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127 Cards in this Set
- Front
- Back
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higher pH
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alkalosis
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lower pH
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acidosis
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Cause of respiratory acidosis
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low pH high CO --> hypoventilation.
-drug overdose -pulmonary edema -chest trauma -neuromusclar disease -COPD, airway obstruction |
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Cause of metabolic acidosis
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low pH low HCO3
-diabetic ketoacidosis -salicylate OD -shock -sepsis -severe diarrhea -renal failure |
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Cause of respiratory alkalosis
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high pH low CO2 --> hyperventilation
-anxiety -high altitudes -pregnancy -fever -hypoxia -initial stages of pulmonary emboli |
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Cause of metabolic alkalosis
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high pH high HCO3
-loss of gastric juices -potassium wasting diuretics (loss of H+) -overuse antacids |
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Symptoms of respiratory acidosis
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-increased cardiac output
-rapid, shallow respirations -increased BP -hypoventilation, dyspnea, hypoxia -headache, disorientation -muscle weakness -hyperventilation -pH below 7.35 CO2 above 45 |
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Symptoms of metabolic acidosis
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-Kussmaul respirations (compensatory hyperventilation)
-headache -hyperkalemia -changes in LOC -muscle twitching -poor renal function -pH below 7.35 HCO3 below 22 |
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Symptoms of respiratory alkalosis
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-deep, rapid breathing
-tingling of extremities, seizures -hyperventilation -confusion, lightheadedness -hypokalemia -pH above 7.45 CO2 below 35 |
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Symptoms of metabolic alkalosis
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-restlessness followed by lethargy
-compensatory hypoventilation, slow respirations -nausea and vomiting, diarrhea -dysrhythmias -hypokalemia -confusion (decreased LOC) -pH above 7.45 HCO3 above 26 |
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Interpreting ABGs
pH |
7.35 - 7.45
Acidosis - low Alkalosis - high pH always determines the acid-base imbalance |
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Interpreting ABGs
Respiratory |
PaCO2: 35 - 45
Acidosis - high Alkalosis - low CO2 indicates respiratory |
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Interpreting ABGs
Metabolic |
HCO3: 22-27
Acidosis - low Alkalosis - high HCO3 indicates metabolic |
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Both CO2 and HCO3 abnormal =
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The one that is the same state as the pH indicates the acid-base imbalance
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Both CO2 and HCO3 abnormal with normal pH =
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full compensation
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Both CO2 and HCO3 abnormal with abnormal pH =
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partial compensation
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Common ways to increase acid
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-hypoventilate
-renal insufficiency -hyperkalemia -diabetic ketoacidosis -lactic acidosis -diarrhea (lose bicarbonate) |
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Common ways to decrease acid
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-hyperventilate
-vomiting -overdose sodium bicarbonate (gain bicarbonate) |
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Altered breathing patterns:
tachypnea |
rapid rate
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Altered breathing patterns:
bradypnea |
abnormally slow rate
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Altered breathing patterns:
apnea |
cessation of breathing
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Altered breathing patterns:
Kussmaul's breathing |
deep rapid breathing
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Altered breathing patterns:
Cheyne-Stokes respirations |
waxing and waning respirations
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Altered breathing patterns:
Biot's respirations |
shallow and apneic breathing
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Altered breathing patterns:
orthopnea, dyspnea |
alterations in ease of breathing
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Partially obstructed airway is indicated by:
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low-pitched snoring during inhalation
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Completely obstructed airway is indicated by:
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extreme inspiratory effort with no chest movement
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Pulmonary hygiene:
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1 - turn, cough, deep breathe
2 - incentive spirometry 3 - early ambulation 4 - adequate hydration |
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Oral airway - advantages
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easy to insert; holds tongue away from oropharynx; inexpensive
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Oral airway - disadvantages
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causes increased oral secretions; easily dislodged; may stimulate gag reflex; contraindicated in facial trauma
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Nasal trumpet - advantages
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prevents trauma to nasal mucosa during suctioning; easy to insert; inexpensive; conscious/unconscious patients; useful if mouth cannot open
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Nasal trumpet - disadvantages
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may cause nosebleed; kinks/clogs easily; contraindicated in nasal obstruction and basal skull fracture
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Endotracheal tube - advantages
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relatively sealed airway for mechanical ventilation, prevention of aspiration; permits easy suctioning
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Endotracheal tube - disadvantages
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skilled personnel to insert; splints epiglottis open, preventing effecting cough; may cause laryngeal or tracheal damage
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Tracheostomy - advantages
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more secure than ETT; minimizes vocal cord damage from ETT during long-term airway maintenance; relative seal to prevent aspiration; easier suctioning; permits effective cough; increased comfort; patient can eat
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Tracheostomy - disadvantages
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requires surgery; scarring; potential fistula [>3 weeks; requires humidification of O2; trach care every 8 hours]
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indications for suctioning
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-dyspnea or signs/symptoms of hypoxia
-rhonchi -noisy/shallow respirations -obvious visible secretions -excessive coughing -high pressure alarms |
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indications for oxygen delivery
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-hypoxemia (PaO2 < 60; SaO2 <90%)
-increased myocardial workload (CHF, hypertensive crisis, MI) -decreased cardiac ouput -increased O2 demand -decreased O2 carrying capacity (CO poisoning, anemia0 -prior to procedures |
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oxygen safety
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-keep source away from open flame
