Week Nine Flashcards
Occult Blood
Hidden blood
Carminative Enema
given to expel flatus. Solution releases gas in rectum which causes distention and stimulates peristalsis
Retention Enema
Introduces oil or medication into the rectum and signmoid colon. Softens feces, lubricates feces and colonic mucosa to facilitate passage of feces.
Cleansing Enema
Removes feces using a variety of solutions
Enema Function
Remove feces and/or flatus
Enema
A solution introduced to the rectum and sigmoid colon
Fecal Impaction
A mass of hardened, puttylike feces in folds of rectum
Signs of Fecal Impaction
passage of liquid fecal seepage and no normal stool
Time it takes to see oil retention enema results
30minutes - 3 hours
Nursing Considerations for Enema
- Amount of fluid used
Soap Suds Enema
Cleansing soapy enema given to remove feces from colon. Relieves constipation and is a prep for diagnostic tests.
Action of Soap Suds Enema
Stimulates peristalsis by irritating mucosa and distending colon volume up to 1,000 mL H20 with soap
Oil Retention Enema
Retention enema that makes defecation easier. Mineral oil is commonly used.
What type of enema is a hypertonic enema?
cleansing enema
Hypertonic Enema
Cleansing sodium enema given to remove feces from the colon. Relieves constipation and preps for diagnostic tests.
Action of hypertonic enema
Draws water into the colon, distends the colon, irritates mucosa
Time it takes to see results from a hypertonic enema
5-10 minutes
Volume Hypertonic Enema
90-120 mL
What type of enema is a tap water enema?
Hypotonic cleansing enema
Carminative enema volume
180mL total
Volume oil retention enema
90-120mL
Tap water enema
Hypotonic Enema. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces.
Volume tap water enema
500-1000mL
What type of enemas should be administered to an infant or child?
isotonic
Enema temperature for infant or child
100 F or 37.7 C unless otherwise ordered
True or False: Elders may fatigue easily when administering an enema
True
What position is appropriate for administering an enema in a small child?
Dorsal recumbent position
How far should the tube be inserted for enema administration in infants?
1-1.5 inch
How far should the tube be inserted for enema administration in children?
2-3 inches
True or False: Tap water enemas should be used with caution in the elderly
True.
What should be assessed in elderly clients during enema administration?
vagal episodes, slow pulse, and irregular pulse
Nursing responsibilities for stool specimens
- Have the client defecate into a clean bedpan or bedside commode
Therapeutic Nursing Interventions for rectal suppository
- Hand hygiene and gloves
Anemia
lack of a normal number of red blood cells
Bradypnea
slow respiratory rate, usually below 10 respirations per minute
Cheyne Stoke Respirations
patter of breathing characterized by gradual increase of depth and sometimes in rate to a maximum level followed by a decrease resulting in apnea
Cyanosis
a bluish discoloration of the skin and mucous membranes
Diffusion
process by which molecules tend to move from an area where they are more concentrated to an area where they are less concentrated
Dyspnea
shortness of breath, difficult or labored respiration
Eupnea
normal relaxed breathing, easy
Hemoptysis
coughing up blood from the respiratory tract
Humidification
process of adding water to gas
Hypercarbia
the presence of an abnormally high level of carbon dioxide in the circulating blood
Hyperventilation
an increased depth and rate of breathing greater than demanded by the body needs
Hypoventilation
respiratory rate remains abnormally low and is insufficient to meet the demands for normal oxygen delivery and carbon dioxide removal. (most common cause of hypercapnia)
Hypoxemia
deficient amount of oxygen in the blood
Hypoxia
deficient amount of oxygen in tissue cells
Orthopnea
form of dyspnea in which the person can breathe comfortably only when standing or sitting erect
Productive Cough
cough with spitting of material from the bronchi
Nonproductive cough
dry, hacking, produces no secretions
Respiratory insufficiency
disturbance oflevels of oxygen and carbon dioxide in the blood stream, inability of body to meet oxygen nees andremove CO2
Tachypnea
an abnormally rapid rate of respiration, usually >20 breaths per minute
Oxygen Status Diagnostic Test Serum Hemoglobin
12-18g/100mL
Oxygen Status Diagnostic Test Serum Red Blood Cell Count
3.5-5.0 million/ cu. mm
Barrel Chest
a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.
