exam 2 Flashcards
(106 cards)
1
Q
You need an intact _______ system and functioning organs in order to void
A
neurological
2
Q
Spinal Cord Injury above the level of the_____ region can result in loss of voluntary control of urination
A
sacral
3
Q
Avg. Volume per voiding:
A
200-500mL
4
Q
Normal urine Output per 24 Hours:
A
1200 mL-1500 mL
5
Q
: begins after discarding first specimen and ends with a final voiding at the end of the time period
A
Timed Urine Specimen
6
Q
What are the 7 factors that influence urinary elimination?
A
- Developmental Factors
- Disease Conditions
- Muscle Tone
- Psychosocial Factors
- Fluid Balance
- Surgical and Diagnostic Procedures
- Medications
7
Q
What information can you get from a urine analysis (U/A)?
5 things
A
- PH
- Protein
- Glucose
- Ketones
- Specific gravity
8
Q
normal pH for urine
A
4.6-8.0
9
Q
Specific gravity for urine
A
(1.0053-1.030),
10
Q
Urine is collected after voiding is initiated (midstream) and before voiding is completed
A
Midstream urine specimen
11
Q
This is required for tests of renal function and urine composition.
A
24-Hour Urine Specimen
12
Q
The entire volume of urine from a 24-hour period is collected.
If urine is accidentally discarded or contaminated or the patient is incontinent, restart the time period.
A
24-Hour Urine Specimen
13
Q
Inability to empty the bladder
Retention of urine in the bladder; condition frequently caused by a temporary loss of muscle function.
A
urinary retention
14
Q
Involuntary loss of urine
A
Urinary incontinence
15
Q
Surgical diversion of the drainage of urine such as a ureterostomy.
A
urinary diversion
16
Q
Can be caused by obstruction of the urinary tract or by nerve problems
A
Urinary Retention
17
Q
inability to void or voiding frequently in small amounts often with sense of incomplete emptying,
bladder distention & tenderness, pain
A
Urinary Retention
18
Q
Urinary Retention Interventions: treat the problem, may need to ________ the client
A
catheterize
19
Q
Affects 50% of men over age 60 and 90% of men over age 70
Common signs and symptoms: voiding in small amounts, frequency, urgency, hesitancy, weak stream
A
Benign Prostatic Hypertrophy(BPH
20
Q
They are the most common health-care associated infection in the United States
A
Urinary Tract Infections(UTIs)
21
Q
infection where Common signs and symptoms: Urgency Burning on urination Fever Chills WBC’s in the urine sample
A
Urinary Tract Infections(UTIs)
22
Q
Adequate fluid intake per day
A
(2000-2500mL)
23
Q
6 ways to prevent UTI
A
Adequate fluid intake Frequent voiding upon urge Promote Complete Emptying-Double voiding Proper perineal care- Avoid using feminine hygiene products Acidify the urine
24
Q
Sometimes the first sign of a bladder infection or UTI in the elderly is_____________
A
confusion
25
involuntary loss of urine associated with effort or exertion on sneezing or coughing
Stress Incontinence
26
Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction
Urge Incontinence
27
Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2
Reflex Incontinence
28
Loss of continence because of causes outside the urinary tract. Usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, poor motivation, or environmental barriers
Functional Incontinence
29
Incontinence caused by medical conditions that in many cases are treatable and reversible
Transient Incontinence
30
this is the remedy for what type of Incontinence
pelvic muscle exercises
Stress Incontinence
31
this is the remedy for what type of Incontinence
Avoid bladder irritants (e.g., caffeine, artificial sweeteners, alcohol).
instruct patient in pelvic muscle exercises, in , urge-inhibition exercises, and/or in bladder training
Urge Incontinence
32
this is the remedy for what type of Incontinence
Follow the prescribed schedule for emptying the bladder either through voiding or by intermittent catheterization.
Supply urine-containment products: condom catheter, undergarments, pads, briefs. Monitor for signs and symptoms of urinary retention and UTI.
Monitor for autonomic dysreflexia
Reflex Incontinence
33
this is the remedy for what type of Incontinence
Adequate lighting in the bathroom
Individualized toileting program
Mobility aides (e.g., raised toilet seats, toilet grab bars)
Toilet area cleared to allow access for a walker or wheelchair
Elastic-waist pants without buttons or zippers
Call bell always within reach
Functional Incontinence
34
this is the remedy for what type of Incontinence
With new-onset or increased incontinence look for reversible causes. Notify health care provider of any suspected reversible causes
Transient Incontinence
35
Severe skin breakdown from urine constantly in contact with skin
Incontinence Associated Dermatitis
36
6 Nursing Care of Client with Urinary Diversion:
```
Provide emotional support
Maintain intact skin around stoma
Referral to WOCN, Provide client education
Maintain fluid intake
Monitor I & O
Monitor for signs of infection
```
37
Estimated ___% loss of nephrons by age 80
30
38
Try to ________ to see if urinary retention is present before proceeding with an invasive procedure (urinary catheterization)- Decrease the risk of infection!
bladder scan
39
Drainage system must be _______ the level of the bladder.
below
40
after Catheter removal, client should void within ____ hours
6-8
41
This device is not a catheter but a drainage system connected to the external male genitalia.
It is used for the incontinent male to minimize skin irritation from urine.
Condom Catheter
42
Secure with care, follow equipment instructions: leave 1-2 inches from end of penis to tip of the catheter, only use elastic tape and apply in a spiral fashion or self securing catheter
Critical to assess circulation at least 30 minutes after applying
Condom Catheter
43
Voiding excessive amounts of urine
Polyuria
44
Diminished urinary output in relation to fluid intake
Oliguria:
45
failure of kidneys to produce urine
Anuria:
46
Awakened from sleep because of the urge to void
Nocturia
47
Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity
Wound edges are clean and intact.
