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Module 1 > IM1-- EXAM 6 > Flashcards

IM1-- EXAM 6 Flashcards

1
Q

What does the Texas Administrative code Title 22 examining board chapter 217
Rule 217.11 state

A

Provide without discrimination, nursing services regardless of age, disability, economic status, national origin, race, religion, health problems or sexual orientation of the client served.

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2
Q

What does the ANA code of ethic for nurses state:

A

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems

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3
Q

What is spirituality?

A
  1. Complex concept that is unique to each individual and is dependent upon a person’s culture, development, life experiences, beliefs and ideas about life
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4
Q

Spirituality encompasses what?

A
  1. Connectdness
  2. Transcendence and self transcendence
  3. Faith and hope
  4. Inner strength and peace
  5. Meaning and purpose in life
  6. Person
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5
Q

Spiritual wellness is….

A
  1. Awareness of one’s inner self
  2. Connection to a higher being, nature
  3. Values
  4. Highly individualized
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6
Q

What are some attributes to spiritual wellness

A
  1. Harmony
  2. Purpose
  3. Self acceptance
  4. Clear values
  5. Positive outlook
  6. Peace
  7. Balance
  8. Growth
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7
Q

Spiritual wellness maintenance includes….

A
  1. making time to relax
  2. Make time for quiet reflection
  3. Do my values guide my decisions and actions?
  4. Am I accepting of the views others?
  5. Do I have a source of hope?
  6. Attempting to offer forgiveness to others
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8
Q

True or false: Spiritual wellness has a positive effect on health?

A

True

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9
Q

True or false: Spiritual wellness can enhance a patient’s quality of life

A

True

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10
Q

Can spiritual wellness help a patient accept hardship and even mortality?

A

Yes

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11
Q

What are the 2 types of spirituality?

A
  1. Religious
  2. non-Religious
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12
Q

When it comes to spirituality and religion what should we know….

A
  1. Spirituality is found in all human cultures
  2. Expressed differently in religious faith
  3. Spirituality does not have to include religion
  4. Being spiritual does not mean practicing religion
  5. Congruency (spirituality outside of religion)
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13
Q

When it comes to Spirituality and Health and the benefits it provides what should we know….

A
  1. Reduces stress
  2. Improved health outcomes with chronic conditions
  3. Helps with pain management
  4. Comfort for the dying and bereaving
  5. Enhances recovery from illness and surgery
  6. Decreases anxiety, depression, anger, discomfort, and feelings of isolation
  7. decreases alcohol and drug abuse
  8. decreases blood pressure and risk of heart disease
  9. increases the ability to cope
  10. Increases feeling of hope, optimism, freedom from regret, inner peace, and satisfaction with life.
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14
Q

How does spirituality help in the healing process

A
  1. enhances comfort
  2. Provides inner peace
  3. Helps patients come to terms with disability and death
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15
Q

In spirituality the “relationship” includes

A
  1. self, family, friends, loved ones
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16
Q

What are aspects of relationships that effect spirituality?

A
  1. Love
  2. Trust
  3. Communication
  4. Hurt
  5. Mistrust
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17
Q

What are some examples of spiritual wellness…

A

Despite suffering
1. Feeling connected to others who are suffering
2. Feeling support love and room in my heart for others
3. Keep up the fight to endure, pushing beyond limitations
4. Transform this world into a place of wholeness and mutual support

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18
Q

What is spiritual distress?

A
  1. “The state in which the individual experiences or is at risk for experiencing a disturbance in his belief system that is the source of his strength and hope”
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19
Q

What are some characteristics of spiritual distress?

A
  1. Concern with the meaning of life, suffering and/or death
  2. Concern about belief system
  3. Anger toward God/religious representatives
  4. No longer participates in religious practices
  5. Concern about his/her relationship with God
  6. Question meaning of own existence
  7. Feels, guilt, shame, remorse
  8. Feels helpless and hopeless
  9. seeks spiritual assistance
  10. Demonstrates gallows humor
  11. Suffers from sleep disturbances
  12. Alterations in mood or behavior
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20
Q

What is some of the information we gather when we do a spiritual assessment?

A
  1. Faith/belief
  2. life and self-responsibility
  3. Connectedness to God or higher power and others
  4. Life satisfaction
  5. Culture
  6. Fellowship and community
  7. Ritual and practice
  8. Vocation
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21
Q

What nursing actions can we perform in regards to spirituality

A
  1. Offer to contact the pastoral care dept
  2. Plan activities to promote healing of body, mind, spirit
  3. offer to teach relaxation, guided imagery, and meditation technique
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22
Q

True or false: Religion is organized beliefs and worship….”state of doing”

A

True

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23
Q

What is agnostic religion?

A

A person who believes that nothing is known or can be known of the existence or nature of God or of anything beyond material phenomena; a person who claims neither faith nor disbelief in God.

