Exam 2 Flashcards

Question

Crutches:

Answer 1

measuring for crutches ---> 2-3 fingers width- prevents nerve damage b/w axillae + rest pad hand grips should be even with hip line elbows flexed 30 degrees

Answer 2

two point gait: partial wt. bearing both feet, move crutches while moving opposite leg (move RC and LF move together, then LC and RF together) three point gait: bear wt. on one foot, using both crutches, move both crutch and injured leg together, then move injured leg four point gait: bear wt. both legs (move RC then LF then LC then RF) swing to gait: swing to crutch swing through gait: swing past crutches

Answer 3

prevention of work related musculoskeletal injury promote activites and exercise improve bone health in patients with osteoporosis

Answer 4

provide high-protein, high calories diet with vitamin B and C supplement

Answer 5

repostion every 1-2 hours cough and deep breaths every 1-2 hours incentive spirometer while awake yawn provide chest physiotherapy suction if unable to expectorate secretions

Answer 6

progress from bed to chair to ambulate change postion as often as possible reducing orthostatic hypotension (move pt gradually) reducing cardiac workload: avoid valsalva maneuver) give stool softner preventing thrombus formation sequential compression devices (anti-embolism hose stocking, leg exercise) isometric exercise to increase activity tolerance

Answer 7

comunicate clearly with members of health care system assess and incorporate the patient priorites of care and preferences use best evidence when making decisions about pt care

Answer 8

orient to time, person, place develop schedule of therapies alert roommate involve in daily care, provide stimuli hygiene refer to psych, spiritual, social worker if not coping well

Answer 9

repositon every 1-2 hours; if mobile have them turn every 15 minutes use corrective devices and therpeutic bed provide skin care monitor nutritonal intake

Answer 10

provide adequate hydration serve diet rich in fiber, fruit, veggie, fluid stool softener, laxative, enema perineal care assess for paralytic ileus

Answer 11

prevent muscle atrophy and joint contractures change patient position every 2 hours passive ROM CPM (continuous passive motion) Active ROM cluster care to promote a proper sleep- wake cycle physical therapy assist with ambulation

Answer 12

gait belt stand-assist and repositioning aid lateral assist devices friction- reducing sheets mechanical lateral assist device transfer chair powered stand assist and repositoning lift powered full body lift

Answer 13

safety is first priority ask pt to help as much as possible determine if pt comprehends what is expected determine patient comfort level determine if you need assistance in moving patient

Answer 14

pillows mattresses adjustable bed bed side rails trapeze bar additional equipment

Answer 15

helps prevent falls use when unsteady or poor balance helps move patient with walking, moving from bed to chair or from sitting to standing

Answer 16

greater than 2000 mL/ day

Answer 17

less than 400 mL/day

Answer 18

total suppression of urine less than 150 mL/per day

Answer 19

painful urination

Answer 20

needing to use bathroom during the night

Answer 21

holding urine after voiding

Answer 22

less than 30 mL/hr for more than 2 hours

Answer 23

Children: voluntary control 18-24 months; toilet training 2-3 years, enuresis Prostate enlargement: 40 years old urinary frequency, hesitation, retention, incontience, and UTI Pregnancy: less space with growing fetus, increase circulatory volume, increase renal output, relaxation of sphinctor, greater risk of UTI Childbirth: gravity weakens pelvic floor, risk of prolapse of bladder, stress incontience: kegel exercise post menopausel: decreased tone due to low estrogen levels, urgency, stress incontience, UTI Older adults: loss of muscle tone in bladder: frequency, ineffective emptying, residual urine, nocturia, neuromuscular problem

Answer 24

conditions: acute and chronic disorders: poor abdominal and pelvic muscle tone, spinal cord issue, pregnancy (kidney disease) Immobility: incontience can occur as result of impaired mobility due to difficult transferring to bathroom surgical procedure: anesthesia + opioid analgesics result in decreased urine output abdominal surgery creating obstructive edema and inflammation pain: suppresion of urge to urinate obstruction in ureter arthritis or painful joints lead to immbility and delayed urination Psychofactors: emotional stress and anxiety having to use public toilets or bedpans lack of privacy during hospital stay not having enough time to urinate Fluid intake and output: Medication: diuretic: prevent reabsorption of water + certain electrolytes antihistamine + anticholinergic: urinary retention analesics + tranqulilzers: suppress CNS, dimish effectiveness of reflex medcation can cause change in urine color Nephrotoxic meds ( chemo)

