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373 Cards in this Set
- Front
- Back
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a hallmark of quality nursing car is a fically responsible intervention tha encourages health care consumers to engage in slef care and to develop healthy lifestyle is?
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CLIENT EDUCATION
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Durind facilitators of learninge basic assumption about adult learners which are applicable to client education:
assume: individual personality develop an orderly fashion fr dependence to independence what is the nursing application |
plan teaching learning activities that promote client participation, thus encouraging independence; this increases client control and self care through empowerment
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assumption: learning readiness is affected by developmental stage and sociocultural factors?
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conduct a thorough psychosocial assessment before planning the teaching learning activities
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assume individual previous learning experiences can be used as a foundation for further learning
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perform a complete assestment to determine what the client already know and build on that knowledge
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what are the 3 domains of learning
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cognitive, affective and psychomotor
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what are the barriers of learning in the external barriers
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Lack of privacy
interruptions multiple stimule socio- language, value system education background |
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learning that involve the acquisition of facts and data used in problem solving and decision making is
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cognitive
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client give self injection what typer of learning
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psychomoto
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learning that involve changeing attitudes, emotions, beliefs, used in making judgement is called
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affective
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teachin a diabetic patient how and why to measure the proper daily balance of insulin against glucose levels is within the
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cognitive
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helping this client learn how to self adiminster insulin fall within the
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psych
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seeing that the client learns to view diabetes or chronic illness is
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affective
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how to document client education
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conent taugt, teaching method use, who was taught and client and family response
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child learn to play with barbie doll is what age group
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toddler
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how to teach adolesent
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engage adolescents in problem solving activities
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patient processing information visually is what type of learner
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visual learner
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patient learn by doing is what type
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kinesthetic learner
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a crucial step in teaching is to determine the clients learning needs by
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what the client needs to know and what the client already knows address the clients immediate need for knowledge first
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potential learning needs include
mrs stone is HCG for the first time potential need is |
infant care
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Mrs carpenter has been dx with diabetes that is currently controled by meds. he has been told that he may have to take insuling daily in the future. potential learning need is
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self administration of insulin
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an indicator that the client is ready to learn is actively participating in
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return demonstration
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to keep teaching goal realistic with patient self eficacy is when, and how does pt self efficacy...
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if an individual sees the information as being personally valuable, information is more likely to be learned
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determination of what to teach is done through comprehensive assesstment, the content taught depends greatly on the pt
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knowledge base
readiness to learn current health status |
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when do you continue to teach a client
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whenever a client asks a question is an opportunity for teaching
when pt is comfortable timing session is crucial use repetition and frequently ask the pt question to allow to you to pace the delivery of information |
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when setting goals with mrs stone who is in her 1st trimester of pregnancy, MUST know is
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guidelines for diet and exercise
nice to kow is infant care |
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for visually imapaired clients what do you use
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provide large print materials
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The PE is done is a sequential....to ensure a thorough assessment of each system is
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head to toe
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What position for pelvic exam.
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Lithotomy position
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When assessing hearing impaired patient client should be given what type of questionnaire?
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written
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When checking patient temperature how do you asssess
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used back of hands
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During assessment of the carotid arteries, how is assessement done
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auscultation
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what is localized hyperthermia
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seen with infection
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patient reading a 4+ what is this scale indicates
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4+ pitting edema
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what do you use to assess the patient for visual acuity
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snellen eye chart
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non palpable 0.5 cm in diameter is
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macule localized changes -flat and elevated
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solid elevated lesion<0.5 cm is
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papule
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localized changes in skin of <1cm is
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patch PU vitiligo
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solid and elevated extend deeper han papule into the dermis
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0.5-2.0 nodule cyst lipoma erythema
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Kilonychia is characterized by
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iron deficiency
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patient with hearing loss- conductive hearing loss is
normal AC>MC |
BC= or >AC
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What do you do to assess abnormal breath sound?
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aucultate
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soft breezy and low pitch sound heard longer on ins>ex that result from air moving through small airways over the lunds periphery is wahy type of normal breath sounds
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VESICULAR-FINAL
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medium pitch blowing sound heard on ins and ex is called
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BVS
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loud nad high pitched sound with a hollow quality heard longer on ex>ins is
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BRONCHIAL SOUND
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heard predominantly on ins over the base of lungs when piece of hair being rolled b.w the fingers is called
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crackles
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heard predominanly on expiration over the trach and bronch as a continous low pitched musical sound is
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Rhonchi
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what are ACS guidelines for BREAST CANCER
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Women in their 20s and 30s should have a CBE as part of a regular health exam by a health professional at least q3years
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one heart beat means
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lub dub
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is apical and peripheral pulse the same
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yes bilaterally equality and symmetry of peripheral pulse
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how do you assess a homans sign
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slightly bend clients knee and sharply dorsiflex the clients foot
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Which is the correct way of doing BSE?