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24
Q

What is atheism?

A

An atheist is a person who disbelieves or lacks belief in the existence of God or gods and an ultimate reality

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25
Q

What are some things we should know about roman Catholicism?

A
  1. May desire Eucharist or mass daily
  2. Sacrament of the anointing of the stick
  3. Last rites
  4. Baptism of infants if prognosis is grave
  5. Praying the rosary
  6. Meat free diet on Friday during lent
  7. Brith control may be prohibited
  8. Confession
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26
Q

What religions do not eat meat on friday?

A
  1. Roman Catholicism
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27
Q

What are some things we should know about Mormonism/church of latter-day saints

A
  1. Joseph Smith-Prophet
  2. Healthful living (no tea, alcohol, coffee or tobacco)
  3. Believe in Jesus
  4. Forgiveness of sins
  5. Baptism for newborn
  6. Last rites
  7. Communion
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28
Q

What are some things we should know about Jehovah’s Witness’s

A
  1. Do not celebrate birthdays or holidays
  2. Refusal of blood products/ no blood in food
  3. Does not believe in immediate afterlife
  4. Jehovah is God - there is no trinity
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29
Q

What are some things we should know about Mennonites

A
  1. Christian
  2. Pacifism
  3. Many speak low German and/or Spanish
  4. Modest apparel for women
  5. Caps indicate submission and headship
    -God>Man> women
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30
Q

What are some things we should know about Islam (muslim) religion

A
  1. May engage in prayer 3-5 times a day facing mecca
  2. Face, hands and feet are washed before prayer
  3. Right hand used for everything but elimination
  4. No pork or alcohol
  5. Gender concordant care
  6. Modesty
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31
Q

What are some things we should now about Judaism and religion?

A
  1. Kosher certified foods
  2. Sabbath is from sunset Friday to sunset Saturday
  3. Sabbath may not want to use call light
  4. Cremation is prohibited or highly discouraged
  5. Daily prayers are valued
  6. Circumcisions
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32
Q

What are some things we should know about buddhism?

A
  1. No belief in a personal creator/God
  2. Mindfulness and mental clarity
  3. Quiet and peaceful environment
  4. May be vegetarian
  5. Prefer family to bathe, toileting, feed…
  6. Suffering is a part of life
  7. Karma
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33
Q

What should we know about hinduism?

A
  1. Reincarnation
  2. Personal hygiene important and must be daily
  3. cremation common on day 2 after death
  4. Right hand for eating, left hand for toileting
  5. Many are vegetarians
  6. accept death and illness as part of life
  7. Elders have a strong influence on decision making
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34
Q

What is diversity?

A
  1. The unique variations between individuals informed by genetics and cultural background, refined by experience and person choice.
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35
Q

What are some variations in diversity?

A
  1. Race
  2. Gender
  3. Sexual orientation
  4. Age
  5. Education
  6. Abilities/disabilities
  7. Life experiences
  8. Geographic
  9. Parental status
  10. Language
  11. Profession/occupation.
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36
Q

What is culture?

A
  1. Learned and shared beliefs involving: knowledge, behaviors, ideas, attitudes, values, habits, work and lifestyle practices, traditions, languages, symbols, rituals,, expression of thoughts and emotions, ceremonies and practices that are unique to a particular group of people
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37
Q

What is transcultural nursing

A

A comparative study of cultures to understand similarities and differences across human groups

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38
Q

What is cultural sensitivity

A

Is being aware of cultural similarities and differences of others with out assigning them value based on similarities or differences.

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39
Q

What is cultural competence

A

Requires acquiring specific knowledge, skills, and attitudes to ensure delivery of culturally congruent care.

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40
Q

What is cultural awareness

A

Self-exam of one’s bias

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41
Q

What is cultural knowledge

A

Sound education base about diversity

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42
Q

What is cultural skills

A
  1. Gathering information through a cultural assessment and being aware of physical findings that are based on race/ethnicity
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43
Q

What is cultural encounters

A

engage face to face

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44
Q

What is cultural desire

A

want to engage with diverse populations

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45
Q

What are the ANA standard 8 cultural congruent care

A

13 competences—-

  1. Demonstrates respect, equity and empathy
  2. Participates in lifelong learning to understand cultural preferences
  3. Creates an inventory of one’s own values, beliefs and cultural heritage
  4. Applies knowledge of variations in health beliefs, practices and communication patterns
  5. Respects decisions based on age, tradition, belief and family influences
  6. Promotes equal access to services, tests, interventions, health promotions
  7. educates nurse colleagues and other professionals about cultural similarities and differences.
  8. Considers the effects and impact of discrimination.
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46
Q

What are some barriers to culturally competent care?

