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N321: Nursing Assessment of Clients > Module 7 > Flashcards

Module 7 Flashcards

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1
Q

Important structures of the GI Region?

A

Esophagus
Stomach
Pancreas
Liver
Gallbladder
Small Intestine
Appendix
Large Intestine
Rectum

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2
Q

Function of the Esophagus?

A

Peristalsis

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3
Q

Function of the Stomach?

A

mix food with enzymes to continue the process of digestion

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4
Q

Peristalsis

A

movement/muscle contractions

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5
Q

Function of the Pancreas

A

Secrete digestive enzymes into the duodenum to break down proteins, fats, and carbs

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6
Q

Where is the pancreas located?

A

Mid-Epigastric Region, behind the liver

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7
Q

Function of the Liver?

A

process absorbed nutrients from the small intestine

produce bile that is secreted into the small intestine to help digest fat

Detoxify

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8
Q

Function of the Gall Bladder?

A

store and concentrate bile

it is within the liver connected to the small intestine for bile release

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9
Q

3 Parts of the Small Intestine

A

Duodenum –> Jejunum –> Ileum

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10
Q

Function of the Small intestines

A

Breaks down food with pancreas and liver help

peristalsis

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11
Q

How long is the S intestine?

A

22 foot long muscular tube

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12
Q

What is the Duodenum largely responsible for?

A

continuous breaking down process of food

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13
Q

What is the Jejunum and Ileum mainly responsible for?

A

absorption of nutrients into the bloodstream

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14
Q

What are the contents of the small intestine ? (form)

A

Semi Solid to Liquid

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15
Q

Once nutrients are absorbed in the small intestine, the contents enter the…

A

large intestine

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16
Q

Function of the Appendix?

A

In the lower Right Abdomen

Function unknown - theory is it stores good bacteria for “Rebooting” the digestive system after illness, or that it is a vestigial organ

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17
Q

Function of the Large Intestine

A

mostly removal of water from contents and formation of stool

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18
Q

Parts of the Large Intestine

A

Cecum
Ascending (Right) Colon
Transverse (Across) Colon
Descending (Left) Colon
Sigmoid Colon (Storage)
Rectum

It has 6 main parts and is a 6 foot long muscular tube

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19
Q

What is stool consisted of?

A

mostly food debris and bacteria

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20
Q

What is the function of the bacteria/natural flora in our gut and stool?

A

Synthesize vitamins
Process waste products and food particles
protect against harmful bacteria

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21
Q

What is the Rectum?

A

8 inch Chamber connecting colon to the anus

When gas or stool enters, neurological sensors message the brain which decides whether to empty or not - if not, sensation to void temporarily ceases

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22
Q

Things to Ask During An Abdominal Health History?

A

Appetite/Weight Change
Difficulty Swallowing
Food Intolerance
Abdominal Pain/Discomfort (Visceral, parietal, referred pain)
Medications taken/allergic to
A nutritional assessment
Vomiting, Nausea (looks, when, amount, etc)
Bowel Habits (amount, timing, etc)
Past Abdominal history

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23
Q

COLDSPA

A

Acronym to remember what to learn about pain/illness

Characteristics, Onset, Location, Duration, Severity, Pattern, Associated Factors (of the pain)

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24
Q

Visceral Pain

A

Organ pain

Dull, Diffuse Pain

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25
Q

Parietal Pain

A

Lining Pain

Sharp pain

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26
Q

Referred Pain

A

pain felt in an area away from the source of it

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27
Q

Important subjective considerations on the Abdominal Health History for Infants/children?

A

do they breast feed/ what kind of food do they eat?

how often do they eat?

constipation?

abdominal pain/discomfort?

weight issues?

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28
Q

Important subjective considerations on the Abdominal Health History for Adolescents?

A

do they regularly eat meals

do they exercise

their activity levels

what is their nutrition like

do they have weight issues (ask carefully since they have body image issues)

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29
Q

Important subjective considerations on the Abdominal health History for Pregnant women?

A

Morning sickness (50-70% have it)

Heartburn (decrease gastroparesis)

constipation

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30
Q

Gastroparesis

A

disease in which the stomach cannot empty itself of food in a normal fashion / delayed gastric emptying (leads to heartburn in people that are pregnant for example)

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31
Q

Equipment needed for an Abdominal Assessment?

A

Stethoscope
Measuring Tape (Size of Liver)
Small Pillow/ Rolled up Blanket
Pen Light
Marking Pen

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32
Q

What is the abdominal assessment technique order?

A

Inspection –> Auscultation –> Percussion –> Palpation

this order is because percussion or palpation can stimulate the abdominal intestinal region leading to false results like noises when there would not have normally been any there

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33
Q

What side of the bed should you stand at during the abdominal assessment?

A

the right side

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34
Q

Important Pre-Abdominal Assessment points to know.

A

Stand on the right

Provide privacy

expose the ENTIRE abdomen

Raise the bed for good body mechanics and lower when done

If can be tolerated, lower the head of the bed into a supine position - if they cannot do this go semi-fowlers

have good lighting

relax patient

patient needs to void

ask about painful areas - examine last

watch the patients face

warm stethoscope and hands

have shortened fingernails

distract patient with convo/questions

visualize organ locations

proceed in correct order

explain what you do and why

cultural considerations

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35
Q

Things to observe during inspection of the abdomen?

A
  1. Contour (Flat, Round, Scaphoid, Protuberant)
  2. Symmetry
  3. Umbilicus (contour, inflammation, hernia, infection - in newborns consider bleeding and infection)
  4. Skin (striae, scars, bruising, lesion, rash, tattoo, pulsations at eye level, hair distribution)
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36
Q

Term for Bruising

A

Ecchymosis

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37
Q

Movement seen or Bruits Heard in Epigastric region…

A

may indicate an aortic aneurism

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38
Q

When inspecting abdominal distension what is important to keep in mind on what may be causing it?

