FINNY 2 Flashcards
What is Micturition
The process of voiding
What is the Micturition reflex process
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
Voluntary control of Micturition is limited to what
Initiating,
Restraining,
Interrupting action of urinating
When/ how do adults feel desire to void
Bladder fills to about 150mL-250mL
Stretch receptors in the bladder are stimulated
Adult feels desire to void
Autonomic bladder
peoples whose bladders are no longer controlled by the brain because of injury or disease void by reflex only
Factors effecting urination
- Developmental considerations: toilet training, effects of aging
- Food and fluid intake
- Psychological variables
- Activity and muscle tone
- Pathological conditions
- Medications
Transient incontinence
appears suddenly and lasts for 6 months or less
Stress incontinence
occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure.
Urge incontinence
the involuntary loss of urine that occurs soon after feeling an urgent need to void
Total incontinence
is the continuous and unpredictable loss of urine resulting from surgery, trauma, of physical malformation
Reflex incontinence
emptying bladder without feeling the sensation of need to void
Mixed incontinence
indicates that there is urine loss with features of 2 or more types of incontinence
Overflow
or chronic retention of urine; involuntary loss of urine associated with over dissension and overflow of the bladder
Functional
urine loss caused by inability to reach the toilet because of the environmental barriers, physical limitations, loss of memory, or disorientation
Incontinence associated dermatitis (IAD):
prolong contact of the skin with urine or feces leads to a form of moisture-associated skin damage
S/S of IAD
Erythema
Maceration
Denuding
Inflammation
Hot spots of IAD
Perineum
Perineal area
Buttocks
Inner thighs
Sacrum
Coccyx
Psychological effects
Anxiety
Caregiver role strain
Risk for infection
S/S UTI
- 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
effects of aging on urinary elimination
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
Anticoagulants turn the color of urine what color
Red
Diuretics turn the color of urine what color
Pale yellow
Pyridium turn the color of urine what color
Orange
Elavil turn the color of urine what color
Green or blue
Levodopa turn the color of urine what color
Brown or black
Cholinergic medications do what to urination
stimulate contraction of detrusor muscle, producing urination
Analgesics and tranquilizers do what to urination
suppress CNS, diminish effectiveness of neural reflex
What is PVR
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
A PVR less than _____ indicates adequate bladder emptying
50mL
A PVR greater than ____ is an indication that the bladder is not emptying correctly
100mL
Criteria for catherization
- 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)
What is stress
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
Can you identify different stressors
anything that is perceived as challenging, threatening, or demanding that triggers a stress reaction
-interpersonal, intrapersonal, extrapersonal
intrapersonal stress
talk to self
-Ex. im not as good as others, im gonna fail, illness
Interpersonal stress
between individuals
-Ex. worried ill disappoint my spouse
Extrapersonal stress
outside stressors
-Ex. pandemic, isolation, online classes
What are the sources of stress for adults?
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)
What are the sources of stress for aging ppl?
retirement, death of spouse, surgical procedures, diagnosis of chronic illness, isolation, chronic pain, alcohol abuse, loss of independent, declining physical/mental capabilities
Analyze stress response theory (Hans Sylye): General Adaptation Syndrome (GAS)
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
what are the effects of long term stress?
- affects physical status
-increase risk for disease or injury (ex. psoriasis, arthritis, graves disease) & compromised recovery
-alcoholism, drug abuse, suicide, eating disorder, depression, accidents
What is adaptation?
change that takes place as a result of the response to a stressor.
How do humans adapt to stress or stressors
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)
How to manage stress? Crisis?
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)
what are stresses in nursing?
pt death, care, lawsuits, burnout
-working w/ unsupportive supervisors & personnel
-mistakes
Mechanisms to control stress
compensation, displacement, projection, repression, undoing, denial, introjection, regression, sublimation
The physiology of urinary system
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
Effects of incontinence
skin breakdown, embarrassment, limits yourself & isolate, lower self esteem
Types of incontinence
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
what are some treatment for incontinence?
kegals, biofeedback device, electrical simulation, bladder training, surgical interventions
wound healing process
Homeostasis
Inflammatory phase
Proliferation phase
Maturation phase
Hemostasis phases
- 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
Inflammatory Phase
-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
Proliferation phase
- 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.
