Midterm Review Flashcards
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. Which of the following is the probable cause of these symptoms and findings?
Cystitis is usually marked by urinary frequency and irritation. The cloudiness is usually indicative of bacterial presence.
Hospital-acquired urinary tract infections (UTIs) are most often related to poor hand hygiene and which of the following?
urinary catheterization has the highest potential for causing UTIs, and improper catheter care can increase the chance of these infections
To minimize nocturia, when should patients avoid fluids?
avoid fluids for 2 hours before bedtime.
A Foley catheter drainage bag is placed below the bladder to prevent which of the following?
prevent urinary reflux, which can lead to infection
When a condom catheter is applied, the catheter should be secured on the penile shaft in such a manner that the catheter is which of the following?
should fit snugly and securely but should not cause constriction that impedes blood flow. It should not be tight or placed in a dependent position and should never be secured with tape in a circular pattern, which could impede blood flow.
A patient undergoes ultrasonography of a kidney. The nurse providing postprocedure care remembers that which of the following is true regarding precautions that should be taken for this procedure?
no special precautions are necessary after ultrasonography
A patient underwent total knee replacement and was placed on patient-controlled analgesia. The patient has been activating the medication button an average of four times per hour. The nurse has assisted the patient on and off the bedpan two or three times an hour for the past 2 hours. Urine output was about 50 mL with each void. The nurse now begins to suspect which of the following?
retention overflow. Urinary retention may cause increased pressure in the bladder to the point that the external urethral sphincter is unable to hold back urine. The sphincter temporarily opens to allow a small volume of urine to escape. Bladder pressure then falls, and the sphincter closes again. The nurse should also assess the lower abdomen for bladder distension
the nurse recognizes that which organism most frequently causes UTIs in women?
Because the female urethra is positioned close to the anus, most UTIs are a result of contamination of the urethra with organisms from the gastrointestinal tract, such as E. coli.
A 34-year-old man is in hospital rehabilitating from a spinal cord injury. He is incontinent of urine at regular intervals. He is unaware when he is incontinent. This describes which of the following types of incontinence?
Reflex incontinence is the involuntary loss of urine at regular intervals. The person is unaware that the bladder is filling and does not feel the urge to void.
Stress incontinence
Stress incontinence occurs with activities that increase intra-abdominal pressure, such as coughing and sneezing.
transient incontinence
Transient incontinence is a temporary incontinence that resolves once its underlying causes are treated, such as dementia or infection.
Urge incontinence
Urge incontinence is associated with a sudden, urgent need to void and often presents with urinary frequency and nocturia. Its causes include nervous system disorders and outflow obstruction.
Urine may appear concentrated and cloudy because of the presence of
white blood cells or bacteria.
An obstruction to the flow of urine in the urinary collecting system may cause which of the following?
renal damage, urinary retention and UTI
Shear
Force exerted parallel to the skin and results from both gravity pushing down on the body and resistance (friction) between the patient and a surface.
Friction
The force of two surfaces moving across one another, such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens
The braden scale is compromised of what six categories
sensory perception, moisture, activity, mobility, nutrition and friction &shear.
The lower the score the higher the risk of a pressure injury development, total scores range from 6-23.
Granulation
red, moist tissue composed of new blood vessels which indicated progression of wound healing
slough
soft yellow or white stringy tissue which needs to be removed before wound will heal (dead tissue)
eschar
black or brown necrotic tissue which needs to be removed before wound will heal (dead tissue)
acute wounds
Abrasion is superficial wound with little bleeding
Laceration is a jagged unintentional wound that sometimes bleeds more profusely
Surgical wounds
a cut or incision that was intentionally made by a scalpel; can also be the result of a drain placed during surgery
Primary intention
skin edges are approximated with sutures, staples or tape
low infection risk
quick healing with minimal scar
surgery wound heals by this time
secondary intention
wound is large and irregular with considerable tissue loss
edges are not approximated
longer healing time with pronounced scarring
higher infection risk
tertiary intention
wound left open due to possible contamination - require observation
edges approximated once wound is clean
Inflammatory phase (wound healing)
Beginning within minutes of the injury and lasting up to three days depending on thickness of wound.
Body process - hemostasis, phagocytosis
Appearance - mild redness, swelling
Proliferative Phase (wound healing)
New blood vessels appear as reconstruction progresses, lasts from 3 to 24 days
Body process - collagen strengthens wound, produces scar tissue. Granulation tissue is highly vascular
Appearance - wound bed whitish then translucent, red/friable. Raised healing ridge on sutured wound
Maturation (remodelling) phase (wound healing
Early - 2-6 weeks, collagen reorganized into more orderly structure, appear as raised scar formation
Later - 6 weeks to 2 years, scar tissue has < 80% of original tissue strength, appears flat, thin scar
hemorrhage
bleeding from a wound site that is normal during and immediately after initial trauma, but not after hemostasis has occurred
internal - look for distention or swelling, a change in type and amount of drainage or signs of hypovolemic shock
external - look for amount of saturation to dressing
Risk of hemorrhage is greatest during the first 24-48 hours after surgery or injury
Infection
bacterial growth; the chances of wound infection are greater when:
- necrotic tissue is present
- contaminants are near or in the wound
- blood supply and local tissue defences are reduced
Signs: fever, tenderness/pain to the site, elevated WBC count, edges of wound inflamed, drainage (odorous, purulent, yellow/green/brown)
How do you take a wound culture?