Funnel Chest
pectus excavatum; depression in the lower portion of the sternum, may cause compression of the heart
Pigeon Chest
pectus carinatum; sternum displaced anteriorly; costal cartilage beside the protruding sternum are depressed
Biorhythms
an innate periodicity in an organism’s physiological processes, as sleep and wake cycles.
Circadian Rhythms
individual is awake when the physiologic and psychologic rhythms are most active and is asleep when the physiologic and psychologic rhythms are most inactive. Rhythmic repetition of patterns each 24 hours.
Hypnotic
depresses the central nervous system and usually produces sleep
Sedative
depresses the central nervous system to produce calm and diminished responsiveness without producing sleep
Sleep
a natural and periodic state of rest during which consciousness of the world is suspended
Somnolence
drowsiness; sleepiness
Insomnia
sleep abnormalities, including difficulty in falling asleep and wakefulness through the night
Hypersomnia
Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficulty maintaining an alert awake state during the day, or undesired daytime sleep episodes.
Narcolepsy
a sleep disorder characterized by sudden and uncontrollable episodes of deep sleep
Parasomnia
abnormal movement or emotions during REM and NREM and wakefulness. bruxism, enuresis, periodic limb movement disorder, sleep talking, sleep walking
Sleep Apnea
a sleep disorder characterized by temporary cessations of breathing during sleep and repeated momentary awakenings
Rest
calmness, relaxation without emotional stress and freedom from anxiety
NREM Sleep
75-80% of sleep, three stages
Stage One NREM
very light sleep, drowsy, relaxed, can be awakened easily and lasts a few minutes
Stage Two NREM
Light sleep which body processes continue to slow down. Lasts only 10-15 minutes but constitutes 44-55% of total sleep
Stage Three NREM
Deepest sleep. only differs in the % of delta waves recorded during a 30 second period. HR and R drop 20-30% below waking hours, individual difficult to arouse. restores energy and releases growth hormones
Changes during NREM sleep
BP falls, HR decrease, peripheral blood vessels dilate, cardiac output decreases, skeletal muscles relax, basal metabolic rate decreases, growth hormone level peaks, intracranial pressure decreases
REM Sleep
rapid eye movement, q 90 minutes for 5-30 minutes, not as restful as NREM, dreams, brain highly active and brain metabolism increases by as much as 20%, may be difficult to arouse or NOT, voluntary muscle tone is decreased, gastric secretions increase, HR irregular, R irregular
Functions of sleep
Restores normal levels of activity, normal balance among parts of the nervous system, necessary for protein synthesis, psychological well being
Newborn sleep
16-18 hr
Infant sleep
14-15 hr
Toddler sleep
12-14 hr
preschooler sleep
11-13 hr
school age children sleep
10-11 hr
adolescents sleep
9-10 hr
adult sleep
7-9 hr
older adults sleep
7-9 hr
Nocturia
excessive urination at night
Factors that affect normal sleep
illness, environment, lifestyle, emotional stress, stimulants and alcohol, diet, smoking, motivation, medications
Sleep History Assessment
sleep history, pattern, problems, medications, health history, medical or psychiatric issues, physical examination, obstructive sleep apnea, sleep diary
Normal Sleep Findings
awaken refreshed and not fatigued during day, fall asleep without difficulty
Sleep deprivation findings
difficulty falling asleep, waking up during the night, difficulty returning to sleep, waking up too early in the morning, unrefreshing sleep, daytime sleepiness, difficulty concentrating, irritability