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patient is to palpate lymph node and breast page 591
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During abdomen examination what are the sequence of abdominal assesstment? page 593
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inspect, auscultate,percuss then palpate
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refers to the increase in muscle size and shape due to an increase in muscle fiber is what type of musculoskeletal problem
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hypertrophy- FINAL
side note- atrophy flabby muscle |
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extra note:
hypertonicity increased muscle tone hypotonicity |
flabby muscle with poor tone
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EXTRA NOTES: an inflammation of the joints that causes pain and swellin is
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arthritis most common is ostroarthrits
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How do you assess for Romberg test
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pt stand erect, feet together, and arms at side, first with eyes open and then closed
20 sec no sway is norm |
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CHAPTER 28 DIAGNOSTIC TESTING
CLIENT LOSES SENSATION TO A LOCALIZED ARE |
local anesthesia- lidocain
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client loses sensation in an area of the body is what type of anesthesia
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REGIONAL
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client loses all seansation and consciousness
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GENERAL ANESTHESIA
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WHAT IS POCT
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intervention to client right away:
advantage prompt pt dx. treatment, and monitor TAT decrease risk for error by eliminating many of the steps decrease prolong hospital stays, delays and minimize bld loss |
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arterial samples are contraindicated in the following condition
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anticoagulant therapy
clotting d/o PVD -allen test |
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Arterial puncture should not be performed if pt is?
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hyperthermic, after breathing and suctioning treatment
if there have been changes in ventilator setting |
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when obtaining sterile urine from drainage bag, where should specimen not be ?obtained from
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drainage bag-
USE aspiration port |
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normal fasting value is?
postrandial is |
70-115
<120 |
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cholesterol optimals
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<200, <130, <250, >40
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what are the ABG'S NORMAL RANGE
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75-100
35-45 PCO2 7.35-7.45 pH |
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When is the best time to collect urine?
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AM after st void
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What is the most commonly performed test of feces is?
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Occult Bld test
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The GI tract can harbor what?
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parasites
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what type of test are used for patient with precancerous screaning
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Pap test
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Which one does not use radiowaves?
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Radiography
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What is the best explanation method for patient who has Angiography being done with contrast medium
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when injected contrast visualize bld vessels and lymphatics
Films are taken in rapid sequence after the injection of an iodinated contrast medium into the vessel |
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what is doppler use for
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reveals bld clots and peripheral disease
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what should nurse monitor when patient had amniocentesis
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vital sign, fetal heart tones, assess sign of labor
after 16th week 10-20 ml |
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When client is having a lumbar puncture done how does nurse assist
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stands facing client with one hand across and the other hand over the buttocks; place the client in a lateral recumbent position
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when obtaining sample from the port how much urine do you withdraw?
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45 degreee 10 ml
clean with iodine swab |
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how many times do you clean patient vagina before obtaining urine
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3 times
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Asked the patient to fill the urine up to how many cc's
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30-60cc
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the passage of a drug from site of administration into the bloodstream is
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absorption
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medications such as nitostat are absorbed and patient should put under tongue
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sublingual
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refers to the mov't of drugs from the blood into various body fluids and tissues is
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DISTRIBUTION
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where is drug metabolize
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in liver
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the proces which drugs are eliminated from the body is
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excretion
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what is half life of 4 hr
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8 hour is 25%
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Time it takes for body to respond after meds is given
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onset
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The time it takes for a drug to reach the highest bld concentration after a plasma level
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Peak plasma level
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The lowest bld serum concentration immediately before the next scheduled dosage
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trough
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the time a drug remains in the system in a therapeutic concentration
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Duration
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bld concentration level maintained after a series of sceduled drug doses is
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plateau
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a patient is taking an androgen which is to given only bucally, where should patient place med at
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superior posterior aspect of the internal cheek next to molar
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what medication are designed quickly when placed under the tongue
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Sublingual meds
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which one is not a parenteral route?