- clean the wound with nonantiseptic solution
- using a sterile swab, rotate the swab in 1cm of clean tissue in the open wound; apply pressure to the swab. Insert the tip of the swab into the appropriate sterile container
Dehiscence
partial or total separation of wound layers
- patients at risk for poor wound healing is at risk (poor nutrition, infection, obesity)
- may occur after a sudden strain (coughing, vomiting , sitting up) especially with abdominal surgeries
- teach to provide support to the area ( fold blanket or pillow over the wound when coughing) because of the constant strain placed on their wounds and the poor healing qualities of fat tissue
Evisceration
protrusion of visceral organs through a wound opening
- surgical repair; as a nurse, quickly place sterile towels soaked in sterile saline over the extruding tissue to reduce the chance of infection and tissue and call the MD
- NPO status and observe for signs and symptoms of shock - prep for emergency surgery
Fistula
Abnormal passage between two organs or between an organ and the outside of the body
- most as a result of poor wound healing or complication of disease (i.e Crohn’s)
- Increase the risk of infection and fluid and electrolyte imbalance
serous
clear, watery plasma
purulent
thick, yellow, green, tan or brown
serosanguineous
pale, red, watery; mixture of clear and red fluid
sanguineous
bright red: indicates active bleeding
Suspected deep tissue injury (staging pressure ulcers)
purple of maroon localized area of discolored intact skin or blood filled blister due to damaged underlying skin
Stage I pressure ulcer
intact skin with nonblanchable redness
In stage I, the injury appears as a defined area of persistent redness in lightly pigmented skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. The skin is warmer or cooler there than in other areas, with a change in consistency and sensation.
Stage 2 pressure ulcer
partial-thickness skin loss involving epidermis, dermis, or both
Stage 3 pressure ulcer
Full thickness tissue loss. SC fat may be visible but no other underlying structures exposed
Stage 4 pressure ulcer
Full thickness tissue loss with exposed bone, tendon, or muscle
Unstageable pressure ulcer
full thickness tissue loss in which the base of the ulcer is covered by slough, eschar or both
micturition
urination; act of passing urine voluntarily through the urethra
oliguria
diminished capacity to form and pass urine
anuria
cessation of urine production
polyuria
excretion of abnormally large volume of urine
dysuria
painful or difficult urination
nocturia
urination at night
cyctitis
inflammation of the urinary bladder characterized by pain, urgency and frequency or urination
urinary retention
accumulation of urine in the bladder due to bladders inability to empty
- overflow incontinence may occur
- in severe cases the bladder may hold as much as 2-3L of urine
intermittent catheterization
- also called in and out catheter
- single use straight catheter with a single lumen is introduced for 5-10 mins
- sterile technique in hospital and clean in community
indwelling catheter
- also known as a continuous foley catheter
- remains in place until the patient is able to void completely and voluntarily or for as long as accurate measurements are needed
- either two or three lumen
- used for a short or long term basis
coude catheter
- type of indwelling catheter
- curved and rigid tip - used for males and patients with enlarged prostates
- less traumatic during insertion because it is stiffer and easier to control
Culture and sensitivity (urine testing)
- infection bacterial growth
- stored in fridge until delivered to lab
- 24-48 hours for results
Timed urine specimen (urine testing)
- between 2-24 hours
- must be free of feces and toilet tissue
- missed specimens make entire collection inaccurate
closed intermittent irrigation (bladder irrigation
- double lumen; an injection port
- useful for frequent intermittent irrigations
- closed system recommended
CBI - closed continuous irrigation
- also called continuous bladder irrigation (CBI)
- triple lumen catheter
- continuous infusion of sterile solution into the bladder
- flow rate is controlled by irrigation clamp
- cold solution could cause bladder spasm and discomfort
Continuous bladder irrigation WHY and WHO
WHY: to prevent the formation of blood clots, to sustain potency of indwelling catheter, to permit free flow of urine
WHO: patient who had genitourinary surgery, trans urethral resection of prostate (TURP), bladder and kidney surgery
Trans Urethral Resection of Prostate (TURP)
- relieve moderate to severe urinary symptoms caused by benign prostatic hypertrophy
- a combined visual and surgical instrument inserted through the tip of penis and into the urethra; excess prostate tissue surrounding the urethra gets trimmed
- CBI post operatively to prevent/flush clots
Percutaneous Endoscopic Gastromoy (PEG)
Percutaneous Endoscopic Jejunostomy (PEJ)
- endoscope
- puncture through skin of SC tissue into stomach or jejunum
- surgical asepsis for care while site heals
Indications for enteral nutrition
- cancer
- critical illness or trauma
- neurological and muscular disorders
- gastrointestinal disorders
Pre-feed assessment
- order
- allergies
- tube placement
- patency
- intake and output
- bowel sounds
Positioning for Enteral Feed
- patient should be in high fowlers with head up right (45 degrees) prior to initiating a feed or administering medication through a feeding tube
- after feed do not lie them flat, could result in aspiration
Metered-dose inhaler (MDI)
- delivers a measure dose of medication with each push
- either squeeze and breathe inhalers or inhalers activated by patient’s breath
- can be used with spacer
Dry Powder Inhaler (PD)
- hold dry, powdered medication which creates an aerosol when the patient inhales
- patients dont need to coordinate puffs with inhalation
- medication may clump with humid climate
How to safely self-administer MDI or PD
- shake the inhaler vigorously 5-6 times
- inhale slowly and deeply through the mouth for 3-5 seconds while depressing the canister
- hold your breath for approximately 10 seconds after
