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Health Assessment > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Components of the nursing process

A

Assessment, diagnosis, planning, implementation, evaluation, outcome

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2
Q

assessment

A

collection of objective and subjective data

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3
Q

diagnosis

A

determine priority problem

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4
Q

planning

A

set SMART goals for positive outcomes

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5
Q

implementation

A

take action

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6
Q

Evaluation

A

evaluate effectiveness

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7
Q

goal of outcome identification and planning

A

establish priorities (what kills pt first), identify + write expected outcomes, select evidence based nursing outcomes, communicate care plan

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8
Q

IOM 6 aims to be met by health care systems

A

safe: avoid injury, effective: avoiding overuse and underuse, patient-centered: responding to patient preferences needs and values, timely: reducing waits and delays, Efficient: avoiding waste, equitable: providing care that does not vary in quality to all recipients

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9
Q

formal care plan allows nurse to

A

individualize care that maximizes outcome achievement, set priorities, facilitate communication, promote continuity of high-quality cost-effective care, coordinate care, evaluate patient response to nursing care, create record used for evaluation, research, reimbursement, and legal reasons

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10
Q

elements of comprehensive panning

A

initial: priority plan for the patient (developed by nurse who performs nursing history and P.A.; develops appropriate goals for pt), ongoing: continues throughout hospital care plan of care begins to change and adapt, discharge: what we do when patients leave (begins on admission)

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11
Q

outcome

A

SMART: specific, measurable, attainable, realistic, time bound

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12
Q

long-term outcome

A

require longer period to be achieved and may be used as discharge goals

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13
Q

short-term outcome

A

may be accomplished in specific period of time

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14
Q

categories of outcomes

A

cognitive, psychomotor, affective, clinical, functional, quality-of-life

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15
Q

cognitive outcome

A

describes increases in patient knowledge or intellectual behaviors

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16
Q

psychomotor outcome

A

describes patients achievement of new skills

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17
Q

affective outcome

A

describes changes in patients values, beliefs, and attitudes

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18
Q

clinical outcome

A

describe expected status of health issues at certain points in time after treatment is complete; address whether problems are resolved or to what degree they improved

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19
Q

functional outcome

A

describe persons ability to function in relation to desired usual activities

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20
Q

quality-of-life outcome

A

focus on key factors that affect someone’s ability to enjoy life and achieve personal goals

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21
Q

types of nursing intervetions

A

nurse initiated, physician initiated, collaborative

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22
Q

nurse initiated interventions

A

actions performed by nurse without physicians order (hygiene, BGL, ambulating)

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23
Q

physician initiated interventions

A

actions initiated by physician in response to medical diagnosis but carried out by nurse under doctor’s orders (fluid bolus, med admin)

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24
Q

collaborative intervention

A

treatments initiated by other providers and carried out by a nurse (nutrition and nurse collab to determine if pt is aspirating)

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25
Q

procedure

A

set of how-to action steps

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26
Q

standard of care

A

description of acceptable level of patient care

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27
Q

algorithm

A

set of steps used to make a decision

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28
Q

clinical practice guideline

A

statement outlining appropriate practice for clinical condition or procedure

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29
Q

institutional plans of care

A

computerized, concept map, change of shift reports, multidisciplinary (collaborative), student

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30
Q

how to assign priority

A

Maslows hierarchy of needs, ABC’s, nursing process, safety + risk reduction, least restrictive/least invasive, Acute vs. chronic/stable vs. unstable/urgent vs. non-urgent

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31
Q

Maslow’s hierarchy of needs

A

basic needs at base to psychological needs in middle, to self-fulfillment at top; needs at bottom must be met first

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32
Q

basic needs maslow

A

physiological (food, water, warmth, rest) then safety (security and safety)

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33
Q

psychological needs

A

belongingness and love needs (intimate relationships, friends) then esteem needs (prstige an feeling of accomplishment)

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34
Q

self-fulfillment needs

A

self actualization (achieving ones full potential including creative activities

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35
Q

ABCDE

A

airway, breathing, circulation, disability (neurological status, response to stimuli, level of orientation), exposure (check client head to toe for concerning signs