ID SUBQ, IM, IV OR ORAL |
oral
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what type of drugs are given to deliver and need to be careful, and applied to the skin are absorbed through the epi layer is
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topical drugs- use gloves
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abuse of antacids can lead to
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osteomalacia
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The nurse are responsible for teaching patients to self administer meds such as insulin and assess the patients ability to self administer correctly, client education include return demostration by the client and
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how to prep and administer meds , ensures the pt can safely and successfully administer their own meds
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an order for a dingle dose of meds to be given immediately is
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stat oder
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what type of meds when the nurse judgement, and the clients condition requires it is -Make sure document time of administration
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prn-nurse cannot give more frequently than the order indicated without consulting with the prescribing practitioner
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used for estimating body surface is called
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nomograms
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when administering any meds the nurse compares the meds and nurse should check the label againsst the MAR
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at least 3 times
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what do you do when pt tell you that i will take pills later i will read for few more min
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call me when your ready
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clients have the right to refuse meds but
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if clients understand the actions of the meds they may be willing to take the medication
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what is your responsibility during change of shifts with regards to narc
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each drug used must be accounted for on the narc record
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what do you do when there's question about the medication orders
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nurse withhold any drug until dr has been notified
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during assestment of data, the nurse determine who should be inlcuded in teaching
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an older pt living alone is physically capable of self medicating herself but have short tem memory loss- obtain permissiion and include family member, friends or neightbor
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when do you not use standard precaution
vaginal, rectal, oral or eye |
oral
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enteral tubes provide means of direct insillation meds into?
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GI of pt who cannot ingest orally
answer=never attempt to give whole or undissolve meds through an enteral tube |
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when should you not administer the medication of enteral tube
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until the placement in the stomach is verified
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what type of syringe use for insulin
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u-100 syringe
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hypodermic is used ost often when a med is ordered in
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ml 2, 2.5, 3 ml
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what do you after you obtain from ampule
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change the needle and use filter needle because irritate the sub q
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vials
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glass single multi dose rubber cap drug containers-change needle because it can dull the needle
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what are the angles of IM, subq,IV,ID
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90,45,25, 10-15
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what should nurse avoid using in infants and children
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deltoid and dorsogluteal
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an obese client usually requires
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21 g 2"
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when doing IM what do you do
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aspirate
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im what size and gauge for well developped
children and thin adult deltoid |
21-23 g
4ml = 1 1/2 " 1-2ml= 1"vg children 0.5-1.0=1" deltoid or vastus |
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for subq needle size and gauge
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0.5-3 ml with 25-29 g 3/8 to 1/2 inch needle
normally use 25 g 5/8 inch needle |
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what is the primary site for client over 7 monsth old
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VG site
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which should topical not used with
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moist skin;;;use it with applicator, follicle, and use a steril tongue depressor to remove the medication the container
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when instilling medication on patient eye you should not
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not touch the tip
with the dominant hand hold eyedropper 1/2-3/4 inch about the eyeball drop into the center of conjuctival sac |
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pinna adult down children is
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up eye, eear and nose use gloves
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What is the correct position of giving enema
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side lying posirion with the left upper leg drawn upward
make sure lubricate dept of insertion will differ if client is a child or infant |
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what is ventilation
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the movement of air into and out of the lungs
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what is stimulated and ventilation regulated by
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CO2
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a decrease in bld oxygen is
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hypoxemia
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the vast majority of oxygein in the bld is carried bound to
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heme
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what are the factors affecting oxygenation
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age-older have barrel chest
loss of alveolar gas and susceptible to respiratory infection becasuse of decreased cilia |
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occurs when the airway is partially or completely blocked, diminished airflow, or the lngs lose some of their elastic recoil, trapp stale air which should be exhaled
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opd
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what is the end result of opd
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impaired exhalation, air trapping and dificulty bringin air into the alveoli
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what is the most common OPD
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asthma, emphysema, COPD, cystic fibrosis
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impair the ability of the chest wall and lungs to expand during the inspiratory phase of ventilation
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restrictive pulmonary disease
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impaiment cause
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incrase the work of breathing and reduce airflow to the alveoli
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what is the most common disease in RPD
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pneaumonia
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what are the risk factors of pneumonia
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WISE ON
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alveolar collapse caused by pleural defects due to tumore or by occlusion of the small airways by secretion is
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aterlectasis
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collection of fl between the pleural layers is
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pleural effusion
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nurse are responsile for teaching pt to self administer med before their discharge pt education incluedes
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demonstration a and observe of pt perfomance by performance that ensure pt can saffely and successfully give their own meds
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a single order of meds to be given immediately is called
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stat
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prn is when the
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Nurse judgement and patient condition requires it
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when administering a drug what is the nurse responsibility
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right drg and check 3 times
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nurse correctly identify patient by asking
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to identify and state full name and check id band
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client state i will take sleeping pill later, i will read for few more minutes what do you do
