Exam 5 Flashcards
What causes skin alterations?
- Thin skin
- Obesity
- Disease of the skin (eczema)
- Jaundice
What are the types of wounds?
- Intentional or unintentional
- Open or closed
- Acute or chronic
With chronic wounds, there is an increased risk for _____.
Infection.
What is an example of a clean wound?
Mole removal
What is an example of a clean contaminated wound?
Appendectomy
What is an example of a contaminated wound?
Fell off a bike and scraped knee.
What is a dirty wound?
Traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination.
_____ ____ is the first line of defense against microorganisms.
Intact skin
What are the four principles of wound healing?
- Intact skin is the first line of defense against microorganisms.
- Hand hygiene!!
- Adequate blood supply
- State of health
What are the phases of wound healing?
Hemostasis, inflammation, proliferation, and maturation (remodeling).
When does hemostasis occur?
Immediately after injury.
Hemostasis increases perfusion causing ____ and ____.
Pain and swelling
What happens during the hemostasis phase of wound healing?
Blood clotting > same blood vessels dilate and capillary permeability increases > plasma and blood components leak out > exudate > swelling and pain.
How long does inflammation last?
2-3 days
What happens during the inflammation phase of wound healing?
Leukocytes and macrophages move to the wound.
How long does proliferation last?
Several weeks
What happens during the proliferation phase of wound healing?
Fibroblasts build new tissue, capillaries bring O2 and nutrients, and granulation tissue forms.
When does maturation (remodeling) start and how long does it last?
Begins 3 weeks after injury and can last month or years.
What happens during the maturation (remodeling) phase of wound healing?
Collagen is remodeled and forms a scar. (Scar tissue is never fully restored)
What is desiccation?
When a wound dries up.
What is maceration?
Wet skin
What kinds of nutrition do you need for wounds to heal?
Protein, carbs, fats, and vitamins.
Vitamins ___ and ___ are important for epithelialization and collagen synthesis.
A and C!!!
What phase in wound healing does zinc help?
Proliferation phase.
What are local factors that affect wound healing?
- Pressure
- Desiccation (dry skin)
- Maceration (wet skin)
- Repeated trauma,
- Edema (stops blood supply to wound)
- Infection
- Excessive bleeding (place for bacteria to grow)
- Necrosis
- Biofilm (this is bad!!).
What are systemic factors that affect wound healing?
- Age
- Circulation and oxygenation
- Nutritional status (protein, carbs, fats, vitamins needed)
- Wound etiology
- Medication (steroids bad for wound healing)
- Immunosuppression
A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate?
A. “Coffee and diet sodas are not factors with being incontinent of urine.”
B. “Performing Kegel exercises can help muscle strengthening.”
C. “You need to decrease your daily fluid intake to help with this.”
D. “It is best to have a Foley catheter inserted to prevent incontinence.”
B. “Performing Kegel exercises can help muscle strengthening.”
Cutting or sharp instrument; wound edges in close approximation and aligned.
Incision
Injury & poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction.
Venous Ulcers
A patient complains of itchy skin. What term would the nurse use to describe this?
A. excoriation
B. pruritus
C. erythema
D. petechiae
B. pruritus
Ultraviolet light or radiation exposure
Irradiation
Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma.
Contusion
Toxic agents such as drugs, acids, alcohols, metals, & substances released from cellular necrosis
Chemical
Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded.
Abrasion
Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure
Diabetic Ulcers
Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures
Avulsion
Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis
Arterial Ulcers
Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental
Puncture
High or low temperatures; cellular necrosis as a possible result
Thermal
Compromised circulation secondary to pressure or pressure combined with friction
Pressure Ulcers
Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering through tissues.
Penetrating
Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
Laceration
19-23 score on the braden scale is ____ risk.
No
What is low risk score on the braden scale?
15-18
13-14 score on the braden scale is what kind of risk?
Moderate
What is a high risk score on the braden scale?