A

7 F’s:

Flat
Flatus
Fluid
Fetus
Feces
Fetal Growth
Fibroid

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39
Q

Hernia

A

when organs squeeze through a spot in muscle, tissue, or skin

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40
Q

Important hernia locations (5)

A
  1. epigastric
  2. umbilical
  3. Inguinal (groin/V-line/pubic bone area)
  4. Femoral (thigh)
  5. Incisional (out of incision/evisceration)
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41
Q

When inspecting the abdomen, you are going to view what regions?

A

The 4 Quadrants (LRQ –> URQ –> ULQ –> LLQ)

Epigastric Region (below xiphoid but above umbilicus)

Periumbilical Region (two finger diameter around umbilicus)

Pelvic Region

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42
Q

What organs are in the RUQ?

A

Gallbladder
Liver
Duodenum
Pancreas Head
R Adrenal Gland
Portion of R Kidney
Some of Ascending/Transverse Colon

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43
Q

What can pain in the RUQ indicate?

A

Cardio - MI, Angina
Pulmonary - Pneumonia
GallB - Cholecystitis, Cholelithiasis
Hepatic - Hepatitis, Cancer (CA)
Intestine - Ulcer, Appendicitis

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44
Q

Cholelithiasis

A

Gallbladder stones

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45
Q

Cholecystitis

A

Gallbladder inflammation

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46
Q

What organs are in the LUQ?

A

Spleen
Left Liver Lobe
Stomach
Pancreas Body
Left Adrenal Gland
Portion of Left Kidney
Some of Transverse/Descending Colon

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47
Q

What can pain in the LUQ indicate?

A

Cardio - MI, Angina
Pulmonary - PE, Pneumonia
Pancreas - Pancreatitis
Spleen - Rupture
Stomach - GERD, Ulcer, Hiatal Hernia

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48
Q

What organs are in the RLQ?

A

Ovaries/Uterus (When enlarged)
Right Spermatic Cord
Ascending Colon
Lower part of R Kidney
Right Ureter
Appendix !!!!
Bladder when distended/full

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49
Q

What organs are in the LLQ?

A

Ovaries/Uterus (when enlarged)
Left Spermatic Cord
Descending/Sigmoid Colon
Left Ureter
Bladder when distended/full

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50
Q

What can pain in the RLQ or LLQ indicate?

A

Ovary/Uterus - Ectopic Preg., Cyst, Pelvic Inflam Disease

Intestines - Perforation, Constipation, Diverticulitis, Hernia

Kidney - Nephrolithiasis, Infection

Appendix (Right) - Appendicitis

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51
Q

Nephrolithiasis

A

kidney stones

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52
Q

Examples of where Referred Pain can occur?

A

Shoulder
Scapula
Thighs and Genitals
Lower Back
Umbilical Area

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53
Q

What can referred pain in shoulder indicate?

A

Ruptured Spleen
Ectopic Pregnancy
Pancreatitis
Perforated Duodenal Ulcer

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54
Q

What can referred pain in the scapula indicate?

A

Cholecystitis
MI
Angina
Pancreatitis

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55
Q

What can referred pain in the thighs or genitals indicate?

A

Renal issues

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56
Q

What can referred pain in the lower back indicate?

A

Pancreatitis
Rectal Lesion
Abdominal Aortic Aneurysm

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57
Q

What can referred pain in the umbilical area indicate?

A

Small Intestine Issue
Appendix Issue
Colon Issue

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58
Q

9 Abdominal Regions

A

(R Hypochondriac)(Epigastric)(L Hypochondriac)
(R Lumbar) (Umbilical) (L Lumbar)
(R Iliac) (Hypogastric) (L Iliac)

(used during palpation and percussion of abdomen)

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59
Q

Striae

A

“Stretch Mark”

Can be Violet or a Pearly White color

occurs when someone gave birth or had a rapid weight change (like: was obese and lost weight fast)

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60
Q

What can cause a protuberant abdomen?

A

Decreased muscle tone

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61
Q

What does an abdominal mass look like?

A

An area where the stomach protrudes out

It may indicate a curable/malignant/benign/painful/non-painful/incurable tumor/mass - needs to be tested

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62
Q

Caput Medusae

A

Issue in the abdomen where superficial blood vessels protrude out due to portal hypertension to appear “snake-like”

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63
Q

Ascites

A

Fluid trapped in the peritoneal cavities (abdomen)

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64
Q

What often is the cause of ascites of the abdomen?

A

Some liver issue like cancer, cirrhosis, etc

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65
Q

What area of the abdomen is auscultated first with the warm stethoscope diaphragm?

A

The Ileocecal Valve

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66
Q

Where is the ileocecal valve ?

A

in the Right Lower Quadrant (where the cecum of the colon is and where the S and L intestines meet)

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67
Q

How often do healthy bowel sounds occur?

A

every 5 to 20 seconds - these are called active bowel sounds

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68
Q

Loud and prolonged (borborygmic) bowel sounds are ____

A

hyperactive

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69
Q

If bowel sounds are occurring every 20-30 seconds due to constipation, beginning of ileus, or decreased motility, they are ____

A

hypoactive

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70
Q

In order to declare bowel sounds as ABSENT, how long must you auscultate?

A

a full 3 to 5 minutes

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71
Q

What may cause absent bowel sounds?

A

Decreased motility due to paralytic ileus, peritonitis, anesthesia (may want to flick abdomen for stimulation) - this is a very serious issue

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72
Q

What are active bowel sounds (sound, why they happen, why we assess them)?