-keep source away from electrical appliances -no smoking in the room -no petroleum based products -turn off when not in use -secure tanks to prevent dropping -O2 is not flammable; it just feeds the fire |
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nasal cannula - advantages
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-allows eating and talking
-comfortable -effective for low oxygen concentrations -inexpensive |
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nasal cannula - disadvantages
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-contraindicated in nasal obstruction
-dries/irritates nasal mucosa -may cause necrosis at ears |
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nasal cannula
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-flow rate must not exceed 6 L/min
-add humidity if flow rate exceeds 4 L/min -gauze at ears to prevent ulceration -oral/nasal care q 8 hours -moisten lips/nose with water soluble lubricant |
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face tent - advantages
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-useful for patients who cannot tolerate nasal prongs or mask
-nasal obstruction -facial trauma -mouth breather |
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face tent - disadvantages
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difficult to deliver a precise amount of oxygen due to lack of seal
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simple face mask - advantages
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-high oxygen concentration
-doesn't dry nose/mouth -useful if patient has nasal obstruction |
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simple face mask - disadvantages
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-hot, uncomfortable and confining
-tight seal necessary -interferes with eating and talking -may cause CO2 retention if flow rate less than 6 L/min -not good for long-term therapy |
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simple face mask
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-6-10 L/min
-40-60% oxygen -place pads between mask and bony facial parts -wash and dry face every 4 hours -clean mask every 8 hours |
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partial rebreather - advantages
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-high oxygen concentration
-doesn't dry mucous membranes |
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partial rebreather - disadvantages
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-uncomfortable
-tight seal necessary -variable oxygen concentrations depending on respirations -interferes wtih eating/talking -may cause CO2 retention if bag is allowed to collapse |
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partial rebreather
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-6-10 L/min
-35-60% oxygen -ensure bag does not totally deflate during inhalation -ensure snug fit |
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nonrebreather
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-6-10 L/min
-60-100% oxygen -one-way valves prevent rebreathing of CO2 and increases O2 concentration -ensure bag does not totally deflate -ensure snug fit |
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Venturi mask
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-4 L/min delivers 24-28% oxygen
-8 L/min delivers 35-40% oxygen |
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Venturi mask - advantages
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-constant oxygen concentration despite changes in respiratory pattern
-oxygen concentration determined by dial on mask -doesn't dry mucous membranes |
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Venturi mask - disadvantages
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-fit must be snug in order to deliver set oxygen concentration
-uncomfortable -interferes with talking and eating |
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Tracheostomy collar
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-21-70% oxygen
-10 L/min -oxygen is diluted by room air -infection/skin irritation due to moisture -condensation collects in the tubing and drains into patient's airway |
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Bag valve mask (CPR)
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-may be used with or without oxygen source
-if used with oxygen source, dial flowmeter to 10-15 L/min -may be used with mask attachment -requires good seal to face (best with 2 hands) -may also be attached to endotracheal or tracheostomy tube |
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Incentive spirometry
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-expand collapsed alveoli
-patient should be in an upright sitting position -slow deep breath and hold x5 seconds -repeat severeal times every 1-2 hours |
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Peak flow meter
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-seal mouth around mouthpiece and blow fast and hard
-take 3 readings and record the best -less than 80% of personal best requires a change in medication -less than 50% of personal best requires medical attention |
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Hand held nebulizer
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-pour the bronchodilator in nebulizer form into the reservoir
-connect to oxygen -turn the oxygen on high enough to create a vapor (generally 8 to 20 L/min) |
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atelectasis
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(alveoli collapse)
-restlessness -diminished breath sounds - lower lobe -increased body temperature - low grade |
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Difference between Ventura mask and other oxygen appliances
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Ventura mask delivers a PRESCRIBED concentration of O2 -- all others not regulated
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O2 delivery for initial shortness of breath
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nasal cannula
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O2 delivery for low O2 saturation
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nonrebreather
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Breath sounds in order (worst)
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1 - absent (airway)
2 - stridor - partial obstruction (airway) 3 - wheezing - constriction (airway) 4 - rhonchi/crackles (breathing) |
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Pulse oximetry problems
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-circulation problems
-anemia (menstruation?) -dehydration -cold *if your pulse count = pulse on pulse ox, sat should be accurate |
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crackles
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air going through fluid --> infiltrates
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Smoking cessation
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-establish a quit date
-pharm or nonpharm to reduce cravings -behavior modification -support group -does not include psychosocial evaluation |
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Chest Tube assessment
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STOP
Site Tubing Output Patency |
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Chest Tube - Site
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-dressing
-bleeding -subcutaneous emphysema ("Rice Krispies") |
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Chest tube - Tube
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-taping
-looping |
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Chest tube - output
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-checking (every 30 min--report bloody drainage faster than 100 mL/hr)
-marking -documenting (total output and drainage characteristics at end of shift) |
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chest tube - patency
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-color, respiratory effort, bilateral chest expansion, O2 saturation
-fluctuation -water-seal level (check levels and refill each shift) |
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Chest tube - How to identify problem
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1-are the vital signs normal for this patient?