Maturation Phase
-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
Local Factors that effect healing
Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Biofilm
What is desiccation
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
What is Maceration
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.
What is Necrosis
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.
What is biofilm
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
Systemic factors that effect wound healing
Age
Circulation & Oxygenation
Nutritional Status
Wound Etiology (cause)
Medications & Health Status
Immunosuppression
Adherence to Treatment Plan:
Pts at risk for pressure injuries
Immobility
Nutrition & Hydration
Moisture
Mental Status
Age
Stage 1 Pressure Injury:
localized area of intact skin w/ nonblanchable erythema (redness). Area may be painful, firm, soft, warmer, or cooler compared to adjacent tissues.
Stage 2 Pressure Injury:
partial thickness loss of dermis & presents a shallow, open ulcer or ruptured/ intact serum filled blister.
Stage 3 Pressure Injury
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
Stage 4 Pressure Injury
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
Unstageable
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.
Deep-tissue injury
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.
Wound Assessment:
inspection (sight & smell), palpate for appearance, drainage, odor, & pain. Determines status of wound & identifies any barriers to healing & complications
What do you assess in a wound
Appearance of Wound
Drainage
Sutures & Staples
Nursing interventions that prevent pressure injuries
- 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
Applying Dry Heat
- 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
Applying Moist Heat
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
Applying Dry Cold
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
Applying Moist Cold
Cold compresses: used for injured eye, headache tooth extraction, & sometimes hemorrhoids.
epidermis
- 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
dermis
- second layer of skin
- made of a framework of elastic connective tissue
- primarily made of collagen
Wound
- 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)
intentional wound:
- 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
unintentional wound
- 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
Developmental considerations - wounds
- 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
State of health
- 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
tunneling
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
slough
Part of the inflammatory Process consisting of fibrin, white blood cells, bacteria and debris, along with dead tissue and other proteinaceous material
Primary intention
Closing a wound with staples, sutures glue
Clean cut wound
Secondary intention
Wounds that cannot be Stitch causing a large amount of tissue loss
tertiary intention
Delayed wound closures that may need draining and other therapies before closing
fistula
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
pressure ulcer
Pressure injury, No longer called pressure ulcer
Friction
Occurs when two surfaces rub against each other
Resembles abrasion
EX: elbows and heels becoming burned through movement
shear
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
ischemia
Deficiency of blood in a particular area
eschar
Dead tissue appearing as SLOUGH
-a dry black and leathery
-removal of eschar must occur before healing can begin
debridement
removal of devitalized tissue and foreign material
wound dressing
a dressing that is sterile pad or Cam press play to a wound to promote sealing and protect the wound from further harm
Stage 1 pressure injury
Non blanchable erythema of intact skin
Stage 2 pressure injury
Partial thickness skin loss with exposed dermis
Stage 3 pressure injury
Full-thickness skin loss
Stage 4 pressure injury
Full thickness skin and tissue loss
serous drainage
clear watery drainage
sanguineous drainage
Right red sanguineous drainage indicative of fresh bleeding
serosanguineous drainage
Light pink to blood red drainage. Mixture of serum and red blood cells
purulent drainage
- 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
exudate
liquid made of plasma and blood components that speak out into the area that is injured
granulation tissue
A thin layer of epithelial cells that form across a wound Foundation for Scar Tissue development
epithelialization
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
Anuria
24-hour urine output is less than 50mL
Dysuria
painful or difficult urination
Frequency
increased incidence of urination
Oliguria
24-hour urine output is less than 400mL
Polyuria
excessive output of urine (diuresis)
Proteinuria
protein in urine
Pyuria
pus in urine
Urgency
strong desire to void
Urinary incontinence
involuntary loss of urine
Elective surgery
