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N112 > FINNY 2 > Flashcards

FINNY 2 Flashcards

1
Q

What is Micturition

A

The process of voiding

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2
Q

What is the Micturition reflex process

A

Detrusor muscle contracts
Internal sphincter relaxes
Urine enters the posterior urethra
Perineum muscle and external sphincter relax
Abdominal walls constrict slightly
Diaphragm lowers
Urination occurs

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3
Q

Voluntary control of Micturition is limited to what

A

Initiating,
Restraining,
Interrupting action of urinating

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4
Q

When/ how do adults feel desire to void

A

Bladder fills to about 150mL-250mL
Stretch receptors in the bladder are stimulated
Adult feels desire to void

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5
Q

Autonomic bladder

A

peoples whose bladders are no longer controlled by the brain because of injury or disease void by reflex only

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6
Q

Factors effecting urination

A
  • Developmental considerations: toilet training, effects of aging
  • Food and fluid intake
  • Psychological variables
  • Activity and muscle tone
  • Pathological conditions
  • Medications
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7
Q

Transient incontinence

A

appears suddenly and lasts for 6 months or less

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8
Q

Stress incontinence

A

occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure.

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9
Q

Urge incontinence

A

the involuntary loss of urine that occurs soon after feeling an urgent need to void

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10
Q

Total incontinence

A

is the continuous and unpredictable loss of urine resulting from surgery, trauma, of physical malformation

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11
Q

Reflex incontinence

A

emptying bladder without feeling the sensation of need to void

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12
Q

Mixed incontinence

A

indicates that there is urine loss with features of 2 or more types of incontinence

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13
Q

Overflow

A

or chronic retention of urine; involuntary loss of urine associated with over dissension and overflow of the bladder

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14
Q

Functional

A

urine loss caused by inability to reach the toilet because of the environmental barriers, physical limitations, loss of memory, or disorientation

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15
Q

Incontinence associated dermatitis (IAD):

A

prolong contact of the skin with urine or feces leads to a form of moisture-associated skin damage

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16
Q

S/S of IAD

A

Erythema
Maceration
Denuding
Inflammation

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17
Q

Hot spots of IAD

A

Perineum
Perineal area
Buttocks
Inner thighs
Sacrum
Coccyx

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18
Q

Psychological effects

A

Anxiety
Caregiver role strain
Risk for infection

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19
Q

S/S UTI

A
  • Burning or pain in the lower abdomen
  • Fever; urine odor
  • Bloody urine may be a sign of infection, but is also caused by other problems
  • Burning during urination or an increase in the frequency of urination after the catheter is removed
  • Changing in LOC in elderly
  • Characteristics of urine; i.e. cloudy
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20
Q

effects of aging on urinary elimination

A

Diminished Kidney function

Nocturia:

Decreased bladder muscle tone= resulting in increased frequency of urination

Decreased bladder contractility- leading to urine retention and stasis - increasing likelihood of UTI

Neuromuscular problems, degenerative joint problems, alterations in that process and weakness

Urgency/ incontinence

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21
Q

Anticoagulants turn the color of urine what color

A

Red

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22
Q

Diuretics turn the color of urine what color

A

Pale yellow

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23
Q

Pyridium turn the color of urine what color

A

Orange

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24
Q

Elavil turn the color of urine what color

A

Green or blue

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25
Q

Levodopa turn the color of urine what color

A

Brown or black

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26
Q

Cholinergic medications do what to urination

A

stimulate contraction of detrusor muscle, producing urination

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27
Q

Analgesics and tranquilizers do what to urination

A

suppress CNS, diminish effectiveness of neural reflex

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28
Q

What is PVR

A

Post void residual
the amount of urine remaining in the bladder immediately after voiding

can be measured by the use of a portable ultrasound.