A

Sporadic, irregular high pitched clicks/gurgles due to peristalsis and we listen to them to assess bowel motility

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73
Q

What other sound should we auscultate when doing the abdominal assessment?

A

The vascular sounds of the aorta using the bell

this area is the epigastric region / below the xiphoid process and above the umbilicus

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74
Q

What is a problematic sound, and what does it indicate, in the epigastric region?

A

If you hear a systolic bruit that could indicate abdominal aortic aneurysm

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75
Q

Why do we percuss the abdomen?

A

To detect fluid, gaseous distention, masses, and asses position and size of various structures

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76
Q

What areas are percussed in an abdominal assessment?

A

all 4 quadrants or the 9 regions including flank areas of the back (where kidneys are)

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77
Q

What is the predominant sound (indicating air) during abdominal percussion?

A

Tympany

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78
Q

What can a dull percussion indicate in abdominal assessments?

A

locations of organs the liver, a distended bladder, pregnant uterus, fluid, feces, or other solid masses

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79
Q

When doing abdominal palpation, what must be done and in what order?

A

Light Palpation x9 –> Deep Palpation x9 –> Rebound Tenderness

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80
Q

Why do light palpation in an abdominal assessment?

A

check for surface abnormalities, muscle rigidity, and tenderness

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81
Q

What is the motion of light and deep palpation?

A

It is a dipping motion with fingers/palm together and flat

the light palp goes about 1-2 cm, while deep goes about 4-6 cm

Deep also uses one hand on top of one another, while Light uses only one hand/fingers

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82
Q

Why do deep palpation in an abdominal assessment?

A

check organs (liver, spleen, kidneys, aorta) for masses or other issues

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83
Q

If there is tenderness/pain expressed or found in light palpation, then you should …

A

NOT do deep palpation

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84
Q

Rebound Tenderness

A

Pressing into the and and releasing quickly to see if pain, grimace, or yelling is elicited

If it is, it is a positive sign of some issue

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85
Q

Blumberg’s Sign

A

Rebound Tenderness

The abdominal wall is compressed slowly and then rapidly released. If there is pain elicited it is a positive sign (indicates something like peritonitis)

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86
Q

Obturator Test

A

Patient lies on back with right hip flexed 90 degrees. Examiner holds patients right ankle in right hand. With left hand examiner rotates hip by moving the right knee to and away from the body. Pain elicited is a positive sign (of appendicitis)

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87
Q

Murphy’s Sign

A

Test where the patient is asked to breath out, followed by placing the hand over the gall bladder (R. MCL) - the patient then breaths in

Normally, the abdominal contents are pushed down as the diaphragm moves up, but if the patient stops breathing and winces to “catch” their breaths it is a POSITIVE sign of a gall bladder issue

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88
Q

Important objective developmental considerations for Infants and Children when doing the abdominal physical assessment?

A

their first stool (meconium) could still be present in newborns

liver takes up more space than an adult

the abdominal wall is thinner

organs are palpable easier

urinary bladder is higher up than in adults

contour is often protuberant / pot bellt shape

Umbilical Herniation in newborns

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89
Q

Important objective developmental considerations for Pregnant Women when doing the abdominal physical assessment?

A

Hemorrhoid presence

Bowel Sounds can be diminished

Appendix is displaced up and to the right

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90
Q

Important objective developmental considerations for Elders when doing the abdominal physical assessment?

A

Increased abdominal fat

Less musculature

Organs may be easier to palpate now

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91
Q

-oscopy

A

test allowing for a test of the GI system

a tiny camera is inserted into the area and can visualize the area for the physician

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92
Q

What things can an -oscopy procedure due?

A

Visualize the area

Biopsy mucosa and lesions

Remove Lesions

Cauterize Bleeding

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93
Q

Difference between a Colonoscopy and a Sigmoidoscopy?

A

Colonoscopy examines the entire colon, but the sigmoidoscopy only examines the lower third (sigmoid colon)

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94
Q

Contrast Medium Study - Barium Swallow/Enema

A

The patient NPO after midnight and must understand the procedure and consent. the barium is chalky and could cause stomach irritation, and laxatives may be needed to flush barium afterward

The barium swallow, radioactive, can help visualize areas like the esophagus, upper GI, stomach, S intestines

A barium enema can help visualize the large intestine

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95
Q

BS

A

Barium Swallow

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96
Q

BE

A

Barium Enema

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97
Q

GI Occult Blood Test

A

Test checking for blood in the stool - if blue, there is a positive for blood present in stool

Up to 3 dasys before avoid red meat, raw fruit, vegetables, aspirin, and vitamin C to prevent False Pos/Neg

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98
Q

NPO

A

Non Per Orum - Nothing By Mouth

Type of Intake Diet requiring that nothing (not even ice) be eaten prior to surgeries, GI abnormalities, N&V, L&D, some lab work, and when comatose

Some health histories may require the use of IV fluids

If well nourished, can be tolerated for a short time

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99
Q

Important Considerations for NPO

A

Keep the mouth moist (do not swallow)

Practice Good Oral Care

They may be grumpy from lack of food/drink

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100
Q

Clear Liquid Diet

A

Any liquid that is see through at room temp (broth, coffee, carbonated beverages, ice pops, gelatin, clear juice, tea)

1st step post-surgery

poor nutritional value (long term would need IV sub)

“clear Diet, advance as tolerated” means nurses can assess advancement

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101
Q

Clear Liquid Diets allow the nurse to …

A

assess tolerance to PO intake, and choose advancements in diet

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102
Q

Concerning Signs to Be on the Look Out For during Clear Liquid Diets?

