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NUR 333 > exam 3 > Flashcards

exam 3 Flashcards

1
Q

bowel diet

A

well balances, increase fiber

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2
Q

constipation

A

fewer than 3/week, hard or dry stools. caused by irregular bowel habits, lack of fiver, stress, meds, immobility, age

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3
Q

diarrhea

A

loose stool, caused by illness, allergies, enteral feedings, causes dehydration

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4
Q

enemas

A

stop if abdomen is rigid, slow if cramping, can cause tissue trauma and bowel perf

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5
Q

flatulence

A

distension, cramping, bloating, can cause obstruction. risk: constipation, food, stress, disease

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6
Q

impaction

A

unrelieved constipation that has caused an obstruction, can be caused by disability, confused, or unconscious, requires digital exam

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7
Q

incontinence

A

inability to control bm/flatulence

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8
Q

laxitives

A

bulk forming, emollient/wetting, osmotic, stimilant, cathartics

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9
Q

gi nursing interventions

A

NG tubes/decompression, keep things out of stomach

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10
Q

NG assessment

A

abdominal pain, respiratory, tube, suction

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11
Q

older adult GI consideration

A

trouble chewing, esophageal emptying slows, impaired absorption, weakened sphincters, decrease in: hcl, vitamin absorption, peristalsis, feeling to poop, lipase to aid in fat digestionol

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12
Q

older adult constipation

A

lack of muscle tone, slowed peristalsis, immobility, excess dairy, lack of fiber, meds

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13
Q

constipation complication

A

hemorrhoids, anal fissure, fecal impaction, rectal prolapse

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14
Q

constipation prevention

A

high fiber, fluid, activity, stress, try to go, make a schedule

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15
Q

bulk forming laxitive

A

methyl cellulose (citrucel)
psyllium (metamucil)
polycarbophil (fibercan)

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16
Q

emollient/wetting laxative

A

docusate sodium

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17
Q

osmotic laxitive

A

saline based, mag citrate, milk of mag, sodium phosphate, polyetheline glycol, lactulose

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18
Q

stimulant cathartics

A

dulcolax, senna

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19
Q

impaction symptoms

A

inability to pass despite urge, oozing, loss of appetite, n/v. distension, cramping, rectal pain

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20
Q

antidiarrheal

A

decreases intestinal muscle tone, body reabsorbs more water

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21
Q

nursing care for diarrhea

A

fix the cause, provide soft texture food, maintain fluid, hand hygiene, skin integrity

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22
Q

cdiff

A

caused by antibiotics sometimes, found in elderly/immunocompromised/long term care, gi procedure