Acute
48
Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity
Continued exposure to insult impedes wound healing.
Chronic
49
Wound that is closed
Primary Intention
50
Wound edges not approximated
Secondary Intention
51
Wound that is left open for several days; then wound edges are approximated
Tertiary Intention
52
_________ wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers)
Partial-thickness
53
________ wounds that involve total loss of the skin layers (epidermis and dermis).
full-thickness
54
________ wounds are shallow in depth, moist, and painful; and the wound base generally appears red
Partial-thickness
55
_______ wound extends into the subcutaneous layer, and the depth and tissue type varies, depending on body location
A full-thickness
56
________ wound heals by regeneration;
A partial-thickness
57
____________ heals by forming new tissue, a process that can take longer
full-thickness wound
58
is localized injury to the skin and other underlying tissue, usually over a bony prominence
A pressure ulcer
59
6 types of people at risk for a pressure ulcer
- Older adults, those who have experienced trauma
- Those with spinal-cord injuries (SCI)
- Those who have sustained a fractured hip
- Those in long-term homes or community care, the acutely ill
- Individuals with diabetes
- Patients in critical care settings
60
A _____________ is an example of a wound with little tissue loss. Heals by primary intention
clean surgical incision
61
5 Factors Affecting Wound Healing
```
Desiccation
Maceration
Edema
Infection
Necrosis
```
62
Scraping or rubbing away of epidermis; may result in localized bleeding and later weeping of serous fluid.
Abrasion
63
The action of pulling or tearing away
Avulsion
64
State of extreme dryness, or the process of extreme drying
desiccation
65
Softening and breaking down of skin from prolonged exposure to moisture.
maceration
66
Termination of bleeding by mechanical or chemical means or the coagulation process of the body.
hemostasis
67
damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and white blood cells into the damaged tissues.
4 to 6 days
inflammatory stage
68
begins and lasts from 3 to 24 days. The main activities during this phase are the filling of a wound with granulation tissue, wound contraction, and wound resurfacing by epithelialization
proliferative phase
69
the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound
Maturation
70
: Shallow. Involves epithelialization.
Partial thickness
71
: Extend into dermis. Involves granulation
Full-thickness
72
Closing a wound
Edges touch— APPROXIMATED
Heals more quickly, makes less of a scar
Primary intention:
73
Wound is left open to heal “from the ground up”—as in a contaminated wound
Takes longer time to heal, leaves bigger scar, greater risk for infection, can be more difficult for patient both physically and psychologically
Secondary intention:
74
Wound is not sutured or stapled closed
Secondary Intention Healing
75
Heals from bottom and sides
Takes time, but does work with right factors in place
Secondary Intention Healing
76
4 Wound Complications
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation
77
__________, or bleeding from a wound site, is normal during and immediately after initial trauma
Hemorrhage
78
wound drainage that is
| Clear, watery plasma
Serous
79
wound drainage that is
Thick, yellow, green, tan, or brown
Purulent
80
wound drainage that is
Pale, pink, watery; mixture of clear and red fluid
Serosanguineous
81
wound drainage that is
Bright red; indicates active bleeding
Sanguineous
82
When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury).
Dehiscence
83
(protrusion of visceral organs through a wound opening) occurs.
Evisceration.
84
4 risk factors for Wound Dehiscence and Evisceration
Obesity
Abdominal
Radiological or chemotherapeutic treament
Increased intraabdominal pressure (coughing,sneezing, laughing)
85
6 things that are on the Braden scale for prediction of PU Development
```
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
```
86
part of Braden scale where
Ability to respond meaningfully to pressure-related discomfort
Sensory Perception
87
part of Braden scale where
Degree to which skin is exposed to moisture
Moisture
88
part of Braden scale where
Degree of physical activity
Moisture
89
part of Braden scale where
Ability to change and control body position
Mobility
90
part of Braden scale where
Usual food intake pattern
Nutrition
91
Worst possible score = __
Best possible score = __
braden scale
6
23
92
stage of pressure ulcer where
nonblanchable erythema of intact skin
1
93
stage of pressure ulcer where
partial-thickness skin loss
2
94
stage of pressure ulcer where
full-thickness tissue loss; not involving underlying fascia. SC fat may be visible. May include tunneling and undermining.
3
95
stage of pressure ulcer where
full-thickness tissue loss with extensive destruction. Exposed bone, tendon or muscle.
4
96
______ determines if there is actual tissue damage v. reactive hyperemia.
Blanch test
97
If the skin does not blanch, then tissue damage or ________ (Ineffective tissue perfusion)
Stage I pressure ulcer
98
Soft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention.
Red and moist, viable
granulation tissue
99
Soft white or yellow, stringy
| wound
Slough
100
Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed.
Black or brown; hard,necrotic
eschar
101
4 things to lok for when assesing a pressure ulcer
Size of wound
Depth of wound
undermining,
tunneling, or sinus tract
102
_______- wound debridement would be necessary in order to get down to the granulating surface
Necrotic tissue
103
______ need to be cultured to determine what is growing in the wound bed and what we need to give the patient (antibiotics) to eliminate the bioburden.
Infected wounds
104
______ is the cleanser of choice for most wounds
Normal Saline
105
3 things in nutrition to help woh wound healing
Protein, Vitamin C, Zinc
106
Decrease pressure times- limit pressure every___ hours whether sitting in a chair, lying in bed, laying on a bony prominence
2