Can also be obtained by catheterizing a patient

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29
Q

A PVR less than _____ indicates adequate bladder emptying

A

50mL

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30
Q

A PVR greater than ____ is an indication that the bladder is not emptying correctly

A

100mL

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31
Q

Criteria for catherization

A
  • urine retention
  • Monitoring output in critically ill
  • Obtaining sterile urine sample, when pt is unable to void
  • Assist in healing open sacral or perineal wounds in incontinent patients
  • Emptying the bladder before, during, and after select surgical procedure/ before certain diagnostic exams
  • Provide improved comfort for end of life care
  • Prolonged pt immobilized (potentially unstable thoracic or lumbar spine, multiple traumatic injuries)
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32
Q

What is stress

A

a condition in which the human system responds to changed in its normal balanced state

-Indicators: backache, chest pain, constipation/diarrhea, decreased sex drive, dry mouth, headache, increased urination, perspiration, VS, & sleep disturbances

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33
Q

Can you identify different stressors

A

anything that is perceived as challenging, threatening, or demanding that triggers a stress reaction
-interpersonal, intrapersonal, extrapersonal

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34
Q

intrapersonal stress

A

talk to self
-Ex. im not as good as others, im gonna fail, illness

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35
Q

Interpersonal stress

A

between individuals
-Ex. worried ill disappoint my spouse

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36
Q

Extrapersonal stress

A

outside stressors
-Ex. pandemic, isolation, online classes

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37
Q

What are the sources of stress for adults?

A

developmental stress (ex. infant not fed, signs of aging in middle age, separation anxiety)

-situational stress (ex. losing job, going through divorce, role change, illness, traumatic injury)

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38
Q

What are the sources of stress for aging ppl?

A

retirement, death of spouse, surgical procedures, diagnosis of chronic illness, isolation, chronic pain, alcohol abuse, loss of independent, declining physical/mental capabilities

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39
Q

Analyze stress response theory (Hans Sylye): General Adaptation Syndrome (GAS)

A

describes bodies general response to stress:

1) Alarm stage: when a person experiences a stressor & defense mechanisms are activated. Fight or flight response, increased energy levels, O2 intake, CO & BP, & mental alertness

2) Stage of Resistance: body attempts to adapt to stressor. VS, hormones, & energy return to normal.

3) Stage of Exhaustion: when body can no longer provide defense. W/o defense against stressor may return to normal or die from exhaustion

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40
Q

what are the effects of long term stress?

A
  • affects physical status
    -increase risk for disease or injury (ex. psoriasis, arthritis, graves disease) & compromised recovery
    -alcoholism, drug abuse, suicide, eating disorder, depression, accidents
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41
Q

What is adaptation?

A

change that takes place as a result of the response to a stressor.

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42
Q

How do humans adapt to stress or stressors

A

problem oriented mechanisms: manipulate person environment relationship that is source of stress (ex. making time schedule for studying, switching jobs bc this one is too hard)

-Emotion focused mechanism: regulation of stressful emotions (ex. blaming someone else for the situation you are in)

-Long term coping mechanism: positive, constructive ways of dealing w/ stress that are effective for long time (ex. talking w/ others about your problems
-Short term coping mechanisms: temporary measures to reduce stress (ex. smoking, drinking, binging)

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43
Q

How to manage stress? Crisis?

A

relaxation, meditation, anticipatory guidance, guided imagery, biofeedback
-crisis intervention (choose alternatives to the problem)
-teaching health ADL’s (exercise, sleep, nutrition, support systems, stress management techniques)

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44
Q

what are stresses in nursing?

A

pt death, care, lawsuits, burnout
-working w/ unsupportive supervisors & personnel
-mistakes

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45
Q

Mechanisms to control stress

A

compensation, displacement, projection, repression, undoing, denial, introjection, regression, sublimation

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46
Q

The physiology of urinary system

A

Kidneys: filter and excrete blood constituents that are not needed and retain those that are. Total body volume passes through kidneys every 30 min.
-Ureters: transports urine from kidney to bladder
-Bladder: temporary reservoir for urine
-Urethra: conveys urine from bladder to the exterior of the body

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47
Q

Effects of incontinence

A

skin breakdown, embarrassment, limits yourself & isolate, lower self esteem

48
Q

Types of incontinence

A

transient: appears suddenly & lasts for 6 months or less (ex. illness, meds, infection)
-stress: involuntary loss of urine R/T increase abdominal pressure (ex. laugh, cough, sneeze)
-Urge: loss of urine from urgent need to void
-Total: cant hold it at all

49
Q

what are some treatment for incontinence?