A

Not Voiding
Full Feeling
Diarrhea
Abdominal pain and distention

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103
Q

What things do we want the patient to experience before advancing past a clear liquid diet?

A

Want them to feel hungry

Have positive bowel sounds

have them pass flatus (sometimes)

be able to eat half or three-fourths of their tray before advancing

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104
Q

Full Liquid Diet

A

Includes all of the clear diet plus milk products, frozen deserts/custards/pudding, pasteurized eggs, veggie juices, milk/egg substitutes

This has better nutrition than a clear diet so it can be taken for a few days without supplementation

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105
Q

Soft Diet

A

“bland diet” or “Low fiber diet”

It is a regular diet to remove food difficult to digest or chew

it meets nutritional satisfactory, but it is very tasteless

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106
Q

What cannot be given in a soft diet?

A

No High Fiber Food (salad, roughage)

No High Fat Food

No Highly Seasoned Food

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107
Q

Pureed Diet

A

Foods (meat, veggies, etc) are blended to a liquid form similar to baby food

It is for patients with difficulty chewing, swallowing, facial control/paralysis, or post oral surgery

Has nutritional value since foods are blended with broths, gravies, cream soups, cheese, milk, juices to increase calorie and nutritional value

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108
Q

Problems with the Pureed Diet

A

A patient could aspirate on the food if they cannot swallow

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109
Q

Mechanical Soft Diet

A

Diet where food is modified for texture (chopped, ground, pureed) when the patient has difficulty chewing or surgery to the head/neck/mouth

Mashed soft ripened fruits and cooked, mashed, soft veggies are common in this diet

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110
Q

Regular Diet

A

“House Diet”

Any food is allowed , and patients can generally order what they want depending on the facilities dietary system

Issue is aspiration though once again

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111
Q

NAS

A

“No Added Salt” or Sodium Restricted Diet

Used for patients with heart disease, hypertension, kidney disease, or ascites

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112
Q

I&O

A

Intake and Output

We need to measure what patients consume and what they put out

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113
Q

Examples of Intake

A

By Mouth Foods

IV Fluids

Antibiotics

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114
Q

Examples of Output / 3 Ways Output is Measured

A

Urine

Sweat

Stool

115
Q

How is intake and output measured?

A

Solid intake - percentage taken in
Liquid Intake - mL or cc

Output - cc or mL for liquids ; weight for solids

116
Q

Important Nursing Considerations on Challenges in Nutrition

A

Impaired Appetite
Eating Alone
culture
Religion
Serving Times
State of Health
Preferences
Cognitive Level
Cognitive Impairment

117
Q

Ways to Stimulate an Appetite in a Patient

A

Offer small and frequent feedings

solicit favorite foods from home when possible

provide a pleasant eating environment

schedule procedures and meds when they are less likely to interfere with appetite

control pain, nausea, depression with meds

offer alternatives for items person will not/ cannot eat

provide good oral hygiene

provide a comfortable position

118
Q

If a patient cannot chew or swallow at all, how may they eat?

A

Enteral Feedings
Parenteral Feedings

119
Q

Enteral Feedings

A

Feedings administered directly into the stomach via a tube (ex: OG, NG, PEG)

120
Q

OG Tube stands for …

A

Oral Gastric Tube

121
Q

NG Tube stands for …

A

Naso Gastric Tube

122
Q

PEG Tube stands for …

A

Percutaneous Gastrostomy or Jejunostomy Tube

123
Q

How are enteral feeding tubes named?

A

based on where they are inserted and then directed

124
Q

NG Tubes

A

Put in the nose down to the stomach

for short term use (< 6 weeks)

125
Q

What is a risk of using an NG tube?

A

aspiration

126
Q

What does aspiration look like during enteral feedings?

A

Increased HR, RR

Anxiety

Auscultated Rhonchi

Vomiting up Solution

Decreased O2 Sat

127
Q

If rhonchi are still present after coughing, this is an indication of …

A

aspiration of solution during enteral feedings

128
Q

Think ____ to help prevent aspiration of NG tube feeding patients

A

positioning (of the tube and the patient)

129
Q

What position should the patient be in during NG tube feedings and up to an hour after?

A

High Fowlers or on their Right Side if Comatose

130
Q

Points to consider when doing enteral feedings?

A

Food at room temp (cold can cause cramps/diarrhea)

Aspirate prior to feeding to assess residuals and evaluate last feeding absorption

May have to check placement with X Ray (first check)

Assess bowel sounds prior to feeding (if absent hold it)

Look for dumping syndrome signs

Flush tubing with water to maintain fluid balance and patency of tubes

131
Q

A piston syringe residual of greater than 150 for enteral feeding means…

A

you should contact the physician (it should be 100-150)

132
Q

Enteral Feeding Schedules

A

Intermittent
Bolus Intermittent
Continuous Feedings
Cyclic Feedings

133
Q

Preferred Enteral Feeding Schedule

A

Intermittent

134
Q

Intermittent Feeding

A

300-500 mL of enteral formula administered several times a day (preferred method)

135
Q

Bolus Intermittent Feeding

A

a bag hanging by gravity or a syringe delivers formula into the stomach - can be fairly quick and therefore may not be tolerated

136
Q

Continuous Feeding

A

infusion pump administers feedings at a constant flow 24 hours a day.

Stomach never gets a rest and patient must be at a 30 degree angle at all times

137
Q

Cyclic Feedings

A

continuous feedings delivered over less than 24 hours (usually at night)

138
Q

What is the bumper in an enteral feeding tube?