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tell pt to call you when your ready
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clients have the right to refuse meds however, what will make pt be willing to take meds
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if pt undertand the action of meds
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what is your responsibility as anurse during shift change with NARC
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each drug used must be accounted on the narc record
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what do you do when an order is unclear
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meds in ques is not given
hold meds and call dr |
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one teaching plan is developed assestment est pt history help nurse to determine who should be includede in teaching session of drug therapy
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an older pt living alone is physically cable of self administering by may have short term memory loss
then include family and friends |
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with ampule what do you use to open it with
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use gauze to help prevent it from being cut on hagged edge of broken ampule
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what positiom is pt with rectal meds administration
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side lying p with upper leg drawn up toward
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with patient taking meds under the tongue what do you tell the pt
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sublingual- allow to dissolve completely
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instilling meds in the nose how
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tilt head slightly and instruct the pt to keep head tilted for 2-3 minutes
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rectal suppository is contraindicated because
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cardiac because stimulate vagus nerve and use lubricant with h20
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what phase start on 3rd and 4th day after injury and last 2-3 weeks
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reconstructive phase
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after surgery what normal wound should look like
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scant serous(clear)
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composed primary of serym watery appearance or blister is
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serous exudate
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79yo taking steroid and is not eating right what intervention
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decadron and nutrition
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when do you assess for PU
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on admission
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what occur when pt viscera protryde through the disrupted wound
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evisceration
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what nutrient enhance wound healing -food
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orange juice
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first to second degree wound that involve the epdermis and upper dermis is called
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partial thickness
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pt black wound contain what type
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necrotic
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pt complain f wound irritation what type of nursing dx
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impaired skin integrity with moisture and irritaion
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what is the purpose of wound dressing
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keep wound moist and enhance epitheliazation
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what promotes and therapeutic effects of heat therapy
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improves bld flow
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nuse should monitor the nutritional status of pt at risk for PU, nutrient help decresease incidence of pU and contribute healing process
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protein and increase fl intake
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when irrigating a wound what do you use
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normal saline
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how do you irrigate a wound
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from clanest to dirtiest area
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cutrure only where and avoid
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granulation tissue
avoid wound edge and eschar |
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a wound with tunneling how do you determine dept
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insert a stterile cotton swab into the deepest point of the wound and mark at the skin surface level
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how often does nurse must empty the reservoir
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when half full closed drainage
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to prevent breakdown what should be applied
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moisture barrier
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with dry dressing how do you change
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clean skin with warm wet washcloth if suture require cleanindg use 1/2 hydrogen peroxi
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serum
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water appearance
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purulent
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pus
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hemorrhagic
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bright red
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what is granulation tissue
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red moist tissue which progress toward wound healing
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what should be removed first in the wound bed before it can heal and how
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slough-yellow tissue viad debride
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necrotic tissue which must be remove before wound healing is called
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eschar-black
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material and cell dc from bld vessel
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exudate
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blister is what type of drainage
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seous
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thisck yellow tan or braoen drainage is called or mucus
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purulent-pus suppuroation
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pale red watery mix with clear and red -surgical incision is
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serosanguinous
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bright red is
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sanguinouse
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with yello or sloght or purulent need to
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flean and remoe nonviable
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with black need
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debridement with necrotic or exar
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name the external barriers
environmental and sociocultural |
intrerruptions
lack of privacy stimuli language value system educational backgorund |
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internal barriers includes
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psych:anxiety, fear, anger depression and inability to comprehend
Physiological: pain, fatigue, sensory deptivation and oxygen deprivation |
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what are the primary health maintenance of care
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disease prevention, health care, growth and development, first aid nutrition, hygiene
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Secondary and dx and treatment
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disease process, methods of care and health care setting
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Tertiary or follow up
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care at home, meds, dieraty mod, activity, rehab, safety, preventionand recurrence
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what age group benefit from the use of art materials and medical supplies with medicine cups and putting bandages on dolls is
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older children-school age
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older adults how do you assess
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assess for reading skills, frequent repetitio, demonstration, discussion, and assess learning style
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when is client teaching may be indicated when a client
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express need for info to make decisions
Has a need for new skills desires to make modifications in lifestyle is in an unfamiliar environment |
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The nurse assesses the client for characteristics that will hinder or facilitate learning waht are some characterisci base on developmental stage
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Age is not synonymous with developmental level;
Observation of behavior provides the clearest clue to developmental level |
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When do you expect the client readiness to learn?