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36
Q

the 6 cognitive skills

A

recognize cues (assessment), analyze cues (diagnosis/analysis), prioritize hypotheses (diagnosis/analysis), generate solutions (planning), take action (implementation), evaluate outcomes (evaluation)

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37
Q

nursing process assessment

A

subjective data, objective data, then assessment type

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38
Q

nursing process analyze

A

identify assessment findings, include additional info (labs or vitals)

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39
Q

prioritize hypothesis

A

evaluate and ranking according to priority: urgency, risk, time, difficulty, likelihood; include diagnostic testing results and nursing note

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40
Q

generate solutions

A

summarize clinical info up to this point and most likely cause of clinical presentation

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41
Q

take action

A

include list of orders from healthcare provider, implement solution that addresses highest priority

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42
Q

evaluate outcomes

A

outline interventions that were taken to care for client; focus on efficacy of intervention

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42
Q

Documentation includes

A

data related to assessing, diagnosing/analyzing, planning, implementing, and evaluating (nursing processes); facilitates quality and evidence based patient care; serves as financial and legal record; helps clinical research; supports decision analysis

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43
Q

characteristic of effective documentation

A

consistent with professional and agency standards, complete, accurate, concise, factual, organized, timely, legally prudent, confidential

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44
Q

characteristics of effective documentation content

A

reflect nursing process and nursing responsibilities, record objective findings/observations, avoid use of subjective words (good, sufficient), avoid copying and pasting, b professional

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45
Q

when to document

A

upon admission, transfer to new unit, discharge, assessment or procedure performed, receiving pt post-op/post-procedure, change in pt status, communicating with health care provider regarding critical pt information (abnormal labs)

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46
Q

pt have right to

A

see and copy health records, update health records, get list of disclosures, request restriction on certain uses, choose how to receive health info

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47
Q

RN receiving verbal orders

A

must come from healthcare provider directly, record orders in pt medical record with initials, read back, date and time orders issues, record verbal order and HCP name followed by RN initials; limited to urgent situations

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48
Q

what to document

A

pt is always the focus, support subjective data with objective facts, report facts, report new or changed info/observations, avoid personal opinions/biased statements, chart problems with the actions taken, chart pt response and reaction

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49
Q

SOAPIER

A

subjective, objective, assessment, plan, interventions, evaluations, response

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50
Q

PIE charting

A

problem, intervention, evaluation

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51
Q

Focus charting

A

patient and patient concern, data, action, response

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52
Q

if not charted than…

A

not done

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53
Q

charting exceptions

A

shorthand for documenting normal findings; document significant findings or exceptions; goo because requires less time but important findings may be left out

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54
Q

when to use handoff reports

A

shift change, unit change, patient transfer (hospital to rehab)

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55
Q

important info for new nurse to obtain coming onto shift

A

Medical HX, chief complaint, head to toe exam, meds on and meds due, feeding, fall risk, discharge, allergies, labs, LOC

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56
Q

ISBARR report nurse to nurse

A

introduction, situation, background, assessment, recommendation, repeat back

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57
Q

SBAR

A

Situation, background, assessment, recommendation

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58
Q

IPASS report nurse to nurse

A

Illness severity, patient summary, action, situation awareness and cognitive planning, synthesis

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59
Q

Incident report

A

used by facilities to document unexpected eventa that resulted or could have resulted in harm, file whenever e=unexpected event occur, used for risk management and QI; senitnel and never events (sentinel = occurs in death, never =
medical error never should have occurred)

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60
Q

shift to shift RN report

A

involves oncoming RN, outgoing RN, pt, and family; records, goals, and orders reviewed

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61
Q

SBAR purpose

A

direct and focused, thorough, logical, used to coordinate pt care, ensure safe med admin., completely conduct handoff/transfers, report change in pt status

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62
Q

Situation (SBAR)

A

frame of reference (your name, status, unit & pt name, room number) & whats going on (state in one sentence: problem, when it happened/started, and severity)

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63
Q

Background (SBAR)

A

what led to current situation, include pertinent pt info

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64
Q

pertinent pt info for SBAR

A

admitting diagnosis and date of admission, current meds/allergies/IV fluids, most recent vitals, current labs (compared to previous), code status

