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Nursing Fundamentals > Skills- Exam 2 > Flashcards

Skills- Exam 2 Flashcards

1
Q

The abdomin can be divides ino

A

4 Quadrant
9 Regions

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2
Q

bruits

A

unusual bowel sound

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3
Q

While in supine position, you should inspect the abdomen for?

A

-Size, shape, and symmetry
-Color lesion and scars
-Movement, respiratory, and peristalsis
-Umbilicus position, contour, or bulging

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4
Q

Abdominal Distension

A

swelling

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5
Q

How should ear plugs of a stethoscope be positioned?

A

toward your nose

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6
Q

Diaphragm

A

high-pitched sounds
(breath & bowel sounds)

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7
Q

Bell

A

low-pitched sounds
(Blood pressure & apical pulse & bruits)

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8
Q

Using a stethoscope

A

-lightly wet chest hair
-Quiet environment
-Warm stethoscope
-Skin to scope
-Close eyes

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9
Q

When listening for bowels sounds, where should you start? And why

A

RLQ
thats where digestion starts

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10
Q

What should you do before saying bowels sounds are absent?

A

Listen for at least 5 mins. each quadrant

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11
Q

Absent-Bowel sounds

A

no bowel sounds

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12
Q

Hypoactive-Bowel sounds

A

soft
infrequent
>20 seconds

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13
Q

Normal-Bowel sounds

A

high-pitched, gurgling
irregular
1-4 sounds heard in 20 seconds

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14
Q

Hyperactive-Bowel sounds

A

high-pitched, rushing, tinking sounds

diarrhea/early intestinal obstruction

> 4 sounds in 20 seconds

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15
Q

Where to auscultate for the bruits?

A

Aorta
Renal
Iliac
Femoral

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16
Q

How to palpate for tenderness?

A

light palpation

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17
Q

Enema

A

solution introduced into the rectum and large intestine

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18
Q

The point of an Enema

A

to distend intestine and increase peristalsis and excretion

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19
Q

Types of enemas

A

FLEETS-hypertonic solution (90-120ml) for 5-10 mins
TAP WATER-hypotonic (500-1000ml) for 15-20 mins
RETENTION-oil solution (90-120ml) for 30mins-3hrs
SOAP SUDS-3-5ml soap (500-1000ml) for 10-15 mins
ISOTONIC-0.9 Normal Saline (500-1000ml) for 15-20 mins.

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20
Q

Can a client administer their own enema if they want to?

A

Yes

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21
Q

Bowel Diversions

A

Watery –> firm

Ileostomy
Ascending Colostomy
Transverse Colostomy
Descending Colostomy
Sigmoidostomy

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22
Q

How often should the ostomy faceplate be changed?

A

Once a week

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23
Q

What can help control odor from ostomy?