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when client ask questions
Participate in learning |
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During Nursing Diagnosis,a pt who does not undertand how to use crutches for assisted ambulation may have dx of
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Deficient knowledge:crutchwalking r/t inexperience AEB multiple questions and heitancy to walk=FINAL
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WHEN IS THE BEST TIME TO DO TEACHING
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WHEN CLIENT ASK QUESTION-FINAL
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WHAT raethe specific learning goals include
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measurable behavior change
time frame methods and intervals for eval IT MUST BE REALISTIC |
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for hearing impaired
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face pt directly when you speak
use short sentence use signals to reingore verbal information, gesture eliminate distracting noises or activities |
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when evaluating the teaching what are used to evaluate teaching effectiveness
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feedback from the learner, colleagues, situational, self evaluation
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play immtiation is what stage
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children
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teach the pt during the time of day in which pt is better ablt to concentrate
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older adults
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identify and build on positive qualities
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adolescents
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prep print based material at an appropriate reading skill level
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older adults
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in order to determine someone discheage plannning needs what is the priority if pt has hypertensive
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his ability to purchase his meds-i think similar to final with diabetes
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what is the largest organ of the body
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skin
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what is vesicular sound-final
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soft breezy low pitch sounds heard longer on inspiration than expiration over lungs
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wht is bronchial
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loud and hight picth heard longer on ex than ins though trachea
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what is crackles
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heard predominantly on ispiration over the base of the luns sound like a piece of hair being rolled
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rhonchi is
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heard predominantly on expiration all over the lungs as continous
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when there's absent on breath sound is considered
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abnormal such empyemam hemotho or pneumothorax
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are pulses equal
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yes equal in rate andrythm listen for 1 full min in apical and 30 sec in peripheral
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what is cystocele
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bulging in the anterior wall throug hthe all of vagina
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what do you intruct pt about tse
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montley for early detection of, during warm shower
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increase in muscle size due to fiber
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hypertrophy
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reduction in muscle size and shape
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atropy
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increase muscle tone
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hypertonicity
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readiness to produce drug effect is
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bioavailability
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what is pharmakokinetics
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refers to the study of absorption, distribution, metabolism and excretion of drugs to determine the relationshp between the dose of drug and drugs concentration in biological fl
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what is absorption
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the passae of drug fr site of administration into the bloodstream
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refers to the movement of drugs from the bld into various body fl and tissues is
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distribution
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what is metabolism
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the physical and chemical processing of drug
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what is the pirmary source of biotransformation
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liver
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define half life
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the time it takes for the bodu to eliminate hafl fr original dose
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onset means
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the time it takes the body to respond to a drug after administration
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the highest bld concentration
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peak plasma before elimination
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the lowest ble serum of a drugh-FINAL
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through
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duration
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the time a drug remains in the system in a concentration great enough to have a therapeutic effect
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what is plateua-final
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bld concentration level maintain after series of scheduled drugs
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chewable tablets enhaces
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gastric absorption
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buccal and sublingual meds must be allowed to dissolve completely before pt
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eat and drink
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waht do u do with emulsion and suspension
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shake it first
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trasdermal is
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topical or nitroglycerin change patch 24-7 days
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adverse reachtioj is
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drug other than those therapeutic
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what is anaphylaxis
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life theatining characterized by respiratory distress, bronchospasm and cario collapse
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drug tolerance
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body is accustomed to it cancer pt may req larger dose bec body builds up tolerance
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single dose order
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one time meds
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standing order are
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routine
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the nurse should correctly identify pt by- -FINAL
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checkin armband
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FINAL-WHAT IS A UNIT DOSE FORM
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SCHEDLED DRUG FOR EACH CLIENT A SYSTEM OF PACKAGING AND LABELING EACH DOSE OF MED BY PHARMACY OFTEN TO SUPPLY 24 HOUR PERIOD-
STORED IN MED CARD TWITH EACH CLITN NAME DECREASES ERROR |
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STOCK SUPPLIED IS
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DISPENSED AND LABELED IN LARGE QUANTITY
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WHAT IS ADDICTION
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defined a psychological and physiologival dependence on sybstance
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dependence is
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continual or periodic use of drug-reliance on or need to take a drug
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nurses who are addicted may display
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suspiciou behacior such as insisting on carrying narc keys
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pharmacognosy
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study of herb
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before administering drug what should nurse establish first
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clients baseline or normal status
ie inspect insulin and heparin should be carefully inspected with pt make sure their doing proper tech |
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planning for safe administration of drug
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overall poc halp ensure that client recd meds at appropriate time and meds that should not be given are withheld until their administraion can be verified
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nursing dx of ineffective breathing patter r/t decreased energy may have aclient outcome
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demoonstrate correct use of metered dose
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before meds administration of oral what should be assess first
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gag reflex
loc present of nausea and vomiting aspiration-to prevent confirm pt gag reflex and ability to swallow |
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what should be assess with bucal
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mm and integrity
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what should nurse asses before NG
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bowel sound and check tube for patency before giving meds
check by aspirating and ph or x ray |
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when dr order drug in tablet for for NG what should be done
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dissolve crushe tab in 15-30 of warm water before instillation
dont immerse in cold-cause abdominal cramps |
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what is max vol in well developed for IM injections
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4 ML
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primary site for 7 mos or older on IM is
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VG
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nuse must avoid using
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d and dorso
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normal for sub q is
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25-5/8"
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IV IS FOR
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rapid drug effect or med irritating to tissue
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what should nurse assess the patency of infusion and condition of site and sighn of complication of ? and ? and define
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infiltation-final=swelling and discomfort at IV site
phlebitis inflammation of vein |
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with intermitten infusion device-using IVPB inserted in to a peropjer or cath in the clients vein commonly referred to as
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heparin lock or saling lock-provide continous access to venous circulation increase pt mobility
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how often do you flush
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8 house to maintain patency heparin or normal saling
heparin must be flushed with normal saling |
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what is the potential problem with eye drop
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cross contaminatin
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before instilling meds to ear whan should be instected
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drainage
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how to give meds via ear
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place side lying straignthen ea pinna down and back-children
up and out in adult dron at least 1/2" and maintain position 2-3 min |
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what do you do with nose
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clear nostril and be in upright position with head tilted back slighlty
aerosols shake occlde and keep head 2-3 min |
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posiotion for rectal
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sims and reamain for at least 15 min use water soluble lubricant
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what fingle should be use with suppository
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index
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before the instillation of drops or the use of a ninhaler what do you ask pt to do
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blose nose and clear nostril have pt exhale and close one nostril
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who has larger urethra
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male have longer female is shorter
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The Gi system begins in the
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mouth and ends at the anus
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what is the primary fnx of colon
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collet, concentratite, transport and eliminate waster materials
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initial awareness to defecate start
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150 ml the urge is stonger at 400 ml
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failure to heed the call to defecate can cause?