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65
Q

Assessment (SBAR)

A

what you think is happening using best judgement

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66
Q

Recommendation (SBAR)

A

course of action you expect to take; what you suggest for the patient (can take time to become comfortable)

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67
Q

functions of respiratory system

A

pulmonary ventilation (inspiration + exhalation), ventilation-respiration (gas exchange), perfusion (oxygenated blood pass through tissues),

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68
Q

upper airway structures

A

nose, pharynx, larynx, epiglottis; warm, filter, humidify air

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69
Q

lower airway structures

A

trachea, L + R mainstem bronchi, segmental bronchi, terminal bronchioles

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70
Q

lower airway function

A

conduction of air, clearance and production of surfactant

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71
Q

mucus purpose

A

traps cells, particles, and debris to keep underlying tissue from becoming irritates; need adequate water to keep mucus thin

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72
Q

cilia purpose

A

hair-like projections that propel trapped material toward upper airway to be removed by coughing

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73
Q

surfactant purpose

A

reduce surface tension, preventing alveolar collapse

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74
Q

thoracic structure landmarks

A

sternal notch, manubrium, manubriosternal junction/sternal angle/angle of louis, body of sternum, costochondral junctions, xiphoid process, costal angle

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75
Q

lowest point posteriorly on exhalation and inhalation

A

T10 and T12 respectively

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76
Q

anterior lines of reference

A

anterior axillary, midclavicular, midsternal

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77
Q

posterior lines of reference

A

scapular, vertebral

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78
Q

lateral lines of reference

A

anterior, mid, and posterior axillary lines

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79
Q

purpose of breathing

A

supply oxygen, remove CO2, maintain acid-base balance, heat exchange

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80
Q

breathing control

A

hypercapnia, hypoxemia, pH

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81
Q

process of ventilation

A

diaphragm contracts and descends, external intercostal muscles contract (lift ribs up and out), sternum is pushed forward, increased lung volume and decreased intrapulmonic pressure allows for air to move from greater pressure in, relax/recoil of these structures allow for expiration

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82
Q

developmental considerations

A

infant and chidren, aging adult

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82
Q

infant and children developmental considerations (respiratory)

A

llergy, colds, wheezing, asthma, childproofing home, smokers, pollution

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83
Q

aging adult developmental considerations (respiratory)

A

dyspnea on exertion, activity level, stress, chronic diseases (renal failure, anemia), loss of elasticity, weaker immune system, medications (opioid decrease RR)

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84
Q

respiratory history components

A

cough, SOB, chest pain with breathing, past history of respiratory illness, smoking history, environmental exposure, self-care

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85
Q

signs of respiratory dysfunction

A

cough, wheeze, sputum production, SOB (dyspnea)

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86
Q

Respiratory assessment

A

Inspection, palpation, percussion, auscultation

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87
Q

Respiratory P.E.

A

inspection: rate, pattern effort (pursed lip? distressed? labored?), thoracic cage shape, use of accessory muscles, posture, skin/nails, level of consciousness, ability to speak, any chest deformities, AP ratio (1:2), barrel chest, spine deformities

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88
Q

clubbed fingers sign of

A

chronic hypoxia

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89
Q

respiratory patterns

A

normal, tachypnea, bradypnea, hyperventilation, hypoventilation, cheyne-stokes, biot’s, apnea (>20 seconds)

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90
Q

pectus excavatum

A

inward depression of sternum

91
Q

pectus carinatum

A

outward protrusion of sternum; pigeon chest

92
Q

kyphosis

A

hunch-back (upper T-spine area)

93
Q

barrel chest

A

AP diameter (transverse diameter) ratio 1:1; common in emphysema d/t air trapping; normal in infants

94
Q

palpation (respiratory)

A

note skin temp., assess expansion (should be symmetrical), note masses/edema/tenderness, palpate PMI, palpate extremities, assess pulse and cap refill

95
Q

percussion (respiratory0

A

no used frequently; done by advanced practice HCP

96
Q

auscultation (respiration)

A

begin on back using diaphragm; Z-pattern comparing sides; note whether sounds are bronchial, bronchovesicular, or vesicular depending on location; make note of unexpected breath sounds