2-are the breathing sounds present in all lung fields? 3-is there any difficulty breathing? 4-is the respiratory rate increased? 5-are the heart sounds muffled? 6-is the patient anxious? 7-is their skin warm and dry? 8-is the pt complaining of pain that is new or worsening? 9-are any arryhthymias present? HR increased or decreased? 10-any subcutaneous emphysema present to palpation? |
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Chest tube dislodged?
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place tube in a bottle of sterile water while another nurse obtains an additional drainage unit to set up.
apply occlusive dressing, such as Vaseline gauze and dry gauze, observe for signs of resp. distress |
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Equipment that should be at the bedside of the patient with a chest tube
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-bottle of sterile water
-2 inch silk tape -Vaseline gauze -sterile gauze -suture removal kit (optional) |
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nocturia
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voiding two or more times per night
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urgency
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sudden strong desire to void
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dysuria
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voiding that is either painful or difficult
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urinary hesitancy
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a delay and difficulty initiating voiding
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enuresis
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involuntary urination in children beyond the age of 4 or 5 years of age
[nocturnal vs diurnal] |
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neurogenic bladder
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no perceived bladder fullness, inability to control urinary sphincters; bladder may become flaccid and distended or spastic, with frequent involuntary urination
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Normal amount of urine in 24 hours
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1200-1500 mL
[urinary output normally is apprx equal to fluid intake; output of less than 30 mL/hr may indicated decreased blood flow to the kidneys and should be reported immediately] |
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Normal pH of urine
Normal specific gravity |
4.5-8
1.010-1.025 |
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normal bladder capacity
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300-600 mL
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functional urinary incontinence
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inability of usually continent person to reach toilet in time to avoid unintentional loss of urine
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reflex urinary incontinence
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involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached
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stress urinary incontinence
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sudden leakage of urine occurring with activities that increase abdominal pressure
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total urinary incontinence
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continuous and unpredictable passage of urine
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urge urinary incontinence
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involuntary passage of urine occuring soon after a strong sense of urgency to void
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Prevention of UTI recurrence:
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-drink 8 8-oz glasses of H2O/day to flush out bacteria
-practice frequent voiding (every 2-4 hours) to flush out bacteria and prevent ascension into bladder; void immediately after intercourse -avoid use of harsh soaps in perineal area -avoid tight fitting pants that prevent ventilation of perineal area -wear cotton rather than nylon underclothes -wipe perineal area from front to back -if recurrence is a problem, take showers rather than baths |
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Intermittent self catheterization:
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-reduces the incidence of UTIs
-enables client to retain independence and gain control of the bladder -allows normal sexual relations without incontinence -protects the UPPER urinary tract from reflux -reduces the use of aids and appliances -frees the client from embarrassing dribbling |
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Preventing catheter-associated urinary infections
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-have established infection control program
-catheterize clients only when necessary -do not disconnect catheter and draining tubing unless absolutely necessary -remove catheter ASAP -follow good hand washing tech. -provide routine perineal hygiene, including cleansing with soap and water after defecation -prevent contamination of catheter with feces in the incontinent client |
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With self-catheterization client should have:
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-sufficient manual dexterity to manipulate a catheter
-sufficient mental ability -motivation and acceptance of procedure -for women, reasonable agility to access the urethra -bladder capacity greater than 100 mL |
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Consistency of feces
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normal: formed, soft, semisolid, moist
abnormal: hard, dry |
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color of feces
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normal adult: brown
normal infant: yellow abnormal: clay or white, black or tarry, red, pale, orange or green |
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clinical manifestations of colorectal ca
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-change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days
-a feeling of needing to have a BM that is not relieved by doing so -rectal bleeding or blood in the stool -cramping or steady abdominal pain -weakness and fatigue |
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ileostomy
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-produces liquid fecal drainage
-drainage is constant and cannot be regulated -contains some digestive enzymes that are damaging to the skin -odor is minimal; less bacteria |
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ascending colostomy
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similar to ileostomy; drainage is liquid and cannot be regulated, digestive enzymes are present; odor is a problem
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transverse colostomy
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produces a malodorous, mushy drainage because some of the liquid has been reabsorbed; usually no control
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descending colostomy