10-12
Anything less than or equal to 9 is considered what kind of risk on the braden scale?
Very high risk
Intact skin with a localized area of nonblanchable erythema is a stage ____ pressure injury.
1
What is a stage 2 pressure injury?
- Partial-thickness loss of skin with exposed dermis.
- The wound bed is viable, pink, moist, and may also present as an intact or ruptured serum-filled blister.
- Adipose (fat) and deeper tissue are not visible.
- Granulation tissue, slough, and eschar are not present.
What stage of pressure injury is this explaining?
- Full-thickness loss of skin, adipose (fat) is visible in the ulcer, granulation tissue, and epibole (rolled wound edges) are often present.
- Slough and/or eschar may be visible.
- Undermining and tunneling may occur.
- Muscle, tendon, ligament, cartilage, and/or bone are not exposed.
Stage 3 pressure injury
What stage of pressure injury is this explaining?
- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
- Slough and/or eschar may be present.
- Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies.
Stage 4 pressure injury
What is an unstageable pressure injury?
- Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because of slough or eschar.
- If slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed.
Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This is what kind of pressure injury?
Deep tissue pressure injury
____ ____ On admission assess the skin, then reassess every shift and with any change in condition.
Acute setting
____ _____ _____ _____ On admission assess the skin, then reassess weekly for 4 weeks, then quarterly and whenever the resident’s condition changes.
Long-term care setting
Clear, serous portion of the blood. Clear and watery. What is this kind of drainage?
Serous
What is sanguineous drainage?
Large numbers of RBCs and looks like blood.
Bright red = fresh bleeding
Dark red = older bleeding
What kind of drainage is this explaining?
A mixture of serum and RBCs. Light pink to blood-tinged.
Serosanguineous
What kind of drainage is this explaining?
Made up of WBCs, liquefied dead tissue debris, and both dead and live bacteria. Thick, often has a musty or foul odor.
Purulent
Red wounds ae in the _____ stage of healing and reflect the color of normal ____ tissue.
Proliferation; granulation
What do red wounds mean in the RYB wound classification?
Protect
What are nursing interventions for protect in RYB wound classification?
Gentle cleansing, use of moist dressing, and changing of the dressing only when necessary.
What do yellow wounds mean in the RYB wound classification?
Cleanse
What does yellow or cleanse indicate in the RYB classification?
The presence of exudate or slough and requires wound cleaning.
What are nursing interventions for cleanse in RYB wound classification?
Use wound cleansers and irrigate the wound.
What does the B stand for in RYB wound classification?
Black or debride
What does black indicate in the RYB classification?
Presence of an eschar, which is usually black but may be brown, gray, or tan.
_____ means growing in the presence of oxygen.
Aerobic
_____ means growing in absence of oxygen.
Anaerobic
When collecting a wound specimen culture where should you collect the specimen?
Clean area of granulation tissue from the sides or base of the wound.
Always assess ____ before dressing change.
Pain
What dressing is typically used for stage 1 and 2 pressure injuries?
Mepilex
What dressing is typically used for stage 2 and 3 pressure injuries?
Hydrocolloid
When irrigating a wound what should the PSI be?
4 -15 PSI
Transparent films are used for?
- Small wounds with partial thickness.
- Stage 1 pressure injuries.
- Wounds with minimal drainage.
- To secure NC, IV, drains, etc.
Hydrocolloid dressings used for?
- Partial and full-thickness wounds.
- Stage 2 and 3 pressure injuries.
- Prevention at high-risk friction areas.
- Light to moderate drainage
- Wounds with necrosis or slough
- First and second-degree burns.
- Not for use with infected wounds!!
Hydrogels dressing are used for?
- Partial and full-thickness wounds.
- Stage 2-4 pressure injuries.
- Necrotic wounds.
- First and second-degree burns.
- Dry wounds.
- Minimal exudate
- Infected wounds
- Radiation tissue damage.
Foam dressings are used for?