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lead to overdistention of the rectum with hardening of the stooll and CONSTIPATION
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IF THE PERSON POSTPONES DEFECTION RECTAL ACCOMODATION CCCURS AND
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DESIRE TO DEFECATE IS POSTPONES
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WHAT FACTORS AFFECT WITH DEFECATION WITH INCREASE WITH AGE?
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LOSS OF MUSCLE TONE -FINAL
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WHAT IS THE PRIMARY CAUSE OF CONSTIPATION
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INADEQUATE INTAKE OF FL AND CERTAIN DAIRY
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DIARRHAR AND ______ DISCHARGE OF GAS FROM THE RECTUM IS DIRRECT RESULT OF FOOD INGESTED
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FLATULENCE
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WHAT IS URINARY INCONTINENCE
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CAN'T CONTROL LOSS OF URINE AND CONSTITURE SOCIAL OR HYGIENIC
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THE INABILITY TO COMPLETELY EVACUTE URINE IS
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URINARY RETENTION
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DUE TO UTI, VAGINITIS, IMMOBILITY SEDATION-FINAL WHICH INCONTINENCE OCCURS
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UTI
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WHAT ARE THE 4 CHRONIC URINE LOSS
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SUI, INSTABILITY, FUNCTIONAL, AND EXTRAURETHRAL
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WHAT IS SUI- INCREASE WITH AGE, AFTER MENOPAUSE`
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cant controll urine due to physical exertion and absent DM contration- related to urethral hypermobility and intrinsic sphincter def.
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obese pt who sneeze is WHAT incontinence
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SUI
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SUI URETHRAL HYPERMOBILITY
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ab movt of bladder and uretha during physical exertion due to
vaginal delivery, estrogen. obesity |
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intinsic SPHINCTER DEFICIENCY is due to
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muscular spincted is compromised and leakage is severe defined as TOTAL INCONTINENCE
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INSTABILITY ONCONTINECE
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LOSS OF URINE CAUSED BY PREMATURE OR HYPERACTIVE CONTRACT OF DETRSOR
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WITH NORM SNSATION IN INSTABILITY
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unstable det contraction -desire to pi and leak to follow if bathroom not available
urge incotinence and reflex |
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functional incotinece
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altered mobility, dexterity and access to toilet, change in mentation
hospital setting, women in second floor confusion -dementia when signals to toilet become unclear |
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extraurethral
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sphincter is bypassed or total incontinence same as severe sui cause
ectopia, fistula, surgery varies from DRIBLING LEAKAGE |
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URINARY RETENTION IS DUE TO BLADDER
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OUTLET OBSTRUCTION AND DEFICIENT DETRUSOR MUSCLE CONTRACTION
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BLADDER OUTLET EVACUATION CAUSES
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INCOMPLETER BLADDER EVA BY BLOCKING THE OUTFLOE OF URIN THEROUG SPINCTER
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DEFICIENT DETRUSOR OCCUR
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WHEN CONTRACTIONS ARE INSUFFICIENT TO MAINTAIN URETHRAL OPENING LONG ENGOUGH TO MAINTAIN URETHRAL
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WHAT IS CONSTIPATION
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FINAL=INFREQUENT AND DIFFICULT PASSFE OF HARDENED STOOL
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WHAT DIETRARY FACTORS THAT CONTRIBUTE TO CONSTIPATION
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DEHYDRATION- DEUROPATHIC CONDITION
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WHAT FUNCTIONAL LIMITATION PREDISPOSE OLDER ADULT CLIENT TO CONSTIPATION
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PROLONGED COLONIC TRANSIT TIME
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RECTOCELE
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HERNIATION OF THE RECTUM AND SORROUNDING TISSUE INTO THE SPACE OF THE VAGINAL CAUSE OBSTRUCTION TO DEFECTION AND SUBSEQUENT CONSTIPATION
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THE PASSAGE OF LIQUEFIED STOOL BECAUSE OF ITS INCREASED FREQUENCY IS
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DIARRHEA
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WHAT IS THE PRIMARY CAUSE
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MALABSOPTION
INFLAMMATORY DISEASE DRUGS ENEMA MISUSE |
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WHAT INFECTIOUS DISAHHEA OCCUR WITH
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OVERGROTHE PATH E COLI, SALMONELLA, SHIGELLA AS WELL MULTIPLE ANTIPMIC CAN PROMOTE OVERGROWHT
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INVOLUNTARY LOSS OF STOLL IS
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FECAL INCONTINENCE
NEUROLOGIC MOST COMON CAUSE OF ANAL SPHINCTER SEVER CONS LEAD TO IMPACION AND BACTER OVERGROWTH VAGINAL DELIVERY, SENSORY DISORDER, LOW COMPLIANCE OF THE RECTUM, ANAL SPHINCTER DYSFUNCTION |
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SUDDEN URGE TO URINATE IS DUE TO -LARGE VOLUME OF LEAK
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URGE INCONTINENCE