A

a balloon that inflated to prevent migration out of the stomach

139
Q

Tubes need to be ____ so we do not clog smaller tubes

A

patent

140
Q

Parenteral Feeding

A

Deliver nutrients directly into bloodstream - bypassing GI tract

used when patients cannot meet nutritional needs orally or enterally

yellow fluids are often the solution with white as the lipid/fat contents

141
Q

Solutions present in Parenteral Feeding

A

Dextrose
Amino Acids
Electrolytes
Vitamins
Trace Elements in Sterile Water

142
Q

What sort of patients need parenteral feedings?

A

Comatose
Non functioning GI Tracts
Extensive Burns
Extensive Surgery
Extensive Cancer Treatments
Premature Infants

143
Q

What is the general duration of parenteral feeding?

A

less than or equal to 14 days / 2 weeks

144
Q

2 Types of Parenteral Nutrition Solution?

A

TPN and PPN

145
Q

TPN

A

Total Parenteral Nutrition

Uses a central IV line (like vena cava), since peripheral with this could cause infection or phlebitis

It is highly concentrated, hypertonic nutrient solution

*Neonates can have this administered in peripheral IV (commonly) or central lines - they often get TPN

146
Q

PPN

A

Peripheral Parenteral Nutrition

Not as nutrient dense as TPN making it less caustic to veins

147
Q

Complications of Parenteral Nutrition

A

Liver Damage (from lipids)

Hyperglycemia (from dextrose)

Sepsis (unclean catheter)

Phlebitis/Infiltration

Central Line Placement Issues (Infection, Catheter Fracture, Clotting)

148
Q

What is important to keep in mind on frequency of BM?

A

frequency varies person to person and it is not necessary for everyone to have a daily BM

149
Q

Common bowel problems?

A

Diarrhea
Fecal Impaction
Flatulence
Constipation
Bowel Incontinence

150
Q

What to assess on patient Bowel Elimination?

A

Color
Odor (C Diff has a distinct smell)
Amount
Consistency
Frequency

151
Q

Contributing Factors for Altered Bowel Function

A

Activity Levels
Physiologic Factors
Defecation Habits
Diagnostic Procedures
Anesthesia
Pathologic Conditions
Pain
Medications

152
Q

How does activity affect bowel function?

A

immobility and lack of exercise can lead to weakened abdominal and pelvic muscles

153
Q

Physiologic Factors that can affect bowel function?

A

Anxiety
Depression
*they have a response on the enteric nervous system

154
Q

How does anesthesia affect bowel function?

A

It can slow normal colonic movement by influencing the ileus

155
Q

Example of a Pathologic Condition that can alter bowel function?

A

a spinal cord injury

156
Q

How do medications affect bowel function?

A

A drug may increase or decrease GI motility and influence appearance of stool

Also, habitual laxative use will inhibit natural defecation reflexes and cause more constipation

157
Q

Ostomy

A

Surgically formed opening from the inside of an organ to the outside of the body - the intestinal mucosa is brought to the abdominal wall, and a STOMA is formed by suturing the mucosa to the skin

158
Q

What is the consistency of ostomy excrement?

A

depends on its location

159
Q

Ileostomy content consistency is ..

A

liquid form since it is from the ileum of the small intestine

160
Q

Colostomy content consistency is ..

A

formed, but depends on location:

Ascending colon is both liquid and formed
Transverse colon is more formed than liquid
Descending and Sigmoid should be formed

161
Q

Why is a colostomy needed?

A

Bowel is blocked or perforated

Portion of bowel has been removed d/t cancer

Trauma

162
Q

Is an ostomy permanent or temporary?

A

both

Temporary allows the bowel to heal and permanent occurs fi rectal cancer or a portion of the GI tract was removed

163
Q

How many stomas are in a temporary ostomy?

A

2 because they will eventually be refused by surgery

164
Q

When assessing a stoma/ostomy, a healthy stoma is …

A

Bright red or dark, pink and moist

has minimal bleeding

size stabilized after 6-8 weeks

protrude about .5 to 1 inch from the abdominal surface

165
Q

A pale stoma indicates…

A

anemia

166
Q

Dark Purple / Blue Stoma indicates …

A

ischemia or compromised circulation

167
Q

Stoma Nursing Interventions

A

Try to limit odors as much as possible

Keep skin around the peristomal area clean and dry

Measure I&O properly

Educate and explain to help get them through it

Encourage patient to participate in care and look at the ostomy

168
Q

Enemas

A

A solution put into the rectum and large intestine to distend the intestines and maybe irritate intestinal mucosa to cause increased peristalsis and expulsion of feces and flatus (lube causes explosive defecation)

169
Q

Purpose of Enemas

A

To relieve constipation or fecal impaction

Promote Visualization of intestinal tract during X ray

Prevent the escape of feces during surgery

treat parasites and worm infestations

170
Q

Types of Enemas

A

Cleansing
Retention
Carminative
Return-Flow

171
Q

How to administer an enema?

A

Sims position on Left Side so the fluid flows down the sigmoid colon on left side –> raise solution to increase flow force slowly –> if there is pain or cramping clamp the tube for 30 s and restart even slower –> instruct client to hold 10-15 minutes unless a bowel movement was the purpose —> have bedpan/commode ready –> document

172
Q

Nursing Interventions to Promote Bowel Elimination

A

Goal to Promote Regular Defecation

Provide Privacy

Schedule

Lots of Fluids and fiber

Provide as normal a position as possible when using bedpan

Milk of Magnesia –> Suppositories’ –> Enema

173
Q

What parts are included in an integumentary assessment?

