Fundamentals V1 Remediation Flashcards
Elimination Assessment
What is the order of assessment with elimination?
The Pt has a fecal impaction (1) and what do you do when assessing pt
1)Med Hx of fecal impaction
2)Last Bowel Mvmt?
3)Observe stool consistency or liquid (particularly in immobile pts - continually or frequent incontient liquid stool
4)express desire to poop but is unable
5)complains of pain when trying
6)Bowel patterns, eating habits, exercise or mobility, meds - esp. narcotic pain
7)Baseline V/S
8)bowel sounds abd. distention
9)Possibly HCP orders for manual removal
Manual removal not for heart pts
- Follow up: if hx of dysrrthymias or heart disease greater risks of heart rhythm changes
What is a vagal nerve response when bearing down?
The pt will pass out on the toilet
-They need to be monitored-
Which statement by a quadriplegic client indicates a need for the nurse to provide further teaching about bowel retraining?
A. “I’ll eat low-fiber foods each day to prevent diarrhea.”
B. “I’ll drink at least a quart of water or other liquids every day.”
C. “I’ll do my daily bowel training routine after I eat breakfast.”
D. “I’ll use a suppository to help empty my rectum.”
A. “I’ll eat low-fiber foods each day to prevent diarrhea.”
They need to have a high fiber diet to prevent constipation
What are the steps of an abdominal assessment
ID
Bowel mvmt (color, size, type)
Inspect (distention?)
Listen to quadrants
Palpate (R -L)
Heart rate and comfort scale
When placing an enema, what side does the pt lay on?
Left Sim’s position
= deep slow breaths with lube and only about an inch
Urine needs to be given to labratory
within 2 hours
UA gives
pH, protein, glucose, ketones, blood, specific gravity, RBC, WBC, bacteria, casts, crystals
24 Hour Urine Collection used to determine
amount of creatinine through kidneys
Creatinine
kidney function
when do you start 24 Hour Urine
first morning void but thrown away and start on the next one
-keep cold-
Maslow’s Hierarchy of Needs
Base to Point
Physiologic - basic survival
Safety and security - comfortable
Love and belonging - affection
self-esteem - need to feel good about oneself
self-actualization - fulfill mx potential and need to grow and change
Spine Precautions related to spine board and rigid collar
skin breakdown
pressure ulcer
Spine Precautions
(1) bedrest;
(2) no neck flexion with a pillow or roll;
(3) no thoracic or lumbar flexion with the head of bed elevation/bed controls (reverse Trendelenburg is acceptable);
(4) manual control of the cervical spine anytime the rigid collar is removed; and
(5) using a “log roll” procedure to reposition the patient.
Oropharyngeal and Nasopharyngeal Suctioning is used when
pt able to cough effectively
unable to clear secretions by expectorating
apply suction
Nasopharyngeal Suctioning
maintain pt airway by removing secretions
-infants, debilitated, unconscious
- amount 80-120 mm
-prevent intro of pathogens with asepsis
- one-time use