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LEAKAGE WITH NO SENSATION
OR WARNING IS GENERALLY ASSOCIATED WITH BYPASSING SPHINCTER |
EXTRAURETHAL
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LOW COMPLIANCE OF THE RECTAL VAULT OR RECTAL URGENCY IS ASSOCIATED WITH
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DIARRHEA
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SMALL VOL DUE TO PHYSICAL EXERTIO
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SUI
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HOW IS MOBILITY MAY BE EVALUATER?
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OBSERVING THE CLIENT UNDRESS OR MOVE ONTO A TABLE CHAIR OR BED
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HOW IS DEXTERITY ASSESSED
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OBSERVING THE PT REMOVE CLOTHING, PARTICULAR ATTN IS PAD TO THE MANIPULATION OF ZIPPER, BUTTONS OR SHOW
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WHAT IS THE PERINEUM INSPECTED FOR
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SKIN INTEGRITY
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WHAT IS IMPORTANT TO ASSESS THAT IS ASSOCIATED WITH SUI
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ATROPHIC VAFINAL CHANGES
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BULGING OF THE ANTERIOR WALL INDICATES A
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CYSTOCELE OR LOSS OF SUPPORT OF THE BLADDER BASE
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HEMORRHAOIS IS
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PERIANAL VARICOSITIES OFTHE HEMORRHOIDAL VEINS AND MAY LAOS BE IDENTIFIED
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WHEN URINARY INCONTINENCE EXISTS WHAT TYPE OF ANALYSIS SHOULD BE DONE
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PYURIA
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HEMATURIA IS
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BLOOD IN THE URINE
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REFLEX URINARY
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INVOLUNTARY LOSS OF URINE AND NO AWARENESS OF BLADDER FILLING NO URGE TO VOID OR FEELING OF BLADDER FULNESS-NEUROLOGIC IMPARMENT-REFLEX OF ARC
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URGE URINARY INCONTINECE
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STATE IN WHICH A INDIVIDUAL EXPERIENCE INVOLUNTARY PASSAGE OF URING AFTER
STRONG SENSE OF URGENCY TO VOID MORE THAN EVERY 2 HOURS |
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FUNCTIONAL URINARY INCONTINENCE
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URGE TO VOID DUE TO SENSORY COGNITIVE OR MOBILITY
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TOTAL URINARY INCONTINECE
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IS THE STAE IN WHICH ITS CONTINOUS AND UNPREDICTABLE LOSS OF URINE
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URINARY RETENTION
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BLADDER DISTENTION, FREQUENT VOIDING, HIGH URETHRAL PRESSURE CAUSED BY WEAK DETRUSOR, INHIBITION OF REFLEX ARC
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PERCIEVED CONSTIPATION
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A DAILY BOWEL MOVEMENT
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WHAT IS THE PROBLEM WITH AN INCREASE IN FIBE
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MAY PRODUCE BLATING AND ABDOMINAL DISCOMFORT
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WHAT IS THE CONDOM CATH FOR
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CONNECTED TO A DRAINAGE BAG VIA LEG OR BED SIDE FOR URINARY CONTAINEMNT- RESERVED FOR SEVERE SUI
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WHAT CAN THEY EXPERIENCE WITH SIGNIFICANT DIAHHERA
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SEVERE DEHYDRATION AND EELECTROLYTE IMBALANCE
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PARALYZE SHOULD BE GIVEN
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BISACODYL OR MINI EENMA SCHEDULED VIGOROUSLY TO AVOID IMPACTION AND FECAL INCONTINENCE
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WHAT IS USED WITH URINARY RETENTION
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INTERMITTENT CATH
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CLEINT WITH DIARHHEA MONITOR
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SKIN FOR INTEGRITY AND TREATED WITH PECTIN POWDER FOLLOWED BY SEALANT
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ONLY WOMEN WITH SEVERE LEAKAGE ARE ADVISED TO USE
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INCONTINENT BRIED-SEVERE SUI
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INITIATE DIET AND FL THEAPHY AND IF UNWILLING MAY BE GIVEN
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BULK LAX
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MANAGE DIARRHET ELEIMINAT FOOD MALABSORBED, GIVE ANTIMICROBIAL AND
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BULKING AGENT WATERY STOOL
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PROVIDE ORAL FL RICH IN ELECTROLUTES RECTAL POUCH
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CONSTIPATION
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BOWEL EVAC ORAL LAX OR PIEE OR BULK FOR
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CONSTIPATION INCREASE FIBER AND FL, LIGHT EXERVISE
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INDWELLING CATH IS FOR
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REFLEXCONTINENCE
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TWHAT IS PURPOSE OF ENEMA
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TO CLENSE THE LOWER BOWEL AND ASSIST TO GET RID OR STOLL
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EXTRAURETHRAL INCONTINENCE IS MANAGE BY A POUCH A
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AN ILEAL CONDUIT
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STOMA
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EVACUATION OF FECAL CONTENTS AND END STOMA IS CREASTED PROXIMAL TO AB WALL
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LOOP STOMA