A

Skin
Hair and Scalp
Nail

174
Q

The skin is the ____ organ, and the most ____

A

largest, neglected

175
Q

The skin accounts for around ___% of your body weight

A

15 %

176
Q

The average person has ___ ____ skin cells

A

300 million

177
Q

Your skin hosts around ____ types of bacteria

A

1000

178
Q

More than half the dust in your home is…

A

actually dead skin

179
Q

The skin renews every …

A

28 days

180
Q

Functions of the integumentary system?

A

Offers Protection (against organisms/weather/etc)

Thermoregulation (subcut. fat allows)

Alerts the Sensory System (pain, heat, etc)

Metabolizes Vitamin D

Affects communication and Identification (people or texture of things)

181
Q

The integumentary system is deeply entwined in the ____ system

A

neuro

182
Q

Epidermis

A

First Skin Layer

Melanocytes (color)

Provides a Barrier

Thin (5 layers to it)

Acidic pH and has a Lipid Layer to ward off organisms and moisturize/protect

Visible

183
Q

Why are skin washing products so important to think about in the hospital?

A

You do not want to wash off the acidic pH of the epidermis and weaken protection

184
Q

Dermis

A

“The Working Layer” below epidemis

Hair Follicles, Capillaries, Sweat Glands, Nerve Ends

Most Dense layer of Skin (2 layers to it)

Fibroblasts here release collagen and elastin

Important to immunity, nutrition, skin repair, heat regulation, equilibrium maintenance

185
Q

Basement Membrane

A

zone dividing the epidermis and dermis

as this membrane degrades with age, the skin becomes less supple, intact, or elastic

186
Q

Collagen

A

Protein released by dermis fibroblasts

helps in the strengthening of the skin

187
Q

Elastin

A

protein released by dermis fibroblasts

helps pull skin back into place / provide elasticity

188
Q

Subcutaneous Tissue

A

“Hypodermis” / Below Dermis

Layer between skin and structures like bone, muscle, tendon

Acts as an insulator and pressure redistributor

Not every area has / has little subcutaneous tissue

189
Q

If there is not much subcutaneous tissue in an area, what may occur?

A

In areas like the ear pinna, bridge of nose, and heel there is little protection and pressure redistribution so skin breakdown can occur more easily here

190
Q

Perfect Wound Healing Trajectory?

A

Hemostasis –> Inflammation –> Proliferation –> Tissue Remodeling

191
Q

Hemostasis

A

First stage of wound healing

body forms a clot almost immediately

can be influenced by age and blood thinners

192
Q

Inflammation

A

Second stage of wound healing

blood vessels have clot, and then WBC immediately come and macrophages eat away at bacteria - rescue and fight

inflammation helps healing without allowing infection

Sometimes suturing or cleaning out the wound occurs here

193
Q

Proliferation

A

Third stage of wound healing

body heals from the inside out

epidermal injuries proliferate and heal faster

comorbidities may cause becoming stuck and this and the inflammation stage without progression, and thus needing intervention

194
Q

Tissue Remodeling

A

Final and Fourth stage of wound healing where the body keeps closing the wound inside out

195
Q

What is a big influence on wound healing?

A

comorbidities

196
Q

In what direction does the body heal skin?

A

From Inside Outward

197
Q

What kind of skin injury heals quickest?

A

Epidermal

198
Q

Full Thickness Wound

A

A wound that goes down into the dermal layer and takes longer to heal than an epidermal injury

199
Q

A wound is ____ not ____

A

closed not healed

Healing means it wont occur again its over, but closing means theres still remodeling occurring

200
Q

Wound Closure

A

Primary, Secondary, Tertiary Intention

201
Q

Primary Intention

A

Wound closure from something like sutures or medical intervention

202
Q

Secondary Intention

A

wound closure that occurs by letting normal body processes occur

203
Q

Tertiary (Delayed Closure) Intention

A

Dirty wound is allowed to be open and heal naturally for a time with cleaning products used, and eventually it will be surgically closed

ex: Fasciotomy

204
Q

Factors that can affect wound healing ?

A

Comorbidities:

Circulation impairment

Hyperglycemia (too much sugar means the wound will not want to close)

Tobacco Use

Poor Nutrition (lack of vitamins, proteins, calories will slow down the process)

Spinal Cord injury

Infections

Dying process (blood is diverted to vital organs so skin is neglected)

205
Q

Nurses are responsible for taking care of the patient’s (potentially neglected) ____

A

skin!

206
Q

How long should a skin assessment take?

A

5 minutes or less

207
Q

What is the skin assessment technique order?

A

Interview, Inspection, Palpation

208
Q

What doing the skin assessment it is important to know what 2 things?

A
  1. Patients and caregivers are best info sources
  2. Ask questions to get the full picture
209
Q

Pressure point Areas

A

Areas that pressure wounds/wounds are more likely to occur

Buttocks > Heels > Elsewhere

210
Q

Skin Inspection

A

Check skin for:

Tone based on ethnicity

Pigmentation

Color changes

lesions

rashes

infections

hygiene issues

211
Q

If you can, it is better to do what during skin assessments?

A

Do it without gloves

212
Q

Skin Palpation

A

Touch the skin:

open or closed?

hot or cold?

erythema? infection?

hydration: cracked, scaly, turgor

Inflammation, edema, rashes

moisture of skin: diaphoretic, oily, dry

213
Q

What is the next step after skin palpation?

A

Hair and Scalp Assessment

214
Q

Hair and Scalp Assessment

A

Inspect hair and scalp:

presence or absence of hair

infections

infestations with things like lice and nits

dry hair, dry scalp

215
Q

What is the next step after hair and scalp assessment?

A

Nail Assessment

216
Q

Nail Assessment

A

Inspect Nails:

condition

infections

trimming/grooming ability

color of nailbeds

capillary refill

dry, brittle, cracked, clubbing?