A
  1. Bias (unconscious and implicit)
  2. prejudices
  3. Ethnocentrism
  4. cultural imposition
  5. Cultural stereotype
  6. discrimination
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47
Q

What is bias

A

One sidedness, tendency to learn a certain way. Lack of impartiality

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48
Q

What is prejudices

A

Negative attitudes towards others based on race, gender, sexual orientation…

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49
Q

What is ethnocentrism

A
  1. Believing your way of living is superior to others. cause of biases and prejudices
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50
Q

What is cultural imposition

A

Use their own values and lifestyles and the absolute guide in dealing with patients

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51
Q

What is cultural sterotype

A

all people of a certain racial or ethnic group are alike in certain aspects

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52
Q

What is discrimination

A

Behavior manifestation of prejudices

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53
Q

What are some culture and life transitions?

A
  1. Pregnancy
  2. Childbirth
  3. Newborn
  4. Grief and loss
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54
Q

What is included in cultural assessment?

A
  1. Family structure
  2. Communication patterns
  3. Foods with cultural significance
  4. time orientation
  5. Space
  6. Control
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55
Q

What are some things to ask/consider during cultural assessments?

A
  1. how do you prefer to be addressed?
  2. Where were you born, your parents, your grandparents?
  3. How long have you been in the US
  4. Are you more comfortable reading materials in your native language if other than English?
  5. How are important healthcare decisions made in your family?
  6. Are there certain health care procedures and tests that your culture prohibits?
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56
Q

What is ethnicity?

A

A cultural group’s shared identity such as values, language, geographical space, racial characteristics

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57
Q

What is “race”

A
  1. the grouping of people based on biological similarities and attributes
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58
Q

How can you improve your relationships with different kinds of people

A
  1. Honestly assess your attitudes
  2. Put yourself in perspective with others
  3. Respect differences but don’t overlook similarities
  4. search for more knowledge
  5. treat people as individuals rather than stereotyping
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59
Q

Review slide 60 in spirituality

A

review slide 60 in spirituality

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60
Q

What is an etic perspective?

A

Outsider perspective

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61
Q

What is an emic perspective

A

insider perspective

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62
Q

What is a health disparities

A

A health difference because of a social, economic or environmental disadvantage or part of marginalized groups (people of color, gay, lesbian, bisexual, transgender, physically or mentally challenged and people not college educated)

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63
Q

Black males have a higher incidence of colorectal cancer than white males…. is an example of….

A

health disparities

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64
Q

What are stressors and stress?

A

Physical, emotional or psychological perceived demands that may lead to growth, personal development or a crisis

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65
Q

True or false: Stress is the result of an exposure to a stressor?

A

True

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66
Q

What are some potentially stressful objective events?

A

A major exam, big date, trouble with one’s boss or a financial setback, which may lead to frustration, conflict, change or pressure

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67
Q

What are some subjective cognitive appraisal stressors

A

Personalized perceptions of threats, which are influenced by familiarity with the event, its controllability its predictability and so on

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68
Q

Stress can lead to what responses?

A
  1. Emotional responses–> annoyance, anger, anxiety, fear, dejection, grief
  2. Physiological response–> autonomic arousal, hormonal fluctuations, neurochemical changes, and so on
  3. Behavioral response —> coping efforts, such as lashing out at others, blaming oneself, seeking help, solving problems, and releasing emotions
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69
Q

Stress can alert our ___ or ___ response

A

Flight or fight

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70
Q

True or false: Stress can cause the arousal of the sympathetic nervous system?

A

True

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71
Q

Selye’s general adaptation syndrome is any event (stressor) that threatens an individual.
leads to a 3-stage response which are as follows

A
  1. Alarm
  2. Resistance
  3. Exhaustion
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72
Q

True or false: Stress is highly variable

A

True

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73
Q

Review slide 70 on spirituality

A

Review slide 70 on spirituality

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74
Q

What does our overall assessment of spirituality include?

A

History
1. Medical
-general state of health
- illnesses
- surgeries
- medications
- tx
- use of alcohol, tobacco and/or drugs
- changes in sleep, eating, sexual patterns
2. Perception of threat
3. Past coping patterns
4. Social
- family dynamics
- work/recreation
- living environment
- financial
5 general examination (observable)
-general description and appearance
- behavior
-communication/speech
- mood, affect and feelings
-judgement/insight
6. physical exam

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75
Q

What are some cognitive S/S of stress?

A

Decreased concentration, comprehension, & memory

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76
Q

What are some signs of behavioral S/S of stress?

A

Irritability, withdrawal, violence

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77
Q

What are some signs of emotional S/S of stress?

A

Fear, anxiety, depression, fatigue

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78
Q

What are some signs of physiological S/S of stress

A

increased bp, hr, respirations, etc
somatic symptoms
decreased immune response

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79
Q

What is coping

A

Coping mechanisms are ways to which external or internal stress is managed, adapted to or acted upon.

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80
Q

What are some coping skills?