A

kegals, biofeedback device, electrical simulation, bladder training, surgical interventions

50
Q

wound healing process

A

Homeostasis
Inflammatory phase
Proliferation phase
Maturation phase

51
Q

Hemostasis phases

A
  • Occurs right after initial injury. Blood vessels constrict & clotting begins.
  • After constriction, blood vessels dilate causing plasma & blood components to leak out (exudate). Accumulation of exudate leads to swelling & pain.
  • Small wound→ clot loses fluid and creates a scab
    Platelets stimulate other cells to migrate to the injury & help w/ the healing process
52
Q

Inflammatory Phase

A

-Lasts 2-3 days. WBC’s (mainly leukocytes & macrophages) move to wound

  • 1st Leukocytes arrive & ingest bacteria & cellular debris
  • 2nd Macrophages arrive after 24hrs & ingest debris but also release growth factor→ growth of new epithelial cells & blood vessels
  • Growth factor attracts fibroblasts to help fill in wound

-During this phase the pt has acute inflammation, mild elevated temp., increase in leukocytes, & general malaise

53
Q

Proliferation phase

A
  • Known as the fibroblastic regenerative or connective tissue phase. Lasts several weeks

-Fibroblasts build new tissue to fill in the wound space by synthesizing & secreting collagen & producing specialized growth factors that induce blood vessel formation to bring O2 & nutrients for healing.

-New tissue called granulation tissue forms & forms the foundation of scar tissue development

-Collagen synthesis & accumulation continue but peaks at 5-7 days. Depending on the size of the wound, collagen continues to be deposited for several weeks to years.

-2nd week of injury lighter colored wound because most WBC’s have left. Systematic symptoms disappear.

-Secondary intention wounds follow the same process but take longer to heal & form scar tissue. Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue.

54
Q

Maturation Phase

A

-Final stage of healing begins 3 weeks after injury

-Collagen that was deposited into the wound is remodeled making the healed wound stronger & more like adjacent tissue. New collagen keeps being deposited which compresses the blood vessels leading to a scar.

-Scar tissue cannot sweat, grow hair, tan, and is less elastic. If the scar is over a joint or other body structure it may limit movement & cause disability

55
Q

Local Factors that effect healing

A

Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Biofilm

56
Q

What is desiccation

A

Process of drying up. Cells dehydrate & die in a dry environment causing a crust to form at the wound & delays healing. Wounds that are hydrated & moist (not wet) enhances cell migration

57
Q

What is Maceration

A

softening & breakdown of skin from prolonged exposure to moisture. The damage from moisture changes skin pH, increases bacteria growth & skin infection, & erosion of the skin. Ex. Overhydration from urinary & fecal incontinence leads to maceration & impaired skin integrity.

58
Q

What is Necrosis

A

dead tissue (appears as slough & eschar) delays healing. Healing will not take place with necrotic tissue in the wound so removal must occur for healing to begin.

59
Q

What is biofilm

A

result of wound bacteria growing in clumps, embedded in a thick, self made, protective slimy barrier of sugars & proteins. This barrier contributes to decreased effectiveness of antibiotics & the normal pt immune response. Biofilms impair wound healing & contribute to chronic inflammation & wound infection

60
Q

Systemic factors that effect wound healing

A

Age
Circulation & Oxygenation
Nutritional Status
Wound Etiology (cause)
Medications & Health Status
Immunosuppression
Adherence to Treatment Plan:

61
Q

Pts at risk for pressure injuries

A

Immobility
Nutrition & Hydration
Moisture
Mental Status
Age

62
Q

Stage 1 Pressure Injury:

A

localized area of intact skin w/ nonblanchable erythema (redness). Area may be painful, firm, soft, warmer, or cooler compared to adjacent tissues.

63
Q

Stage 2 Pressure Injury:

A

partial thickness loss of dermis & presents a shallow, open ulcer or ruptured/ intact serum filled blister.