A

Charcoal filters
Diet change
Sprays for room

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24
Q

Enteral

A

of or relating to the intestines

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25
Enteral Tubes
Nasogastric Nasoduodenal Nasojejunal Gastrostomy Jejunostomy
26
Gastrointestinal Suction
-relieves abdominal distention -maintains gastric decompression after surgery -removes blood and secretions from the gastrointestinal tract -maintains the patency of the NG tube
27
If any pain of abdomen when should you palpate that area?
Last
28
Gastric Secretions
grassy green/off white/tan pH 1-4
29
Intestinal Secretions
golden yellow/brownish-green pH = to or > 6
30
Respiratory Secretions
more alkaline 7 or greater
31
Gastrointestinal Suction
Confirm placement Assess function Maintain patency with irrigation Maintain mouth care
32
Removing a Nasogastric Tube
Assess abdomen -check for bowel sounds -check for flatus -check for nausea & vomiting
33
Enteral Feeding
the introduction of nutrients directly into the GI tract by a feeding tube
34
Percutaneous Endoscopic Gastrostomy (PEG) Tube
surgically installed
35
Types of Enteral Feedings
OPEN only 4-8hrs (Powders/Cans) CLOSED 24-48 hrs (ready to hang)
36
Tube Feeding bag and tubes should be changed?
every 24 hrs/change daily
37
Continuous Feeding
-Specific amount & rate of formula over 18-24hrs -recommended by dietician -well tolerated by patient -Inhibits mobility and ADLs
38
Intermittent Feeding
-300-500ml of formula several times per day over atleast 30 minutes -administered by syringe/gravity -check for residual before every feeding -not always tolerated by patient -promotes mobility & ADLs
39
CAUTI
Catheter Associated UTI
40
Why do people need urinary catheterization?
-Incontinence -Urinary retention -Difficulty voiding after surgery -During long surgical procedures -Measuring accurate I&O
41
What are catheters measured in?
French (fr) scales
42
Catheter sizing:
#8-10 French = children (3ml ballon) #14-16 French = women (10 ml ballon) #18 French = men (10 ml ballon except prostate procedures, 30 ml)
43
Supra-Pubic Catheter
surgically inserted by doctor
44
Venous vs. capillary Blood glucose
Venous- blood draw (should not be done for morning) Capillary- Finger stick
45
Normal Blood Sugar Ranges
Adults & Children >2 = 70-99mg/dl Infants= 40-90mg/dl Neonates= 30-60 mg/dl
46
Blood glucose in adults
Normal = 70-99mg/dl Impaired = 100-125mg/dl At risk for diabetes = >126 mg/dl
47
Type I vs Type II Diabetes Mellitus
Type I = Insulin dependent (born with it/genetics) Type II = Non insulin dependent (adult onset)
48
Hyperglycemia
High blood sugar >140mg/dl Symptoms: -Extreme thirsts -Frequent urination -Dry skin -Hunger -Blurry vision -Drowsiness -Nausea
49
Hypoglycemia
Low Blood Sugar <70 mg/dl Symptoms: -Shaking -Fast Heartbeat -Sweating -Anxious -Impaired vision -weakness/fatigue -Hunger --Drowsiness -Headache -irritable
50
Glycosylated Hemoglobin (Hmg A1c or A1C or Hgb A1C)
Normal = 4%-5.6% Increased risk = 5.7%-6.4 % Diabetes = 6.5% or higher (Goal is <7%) Testing occurs 3-4x /year
51
Clean Void Urine Specimen
Used for routine examination First am void (10ml)
52
Clean catch/Midstream Specimen
Used for possible UTI/ culture void-stop-void into sterile container (30ml, need 3 ml for culture)
53
Timed Urine Specimen
24 hour urine collection Same container for all urine Kept on ice send to lab at 24 hrs
54
Indwelling Urine Catheter Specimen
-Clamp Foley Catheter 30 mins before collecting sample -Don't for
55
Orthopnea
Need to sit/stand to breath comfortable
56
Tachypnea
abnormal breathing rate >20
57
Dyspnea
difficulty breathing
58
Apnea
no breathing
59
Hyperventilation
increased rate/depth rate >20
60
Eupnea
normal breathing
61
Lobes of the lungs
2 Lobes on the Left 3 Lobes on the right (BC of position of heart)
62
Normal Breath Sounds
Vesicular Bronchovesicular
63
Adventitious Breath Sounds
Wheezes (whistling) Crackles/Rales (fire) Gurgles/Rhonchi -may clear w/ coughing Friction rub (leather)
64
Wheeze
(whistling) expiratory
65
Friction rub
(leather) inspriation & expiration
66
Crackles/Rales
(fire) soft/high pitched
67
Gurgles/Rhonchi -may clear w/ coughing
Low Expiratory
68
Vesicular
Soft/low pitched
69
Bronchovesicular
Medium pitch
70
Stridor
Medical Emergency suggests obstructed trachea/ larynx
71
Early Signs of Hypoxia/Hypoxemia
-Rising vital signs -Irritability -Headache -Agitation -Confusion
72
Late Signs of Hypoxia/Hypoxemia
-Falling Vital Signs -Seizures -Coma -Brain Tissue Swelling
73
Pulse Oximetry
noninvasive device that measures the arterial blood oxygen by saturation
74
Why use a Peak Flow Meter?
-Assesses if medication is working -Evaluate when to add or stop medicine -Decide when to seek emergency care
75
Peak Flow Zones
Green = 80-100% Good control Yellow = 50-79% Asthma is getting worse Red = Below 50% Seek help STAT
76
Nasal Cannula
1-6 liters/min Oxygen concentration of 24-40%
77
Simple Face Mask
6-10 liters/min Oxygen concentration of 40-60%
78
Non-Rebreather Mask
10-15liters/min Oxygen concentration of 95-100%
79
Advair
DPI= dry powder inhaler should not be taken more than twice a day breath quickly and deeply
80
Nebulizer
-used to deliver humidity & medication -for patients who can not use MDI/DPI -children under 5 -patients with severe asthma
81

Nursing Fundamentals (12 decks)

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