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CREATED BY OPENIGN THE ANTERIOR ASPECT OF THE BOWEL EITHER longtudinally or transverse
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ileostomy
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loop in an ileoanal reservoir by ascending colon
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colostomy
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temp fecal diversion created from the TRANSVVERSE COLON OR FROM THE CECUM
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WHAT SHOULD YOU ELEVATE THE BED WHEN YOUR PUTTING BED PAN
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45 DEGREES
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ATTACHE THE DRAINAGE AFTER CONDOM CATH AND MAKE SRE THE TUBE
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LAYS OVER THE CLIENTS LED TO THE SIDE OF THE BED OF CLIENT LADDER OR THE CLIENT LEG
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HOW DO YOU HOLD PENIS
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PERPENDICULAR
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IF ITS INDWELLING WITH RETENTION BALLOON CONTINUE INSERTING ANOTHER
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1 TO 3 INCHES
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ENEMA IS GIVEN AT WAHT TEMP
POSITION |
105-110 BODY TEMP
KNEE CHEST OR SIMS |
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SPRAYING THE back of the throat with lidocain is what type of anesthesia
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local
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laparoscope for tybal serilization is what type
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regional
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what is allen test for
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assess the pt for bleeding of occclusion bleeding-pressure minimun of 5 min
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symptoms of imparired circulation in clude
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numbness tingling
blui color absent peripheral pulse-final |
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central lin
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treatment and to withdraw bld for analysis
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random collection
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collection anutime with clean cup
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RBC,WBC and platelets
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4.0-5.2 to the 12
5.0-20 to 9th 140-400 x 3 |
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how many wbs
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6
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funx of rbc
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transpor ox , co2 and acid base
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platelets maintain
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vascular repair
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ptt measure
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blood clot
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pt
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measure effectiveness of coumadim
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sicle cell
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clumping of rbc
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type and crossmatch
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identify the pt blood type and donor is compatible
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how manyy bld tupe
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8
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RBC
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4.0-5.9
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HB
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120-163
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HCT
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36-53 FINAL
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MCH
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26-34
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MCHC-FINAL
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310-370
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WBC
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5-10
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NA
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135-148
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,G
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1.3-2.1
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PHOS
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2.7-4.5
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HCO3
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22-26
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PCO2
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35-45
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PH
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7.35-7.45
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SAT
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94 AND UP
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GLUCOSE
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70-120
2 HR <120 LOW BLD GLUCOSE |
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PO2
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75-100
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ASCITESC
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ACCUMULATION OF FL IN THE ABDOMEN
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ANGIOGRAMS
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USED TO EVALUATE SIZE SHAPE AND PATENCY OF VEINS
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VENIPUNCTURE
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COLLECT SPECIMENS
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PORT A CATH
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INSERTERD INTO THE SUPERIOR VENA CAVA OR RITHGHT ATRIUM UNDER THE SKIN
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