217
Q

What may clubbed nails be an indicator of?

A

COPD, sickle cell, cystic fibrosis, anemia

218
Q

What to look at when assessing a wound?

A

First: ASSESS WHOLE PATIENT (holistically)

Etiology/location

wound bed color

drainage amount and color (COCA/REEDA)

Odor

size

periwound condition

pain

219
Q

Wound assessments need you to first assess the whole patient, what does this mean?

A

Assess them holistically: spiritually, physically, psychologically, etc

Use the science AND THE ART of nursing

220
Q

REEDA

A

Wound assessment mnemonic

Red
Ecchymosis
Edema
Drainage
Approximation

221
Q

COCA

A

Wound drainage mnemonic

Color
Odor
Consistency
Amount

222
Q

Drainage Types

A

Serous
Serosanguinous
Sanguineous

223
Q

Serous Drainage

A

Clear stick fluid / light yellow (seen near end of wound healing)

224
Q

Serosanguinous Drainage

A

Slightly bloody/pink mixed with some serous drainage near mid to late healing

225
Q

Sanguineous

A

Bloody Drainage

226
Q

Braden Scale

A

Pressure ulcer risk predictor score with 6 categories

227
Q

6 Braden Scale Categories

A

Sensory Perception
Moisture
Activity
Mobility
Friction and Shear
Nutrition

228
Q

The lower the Braden scale score…

A

the higher the risk of pressure ulcer (18 or less is high risk)

229
Q

Slough

A

light yellow wound area that can probably be cleaned off

230
Q

Granulation Tissue

A

red healthy tissue indicative of healing

231
Q

Eschar

A

black wound made of necrotic dry tissue that may need debridement or natural sloughing off

232
Q

Maceration

A

break down of skin due to too much moisture

233
Q

How to measure a wound?

A

Length is cephalocaudal direction in cm
Width is hip to hip direction in cm
Depth is from the deepest part in cm

Tunnels need depth in cm and clock direction

Undermining needs start and stop direction in clock direction

234
Q

Tunnelling

A

A deeper wound that “tunnels” under the skin and must be measured in cm and referred to by clock direction

235
Q

Undermining

A

Areas where the wound bed are wider than the peri wound and need to be measured according to clock direction

236
Q

Potential Wound Complications?

A

In Hospital:
Poor Drainage Management
Wound Healing Stalled
S/S of Infection present in wound or systemic
Wound Pain

In community:
Patient goals change
Patient does not follow care plan
Treatment expensive
No caregiver to help with wound care
Comorbid conditions not well controlled

237
Q

Ways to Manage Wound complications?

A

Notify the Provider

Request Specialist Consult

Wound Culture/Blood Work

Antibiotic Therapy when Infected

Teach pain management

Communicate with patient to address concerns

Include patient in plan of care

Social workers may be needed to address financial or caregiver concerns

Dietician consultation

238
Q

Pressure Ulcers/Injury

A

“Cubuteous Ulcers” / “Bed Sores” - Now called pressure injuries

A bottoms up skin injury (not surface) rated as a stage I to IV scale, unstageable, or deep tissue pressure injury

239
Q

Pressure Injuries are ___ ___

A

bottoms up

240
Q

Stage I Pressure Injury

A

Non blanchable area of erythema over a bony prominence (stays red when blanched - wont turn white)

241
Q

Stage II Pressure Injury

A

Partial thickness skin loss with the dermis now present visibly

Pink/red wound bed or serous filled blister

fat, granulation, slough, or eschar ARE NOT PRESENT

due to shearing/external forces

242
Q

Stage III Pressure Injury

A

Full thickness skin loss, adipose tissue present, nonviable tissue may also be present

Supporting structures ARE NOT PRESENT

may have tunneling or undermining

Epithelial tissue growth may not return to normal color

CAN HAVE granulation, slough, non viable tissue present unlike stage II

243
Q

Stage IV Pressure Injury

A

Full thickness skin loss with the supporting structures (bone, tendon, muscle, fascia) present/visible

244
Q

Unstageable Pressure injury

A

Full thickness wound that cannot be staged since it is covered by nonviable slough tissue or eschar

must be unroofed to determine

245
Q

Deep tissue injury

A

Area of intact or nonintact skin with area of NON BLANCHABLE deep red, maroon, or purple discoloration

may also be a blood filled blister

246
Q

Venous Ulcers / Lymphedema in regards to Healthcare settings

A

80% of all lower limb wounds, reoccurs very commonly, and costs 2 billion annually

hard to treat may need lifelong compression

247
Q

CVI stands for

A

Chronic Venous Insufficiency (Venous Ulcers)

248
Q

Etiology of Venous Ulcers

A

High pressure in lower leg vessels

Decreased venous return

Damage to valves

Vein distention and obstruction

venous stasis (hard to return blood to heart)

249
Q

S/S of CVI and Venous Wounds

A

Lower Limb Edema (pulses felt if not)

Dry Scaly Skin

Sensitive Skin

Itchy Skin

Maceration

Hemosiderin Staining

Varicosities

Lipodermatosclerosis (lower leg skin changes)

Wounds located in medial limb (calf), and gaiter area

Irregular Wound Borders

LARGE amount of exudate

Feet are warm/pink

Can be painful

Leg takes on an upside down / bottleneck shape

250
Q

Hemosiderin Staining

A

Venous ulceration occurring with a red/purple color

251
Q

Venous Ulcers/CVI may require…

A

lifelong compression that is difficult to maintain

252
Q

Lymphedema etiology

A

Edema in Lymph:

Trauma to area

Radiation

cancer

vessel infections

253
Q

Lymphedema is often …

A

unilateral (because circulation is broke by a disease on one side)

254
Q

Lipedema

A

symmetric enlargement of legs due to fat deposits in obesity

255
Q

Treatment of Lymphedema?