can cause dehydration, kidney failure, toxic megacolon, perf, death

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23
Q

nursing care of flatulence

A

avoid trigger foods, eat smaller meals, eat and drink slowly

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24
Q

hemorrhoids

A

dilated or engorged vessels in rectum, sitz bath

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25
colon cancer
risk: african american, red meat intake, low fiber, obesity, 50+, inactive, alcohol, tobacco, fam hx, IBD
26
GI nursing assessment
elimination pattern, stool description, method of going, diet and fluid, hx gi isues, emotions, mobility
27
fecal characteristic assessments
amount, color, odor, consistency, frequency, shape, constituents
28
fecal occult blood test
hidden blood in poop can detect cancer
29
micturition
complex process involving bladder, urinary sphincter, CNS
30
factors influencing urinary elimination
growth, sociocultural, psych, habits, fluid intake, pathology, surgery, procedures
31
urinary changes in older adults (decrease)
amount of nephrons bladder tone bladder capacity time from initial desire to urgent need
32
urinary changes in older adults (increase)
bladder irritability bladder contractions risk of incontinence
33
urinary retention
inability to partially or completely empty bladder, diagnosed with PVR
34
UTI risk
catheter, retention, incontinence, poor hygeine, females, frequent intercourse, uncircumcised
35
CAUTI
catheter, hospital gets no reimbursement preventable, need early recognition and treatment
36
urinary assessment
frequency, when, amount, recent changes
37
incontinence
involuntary urgency, stress, residual
38
risk for incontinence
women, elderly, obesity, hesitancy, polyuria, nocturia, dribbling, hematuria
39
CVA tenderness
costovertebral angle, between kidneys
40
how much should be voided per hour
>30mL
41
abnormal urine color indicates
bacteria, food, blood, med
42
abnormal urine odor
infection
43
abnormal urine PH
alkaline=loss of acid acidodic=urine that sits, during sleep
44
abnormal urine protein
kidney function
45
abnormal urine glucose
diabetes
46
ketones in urine
DM, starvation, excess aspirin
47
specific gravity
high=concentrated low=overhydration
48
RBC in urine
trauma, glomeruli, damage, catheter
49
WBC in urine
inflammation or infection
50
casts in urine
renal disease
51
crystals in urine
renal caliculi
52
Urinary abdominal xray
size, shape, symmetry, measure caliculi
53
urinary health promotion
self care, routine, nutrition, strengthen pelvic floor, prostate health
54
adequate fluid intake
over 2300 ml/day
55
nursing care for urinary retention
output, distension, assist to correct position, run water, cold compress, encourage double voiding self cath
56
incontinence treatment
meds, stimulators, botox, surgery
57
suprapubic catheter
in bladder, through abdominal wall
58
nursing catheter care
peri care, secure catheter, empty when half full, no kinks, keep of floor, monitor output, remove asap
59
after cath removal
pt must void 6-8 hours. first time will be uncomfortable
60
basic neuro assessment
general survey, LOC, orientation
61
who needs a focused neuro assessment
neuro disease neurological change abnormal in basic finding trauma drug induced state neurological complaints
62
4 H's
hypoxia hypoglycemia hypotension hypoventilation
63
focused neuro
subjective data, mental status, gait, reflexes, sensation, coordination, proprioception, GCS, pupils, visual fields, muscle strength, speech, swallowing, gag
64
lethargic, somnolent
not fully alert, drifts to sleep, drowsy, awakens to name, responds appropriately just slow
65
obtunded
sleeps most of the time, difficult to arouse, confused, mumbled speech, constant stimulation
66
stupor or semi comatose
spontaneously unconscious, only responsive to shake or pain
67
comatose
no response to stimuli, may have reflexes
68
proprioception
body ability to sense movement action and location
69
coordination
rapid alternating movement
70
skin care and mobility
monitor and assess skin, turn q2, redistribute pressure mobility-out of bed , range of motion, pt/ot
71
xray for neuro diagnostic
bones in skill, spine
72
ct scan neuro
3d images of organs, bones, tissues detects hemorrhage, bone, vascular abnormalities
73
nursing care for ct
informed consent allergies to iodine, some may be NPO, claustrophobic
74
contrast
po. rectal, iv, distinguishes body areas, iodine based, monitor for allergic reaction
75
MRI neuro
more detailed than CT no radiation, expensive, can have no metal
76
EEG
monitors brain electrical activity, confirms brain death
77
presbyopia
unable to focus on objects
78
xerostomia
thicker mucus dry mouth
79
expressive aphasia
inability to name objects or express words
80
receptive aphasia
cannot understand written or spoken language
81
caring for pt with tactile defecits
touch therapy, turn and reposition hyperethesia, make adaptations
82
sensory deprivation
caused by isolation, loss of senses, confinement, emotional disorders, brain injury
83
nursing care for sensory deprivation
interaction, tactile stimuli, reorient, encourage visitors, environment changes, assistive devices
84
sensory overload
excessive stimuli, caused by pain, lack of sleep, icu, visitors
85
symptoms of sensory overload
fatigue, sleepy, disoriented, restless
86
care for sensory overload
orient, control stimuli, uninterrupted periods, schedule, visitor control
87
migraine
unilateral throbbing pain
88
care of migraine
rule out disease triptan high flow o2 for cluster
89
two layers of skin
epidermis and dermis
90
pallor
loss of color, grey or ghost white
91
cyanosis
blue. can turn yellow or grey
92
jaundice
yellow discoloration, liver disfunction
93
erythema
redness! warmth and temp changes
94
risk factors for impaired skin integrity
impaired perceptions, impaired mobility, altered LOC
95
shear
sliding movement of skin and subq tissue
96
friction
two surfaces moving across one another
97
moisture
determine risk by duration and amount
98
pressure injuries factors
pressure intensity, pressure duration, tissue tolerance
99
deep tissue injury
persistent non-blancheable deep red, maroon, purple
100
blancheable
turns lighter when pressed
101
non-blancheable
no color change
102
moisture associated skin damage
incontinence, inflammatory dermatitis, periwound associated with exudate
103
factors affecting would healing
nutrition, tissue perfusion, infection, age
104
nutrition wound healing
need adequate intake, albumin, prealbumin
105
tissue perfusion wound healing
ability to perfuse to promote healing, diabetes
106
infection would healing
prolonged inflammation, drainage, low wbc can impact
107
nursing interventions for wound prevention
nutrition, incontinence management, turn every 2 hours, protect integrity!!
108
components of wound management
assessment, cleansing, protection
109
wound assessment
appearance, size, closed wounds, drains, pain, odor
110
wound drainage
normal or abnormal, document drainage, note integrity of surrounding skin, observe for breakdown
111
serous exudate
watery serum
112
sanguineous exudate
serum and red blood cells, reddish
113
serosanguinous exudate
contains serum and blood, watery, pale pink
114
purulent exudate
thick, wbc, debris, bacteria
115
hemhorrage
24-48 hours after surgery, clot could dislodged. monitor vitals, hold pressure, let provider know
116
dehiscence
partial or total seaparation of a sutured wound
117
evisceration
protrusion of organs through would opening
118
evisceration manifestation
increase of fluid, sudden straining, popping sensationn
119
nursing management of dehiscence of evisceration
notify provider immediately stay with patient cover any protruding organs with sterile gauze soaked in saline supine with hips and lneed bent, stay NPO
120
surgical wound infection

NUR 333 (3 decks)

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