- Partial and full-thickness wounds.
- Stages 2-4 pressure injuries.
- Surgical wounds
- Absorb light to heavy amounts of drainage
Antimicrobial dressings are used for?
- Partial and full-thickness wounds.
- Stages 2-4 pressure injuries.
- Burns
- Draining, exuding, and nonhealing wounds of any kind.
- Acute and chronic
Negative pressure wound therapy is used for?
- Partial and full-thickness wounds.
- Stage 3 and 4 pressure injuries.
- Draining, exuding, and nonhealing wounds of any kind.
_____ _____ is fluid within the cells.
Intracellular fluid (ICF)
____ _____ is all the fluid outside the cells.
Extracellular fluid (ECF)
Which patient is more at risk for fluid balance problems?
A. 25-year-old construction worker.
B. 60-year-old female visiting her daughter.
C. 6-year-old playing video games.
D. 46-year-old male swimming.
A. 25-year-old construction worker.
Which statement from the nursing student would the nurse be concerned about when talking about osmosis?
A. “Water moves from a higher concentration to a lower concentration.”
B. “Osmosis is passive and does not use energy.”
C. “Water cannot move through a semipermeable membrane without a channel.”
C. “Water cannot move through a semipermeable membrane without a channel.”
Hydrostatic pressure _____ fluid ___. Colloid osmotic pressure ____ fluid ____
Pushing fluid out; Pulling fluid in
Mrs. Smith has a history of chronic kidney disease and hypertension. During the assessment, the nurse noted hypotension and 4+ pitting edema in Mrs. Smith’s lower extremities. The nurse knows that this is most likely related to ____?
A. The damaged kidney’s ability to sense the antidiuretic hormone.
B. The patient intaking too much sodium in their diet.
C. The patient’s vascular system shutting down.
A. The damaged kidney’s ability to sense the antidiuretic hormone.
What is a loading dose for?
Therapeutic levels
A continuous rate of an infusion is called the ___ ___.
Basal rate
Cutaneous is like a ____ ____.
Paper cut
Somatic pain refers to ……
Muscles
Visceral pain is pain felt in the ____ ____.
Internal organs
What are the 5 medication rights?
- Right pt
- Right time
- Right route
- Right medication
- Right dose
What are peak and trough levels?
The peak is the highest level of medication in the body and gets drawn 1.5 hours after administering the medication.
The trough levels indicate the lowest concentration and is drawn 30 minutes before the next dose.
What does FICA stand for?
Faith, Importance, Community, and actions to address.
What does HOUDINI stand for?
Hematuria
Obstruction
Urologic surgery or consult
Decubitus ulcer
I/O monitoring
Nursing care
Immobility
A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply.
A. Diminished ability of kidneys to concentrate urine may result in nocturia.
B. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine.
C. Decreased bladder contractility may lead to urine retention and stasis.
D. Neuromuscular problems may interfere with voluntary control of urination.
E. Increased bladder mobility decreased the incidence of UTIs.
F. Altered thought process may cause urinary frequency.
A. Diminished ability of kidneys to concentrate urine may result in nocturia.
B. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine.
C. Decreased bladder contractility may lead to urine retention and stasis.
D. Neuromuscular problems may interfere with voluntary control of urination.
F. Altered thought process may cause urinary frequency.
What is Psyllium (Metamucil)?
A bulk-forming laxative
What is Loperamide (Imodium A-D)?
Antidiarrheals
The _____ _____ _____ is what stimulates the bladder.
Autonomic nervous system
____ ____ is when your bladder is no longer controlled by the brain because of injury or disease.
Autonomic bladder
____ ____ are what tell your body there is enough urine in the bladder.
Stretch receptors
A decrease in urinary muscle tone means an increase in
Frequency of urination
Decreased contractility means increased….
Risk of infection
Patients with ____ stress void in ___ amounts.
High; smaller
What are diseases associated with renal problems?
