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
Mechanic GI complications
tube displacement
pulmonary aspirations
mucosal damage
Metabolic GI problems
hyperosmolar dehydration
overhydration
abnormal blood concentrations of Na, K, Phosphorus, and mg
hyperglycemia
respiratory insufficiency
rapid wt gain
Diarrhea Tx
switch to isotonic formula slowly
cultures
malabsorption = continuous feedings
decrease bolus col and increase the frequency of feedings
antibiotics,, k SUPPLEMENTS
Overhydration Tx
restrict fluids
Hyponatremia Causes
CHF
Cirrhosis
low albumin
edema
ascites
Hyponatremia Tx
restrict fluids
replace Na slowly (never exceed 12 mEq in a day) - cerebral edema
diuretics
concentrated formulas
monitor Na and hydration
Hypernatremia
dehydration
-increase fluids
Hypokalemia
renal failure
- phosphate binder
Hypophosphatemia
GI feedings alcoholism
replete with mg sulfate
Hyperglycemia
DM
-blood glucose frequently
adjust insulin dose
reduce tube feeding rate
Working phase
data-gathering
-open ended questions (narrative, paragraph answers, feeling, opinions, ideas, rapport)
- direct questions (when needing specific situation
-
facilitation, silence, reflection, empathy, clarification involve your
reactions to the facts or feelings that the person has communicated
confrontation, interpretation, explanation, summary involve your
start to express your own thoughts and feelings
Ten Traps of Interviewing
providing false assurance or reassurance
giving unwanted advice
using authority
using avoidance language
distancing
using professional jargon
using leading or biased questions
talking too much
interrupting
using “why” questions
non-verbal skills
professional appearance
posture (relaxed and open) - slightly towards
gestures
facial expression (interest, appropriate smiling
eye contact
voice (moderate)
moderate rate of speech
touch approprate
Closing the interview should be
graceful
-self-expression
-summary of learned
-agreeable
-positive notes
-explanation of examine
-thank them for the time spent and cooperation
Applying an Absorption Dressing - Skill ORDER
Allergies
Inspect local, size, condition of wound
Pain rate
Analgesic 30 mins before dressing change
Orders and type
Customized shape of dressing
knowledge and purpose of dressing
Nursing Dx of Absorption Dressing
acute pain
chronic pain
deficient knowledge
impaired skin integrity
risk for infection
Absorption Dressing expected outcomes
evidence of healing
less pain
clean, dry, and intact dressing
explains procedure correctly
What herb has a positive effect with insomnia patients?
Valerian Root
Melatonin
S/S of Vascular Insufficiency
Decreased hair growth on legs and feet
• Absent or decreased pulses
• Infection of the foot
Poor wound healing
Thickened nails
Shiny appearance of the skin
Blanching of the skin on elevation
S/S of Peripheral Neuropathy
Muscle wasting of lower
Foot deformities
Soft tissue infection of lower
Abnormal gait
Decreased or absent stimuli