64
Q

Stage 3 Pressure Injury

A

full thickness tissue loss. Subcutaneous fat may be visible & epibole (rolled wound edges) may occur. Bone, tendon, or muscle not exposed. Slough/eschar may be present but do not obscure the depth of tissue loss. Ulcers at this stage may include undermining & tunneling

65
Q

Stage 4 Pressure Injury

A

full thickness tissue loss w/ exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be present on some part of the wound. Epibole, undermining, or tunneling often occur

66
Q

Unstageable

A

unable to visualize extent of tissue damage due to slough or eschar. Slough is yellow, tan, gray, green, or brown dead tissue. Eschar is tan, brown, or black hardened tissue (necrosis). Eschar must be removed before stage (3 or 4) can be determined. However, stable (dry, adherent, intact, w/o erythema) eschar on heels or ischemic limb should not be removed.

67
Q

Deep-tissue injury

A

nonblanchable purple or maroon discoloration of intact or non intact skin, or separation of the epidermis that reveals dark wound bed or blood blister. May be present as painful, firm, mushy, boggy, warmer, or cooler areas as compared to adjacent tissue. This injury usually results from intense/ prolonged pressure & shearing where bone & muscle interface.

68
Q

Wound Assessment:

A

inspection (sight & smell), palpate for appearance, drainage, odor, & pain. Determines status of wound & identifies any barriers to healing & complications

69
Q

What do you assess in a wound

A

Appearance of Wound
Drainage
Sutures & Staples

70
Q

Nursing interventions that prevent pressure injuries

A
  • Assess the skin of pts on a daily basis
  • Cleanse the skin routinely whenever soiling occurs. Use mild cleansing agent, minimal friction & avoid hot water
  • Maintain higher humidity in the environment & use skin moisturizer for dry skin
  • Avoid massage over bony prominences
    Protect skin from moisture w/ episodes of incontinence or exposure to wound drainage
  • Minimize skin injury from friction & shearing forces by using proper positioning, turning, & transferring techniques. Use lubricants, protective films, dressings, & padding to diminish effects of friction
  • Investigate reasons for inadequate dietary intake of protein & calories.

-Continue efforts to improve mobility & activity

-Document measures used to prevent pressure injuries

71
Q

Applying Dry Heat

A
  • Hot water bags: easy & inexpensive but may leak & can be uncomfortable. Danger of burns from improper use.

-Electric Heating Pads: Avoid using pins to secure heating pad (electric shock danger), place moisture proof covering over pad, place heating pad not under the body part (between pt & mattress can cause burns), assess the skin for redness

-Aquathermia Pads: safer than heating pads but must be checked carefully. Common in healthcare setting

-Hot Packs

72
Q

Applying Moist Heat

A

Warm moist Compresses: promote circulation & healing to reduce edema

Sitz Bath: method of applying tepid or warm water to pelvic, perineal, or rectal areas by sitting in a tub.

Warm Soaks: immersion of body area into warm water or medicated solution. Purpose is to increase blood to infected areas, aid in cleaning large wounds (ex. burns), improve circulation, & apply medication to infected area

73
Q

Applying Dry Cold

A

Ice bags: apply ice bag for 30 min then remove for about an hr before applying

Cold packs: advantageous because frozen solution remains pliable & easily molded to fit body part

74
Q

Applying Moist Cold

A

Cold compresses: used for injured eye, headache tooth extraction, & sometimes hemorrhoids.

75
Q

epidermis

A
  • top layer or outermost portion of skin
  • composed of layers of stratified epithelial cells
  • forms a protective, waterproof layer

-made of KERATIN material

-no blood vessels

-depend on underlying tissue for nourishment and waste removal

-the cells regenerate easily and quickly

76
Q

dermis

A
  • second layer of skin
  • made of a framework of elastic connective tissue
  • primarily made of collagen
77
Q

Wound

A
  • Break or disruption in the normal Integrity of skin and tissues
  • From a small cut to a third degree burn covering the body
  • Can be the result of mechanical forces (surgical incision) or physical injury (burn)
78
Q

intentional wound:

A
  • Result of planned invasive therapy or treatment
  • Purposefully created for therapeutic purposes
  • Result from surgery, intravenous therapy, lumbar puncture