Polycystic kidney disease, UTI, kidney stones, HTN, and diabetes.
What is renal failure?
Where the kidneys fail to remove metabolic end products.
____ ____ ___ is a sudden decline in kidney function.
Acute kidney injury (AKI)
What can cause an acute kidney injury?
Severe dehydration, anaphylactic shock, sepsis, and urethral obstruction.
_____ ____ ___ is a slow loss of function over months or years as result of irreparable damage to the kidneys.
Chronic kidney disease (CKD)
What can cause chronic kidney disease?
Diabetes, HTN, and glomerulonephritis
Progression of chronic kidney disease (CKD) will lead to _____ ____ or ___ ____ ____ _____.
Renal failure or end-stage renal disease.
In kidney failure, kidney function drops below ___% and kidneys are unable to adequately excrete _____ waste and regulate ____ & _____ balance.
15%; metabolic; fluid and electrolyte.
What do anticoagulants do to your urine?
Hematuria (blood in urine). The color will be pink or red.
What color do diuretics turn urine?
Pale yellow
What color does phenazopyridine (urinary tract analgesic) turn urine?
Orange or orange-red
What color do amitriptyline (antidepressant) and B-complex vitamins turn urine?
Green or blue
Levodopa (antiparkinson drug) and injectable iron compounds turn urine what color?
Brown or black
The bladder cannot be ____ or ___ when empty.
Percussed or palpated
Voiding habits include….
- Schedule
- Privacy
- Hygiene
- Urge to void
- Position
What is transient incontinence?
Comes quickly and generally temporary
What is stress incontinence?
Often related to weak pelvic floor muscle. Common in women who have given birth; sneezing, coughing, and position changes.
____ ____ is a combination of stress incontinence and urgency.
Mixed incontinence.
____ ____ is involuntary loss of urine associated with over distention and overflow of the bladder.
Overflow incontinence
What is functional incontinence?
Urine loss caused by the inability to reach the toilet in time.
____ ____ is emptying of the bladder without sensation due to damaged nerves.
Reflux incontinence
What are some treatments for urinary incontinence?
- Pelvic floor muscle exercises.
- Weight loss for obese pt having issues.
- Pharmacologic treatment
- Mechanical treatment (not used often)
What are the effects of aging in urination?
- The diminished ability of the kidneys to concentrate urine may result in nocturia.
- Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination.
- Decreased bladder contractility may lead to urine retention and stasis, which increases the risk of UTI.
- Neuromuscular problems, degenerative joint problems, alterations in thought process, and weakness may interfere with voluntary control and the ability to reach a toilet in time.
____ ____ involves the surgical creation of an alternate route for excretion of urine.
Urinary diversion
_____ _____ is the amount of urine remaining in the bladder immediately after voiding.
Postvoid residual
A new graduate nurse and their preceptor must collect several urine specimens for laboratory testing. Which techniques for urine collection by the graduate nurse are performed incorrectly, requiring the preceptor to intervene? Select all that apply.
A. Catheterizing a patient to collect a sterile urine sample for routine urinalysis
B. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up
C. Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter
D. Collecting about 3 mL of urine from a patient’s indwelling catheter to send for a urine culture
E. Planning to collect a sterile specimen from a patient with a urinary diversion by catheterizing the stoma
F. Discarding the first urine of the day when performing a 24-hour urine specimen collection on a patient
A. Catheterizing a patient to collect a sterile urine sample for routine urinalysis
B. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up
C. Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter
A nurse caring for older adults in an extended-care facility performs regular assessments of the patients’ urinary functioning. Which patients would the nurse identify as at risk for urinary retention? Select all that apply.
A. Patient who is diagnosed with an enlarged prostate
B. Patient who is on bedrest
C. Patient who is diagnosed with vaginal prolapse
D. Older adult patient with dementia
E. Patient who is taking antihistamines to treat allergies
F. Patient who has difficulty walking to the bathroom
A. Patient who is diagnosed with an enlarged prostate
C. Patient who is diagnosed with vaginal prolapse
E. Patient who is taking antihistamines to treat allergies
A nurse in the gynecology clinic is preparing an educational brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply.