Teenage sleep deprivation findings
difficulty waking, falls asleep, late for class, has to drink caffeinated bev, difficulty in school, irritable, anxious, angry, always on the run, naps and sleeps in on weekend
Definition disturbed sleep pattern
time limited interruptions of sleep amount and quality due to external factors
Defining characteristics disturbed sleep pattern
change in normal sleep pattern, verbal complaints of not feeling well rested, dissatisfaction with sleep, decreased ability to function, reports being awakened, reports difficulty falling asleep
sleep deprivation definition
prolonged periods without sleep(sustained natural, periodic suspension of relative consciousness)
defining characteristics of sleep deprivation
actue confusion, agitation, anxiety, apathy, combativeness, daytime drowsiness, decreased ability to function, fatigue, feeling nystagmus, hallucinations, hand tremors, heightened sensitivity to pain, inability to concentrate, irritability, lethargy, listlessness, malaise, perceptual disorders, restlessness, slowed reaction, transient paranoia
safety measures for sleep in health care setting
put side rails up, place beds in low position, use night lights, place call bells within easy reach
Ambien
Sonata
Zolpidem
Zaleplon
Ambien Use
short term treatment insomnia
Ambien action
CNS depression at limbic, thalamic, hypothalamic levels, may be mediated by GABA, sedation, hynosis, skeletal muscle relaxant, anticonvulsant activity, anxiolytic action
Side/Adverse effects ambien
lethargy, drowsiness, daytime sedation
nursing implications ambien
administer after removal of cigarettes to prevent fires, after trying conservative measures for insomnia, 30min-1hr before bedtime for sleeplessness
sonata use
insomnia
sonata action
binds selectively to omega-1 receptor of the GABA receptor complex, sedation, hypnosis, skeletal muscle relation, anticonvulsant activity, anxiolytic action
sonata side/adverse effects
lethargy, drowsiness, daytime sedation
sonata nursing implications
administer after removal or cigarettes to prevent fires, after trying conservative measures for insomnia, immediately before bedtime for sleeplessness
Phases of respiration
pulmonary ventilation, alveolar - capillary gas exchange, transport of gases, peripheral capillary gas exchange
Pulmonary Ventilation
Movement of air between the atmosphere and the alveoli of the lungs (inspiration, expiration)
Inspiration
active process
Expiration
passive process
Requirements for pulmonary ventilation
unobstructed airway, intact CNS, intact brain stem, ability of chest cavity to expand and contract, ability of lungs to expand and contract
Alveolar - Capillary Gas Exchange
diffusion=distribution. movement of gases from an area of higher concentration to an area of lower concentration, diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries
Transport of gases
Movement of gases lungs and heart, heart and tissues
Requirements of transport of gases
intact cardiovascular system
Oxygen is transported VIA what?
hemoglobin of RBC
Carbon Dioxide transported VIA what?
RBC and is dissolved in plasma
Peripheral Capillary Gas Exchange
Diffusion = Distribution. Movement of gases from an area of higher concentration to an area of lower concentration, diffusion of oxygen and carbon dioxide between the peripheral capillaries and body cells
Right Side Heart
Pulmonary Ventilation
Left Side Heart
Transport
Lungs
gas exchange
What mechanisms regulate the respiratory process?