97
Q

breath sounds

A

bronchial, bronchovesicular, vesicular

98
Q

bronchial breath sounds

A

heard over trachea; high-pitched; inspiration slightly shorter than expiration

99
Q

bronchovesicular

A

heard over main bronchi; medium pitch; inspiration = exhalation

100
Q

vesicular

A

heard over peripheral lung fields; low pitched; inspiration longer than expiration

101
Q

hearing decrease in intensity

A

often first sign of disease

102
Q

crackle lung sounds

A

high pitched, discontinuous, popping sound, heard on inspiration; does not clear with coughing (heard with CHF and pneumonia); air passing through fluid in small airways

103
Q

crackle sound interventions

A

fluid restriction, diuretics; does not clear with coughing

104
Q

wheeze lung sounds

A

high pitched, continuous, musical, squeaking, heard during inspiration and expiration; passes through narrow constricted airway

105
Q

rhonchi lung sound

A

low pitched, continuous, snoring or rumbling, heard during inspiration and expiration, sounds like “junk in lungs”; can clear with coughing and deep breaths

106
Q

stridor lung sounds

A

high pitched crowning sound, heard on inspiration and expiration, upper airway obstruction and croup

107
Q

rhyme to remember

A

rhonchi in the bronchi; rales in the tails

108
Q

peak flow monitoring

A

measures peak expiratory flow rate in L/min (PEFR); reflects changes in size of airways; aka point of highest flow during expiration

109
Q

green zone PEFR

A

medication is working; go ahead with normal activities

110
Q

yellow zone PEFR

A

use caution in your activities; refer to treatment plan for actions to be taken

111
Q

red zone PEFR

A

medical alert; get immediate medical attention

112
Q

oxygen administration

A

use lowest concentration to maintain O2 >90%; target SpO2 88-92%for COPD; use humidified O2 for high flow

113
Q

Nasal Cannula

A

24-44% oxygen; 1-6L; nasal prongs point down

114
Q

Rules of 4s Low flow NC

A

1L = 24%; 2L = 28%; 3L = 32%; 4L = 36%, 5L = 40%; 6L = 44%

115
Q

Simple mask

A

40-60%; 5-8L (low flow); assess for claustrophobia; put in order for NC during meal time

116
Q

venturi mask

A

24-40%; delivers most precise concentration of O2; color coded

117
Q

reservoir masks

A

partial rebreather mask and nonrebreather mask

118
Q

partial rebreather mask

A

50-75%; 8-11L/min; air in reservoir mixes with 100% O2 for next inhalation; conserves O2 in this manner

119
Q

nonrebreather mask

A

80-95%; 10-15L/min; one-way valves prevent pt from rebreathing exhaled air; reservoir filled with 100% O2 that enters mask on inhalation

120
Q

safety considerations for oxygen

A

no smoking. check flow rate regularly (part of gen. survey), check water level in reservoir for humidified oxygen

121
Q

nebulizer treatments

A

disperses fine particles of liquid medication into resp. tract; meds such as bronchodilator continued treatment until med is gone (~15min)

122
Q

nursing considerations after nebulizer treatment

A

reassess lung sounds, O2 sat., resp. after treatment

123
Q

Metered dose inhalers (MDIs)

A

uses controlled dose of med with each compression (bronchodilators, mucolytic, corticosteroids); rinse mouth out after to prevent thrush (oral candidiasis); always use spacer (aerochamber)

124
Q

MDI common mistakes

A

failure to shake cannister, holding upside down, inhaling through nose, inhaling too rapidly, stopping inhalation too early, failing to hold breath, two sprays in one breath

125
Q

dry powder inhalers (DPI)

A

flow of med activated by pt breath; pt must be able to take powerful inspiration for adequate drug inhalation; some DPI require loading dose

126
Q

respiratory pearls

A

hydration to maintain fluidity of secretions (thick secretions = airway resistance); drink 1.0-2.9L/day unless CHF; high fowlers to increase respiratory excursion (prevents pooling of mucus), progressive ambulation (promotes peristalsis, increases circulation, gravity to expand thorax)

127
Q

leg exercises (respiratory)

A

prevent venous stasis and thrombus formation via contraction of quadriceps and gastrocnemius