A. Wear underwear with a cotton crotch.
B. Take baths rather than showers.
C. Drink of six to eight 8-oz glasses of liquid per day.
D. Urinate before and after intercourse.
E. After defecation, dry the perineal area from the front to the back.
F. Observe the urine for color, amount, odor, and frequency.
A. Wear underwear with a cotton crotch.
C. Drink of six to eight 8-oz glasses of liquid per day.
D. Urinate before and after intercourse.
E. After defecation, dry the perineal area from the front to the back.
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient’s urine output?
A. Decreased amount and highly concentrated
B. Decreased amount and very pale like water
C. Increased amount and very concentrated
D. Increased amount and dilute appearing
A. Decreased amount and highly concentrated
The healthcare provider has ordered an indwelling catheter to be inserted to relieve urinary retention in a male patient with prostate enlargement. What consideration will the nurse keep in mind when performing this procedure?
A. The male urethra is more vulnerable to injury during insertion.
B. In the hospital, a clean technique is used for catheter insertion.
C. The catheter is inserted 2 to 3 inches into the meatus.
D. Since it uses a closed system, the risk for UTI is absent.
A. The male urethra is more vulnerable to injury during insertion.
A nurse is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
A. Catheter infection due to long-term use
B. Need to flush the catheter of organisms post procedure
C. Blood clots that could block the catheter
D. Need for increased fluid intake
C. Blood clots that could block the catheter
A nurse is caring for a patient who has a urinary diversion (urostomy) after cystectomy (removal of the bladder) to treat bladder cancer. What interventions are indicated for this patient? Select all that apply.
A. Measuring the patient’s fluid intake and output
B. Keeping the skin around the stoma moist
C. Emptying the appliance frequently
D. Reporting any mucus in the urine to the primary care provider
E. Encouraging the patient to look away when changing the appliance
F. Monitoring the return of intestinal function and peristalsis
A. Measuring the patient’s fluid intake and output
E. Encouraging the patient to look away when changing the appliance
F. Monitoring the return of intestinal function and peristalsis
A nurse is changing the stoma appliance on a patient’s ileal conduit. Which finding requires the nurse to follow up with the provider?
A. Stoma is moist.
B. Skin around the stoma is irritated.
C. Urine is leaking from the stoma.
D. Stoma is a purple-black color.
D. Stoma is a purple-black color.
A postoperative patient is having difficulty voiding and reports suprapubic pressure. What action can the nurse take to promote voiding?
A. Pouring cold water over the patient’s fingers and perineum
B. Assessing bladder residual using the bladder scanner
C. Immediately encouraging the patient to void
D. Recommending an indwelling catheter
B. Assessing bladder residual using the bladder scanner
A nurse caring for a patient who just began hemodialysis assesses the patient’s AV fistula. Nursing documentation includes: “5/10/25 0930 AV fistula in the right forearm negative for thrill and bruit. Patient denies pain and tenderness.” Which finding is essential for the nurse report to the health care provider?
A. Thrill and bruit are absent.
B. Area is without redness or swelling.
C. Patient denies pain and tenderness.
D. Trace edema of the fingers is present.
A. Thrill and bruit are absent.
A nurse is caring for an alert, ambulatory, older adult with urinary frequency who has difficulty making it to the bathroom in time. Which nursing intervention is most appropriate to include in the care plan for this patient?
A. Explaining that incontinence is an expected occurrence with aging
B. Asking the patient’s family/caregivers to purchase incontinence pads for the patient
C. Teaching the patient how to perform PFMT exercises at regular intervals
D. Inserting an indwelling catheter to prevent skin breakdown
C. Teaching the patient how to perform PFMT exercises at regular intervals
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic) for a UTI. The patient states, “My urine was bright orange-red today; I think I’m bleeding. Something is terribly wrong.” How will the nurse best respond?