neural control- brain stem: medulla oblongata and pons, cerebral cortex, chemoreceptors
Medulla Oblongata and Pons
automatic control of R
Cerebral Cortex
Voluntary or conscious control of R, singing, swimming
Chemoreceptors
increase in carbon dioxide increase R, co2 blown off
Aorta and Carotid arteries
decrease o2 increases R, increase o2, emergency ventilation, fight or flight response
Stress
flight or fight mechanism
Environment
Altitude, occupational hazards
Lifestyle
exercise, smoking
Health Status/Disease
lungs, nervous system, cardiovascular
Age
infants, children, elders
Factors that affect R function
stress, environment, lifestyle, diet, health status/disease, medications, age
Factors affecting gas transport
effective cardiac pump, adequate peripheral blood vessels for diffusion, adequate amount of plasma intravascular, normal RBCs
Infants R
30-60
Child >1 year R
25
Infant risk
maturing R center increases risk for R illness
Elder Risk
decrease lung elasticity, decrease in ability to pump and transport gases, exposure to environmental hazards through life time, decrease immune response = risk for respiratory illness
Information collected during nursing history when assessing oxygenation
restlessness, confusion, abnormal breathing patterns, cough, sputum, chest pain, fatigue, weakness, lightheadedness, med history respiratory, neurological, cardiovascular, environment, lifestyle, medications, diet
Function of Iron
Formation of Hgb - transports oxygen
Sources of Iron
organ meats, oats, prune juice
Absorption of Iron
Vitamin C increases absorption, calcium decreases absorption
Populations at risk for iron def
less than 18 months, pregnancy, lactation, menstruation, vegetarians, low socioeconomic groups
Oxygen Sat normal
95-100%
Areas to assess for cyanosis
nail beds, circumoral skin (around mouth), sublingual mucous membranes (under tongue), conjunctiva (eyes), earlobes, buccal mucosa (cheeks), lips, palms of hands, soles of feet
RBC Venous blood sample
trasport mechanism for oxygen
RBC normal value
3.5-5.0 million
Hemoglobin
binging site for oxygen inside the RBC, dependent on adequate iron intake
Normal Hgb
12-18g/100mL
Hematocrit
indicates adequate percentage of RBCs and fluid
Normal Hct
35-50%
Normal Chest
symmetrical from side to side, prominent clavicle, flat sternum, anterior/posterior diameter 1/3 to 1/2 the transverse diameter
Hypoxia
insufficient oxygen to body cells
Signs of hypoxia
mental status change, restlessness, tachypnea, dyspnea, lightheadedness, tachycardia, cyanosis
What information to be collected when assessing cough?
occurrence, triggers, productive or non-productive, sounds, presence of sputum-productive
Sputum
Normal lung and airway secretions that may increase to compensate for disease
Note sputum
color, amount, odor, consistency, presence of blood
Definition of ineffective airway clearance
inability to clear secretions or obstructions from the R tract r/t obstructed airways (mucous, foreign body), R disease, smoke, airway spasm
Defining characteristics of ineffective airway clearance
adventitious breath sounds, diminished breath sounds, cough, increase sputum, cyanosis, change in R depth (deep or shallow), dyspnea, orthopnea, tachypnea or bradypnea
Definition of ineffective breathing pattern
Inspiration and/or expiration that does not provide adequate ventilation R/T fatigue, impairment of musculoskeletal, respiratory, neuromuscular systems, anxiety
Defining characteristics of ineffective breathing pattern
dyspnea, othopnea, tachypnea, bradypnea, use of accessory muscles, increase A/P diameter, change in respiratory depth (increase or decrease)
Definition for risk for activity intolerance
At risk for experiencing insufficient energy to complete ADLs
Defining characteristics for risk for activity intolerance
respiratory signs and symptoms, cardiac signs and symptoms, de-conditioned status
nursing interventions for oxygenation related nur dx
position patient to optimize R (fowlers), assist with deep breathing and coughing techniques, promote fluid intake, humidification, administer medications for cough/sputum production
Why promote fluid intake?
liquefies secretions, facilitates expectoration, moistens mucous membranes
Why humidification?
moistens airway, facilitates cough and expectoration
Expectoration
coughing up and spitting out of material from the lungs
Guaifenesin indication
productive and non-productive cough
Guaifenesin action
increase volume of secretions, decrease viscosity of secretions
Dextromethorphan Indication
non-productive cough due to irritation of airways
Dextromethorphan action
suppresses cough center in medulla oblongata
Nursing implications for dextromethorphan
treat other symptoms, decrease oxygen demand, monitor R, breathing, breath sounds, cough, sputum
Health promotion measures that relate to healthy breathing?
change position frequently, exercise, ambulate, no smoking, avoid exposure to toxins, safety in the home, furnaces, gas appliances, smoke, and CO detectors
What are the reasons for supplemental oxygenation
increase the amount of oxygen available for transport. based on symptoms, blood work, 02 sat
Ferrous gluconate
more expensive than ferrous sulfate, easier on the stomach
ferrous gluconate and sulfate
replaces iron stores necessary for RBC development for iron deficient anemia