-Edges are clean and bleeding is usually controlled

  • made under sterile conditions with sterile supplies

-risk for infection is decreased and healing is facilitated

79
Q

unintentional wound

A
  • accidents, unexpected trauma, “forcible” injuries
  • stabbing, gunshot, burns, falls, etc
  • Result from unsterile environments, contamination is likely
  • wound edges are typically jagged, Multiple traumas are common, leading is uncontrolled
  • High risk for infection and longer healing time
80
Q

Developmental considerations - wounds

A
  • children under 2 - skin thinner and weaker

-infant skin and mucous membranes injure easily

-childrens’ skin becomes increasingly resistant to injury/infection

-STRUCTURE of skin changes with age, maturation, circulatory changes, elasticity changes

81
Q

State of health

A
  • thin and obese patienst more at raisk to skin injury

-fluid loss - fever, vomiting, diarrhea

-perspiration - skin breakdown, especially in folded areas, areas skin on skin

  • jaundice - comes with itchy dry skin - scratching and lesions more possible
82
Q

tunneling

A

Wounds that progress to form passageways underneath the surface of the skin. Walking end of it may be shallow or deep and take twists and turns

83
Q

slough

A

Part of the inflammatory Process consisting of fibrin, white blood cells, bacteria and debris, along with dead tissue and other proteinaceous material

84
Q

Primary intention

A

Closing a wound with staples, sutures glue
Clean cut wound

85
Q

Secondary intention

A

Wounds that cannot be Stitch causing a large amount of tissue loss

86
Q

tertiary intention

A

Delayed wound closures that may need draining and other therapies before closing

87
Q

fistula

A

Abnormal passage from an internal organ or a vessel to the outside of the body or from One internal organ or vessel to another Sometimes created surgically to provide circulatory access for kidney dialysis

88
Q

pressure ulcer

A

Pressure injury, No longer called pressure ulcer

89
Q

Friction

A

Occurs when two surfaces rub against each other
Resembles abrasion

EX: elbows and heels becoming burned through movement

90
Q

shear

A

Results when one layer of tissue slides over another layer.

Small blood vessels and capillaries in the area are stretched and tear

results in decrease circulation to the tissue cells under the skin

EX: When skin sticks to the sheet and the patient is pulled

91
Q

ischemia

A

Deficiency of blood in a particular area

92
Q

eschar

A

Dead tissue appearing as SLOUGH

-a dry black and leathery

-removal of eschar must occur before healing can begin

93
Q

debridement

A

removal of devitalized tissue and foreign material

94
Q

wound dressing

A

a dressing that is sterile pad or Cam press play to a wound to promote sealing and protect the wound from further harm

95
Q

Stage 1 pressure injury

A

Non blanchable erythema of intact skin

96
Q

Stage 2 pressure injury

A

Partial thickness skin loss with exposed dermis

97
Q

Stage 3 pressure injury

A

Full-thickness skin loss

98
Q

Stage 4 pressure injury

A

Full thickness skin and tissue loss

99
Q

serous drainage

A

clear watery drainage

100
Q

sanguineous drainage

A

Right red sanguineous drainage indicative of fresh bleeding

101
Q

serosanguineous drainage

A

Light pink to blood red drainage. Mixture of serum and red blood cells

102
Q

purulent drainage

A
  • Made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

-tHick drainage with a musty foul odor

-varies in color from dark yellow or green depending on causative organism

103
Q

exudate

A

liquid made of plasma and blood components that speak out into the area that is injured

104
Q

granulation tissue

A

A thin layer of epithelial cells that form across a wound Foundation for Scar Tissue development

105
Q

epithelialization

A

process of Epidermis regenerating over a partial thickness wound surface or in Scar Tissue forming on a full thickness wound

essential for successful wound closure

106
Q

Anuria

A

24-hour urine output is less than 50mL

107
Q

Dysuria

A

painful or difficult urination

108
Q

Frequency

A

increased incidence of urination

109
Q

Oliguria

A

24-hour urine output is less than 400mL

110
Q

Polyuria

A

excessive output of urine (diuresis)

111
Q

Proteinuria

A

protein in urine

112
Q

Pyuria

A

pus in urine

113
Q

Urgency

A

strong desire to void

114
Q

Urinary incontinence

A

involuntary loss of urine

115
Q

Elective surgery

A

N112 (13 decks)

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