A
  1. Regular excercise
  2. support systems
  3. Time management
  4. guided imagery/visualization
  5. progressive music relaxations
  6. assertiveness training
  7. journal writing
  8. positive affirmations
  9. massage
  10. Pets
  11. Prayer/meditation
  12. Music
  13. Singing
  14. Laughter
  15. Aromatherapy
  16. sleep
  17. healthy eating
  18. decrease use of phone/internet
  19. organization
  20. b vitamins
  21. sex
  22. hugging
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81
Q

What are some key points of coping

A
  1. coping can apply to an individual a family, or an entire community
  2. coping occurs along a spectrum from effective/adaptive response to ineffective/maladaptive responses
  3. coping may be problem focused or emotion focused
  4. all individuals use coping mechanisms regardless of race, sex, or gender
  5. Outcomes of coping range from resolution to acceptance
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82
Q

What is elimination? (bowel definitions)

A

Excretion of waste products from kidneys and intestines

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83
Q

What is defecation?

A

Process of elimination of waste

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84
Q

What is feces?

A

Semisolid mass of fiber, undigested food, inorganic matter

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85
Q

What is incontinence?

A

Inability to control urine or feces

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86
Q

What is void (urinary elimination definitions)

A

To urinate

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87
Q

What is Micturate

A

To urinate

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88
Q

What is dysuria?

A

Painful or difficult urination

89
Q

What is hematuria?

A

Blood in urine

90
Q

What is nocturia?

A

Frequent night urination

91
Q

What is polyuria?

A

Large amounts of urine

92
Q

What is urinary frequency?

A

Voiding at frequent intervals

93
Q

What is urinary urgency

A

The need to void all at once

94
Q

What is proteinuria?

A

Presence of larg protein in the urine

95
Q

What is proteinuria?

A

Presence of large protein in the urine

96
Q

What is hesitancy?

A

Difficulty initiating urination

97
Q

What is dribbling? (urinary eleimination definitions)

A

Leakage of urine despite voluntary control of urination

98
Q

What is retention?

A

Accumulation of urine in bladder without the ability to completely empty

99
Q

What is residual?

A

Urine remaining post void > 100 ml

100
Q

What are the steps of the bowel elimination process?

A
  1. Fecal material reaches the rectum and causes it to distend
  2. Stretch receptors are stimulated to initiate contraction of the sigmoid colon/rectal muscles
  3. Internal anal sphincter relaxes
  4. At the same time, Sensory impulses transmitted to the CNS produce a conscious urge to defecate—causing voluntary diaphragmatic and abominal muscles to increase downward “bearing down”
  5. While at the same External sphincter relaxes allowing stool to pass through
101
Q

What is the Valsalva maneuver?

A

When a person increases the pressure to expel feces by contracting the abdominal muscles (straining) while maintaining a closed airway (holding breath)

102
Q

What are some ways we can stimulate the body to urinate for patient experiencing hesitancy?

A
  1. Pour warm water over leg or genital area
  2. Drink warm fluid
  3. Turning on water
103
Q

How can we detect urinary retention in patients?

A

By using a bladder scanner

104
Q

True or false: Dribbling occurs more often in women due to women having a shorter urethra?

A

True

105
Q

True or false: Pregnancy is not a cause for dribbling?

A

False

106
Q

True or false: It is not normal to have to urinate alot at night?

A

True

107
Q

People with heart failure are more prone to? (urinary)

A

Nocturia

108
Q

In what situations would we want a patient to avoid valsalva maneuver?

A
  1. Any surgery that might manipulate the bowel
  2. Patients with potential neurological disorders/problems
109
Q

If the signal to defecate is ignored what will happen?

A

The reflexive contraction will ease for a few mins, until mass peristalsis occurs again.

110
Q

What are factors that affect bowel elimination?

A
  1. Developmental stages
  2. Personal factors
  3. sociocultural factors
  4. Nutrition/Hydration
  5. Activity
  6. Medications
  7. Surgery/procedures
  8. Pregnancy
  9. Pathological conditions
111
Q

How is developmental stage a factor in bowel elimination?

A
  1. Bowel elimination patterns change throughout the life span.
    For example: Babies do not recognize the urge to use the bathroom until later in life
112
Q

How can personal factors affect bowel elimination?

A
  1. Privacy is important to most, as sufficient time.
    • Some patients/people will only use the bathroom at home and may be very hesitant to go Infront of others or away from home
  2. Fast-paced jobs may cause a person to ignore the need to defecate.

Remember when you ignore the need, it promotes bowel dysfunction.

113
Q

How can sociocultural factors affect bowel elimination?

A
  1. stress has a major influence and can cause diarrhea or constipation.
  2. Stress is a primary risk factor in the development of IBS
114
Q

Irritable bowel syndrome can be associated with what symptoms?

A

1.Bloating
2. Pain
3. Altered bowel function

115
Q

How can Nutrition/Hydration be a factor in bowel elimination?