128
Q

deep breathing

A

used to overcome hypoventilation; in through nose out through mouth; 3-4 times per day/ 10 breaths per set; used post-operatively or for bedrest pt

129
Q

pursed lip breathing

A

prolong exhalation creating smaller opening for air movement; helps with feelings of dyspnea or panic

130
Q

diaphragmatic breathing

A

reduces RR, increases alveolar ventilation, promotes effective expiration; one hand on abdomen one hand on middle of chest; breathe in via abdomen breathe out via pursed lip while contracting abs (do for1 minute then rest for 2); helpful for COPD pt

131
Q

incentive spirometry

A

visual reinforcement for deep breathing; helps to breathe slow and deeply (promotes optimal gas exchange); measures maximal inhalation in mL; used post-operatively; 10x per hour is goal

132
Q

respiratory interventions

A

coughing and deep breathing; coughing cleanses airway; use pillow to splint chest or cover abdominal incisions

133
Q

chest physiotherapy

A

mobilizes/loosens mucus, includes percussion, no used in peds/pneumonia/COPD/ post-op pt, common inf CF pt., performed by RT

134
Q

sputum culture

A

suctioned or coughed up; used for gram stain and to find culture + sensitivity

135
Q

nursing interventions to promote adequate respiratory function

A

teaching of pollution-free envir., promote optimal function, promote comfort, promote adequate hydration/humidification, encourage activity, promote proper breathing, promote/control coughing, meet oxygen needs with O2 and meds

136
Q

factors that affect bowel elimination

A

diet/fluid intake, body position (bed rest), activity and exercise (improves GI motility/muscle tone

137
Q

recommended fluid intake

A

2000+ mL/day

138
Q

recommended fiber intake

A

25-38g per day; from whole grains, bran, beans, fruits, vegetables

139
Q

defecation

A

emptying of large intestine stimulated by distension of rectum by fecal mass (parasympathetic stimulation)

140
Q

defecation controlled by

A

medulla, spinal cord, PNS stimulates internal anal sphincter relaxation, Somatic NS causes voluntary relaxation of external sphincter

141
Q

GI coditions

A

constipation, diarrhea, bowel/fecal incontinence

142
Q

constipation

A

has to occur 3x within one week; can be caused by medication (narcotic and iron)

143
Q

diarrhea

A

high water and electrolyte content; 3x in one day; caused by hyperthyroidism, meds, infection, malabsorption, diabetes

144
Q

causes of bowel incontinence

A

brain injury, spinal cord injury, disorientation/confusion (causes inhibition of defecation reflex)

145
Q

fecal impaction

A

seepage or incontinence of liquid stool with no signs of normal feces; flatulence still occurs; treatment of oil retention enemas and digital impaction

146
Q

GI signs/symptoms

A

flatulence, distention, melena, clay/white stool

147
Q

flatulence

A

accumulation of gas in GI tract from swallowed air, undigested food, bacteria breakdown

148
Q

distension

A

when gas accumulates

149
Q

melena

A

dark/black stools (upper GI bleed)

150
Q

clay/white stool

A

lack of bile; difficulty with digestion of fat

151
Q

colorectal screening

A

stool guaiac test (test for peroxidase), colonoscopy (visualize large intestine), colorguard

152
Q

meds that alter bowel issues

A

laxatives/cathartics, antibiotics, narcotics

153
Q

collecting stool specimens protocol

A

void first to avoid contamination, defecate into container not toilet, no toilet paper or soap, 1 inch of solid stool or 30mL of liquid

154
Q

stool culture tests for

A

ova/parasites and needs to be transported warm or bugs die

155
Q

hemoccult testing

A

guaiac test, fecal immunochemical test

156
Q

guaiac test

A

for blood not visible, blue = positive; false positives d/t NSAIDs steroids iron

157
Q

fecal immunochemical test

A

uses antibodies against Hgb to detect blood, positive for bleeding in lower GI, perks are no drug or dietary restrictions

158
Q

enema

A

clears bowel; cleansing evacuates feces vs. retention stays in bowel for longer to lubricate mucosa, relieve gas, provide meds absorbed in mucosa