A

massage and compression for life (but venous ulcers mostly take compression)

256
Q

Arterial Ulcer

A

Limited or no arterial blood flow feeding lower limbs leading to ischemia which causes ulceration and bad healing

257
Q

Etiology of Arterial Ulcers

A

Major cause - Tobacco Use

Others: Diabetes, Raynaud’s, HTN, Auto Immune Disease

258
Q

Arterial Ulcer and Ischemia Characteristics

A

Punched out appearance

defined borders

typically unhealthy wound bed colors (yellow, brown, black)

often infected with minimal drainage

often present on distal toes, ankles, feet

pedal pulses nonpalpable or faint

feet may be dusky or cool to the touch

toe nail fungus often present

lack of hair growth on limbs

necrosis may be present

very painful ulcers

complain of intermittent claudication (walking pain) and pain with leg elevation

259
Q

Lower Extremity Neuropathic Disease (LEND)

A

Disease leading to neuropathic ulcers from various conditions, most commonly diabetes

260
Q

Etiology/Causes of Neuropathic Ulcers

A

Most Commonly: Diabetes

Other: Kidney disease, traumatic spinal cord/nerve injury, infection, vitamin deficiency, medications, chemotherapy

It is due to perfusion impairment contributing to damage of the nerves to the extremities

261
Q

Most common type of neuropathic ulcer

A

Diabetic Foot Ulcers

262
Q

Sensory neuropathy pathology of Neuropathic Ulceration

A

Paresthesia
Loss of sensation, recognition, balance
Risk of falls

263
Q

Paresthesia

A

loss of the ability to feel

264
Q

Motor neuropathy pathology of Neuropathic Ulceration

A

Foot Deformities

Changes in Gait / Autonomic Neuropathy

Sweat Gland Regulation - cracks, fissures in skin occur

Bone changes - osteopenia, fractures

Charcot Foot

265
Q

Neuropathic Ulcers are typically on what surface?

A

Plantar surface where a boney issue is underneath (often where someone stepped on something or a shoe rubbed it)

266
Q

Charcot foot

A

condition causing the weakening of the foot bones occurring in people with significant nerve damage (neuropathy)

267
Q

Diabetic foot ulcers increase risk of …

A

Amputation significantly, which leads to a drastic increase in mortality rate

268
Q

Surgical Wounds

A

incisions made purposefully by a professional and are cut precisely, creating clean edges around the wound, and then often closed by primary intention

269
Q

Why might a surgical wound be left open to heal by tertiary intention?

A

to allow better granulation tissue formation depending on wound characteristics and the reasoning behind the surgical intervention

270
Q

Clean Surgical Wound

A

Non-contaminated surgical wound

Performed in operating room which is a sterile environment

can be left opened or closed

271
Q

Contaminated Surgical Wound

A

wound without infection, but at high risk for infection

high microorganism load occurred

272
Q

Dirty Surgical Wound

A

Surgical wound done in a dirty/non-sterile area with high risk of infection and infection probably already present

273
Q

MASD

A

Moisture Associated Skin Damage

Often forgotten, but needs management

It is the inflammation of the epidermis from exposure to urine, stool, sweat, drainage over time

The skin is saturated, injured, and susceptible to disease/breaking

Can be difficult to treat, and moisture must be managed

274
Q

Palliative Wound Care

A

approach of wound care on relieving suffering and improving QOL when curing is difficult/impossible

one of the most challenging areas, with long term wounds difficult to heal

Patient MAY be on end of life care

275
Q

Palliative Wound Care Goals

A

What is most concerning to patient?

What are the patient/caregiver willing to do?

What are the comorbid factors/prognosis involved?

We want to know what is most concerning to the patient and caregiver and be on the same page of treatment, be inline with them and not gung-ho about it

276
Q

What symptoms may be most problematic for a patient in palliative wound care?

A

Odor
Pain
Drainage Management
Location
Emotional Problems

277
Q

Kennedy terminal ulcer

A

Wound requiring palliative care/palliative wound

Sudden onset of a deep purple/maroon color over an area like the sacrococcygeal/ischium

It is butterfly/pear shaped with irregular borders and progresses rapidly

it often indicates the patient as being near death

278
Q

Gangrenous Ulcers and Weepy Edema

A

Palliative Care Wounds

Often indicate the patient is at end of life

Gangrenous appears as crusty and blackened on lower limbs, and weepy edema has pitting edema with fluid leaking out

279
Q

Malignant Lesions

A

“Fungating Lesions”

Type of Palliative care wound

It is cancer that breaks through the skin

Offensive odor

Very Painful

Drainage is excessive because it is very vascularized and bleeds easily

Common in hospitce populations

280
Q

What is important to critical thinking when dealing with malignant lesions?

A
  1. We need a dressing that wont stick or cause more damage/bleeding
  2. We need to understand the patients problem and get creative in covering them up so they can be part of the community in their final time
281
Q

Overall, when managing wounds it is important to do what?

A

GO BACK TO THE ASSESSMENT AND GOALS

everyone should be on the same page during treatment

282
Q

Dehisced

A

wound surgically created that has opened back up

283
Q

Evisceration

A

when bowel comes out of a wound that has opened up on the anterior/abdomen - it is a surgical emergency since pinching can occur leading to loss of blood flow and necrosis followed by sepsis and death

284
Q

Herniation

A

bowel comes through the muscle layer, but not all the way out like in evisceration

N321: Nursing Assessment of Clients (18 decks)

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