A
  1. Regular intake of food promotes peristalsis
  2. Regular intake schedule =regularity
  3. Irregular schedule = irregularity
  4. High fiber: promotes peristalsis and defecation by increasing bulk, bulky foods absorb fluids and increase stool mass
  5. Fluid intake- (6 to 8) 8oz glasses of water/day, is what we should promote, inadequate fluid intake can lead to dry hard stools that are difficult to pass.
116
Q

How does activity affect bowel elimination?

A
  1. Can stimulate peristalsis
  2. Sedentary people have weaker abdominal muscles
  3. Patients with limited activity often experience constipation
117
Q

How do medications affect bowel elimination

A
  1. All oral medications have the potential to affect function of the GI tract (can cause nausea, vomiting, diarrhea and constipation)
118
Q

How can surgery and procedures affect bowel elimination?

A
  1. Bowel manipulation can lead to a paralytic ileus thus #2 can happen as a result
  2. Nasogastric (NG tube) on low or intermittent suction until peristalsis returns
119
Q

What is paralytic ileus?

A

Cessation of bowel peristalsis, bowel continues to produce secretions which remain stagnant causing distention and discomfort. AKA bowel obstructions.

120
Q

How can pregnancy affect bowel elimination?

A
  1. Morning sickness
  2. Slowing of intestinal motility
  3. Risk of hemorrhoids

Mrs. Stunkards note FYI–Morning sickness can happen at any time, growing uterus crowds and displaces intestines, increase in progesterone slows motility, often experience constipation, decreased appetite, irregular food intake, hemorrhoids occur due to pressure of uterus and increased blood volume.

121
Q

How does pathological conditions affect bowel elimination?

A
  1. Neurological disorders that affect innervation (stimulating) of lower GI tract
  2. Cognitive conditions that limit the ability to sense “the urge”
  3. Pain or immobility that leads to sluggish peristalsis
122
Q

True or false: Opioids can affect bowel elimination?

A

True- Can cause them to be slow

123
Q

What is the general overall goal for GI elimination?

A

For the patient to have a soft, formed, regular bowel movement and be free of nausea, vomiting and bloating.

124
Q

How can we promote regular defecation?

A
  1. Privacy
  2. Correct position (seated upright or squatting)
  3. Timing (often after meals and the patient may need assistance)
  4. Fluid intake (at least 6-8 8oz glasses)
  5. Proper diet (fresh fruits/veggies, whole grains, fiber)
  6. Exercise (3-5 times a week, ROM for pts on bedrest, positioning, encourage exercise)
125
Q

Review the Bristol Stool chart

A

Review the Bristol Stool Chart

126
Q

What does severe constipation look like?

A

Separate hard lumps

127
Q

What does mild constipation look like?

A

Lumpy and sausage like

128
Q

What do the two ideal stools look like?

A
  1. Sausage shape w/cracks
  2. Smooth soft sausage
129
Q

What does a lacking fiber stool look like?

A
  1. Soft blobs w. clear edges
130
Q

What does mild diarrhea look like?

A
  1. Mushy consistency
131
Q

What does severe diarrhea look like

A
  1. Liquid consistency
132
Q

What are the seven types of stool according to the Bristol chart

A
  1. severe constipation
  2. Mild constipation
  3. Ideal
  4. Ideal
  5. Lacking fiber
  6. Mild diarrhea
  7. Severe diarrhea
133
Q

What do we need to know about fluid balance?

A
  1. The kidneys maintain fluid balance in the body by regulating the amount of make-up of the fluid inside and around the cell
  2. This is done by the kidneys maintaining the volume and composition of extracellular and to a lesser extent, intracellular fluid by continuously exchanging water and solutes like hydrogen, sodium, potassium, chloride, bicarbonate, sulfate, and phosphate ions, across their cell membranes.
  3. The kidneys role in fluid balance is partially controlled by hormones
134
Q

What are the two hormones involved in fluid balance?

A
  1. Antidiuretic hormone (ADH) produced by the pituitary gland
  2. Aldosterone, produced by the adrenal glands
135
Q

In terms of fluid intake what should we know about the hormone ADH (antidiuretic hormone)

A
  1. If ADH is high- causes more water to be absorbed creating a high concentration but small volume of urine
  2. If ADH is low it causes more water to be excreted creating a larger volume of urine and smaller concentration.
  3. Produced by the pituitary gland
136
Q

In terms of fluid intake what should we know about the hormone Aldosterone?

A
  1. Regulates water reabsorption and changed in urine concentration by increasing sodium reabsorption
  2. Helps control secretion of potassium
  3. Produced by the adrenal gland
137
Q

What do normal urinary patterns look like?