Answer 25

congential urinary tract abnormalites polycystic kidney disease urinary tract infection urinary calculi hypertension diabetes gout connective tissue disorders

Answer 26

an accumulation of urine due to inability of bladder to empty

Answer 27

Follow principles of surgical and medical asepsis as indicted identify patient at risk for latex allergies

Answer 28

frequent check for incontience episodes turning and repositoning schedule no rinse skin cleansers are preferable to soap and water avoid excessive fricition or scrubbing low air loss/pressure distrubution mattress change cloth pads frequently limit disposable brief moisture barrier creams skin protectant spray

Answer 29

behavioral therapy pelvic floor muscle training (kegals) bladder retraining: increase uriniation intervals till no incontinence episodes toileting schedule (q-2-3 hours or before and after meals) intermittent catherterization (drain 300-400 mL of urine on schedule) skin care foods and fluids: avoid artifitcal sweetner, spicy foods, citrus products, caffeine) increase fluid intake during daytime and decrease fluid intake prior to bedtime

Answer 30

Overflow: bladder is full and urine leaks, drippling of urine, due to blockage of urethra Urge/urgency: overactive bladder urgency ("gotta go") brain telling bladder is full, overactive detrusor muscle with increased bladder pressure Stress: weak pelvic muscles let urine escape with increased abdominal pressure associated with effort or exertion, sneezing, or coughing, pregnancy, bending, walking

Answer 31

Risk factors: sexually active women women who use diaphragm for contraception postmenopausal women, individuals with diabetes, uncircumcised patients, use of indwelling catheters, older adults

Answer 32

frequency, urgency, nocturia, burning and pain (dysuria) irritation of the bladder (cysitis) hematuria flank pain suprapubic tenderness fever foul smelling cloudy urine

Answer 33

increased confusion recent falls new onset incontience anorexia fever tacycardia hypotension

Answer 34

are created to reroute urine can be temporary or permanent continent or incontinent Types: ureterostomy (ileal conduit) nephrostomy indiana pouch neobladder

Answer 35

fluid intake amount pattern of urination (frequency and times of day, normal volume with voiding, history of recent change) symptoms of urinary alterations factors affecting ability to urinate normally: medical conditions, medications past history of problem adequacy of self care behaviors urinary diversion

Answer 36

bladder if indicted + urethral meatus: assessment of skin integrity and hydration; exam of urine Kidney: tenderness, auscultate to detect renal artery bruit bladder: palpate, percussion, bedside scanner ---> external genitalia, urethral meatus: identify infection, inflammation, discharge, lesion catheter insertion: for inflammation or breakdown perineal skin skin exposed to moisture

Answer 37

intake and output characteristic of urine: color clarity odor pH specific gravity constituents UTI: + nitrates, leukocyte esterase (WBC) bacteria

Answer 38

urinalysis: random nonsterile specimen clean catch midstream for culture and sensitivity (C&S) catheter: sterile urine specimen for C&S timed urine specimen point of care testing

Answer 39

maintaining normal voiding habits strengthening muscle tone (kegel exercise) assisting with toileting privacy important close door and bedside curtain mask sounds with running water ask family to leave room respond quickly to assistance maintaining adequate fluid intake: helps flush solutes or particles that collect in urinary system and decrease bladder irritability promoting complete bladder emptying: sitting for women and standing for me preventing infection: increase fluid intake, perineal hygiene and voiding at regular intervals

Answer 40

ask patient to void into bedpan, urinal, specimen container in bed or bathroom put on gloves: pour urine into appropraite measuring device place calibrated container on flat surface and read at eye level note amount of urine voided and record on appropriate form discard urine in toilet unless specimen is needed, if specimen is required pour urine into appropriate specimen container

Answer 41

Foley ( baloon) catheter: indwelling catheter Straight catheter: without ballon are used for clean intermittent catheterization triple lumen (three-way): used to instill medications or continous bladder irrigation coude (curved) catheter: semirigid curved tip for prostate enlargement

Answer 42

changing pouch: gently cleanse the skin surrounding the stoma measure stoma and cut opening in pouch remove the adhesive backing and apply pouch press firmly into place over stoma observe appearance of stoma and surrounding skin change every 4-6 days continent diversion: catheretize 4-6 times a day

Answer 43

use soap and water at insertion site routine perineal care with soap and water at least q 8 hours and after defectation empty drainage bag when half full or depending on orders