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produces increasingly solid fecal drainage; stools from sigmoidoscopy are of normal of formed consistency; frequency of discharge can be regulated; may not need an appliance at all times and odors can usually be controlled
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end or terminal colostomy
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one end of the bowel is brought out through an opening onto the anterior abdominal wall; permanent
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managing diarrhea
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drink at least 8 glass of water/day; eat foods with Na and K; increase soluble fiber; avoid alcohol and caffeine; limit insoluble fiber; limit fatty foods
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bulk forming laxative
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action: increases fluid, gaseous, or solid bulk in the intestines
may take 12 or more hours to act; sufficient fluid must be taken; safe for long-term use |
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emollient/stool softener
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action: softens and delays the drying of the feces; permits fat and water to penetrate the feces
slow-acting, may take several days |
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stimulant/irritant laxative
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action: irritates the intestinal mucosa or stimulates nerve endings in the wall of the intestine, causing rapid propulsion of the contents
acts more quickly than bulk-forming agents; fluid is passed with the feces; may cause cramps; prolonged use may cause fluid/ electrolyte imbalance |
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lubricant laxative
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action: lubricates the feces in the colon
prolonged use inhibits the absorption of some fat-soluble vitamins |
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saline/osmotic laxative
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action: draws water into the intestine by osmosis, distends bowel, and stimulates peristalsis
may be rapid acting; can cause fluid and electrolyte imbalance; should not be used with elderly; prolonged use inhibits absorption fat-soluble vitamins |
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hypertonic enema
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90-120 ml of solution (sodium phosphate/ Fleet phosphate); draws water into the colon; 5-10 min; retention of sodium
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hypotonic enema
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500-1000 ml of solution (tap water); distends colon, stimulates peristalsis, softens feces; 15-20 min; possible sodium retention
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isotonic enema
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500-1000 ml of normal saline; distends colon, stimulates peristalsis, softens feces; 15-20 min; possible sodium retention
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soapsuds enema
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500-1000 ml (3-5 ml soap to 1000 ml water); irritates mucosa, distends colon; 10-15 min; irritates and may damage mucosa
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oil enema (mineral, olive, cottonseed)
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90-120 ml; lubricates the feces and colonic mucosa; 30 min-3 hours
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carminative enema
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given primarily to expel flatus; solution releases gas, which in turn distends the rectum and colon, stimulating peristalsis (adult, 60-80 ml)
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retention enema
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introduces oil or medication into the rectum and sigmoid colon; liquid retained a relatively long period of time (1-3 hrs); softens feces, lubricates rectum and anal canal, facilitating passage of feces
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return flow enema
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used to occasionally expel flatus; alternating flow of 100-200 ml of fluid into and out of the rectum and sigmoid colon stimulates peristalsis
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client position for administration of enema
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left lateral position with right leg as acutely flexed as possible
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ostomy appliances
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-most contain odor-barrier material; some have filter which allows gas out of the pouch but not the odor
-can be applied up to 7 days; recommend removing skin barrier twice a week to examine skin -emptied when 1/3 to 1/2 full. |
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management of urinary incontinence
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-Keep walk areas clear of equipment
-clothing with easy fastening reduce fluid intake 2 hours before bedtime -nocturnal voiding -physical examination |
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contraindications for enema
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• Increased intracranial pressure
• Glaucoma • Recent rectal or prostate surgery |
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Impaction - digital removal of stool
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– Requires a physician’s order
– Obtain baseline vital signs – Position in left-sided Sims’ position – Break up stool using scissors motion –Work feces down towards rectum – Remove hardened feces in small pieces – Periodically assess vital signs and client tolerance |
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diarrhea - enteral feedings
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– Administer canned formulas at room temperature
– Follow strict sanitation when preparing the formula – Increase rate and volume slowly – May need to start at ½ strength – Monitor tolerance and residuals |
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purposes of surgical procedures:
diagnostic |
confirms or establishes a diagnosis; for example, biopsy of a mass in a breast
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purposes of surgical procedures:
palliative |
relieves or reduces pain or symptoms of a disease; it does not cure; for example, resection of nerve roots
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purposes of surgical procedures:
ablative |
removes a disease body part; for example, cholecystectomy
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purposes of surgical procedures:
constructive |
restores function or appearance that has been lost or reduced; for example, breast implant
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purposes of surgical procedures:
transplant |
replaces malfunctioning structures; for example, kidney transplant
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Factors that increase surgical risk:
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-age
-general health (obesity, diabetes, liver disease, HTN) -nutritional status -medications -mental status |