A
  1. Kidneys produce approximately 50-60mL per hour or 1500 mL per day.
  2. Normal voiding is typically 5-6 times per day, depending on fluid intake.
138
Q

What are the characteristics of normal urine

A

Specific gravity-measure of dissolved solutes in a solution
1. If urine solutes increase–specific gravity INCREASES
2. Normal specific gravity in urine is 1.002 to 1.003
3. Fluid intake increases urine becomes more diluted and lighter in color
4. Fluid intake decreases urine becomes darker and specific gravity rises

139
Q

What colors can urine be and what could they indicate?

A
  1. Dark yellow- less water, more waste–> dehydration
  2. Red/Pink- Blood in urine
  3. Brown- liver conditions, gallbladder(bile) fava beans, rhubarb
  4. Orange- TB drugs, carrots (beta carotene)
  5. Milky white- WBC’s, purine rich foods like anchovies, herring, red meat
  6. Blue- methylene blue (dye in diagnostic tests)
  7. Green- Drugs (tagamet, elavil)
  8. Purple– “Purple urine bag syndrome” colonized bacteria in a catheter or collection
140
Q

How can we promote normal urination?

A
  1. Provide privacy
  2. Assist with positioning
    • Men prefer to stand, women like to be upright seated (semi-fowler’s) or squatting
  3. Facilitate toileting routines- times, patterns etc.
  4. promote adequate fluids and nutrition
  5. Assist with hygiene as needed
141
Q

What are normal characteristics of urine?

A
  1. Normal urine should be very pale yellow, clear and without smell
142
Q

What could color in urine indicate?

A

Can indicate some form of intake or lack of fluid

143
Q

What could clarity in urine indicate?

A
  1. Urine will appear cloudy if a pathogen is present
144
Q

What could odor in urine indicate?

A

Pathogen can change odor, as well as intake (asparagus)

145
Q

What are types of specimen collection devices?

A
  1. urinal
  2. Hat
  3. Bedpan
  4. bedside commode
  5. Pure wick
  6. Condom cath.
146
Q

True or false: Depending on how much help the patient needs will determine which urine/fecal collection device to use?

A

True

147
Q

True or false: When collecting urine you want to use a sterile collection process

A

True- make sure to clean area and avoid touching the syringe to lid of collection cup

148
Q

Intake fluids include what?

A
  1. Semi-liquid foods
  2. Ice chips
  3. Fluids
  4. IV fluids
  5. Tube feeding
  6. Irrigations instilled and not immediately removed
149
Q

Output fluids include?

A
  1. Fluid loss via emesis
  2. Urine output
  3. Diarrhea
  4. Drainage from suction or wounds
150
Q

True or false: As nurses we should teach patient and family about I & O

A

True

151
Q

True or false: Use measured collection devices to get accurate counts of output?

A

True

152
Q

What is immunity?

A
  1. Immunity is a physiologic process that provides an individual with protection or defense from disease
153
Q

Immunity responds to threats on an _______ basis

A

Individualized basis

154
Q

Innate immunity is…

A

Genetically determined (what you are born with)- no prior exposure or antibody production involved

155
Q

Acquired immunity is….

A

Produced by prior exposure or antibody production

156
Q

Acquired immunity leads to what two types of immunity?

A

Do not use

157
Q

What is active immunity

A

Produced by antibodies that develop in response to antigens (Immune response)

158
Q

What is passive immunity

A

Produced by transfer of antibodies from another person

159
Q

Active immunity branches into what other types of immunity?

A
  1. Naturally acquired immunity
  2. Induced active immunity
160
Q

What is naturally acquired immunity

A

Develops after exposure to antigens in environment

example you get the flu–> 1month later you are exposed again. This time it isnt as bad

161
Q

What is induced active immunity

A

Develops after administration of antigen to prevent disease

162
Q

Passive immunity branches into what other type of immunities

A
  1. Induced passive immunity
  2. Conferred by transfer of maternal antibodies across placenta or in breath milk
163
Q

What is induced passive immunity

A

conferred by administration of antibodies to combat infection

example– during covid–> blood transfusions passed on antibodies

164
Q

What is natural passive immunity

A

Conferred by transfer of maternal antibodies across placenta or in breast milk

165
Q

True or false: Nutrition is vital to our immunity?

A

True

166
Q

True or false: Lots of foods we eat can help provide us with innate immunity, anti-inflammation, anti-ageing anti-cancer properties?

A

True

167
Q

What are some normal attributes of immunity

A
  1. Normal WBC and deferential counts
  2. Negative bacterial and viral cultures
  3. Soft, non-tender lymph nodes
  4. Recognition of self
  5. Recognition of foreign protiens
168
Q

Social isolation, grieving, finances, mistreatment, hospitalization and changes in lifestyle can contribute to what malnutrition factors

A
  1. Psychological
  2. Social
  3. Environmental
169
Q

Poorly fitted dentures, mouth dryness, poor dental status, taste disorders and oral mucosa disorders can contribute to what malnutrition factors?

A

Oral and dental disorders

170
Q

Dysphagia can contribute to what malnutrition factors?