A. “The medication causes a red-orange tinge to the urine; it is expected.”
B. “I will test your urine for blood.”
C. “This may be the result of an injury to your bladder.”
D. “I’ll hold the medication and let the provider know you are allergic to the drug.”
A. “The medication causes a red-orange tinge to the urine; it is expected.”
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient? Select all that apply.
A. Preventing the tubing from kinking to maintain free urinary drainage
B. Changing the sheath weekly and provide hygiene
C. Fastening the sheath tightly to prevent the possibility of leakage
D. Having the patient maintain bedrest to prevent the sheath from slipping off
E. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
F. Ensuring the device does not restrict blood flow.
A. Preventing the tubing from kinking to maintain free urinary drainage
E. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
F. Ensuring the device does not restrict blood flow.
A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
A. Planning to use different equipment for catheterization of male versus female patients
B. Selecting the smallest appropriate size indwelling urinary catheter
C. Sterilizing the equipment prior to insertion
D. Avoiding filling the balloon with sterile water to prevent pressure on tissues
B. Selecting the smallest appropriate size indwelling urinary catheter
A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient? Select all that apply.
A. Wash your hands with soap and water.
B. Open the container and place the lid face down on the counter.
C. Separate your labia and wipe with the antiseptic towelettes in the kit.
D. Without letting go of the labia, void a small amount into the toilet or collection hat.
E. Lean the collection container against the urinary opening and void into the container.
F. Void an ounce, then remove the container and finish voiding in the toilet.
A. Wash your hands with soap and water.
C. Separate your labia and wipe with the antiseptic towelettes in the kit.
D. Without letting go of the labia, void a small amount into the toilet or collection hat.
E. Lean the collection container against the urinary opening and void into the container.
A nurse on a pediatric surgical unit notes a 10-year-old child has developed nocturnal enuresis. What health concern will the nurse plan for?
A. Constipation
B. Bedwetting after the age of toilet training
C. Patient who is manipulative
D. Infection
B. Bedwetting after the age of toilet training
A nursing student hears in report that their patient is receiving a nephrotoxic medication. The student plans care to include what action?
A. Teaching the patient to expect increased voiding
B. Assessing for kidney damage
C. Preventing urinary incontinence
D. Observing for nocturia
B. Assessing for kidney damage
What is Cholecystitis?
Inflammation of the gallbladder
What is the main cause of Cholecystitis?
Gall stones!
Clinical manifestations of ACUTE Cholecystitis include
Right upper quadrant or epigastric pain (may radiate to right shoulder), mild fever, anorexia, n/v
Clinical Manifestations of CHRONIC Cholecystitis
Intolerance to fatty foods, belching, and colicky pain
What is Cholelithiasis?
Gall stones
Who is at risk for Cholelithiasis?
Obese women over 40 who have had multiple pregnancies
Clinical manifestations of Cholelithiasis
Many times asymptomatic, indigestion, RUG or epigastric pain (may radiate to upper back, right shoulder, or mid-scapular region)
The nurse is assessing a client who reports being constipated. Which assessment data confirm the client report? Select all that apply.
A. The client reports frequent abdominal cramping
B. The client has a distended, hard abdomen.
C. The client reports bowel urgency.
D. The client reports fullness in the rectum.
E. The client reports having a formed stool every other day.
B. The client has a distended, hard abdomen.
D. The client reports fullness in the rectum.
What are the factors affecting bowel elimination?
Daily patterns, lifestyle, medications, fluids and foods, psychological variables, activity and muscle tone, and pathologic conditions.
What are the warning signs of colorectal cancer?
- Rectal bleeding
- Blood in the stool
- Persistent change in bowel patterns
- Persistent cramping or pain in the lower abdomen
- A feeling that the bowel doesn’t empty completely
- Weakness or fatigue
- Losing weight without trying
How do you get a stool collection?