Answer 44

always hang bag below bladder on bedframe bag should never touch floor assess for cloting or kinks in tube

Answer 45

developmental considerations (Age) food and fluid psychological factors pathologic conditions surgery + anesthesia diagnostic test: colonoscopy, endoscopy lifestyle physical activity personal habits pain pregnancy medications

Answer 46

a symptom, not disease infrequent stool and/or hard, dry small stools that are difficult to eliminate

Answer 47

increase in number of stools and passage of liquid, unformed feces

Answer 48

accumulation of gas in intestines causing walls to stretch

Answer 49

results from unrelieved constipation; a collection of hardened feces wedged in rectum that person cannot expel

Answer 50

inability to control passage of feces and gas into anus

Answer 51

dilated, engorged veins in lining of rectum

Answer 52

What patient describes as normal vs abnormal is often different and conditions that tend to promote normal elimination identifying normal and abnormal patterns, habits, and that patient perception of normal and abnormal with regard to bowel eliminiation allows you to accurately determine a patient problem recent changes in type, color, smell of stool: black tarry stool could be a sign of internal bleeding in GI tract or just from iron supplement

Answer 53

elimination pattern stool characteristic routines bowel diversion appetite changes diet history daily fluid intake surgery/illness medications emotional state exercise pain/discomfort social history mobility and dexterity

Answer 54

Inspection + palpation: lesion, ulcers, fissure (linear break on margin of anus), inflammation, external hemorrhoids ask the patient to bear down as though having a bowel movement: assess for appearance of internal hemorrhoids or fissures and fecal masses inspect perineal area for skin irritation secondary to diarrhea or fecal incontinence

Answer 55

sequence for abdominal assessment proceeds from inspection, auscultation, percussion to palpate Inspection: observe contour, any masses, scars, or distention Auscultation: listen for bowel sounds in all quadrants ----> note frequency, character, audible clicks, flatus -----> describe bowel sounds as hypoactive, hyperactive, absent or infrequent percussion + palpation: performed by advanced practice professionals

Answer 56

H/H (hemoglobin + hematocrit) for anemia LFTs (liver function test) serum amylase and serum lipase used to assess for hepatobiliary disease and pancreatitis fecal specimens

Answer 57

Direct Visualization: endoscopy, colonoscopy, esophagogastroduodenoscopy wireless capsule endoscopy indirect visualization: upper gastrointestinal (UGI) small bowel series barium enema admominal ultrasound magnetic resonance imaging (MRI) abdominal CT scan bowel preparation patient teaching: report abdominal pain, fever, chills or bleeding

Answer 58

guaiac fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) vit c can affect results

Answer 59

Medical aseptic technique is imperative hand hygiene before + after glove use, is essential wear disposable gloves do not contaminate outside of container with stool obtain stool and package, label, transport according to agency policy Patient Guidelines: void first so that urine is not in stool sample defecate into container rather than toilet bowl do not place toilet tissue in bed pan or specimen container avoid contact with soaps, detergents, disinfectants as these may affect test results notify nurse when specimen is avaiable

Answer 60

use if enemas fail to remove impaction last resort in managing severe constipation can cause stimulation of vagus nerve

Answer 61

promotion of regular exercise (150 minutes of exercise each week, if immoble promote ambulation as soon as possible) management of patient with fecal incontinence or diarrhea ---> fecal collector for short term use ---> maintenance of skin integrity ----> liquid stool contains digestive enzymes that can cause rapid skin breakdown. Irritation for repeat wiping or frequent ostomy pouch changes can irritate skin --->good skin care: cleansing with a no rinse cleanser: apply a barrier ointment ---rehydration management of patient with constipation: increase fiber diet, hydration, exercise, avoid opioids

Answer 62

prevent muscle strain and discomfort elevate head of bed 30-45 degrees sitting positon increases downward pressure to rectum wear gloves when handling bedpans when patient are immobile or it is unsafe to allow them to raise hip, they remain flat and roll onto bedpan

Answer 63

cleansing enemas: - normal saline: safest (isotonic) - warm tap water: hypotonic and exerts osmotic pressure lower than fluid in intersitital spaces: cause water intoxication - hypertonic: (fleets) pulls fluid out of interstitial spaces: used for patient who cant tolerate large volumes of fluids - soapsuds: intestinal irritation stimulates peristalsis (caution with pregnant + elderly) oil retention: lubricate and soften stool other types of enema: - carminative (relieve gas distention) kayexalate (treat high serum K+ levels)