A
  1. Swollowing disorders
171
Q

Eating and depressive disorders can contribute to what malnutriton factors?

A

Pschiatric disorders

172
Q

Confusion… can contribute to what malnutrition factors?

A

Changes in mental status

173
Q

A stroke can contribute to what malnutrition factors?

A

other neurological disorders

174
Q

Loss of appetite, dry mouth, drowsiness… can contribute to what malnutrition factors?

A
  1. Long-term drug therapy/polymedication
175
Q

Pain, constipation and disability contribute to what malnutrition factor

A
  1. Acute/chronic disease
176
Q

Needing assistance with cooking, eating and mobility may contribute to what malnutrition factor?

A
  1. Dependency of ADL’s
177
Q

Physican orders diets or slimming diets which could contribute to what malnutrition factor?

A

Restrictive diet.

178
Q

What are some factors of malnutrition? list 10

A
  1. Phycological, social and environmental
  2. Oral and dental disorders
  3. Swallowing disorders
  4. Psychiatric disorders
  5. Changes in mental status
  6. Other neurological disorders
  7. Long-term drug therapy/Polymedication
  8. chronic/acute disease
  9. dependency of ADL’s
  10. Restrictive diets
179
Q

What is an antigen?

A

Proteins that induce an immune response when they enter the body.

180
Q

Antigens can be found within…

A
  1. Microorganisms
  2. Vaccines
  3. Transplanted organs
  4. Allergens (animal dander, pollen, foods)
181
Q

What is inflammation

A
  1. Cellular response to injury, infection, or irritation
182
Q

What are localized S/S of inflammation?

A
  1. Redness
  2. Swelling
  3. heat
  4. Pain
  5. Loss of functionality
183
Q

What are systemic S/S of inflammation?

A
  1. Fever
  2. Increased WBC
  3. Malaise
  4. Anorexia
  5. Nausea/vomiting
  6. Lymph node tenderness/enlargement
  7. Organ failure
184
Q

True or false: Inflammation is a non-specific response to something that is harmful to the body (infection, injury, or allergen)

A

True

185
Q

What are some things we should know about chronic inflammation?

A
  1. Cause of inflammation remains active
  2. Tissue destruction continues
  3. Scar tissue may continue to form rather than normal functional tissue
  4. Response to infections is inadequate
  5. Patient experiences chronic symptoms (pain)
186
Q

True or false: Inflammation does not play a role in many chronic diseases

A

False

187
Q

What is an allergic response?

A
  1. Hypersensitive immune reaction to a substance that normally is harmless or would not cause an immune response in everyone. Can be mild or life threatening
188
Q

True or false: during a allergic response, histamines are released, and the body produces antibodies to the substance

A

True

189
Q

What are factors that increase the host susceptibility to infection? list 9

A
  1. developmental stage
  2. Breaks in the first line of defense (skin)
  3. Illness or injury/chronic disease
  4. Smoking
  5. Substance abuse
  6. Multiple sex partners
  7. Environmental factors (pollution/dirty water)
  8. Invasive procedures
  9. Suppressed immune system/medications
190
Q

Malnutrition can lead to…

A
  1. Frequent and chronic infections
  2. If left without Protein for long periods it can lead to - energy malnutrition that results in thymus changes
  3. Micronutrient deficiencies affect inate and adaptive immune responses
191
Q

Micronutrients include…. list 5

A
  1. Iron
  2. Zinc
  3. Copper
  4. Selenium
  5. Vitamins
192
Q

Which vitamins are important to our immune system?

A
  1. Vitamin c
  2. Vitamin D
  3. Vitamin a
  4. Vitamin e
  5. Vitamin B6
  6. Vitamin b12
  7. Folate
  8. Zinc
  9. Copper
  10. Selenium
193
Q

What things could lead to a compromised immune function and increase your risk for infection? list 10

A

0.Poor diet which leads to suboptimal nutritional status
1. hectic, stressful lifestyle
2. fast food, energy-dense but micronutrients poor food
3. Low income, lack of fresh nutrients
4. restricted diets
5. pollution, cigarette smoke
6. chronic stress (physical and psychological)
7. Sleep disturbances/deprevation
8. excessive alcohol consumption
9. Prolonged excessive exercise

194
Q

What is corticosteriod

A

Stress hormone that suppresses the immune system

195
Q

What happens when you stress?

A
  1. Decrease in T cells
  2. Corticosteroid released
  3. Unhealthy coping strategies develop
    – drinking
    – smoking
    – insomina
196
Q

What happens in the body when you excercise

A
  1. Increase t-cell production
  2. Lowers levels of inflammation
  3. Causes WBC to circulate more rapidly
  4. Greater response to vaccines
  5. flushes out toxins from the body through sweat, urine and respiratory tract
197
Q

What are things we should know about older adults and immune responses?