159
Q

enema mechanism of action

A

distends bowel, irritates bowel mucosa, increases peristalsis, lubes stool and mucosa

160
Q

contraindications of enema

A

thrombocytopenia/leukopenia, immunocompromised, fistula, bowel obstruction, paralytic ileus

161
Q

large enemaa

A

tap water, saline, soap suds (irritates mucosa to stimulate peristalsis; 500-1L and retain for ~15 min

162
Q

small volume enemas

A

70-130mL, distends bowel, retain for 5-10 min

163
Q

retention enemas

A

30-60 min, 150-200 mL, lubricates stool and intestinal mucosa

164
Q

enema care considerations

A

pt on left side, flush tubing of air, insert 4 inches and towards umbilicus, administer slow with gravity at room temp, assess for cramping and slow down if present

165
Q

nutrition developmental considerations

A

growth, infancy, adolescence, pregnancy, activity, age-related changes in metabolism and body composition, birth sex, state of health, alcohol use disorder, medications, megadoses of nutrient supplements

166
Q

factors that influence food choices

A

social determinants of health, religion, meaning of food, culture

167
Q

output

A

urine should be about 0.5-1.5mL/kg/hour; 30mL per hour

168
Q

insensible loss

A

cannot be seen or measured (respiration)

169
Q

fluid output

A

should equal input; 1500 as urine, 600 from skin, 400 from lung, 100 in feces; total 2600mL

170
Q

skin trgor

A

assesses fluid balance; sternum and under clavicle

171
Q

documenting I/O

A

time and amount, add totals every shift, compare 24 hour totals

172
Q

fluid restriction

A

ice chips as allowed, offer fluids 1-2 hour intervals between meals

173
Q

modified consistency diets

A

liquid (clear, full liquid), mechanically altered (pureed is good for dysphagia, mechanical soft)

174
Q

pt with dysphagia feeding

A

sit pt upright (high fowlers) at 90 degrees, chin tucked when swallowing, small frequent meals, signs of choking are coughing and cyanosis

175
Q

diet progression

A

liquid: clear to full, soft, regular

176
Q

therapeutic diets types

A

fat-restricted (atherosclerosis/gallstones), sodium restricted (500-3000mg/day for heart, renal, liver disease), high-residue/high-fiber (diverticulitis, IBS, constipation), diabetic diet/consistent carbs, gluten free (celiac disease), renal diet (low potassium, low protein, sodium restriction for CKD)

177
Q

nutrition assessment

A

part of gen. survey that assesses gen appearance, interactions, energy

178
Q

malnourishment assessment

A

dry brittle hair, dry scaly pallor skin (poor turgor), dry mucous membranes, pail brittle spoon shaped nails (koilonychia), interactions, vitality (sleep pattern, fatigue, decreased activity)

179
Q

assessing dietary intake

A

24 hour recall, food diaries/calorie count, food frequency records, diet history

180
Q

mini nutritional assessment (MNA)

A

gold standard; decline in intake and why, presence of involuntary weight loss?, mobility, psychological stress?, neuropsychological disorder?, BMI; max is 14 points: 12-14 normal, 8-11 at risk, 0-7 malnourished

181
Q

nutritional screening

A

DETERMINE

182
Q

DETERMINE

A

disease, eating poorly, tooth loss/mouth pain, economic hardship, reduced social contact, multiple medicines, involuntary weight loss, needs assistance in self-care, elder (>80)

183
Q

BMI

A

<18.5 - underweight, 18.5-24.9 - normal, 25-29.9 - overweight, 30-34.9 obese I, 35-39.9 - overweight II, >40 extreme obesity

184
Q

weight loss

A

unexplained is indicative of malnutrition (generally >5% in 6 moths)

185
Q

enteral feeding

A

tube feeding: NG tube or nasointestinal tube

186
Q

structures of urinary tract

A

kidneys, ureters, bladder, urethra (women 1.6in and men 8in)

187
Q

micturition

A

act of voiding; pressure stretches detrusor muscle in bladder at about 150-250mL; urination initiated and causes detrusor muscle to contract and internal muscle sphincter relaxes then perineal and external sphincter relax; micturition center in pons