- Void first
- Use a clean or sterile bedpan
- No toilet paper in bedpan
- Avoid contact with soaps, detergents, and disinfectants as these may affect test results
- Use 2 tongue depressors to get 1 inch or 30 mL of stool
- Place in a collection device, label, and send to lab
Cutting or sharp instrument; wound edges well approximated and aligned; surrounding tissue undamaged; bleeds freely and less likely to become infected
Incision
Blunt instrument; overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma
Contusion
Friction; rubbing or scraping epidermal layers of skin; top layer of skin scraped away
Abrasion
Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue; contaminated and likely to become infected
Laceration
Blunt or sharp instrument puncturing the skin; intentional or accidental
Puncture
Foreign body entering the skin or mucous membrane and lodging in underlying tissue; fragments possible scattering throughout tissues
Penetrating
Tearing a structure from normal anatomic position; possible damaged blood vessels, nerves, and other structures
Avulsion
Respiratory Acidosis
• pH below 7.35
• decreased RR and increased levels of CO2
• low and slow respirations
Who is at risk for Respiratory Acidosis?
• post op patients, patients on opioids
• those with COPD and asthma
• alcoholics
• those with head trauma
• patients who are taking benzodiazepines
What can cause Respiratory Acidosis?
• stoke
• med. overdose
• airway obstructions
• pulmonary edema
Respiratory Alkalosis
• pH greater than 7.45
• increased RR
• decreased CO2
• fast respirations
What can cause Respiratory Alkalosis?
Hyperventilating!!
Panic attack
Nursing Intervention for Respiratory Alkalosis:
• calm down the patient, breathe in a bag
Metabolic Acidosis
• increased H and decreased HCO3
What can cause Metabolic Acidosis?
• renal failure
• diarrhea
• DKA
Metabolic Alkalosis
• decreased H and increased HCO3
What can cause Metabolic Alkalosis?
• vomiting
• NG suction
Signs and Symptoms of Metabolic Acidosis
- decreased HR
- decreased BP
- decreased RR
Signs and symptoms of Metabolic Alkalosis
- tachycardia
- increased BP and pulse
- increased RR
Hypocalcemia symptoms:
- muscle spasms
- seizures
- numbness
- increased muscle reflexes
Hypercalcemia symptoms
- slow muscle reflexes
- nausea & vomiting
- slurred speech and confusion
Causes of hypocalcemia
- low vitamin D
- Crohns Disease
- celiac disease
- immobility
- kidney disease
Causes of hypercalcemia
- hyperthyroidism
- too much vitamin D
Symptoms of hypomagnesemia
- increased reflexes
- decreased bowel motility
- increased HR & BP
- cardiac changes
- altered LOC
Symptoms of hypermagnesemia
- muscle weakness
- decreased HR and BP
- n/v
- decreased reflexes
Causes of hypomagnesemia
- malnutrition
- DKA
- alcoholism
- diarrhea and vomiting
Causes of hypermagnesemia
- Laxatives & antacids
Symptoms of hypokalemia
- weak contractions
- dysrhythmias
- fatigue
- decreased muscle reflexes
Symptoms of hyperkalemia
- muscle spasms
- decreased urine output
- decreased HR and BP
Causes of hypokalemia
- fluid loss
- vomiting
- diarrhea
- alkalosis
Causes of hyperkalemia
- NSAIDS
- Ace Inhibitors
- Potassium sparing diuretics
- Renal Failure
Symptoms of hyponatremia
- muscle spasms
- confusion!
- seizures!
- edema
- decreases UOP
- decreased BP and increased HR
Causes of hyponatremia
- diarrhea, vomiting, and NG suction!!
Symptoms of hypernatremia
- restlessness, agitation
- thirst
- dehydration
- fever
- increased fluid retention, edema
Causes of hypernatremia
- infection
- decreased excretion
- diarrhea