Answer 64

sterile technique is unnecessary wear gloves explain procedure, positioning, precautions to avoid discomfort, length of time necessary to retain solution before defecation unsafe to give enema on toilet

Answer 65

Goal: eliminate a soft, formed stool at regular intervals without laxative when achieved continue to offer assistance with toileting at successful time Factors within patient control: - timing ( 1 hour after meal) - positioning (upright, use toilet or bedside commode over bedpan) - privacy - nutrition (fluid + fiber) -exercise (2 1/2 hours per week)

Answer 66

categories of nasogastric (NG) tube: - fine or small bore medication administration and enteral feeding - large bore (12 french and above) for gastric decompression or removal of gastric secretions Maintaining Patency of NG Tube: - flush with normal saline or warm water - if an NG tube does not drain properly after flushing, reposition it by advancing or withdrawing it slightly (any change in tube postion requires you to verify its placement in patient GI tract)

Answer 67

Care for ostomies: - use mild soap and water to cleanse skin, then dry it gently and completely - custom cut to stoma size, 1/8 larger than stoma - empty pouch when 1/3-1/2 full - change pouch 3-7 days - apply paste if necessary Assess: stoma (pink or red) skin ( no breakdown) - note size, which should stabilize within 6-8 weeks - keep skin around stoma site clean and dry measure patient fluid intake + output (ileostomies higher risk for dehydration) Psychological consideration: self esteem, body image, sexuality emotional support promote self care - encourage patient to care for and look at ostomy

Answer 68

Colostomy: end of colon (depending on where in the colon) should be more formed Ileostomy: end of ileum will be liquid (watch for undigested foods/ medications

Answer 69

be careful what is said in patient presence; hearing is last sense that is lost assume that patient can hear you and talk in normal tone of voice speak to patient before touching keep enviromental noise at a low level

Answer 70

maintain patient safety use frequent face to face contact to communicate the social process speak calmly, simply, directly to patient orient and reorient the patient to environment orient the patient to time, place, person offer explanations for care reinforce reality if patient is delusional

Answer 71

teach measures to prevent hearing problems orient patient to presence before speaking decrease background noises before speaking check patient hearing aid postion yourself so that light is on your face talk directly to patient while facing him/her use pantomime or sign language as appropriate write any ideas you cannot convey in another manner

Answer 72

orient patient to room arrangement and furnishing assist with ambulation by walking slightly ahead of patient stay in patient field of vision if he or she has partial vision provide diversion using other sense indicate conversation has ended when leaving room teach patient self care behaviors to maintain vision and prevent blindness acknowledge your presence in patient room speak in normal tone of voice explain the reason for touching the patient before doing so keep call light within reach orient the patient to sound in enviroment

Answer 73

environment with decreased or monotonous stimuli - nursing home - patient living alone at home impaired ability to recieve enviromental stimuli inability to process environmental stimuli

Answer 74

control patient discomfort whenever possible offer care that provides rest and comfort be aware of need for sensory aids and prostheses use social activities to stimulate sense and mind enlist aid of family member to participate in or encourage activites encourage physical activity and exercise provide stimulation for as many sense as possible

Answer 75

through patient eye... sensory alteration history physical assessment health promotion habit communciation methods use of assistive device person at risk mental status ability to perform self care enviromental hazards social support other factors affecting perception

Answer 76

Developmental consideration culture personality and lifestyle stress and illness medications social interaction enviromental illness

Answer 77

Perceptual Disturbance: inaccurate perceptions in sights, sounds taste, smell, body positon, coordination, equilibrium cognitive disturbance: problems with concentration, attention span, memory, problem solving, task performance emotional disturbance: manifested in apathy, anxiety, fear, anger, belliegerence, panic, depression

Answer 78

The patient experiences so much sensory stimuli that the brain is unable to respond meaningfully or ignore stimuli. The patient feels out of control and exhibits manifestations observed in sensory deprivation. Nursing care focuses on reducing distressing stimuli and helping the patient gain control over the environment. Noise above 80 dB can cause damage if exposed too long Sources of noise into categories: Staff conversation (65%), roommates (54%), alarms (42%), intercoms (39%), and pagers (38%) were the most common sources of noise disruption reported by patients

Exam 2 Flashcards

(102 cards)