188
Q

micturition nervous system control

A

PNS innervates from sacrum to promote urination, SNS from thoracic spine inhibits urination

189
Q

frequency f urination

A

3-4 hours

190
Q

factors affecting urination

A

food/fluid intake: EtOH diuretic effect d/t inhibition of ADH, high in Na less urine formed; activity/muscle tone: immobile causes decreased bladder/sphincter tone (poor urinary control and stasis) regular exercise is optimal for urine production and elimination; pathological conditions (UTI, HTN, PKD, diabetes); medications (diuretics, cholinergic meds stim. urination)

191
Q

anuria

A

24 hr urine output less than 50mL

192
Q

dysuria

A

painful or difficult urination

193
Q

frequency

A

increased incidence of voiding

194
Q

glycosuria

A

presence of glucose in urine

195
Q

nocturia

A

awakening at night to urinate

196
Q

oliguria

A

24 hr urine outpu less than 400mL

197
Q

polyuria

A

excessive output of urine

198
Q

proteinuria

A

protein in urine

199
Q

pyuria

A

pus in urine

200
Q

urgency

A

strong desire to void

201
Q

urinary incontinence

A

involuntary loss of urine

202
Q

ketonuria

A

ketones in urine

203
Q

heistancy

A

involuntary delay in initiating uringation

204
Q

hematuria

A

blood in urine

205
Q

obstruction of urine flow

A

calculi, BPH, patency of indwelling catheter (is it blocked)

206
Q

altered urinary output

A

UTI, causes of decreased muscle tone or chronic constipation, incontinence

207
Q

UTI causes

A

CAUTI

208
Q

UTI

A

can affect upper tract (kidneys/ureters-pyelonephritis or lower tract bladder/urethra-cystitis)

209
Q

UTI symptoms

A

pain/burning, frequent urination, hematuria, pressure/cramping

210
Q

stress incontinence

A

involuntary loss of urine caused by increase in intraabdominal pressure and weak perineal/abdominal muscle tone (laugh, cough, sneeze, exercise, heavy lifting)

211
Q

stress incontinence causes, risk factors, treatment

A

caused by urethral external sphincter dysfunction, risk factors are poor muscle tone, treatment are pelvic floor exercises (kegel)

212
Q

urge incontinence

A

loss of urine from time pt feels urge to urinate to time it takes to get to bathroom

213
Q

urge incontinence cause, risk factor, treatment

A

cause: involuntary bladder contractions (bladder spasms) and decreased capacity, risk: UTI, meds, bladder irritants, over distended bladder, treatment- prompted voiding and q2 hours

214
Q

managing incontinence

A

skin care (perineal care, skin barriers), pads, briefs

215
Q

urinary assessment

A

inspection, palpation, percussion

216
Q

urinary assessment palpate

A

bladder location and size; palpate gently and lightly; non-distended bladder is not palpable

217
Q

urinary assessment palpation

A

can indicate if bladder is distended

218
Q

urinary assessment inspection

A

urethral meatus if needed, empty bladder below pubic symphysis, lower abdominal wall swelling?, skin integrity, hydration status, examination of urine, bladder scan for fullness

219
Q

alternative to indwelling urinary catheter

A

pure wick, condom catheter

220
Q

collection bags

A

hanging bag, nelly bag, bag with urimeter, leg bag

221
Q

indwelling catheter care

A

prevent pulling with tape, leg band, anchor but allow leg movement, ensure drainage to prevent hydronephrosis, urine assessment of tubing not bag d/t stasis changes

222
Q

urine collection guidelines

A

avoid contamination with feces or tissue, store in fridge, note meses, minimum of 10mL in urinalysis, minimum of 3mL in culture

223
Q

routine urinalysis

A

first morning void preferred, collect from bed pan, hat, condom cath, refrigerate immediately, tested with reagent sticks

224
Q

clean catch specimen

A

used for culture and sensitivity, can be used for UA, if used for microbial testing send to lab immediately while warm; dont touch inside of cap

225
Q

24 hour urine collection

A

initiate at specific time, discard first void, include last void, do not miss other urine or have to restart; do not use preservative but refrigerate or on ice

226
Q
A

Health Assessment (5 decks)

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