for a full bladder such as with a pelvic ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such as with cystoscopy
A post-op patient with a three-way indewelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurses initial intervention?
Assess intake and output
An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage urine and irritant, the irritant should be stopped immediately, the catheter may be occluded and the bladder distended
.
Pelvic muscle training is effective in treating
Stress urinary incontinence
Bladder retraining is?
Behavioral therapy
Behavioral therapy that includes pelvic muscle training should be offered as?
First-line treatment for stress, urge, and mixed incontinence in women of all ages
Common causes of constipation
- irregular bowel habits and ignoring urge to defecate
- chronic illnesses (parkinson’s, MS, rheumatoid arthritis, chronic bowel diseases, depression, eating disorders)
- low-fiber diet high in animal fats (meats, and carbs); low fluid intake
- stress (illness of family member, death of loved one, divorce)
- physical inactivity
- medications, especially use of opiates
- changes in life or routine such as pregnancy, aging, travel
- neurological conditions that block nerve impulses to the colon (stroke, spinal cord injury, tumor)
- chronic bowel dysfunction (colonic inertia, irritable bowel)
Signs of dehydration in adults
Signs of dehydration in adults:
- thirst
- less frequent urination than usual
- dark-colored urine
- dry skin
- fatique
- dizziness
- light-headedness
Signs of dehydration in infants and young children
- dry mouth/tongue
- no tears when crying
- no wet diapers for 3 hours or more
- sunken eyes or cheeks or soft spot in the skull
- high fever
- listlesness or irritability
The proper position for the patient on a bedpan is?
With the head of the bed elevated 30-45 degrees
Which skills must a patient with a new colostomy be taught before discharge from the hospital?
- How to change the pouch
- How to empty the pouch
- How to open and close the pouch
Initial steps of chronic constipation
Increase fluid and fiber, exercise 30 min/day, schedule time to use the toilet every day
Frequent or continuous oozing of liquid stools occurs when?
Liquid fecal matter above the impacted stool seeps around the fecal impaction
pH
<7.35 is acidic
>7.45 is alkalosis
HCO
22-26
PaCO2
35-45
Left sided heart failure
Decreased function of left ventricle, resulting in decreased cardiac output
S/S of left sided heart failure
Fatigue, SOB, dizziness, and confusion due to tissue hypoxia and decrease cardiac output b/c left ventricle is failing, blood pools in the pulmonary circulation > pulmonary congestion
Clinical findings for left sided heart failure
Crackles, hypoxia, SOB on exertion, cough, paroxysmal nocturnal dyspnea
Right sided heart failure
Impaired function of right ventricle, results from pulmonary disease or long term left sided heart failure. Blood backs up in the systemic circulation
Clinical findings for right sided heart failure
Weight gain, distended neck veins, hepatomegaly and splenogaly, and dependent peripheral edema
Effects of aging on assessment findings of the cardiopulmonary system: function Heart
Muscle contraction
pathophysiological change: thickening of the ventricular wall, increased collagen and decreased elastin in the heart muscle
Clinical findings: Decreased cardiac output, diminished cardiac reserve
Effects of aging on assessment findings of the cardiopulmonary system: function blood flow
Pathophysiological change: Heart valves become thicker and stiffer, more often in the mitral and aortic valves
Clinical findings: systolic murmur
Effects of aging on assessment findings of the cardiopulmonary system: function conduction system
- Pathophysiological change: SA node becomes fibrotic from calcification; decrease of number of pacemaker cells in SA node
- Clinical findings: increased PR, QRS, Q-T intervals, decreased amplitude of QRS complex. Irregular heart rhythm
Effects of aging on assessment findings of the cardiopulmonary system: function arterial vessel compliance
- Pathophysiological change: calcified vessels, loss of arterial distensibility, decreased elastin in vessel walls, more tortuous vessels
- clinical findings: hypertension w/an increase in systolic blood pressure