A
  1. Less able to distinguish self from non-self
  2. Macrophages destroy antigens more slowly
  3. T-cells respond less quickly to antigens
  4. White blood cells are fewer therefore the body is less able to remember and defend itself
  5. antibodies become less able to attach to antigens
  6. decrease in thirst therefore an increase in UTIs
198
Q

What are nursing interventions for immunity?

A
  1. Encourage and promote healthy nutrition
  2. Hygiene/Hand hygiene promotion
  3. Immunization promotion and education
  4. Adequate rest and exercise promotion
  5. Education promotion and
199
Q

True or false: The secondary mediator of type I hypersensitivity reaction is immunoglobulin E(igE)

A

False- primary mediator

200
Q

What are some things you should know about allergy type I?

A
  1. Allergy
  2. Deleterious effects of hypersensitivity to exogenous antigens
  3. Most common allergies are type 1
  4. Pollen, mold, fungi, foods, animals, dust and almost anything we encounter in our environment
  5. Atopic- genetic predisposed
201
Q

What are some S/S of allergies?

A
  1. Water, runny eyes
  2. Runny nose
  3. Sneezing
  4. Nasal congestion
  5. An itchy rash or hives
202
Q

What are things we should know about anaphylaxis?

A
  1. Immediate type 1 hypersensitivity
  2. Rapid release of IgE- mediated chemicals
  3. Induces severe, life threatening allergic reactions
  4. Food, drug and insect bites are causes.
203
Q

What are some lung anaphylaxis signs and symptoms?

A
  1. Trouble breathing or nosey breathing (stridor)
  2. Coughing, wheezing
  3. Sneezing
  4. Congestion
  5. Tightness in lungs
  6. Hoarseness
  7. Tachypnea
  8. Respiratory arrest
  9. Sensation of narrowed airway
204
Q

What are some S/S of anaphylaxis in skin?

A
  1. Pale or flushed skin
  2. Hives or welts
  3. Itchy skin
  4. Sweating
  5. Angioedema (swelling in face)
205
Q

What are some S/S of anaphylaxis in the heart and blood vessels?

A
  1. Chest pain
  2. Low blood pressure (hypotension)
  3. Weak, rapid pulse, dysthymias (tachycardia)
  4. Dizziness, fainting
  5. Cardiac arrest
206
Q

What are some S/S of anaphylaxis in the mouth?

A
  1. Swelling of throat, face, lips, or tongue
207
Q

What are some S/S of anaphylaxis in the stomach and digestive tract?

A
  1. Abdominal pain
  2. Nausea, vommiting
208
Q

What are some S/S of anaphylaxis in the stomach and digestive tract?

A
  1. Abdominal pain
  2. Nausea, vomiting,
  3. Diarrhea
  4. Cramping
209
Q

What are mast cells known for during an allergic reaction?

A

Releasing histamine

210
Q

True or false: Mast cells can detect and respond to foreign substances?

A

True

211
Q

What is the first line of treatment for a patient experiencing anaphylaxis?

A

Epinephrine.

Benadryl is good for much milder cases

212
Q

When does an anaphylactic reaction occur?

A

If not immediate than within 5-10mins.

213
Q

True or false: the feeling of impending doom is a symptom of anaphylaxis?

A

True

214
Q

What should we know about an EPI-pen?

A
  1. Dosage: 0.3mg IM, one time use (do not need to know dosage for exam)
  2. Light sensitive, keep in storage tube
  3. Admin in thigh
  4. Very expensive
215
Q

What action does epinephrine produce?

A
  1. Adrenergic response
216
Q

What routes can epinephrine be given?

A
  1. SQ
    -Onset: 5-10mins
    -Peak: 20 mins
    -Duration 1-4 hours
    (0.1-0.5mg not to exceed 1mg)- may repeat every 10-15 mins
  2. IM
    -Onset: 6-12mins
    -Peak: Unkown
    -Duration 1-4 hours
    (0.1-0.5mg not to exceed 1mg)- may repeat every 10-15 mins
  3. IV
    -Onset: rapid
    -Peak: 20mins
    -Duration 20-30mins
    (0.25mg every 5-15 mins)- may be followed by 1-4mcg continuous infusion
217
Q

What action does benadryl have?

A

Antagonizes the effects of histamine at the receptor site

218
Q

What routes can Benadryl be given?

A

1.PO:
-Onset 15-60 mins
-Peak 2-4 hrs
-Duration 4-8 hrs
(PO: 25-50mg every 4-6 hrs, not to exceed 300mg/ day)

  1. IM:
    -Onset 20-30 mins
    -Peak 2-4 hrs
    -Duration 4-8 hrs
    (25-50mg every 4 hrs, not to exceed 400mg/day)
    3.IV:
    -Onset Rapid
    -Peak Unknown
    -Duration 4-8 hrs
    (25-50mg every 4 hrs, not to exceed 400mg/day)

Module 1 (20 decks)

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