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373 Cards in this Set

  • Front
  • Back
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?
CLIENT EDUCATION
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
assumption: learning readiness is affected by developmental stage and sociocultural factors?
conduct a thorough psychosocial assessment before planning the teaching learning activities
assume individual previous learning experiences can be used as a foundation for further learning
perform a complete assestment to determine what the client already know and build on that knowledge
what are the 3 domains of learning
cognitive, affective and psychomotor
what are the barriers of learning in the external barriers
Lack of privacy
interruptions
multiple stimule
socio- language, value system
education background
learning that involve the acquisition of facts and data used in problem solving and decision making is
cognitive
client give self injection what typer of learning
psychomoto
learning that involve changeing attitudes, emotions, beliefs, used in making judgement is called
affective
teachin a diabetic patient how and why to measure the proper daily balance of insulin against glucose levels is within the
cognitive
helping this client learn how to self adiminster insulin fall within the
psych
seeing that the client learns to view diabetes or chronic illness is
affective
how to document client education
conent taugt, teaching method use, who was taught and client and family response
child learn to play with barbie doll is what age group
toddler
how to teach adolesent
engage adolescents in problem solving activities
patient processing information visually is what type of learner
visual learner
patient learn by doing is what type
kinesthetic learner
a crucial step in teaching is to determine the clients learning needs by
what the client needs to know and what the client already knows address the clients immediate need for knowledge first
potential learning needs include
mrs stone is HCG for the first time potential need is
infant care
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
self administration of insulin
an indicator that the client is ready to learn is actively participating in
return demonstration
to keep teaching goal realistic with patient self eficacy is when, and how does pt self efficacy...
if an individual sees the information as being personally valuable, information is more likely to be learned
determination of what to teach is done through comprehensive assesstment, the content taught depends greatly on the pt
knowledge base
readiness to learn
current health status
when do you continue to teach a client
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
when setting goals with mrs stone who is in her 1st trimester of pregnancy, MUST know is
guidelines for diet and exercise

nice to kow is infant care
for visually imapaired clients what do you use
provide large print materials
The PE is done is a sequential....to ensure a thorough assessment of each system is
head to toe
What position for pelvic exam.
Lithotomy position
When assessing hearing impaired patient client should be given what type of questionnaire?
written
When checking patient temperature how do you asssess
used back of hands
During assessment of the carotid arteries, how is assessement done
auscultation
what is localized hyperthermia
seen with infection
patient reading a 4+ what is this scale indicates
4+ pitting edema
what do you use to assess the patient for visual acuity
snellen eye chart
non palpable 0.5 cm in diameter is
macule localized changes -flat and elevated
solid elevated lesion<0.5 cm is
papule
localized changes in skin of <1cm is
patch PU vitiligo
solid and elevated extend deeper han papule into the dermis
0.5-2.0 nodule cyst lipoma erythema
Kilonychia is characterized by
iron deficiency
patient with hearing loss- conductive hearing loss is
normal AC>MC
BC= or >AC
What do you do to assess abnormal breath sound?
aucultate
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
VESICULAR-FINAL
medium pitch blowing sound heard on ins and ex is called
BVS
loud nad high pitched sound with a hollow quality heard longer on ex>ins is
BRONCHIAL SOUND
heard predominantly on ins over the base of lungs when piece of hair being rolled b.w the fingers is called
crackles
heard predominanly on expiration over the trach and bronch as a continous low pitched musical sound is
Rhonchi
what are ACS guidelines for BREAST CANCER
Women in their 20s and 30s should have a CBE as part of a regular health exam by a health professional at least q3years
one heart beat means
lub dub
is apical and peripheral pulse the same
yes bilaterally equality and symmetry of peripheral pulse
how do you assess a homans sign
slightly bend clients knee and sharply dorsiflex the clients foot
Which is the correct way of doing BSE?
patient is to palpate lymph node and breast page 591
During abdomen examination what are the sequence of abdominal assesstment? page 593
inspect, auscultate,percuss then palpate
refers to the increase in muscle size and shape due to an increase in muscle fiber is what type of musculoskeletal problem
hypertrophy- FINAL

side note- atrophy flabby muscle
extra note:
hypertonicity increased muscle tone
hypotonicity
flabby muscle with poor tone
EXTRA NOTES: an inflammation of the joints that causes pain and swellin is
arthritis most common is ostroarthrits
How do you assess for Romberg test
pt stand erect, feet together, and arms at side, first with eyes open and then closed
20 sec no sway is norm
CHAPTER 28 DIAGNOSTIC TESTING
CLIENT LOSES SENSATION TO A LOCALIZED ARE
local anesthesia- lidocain
client loses sensation in an area of the body is what type of anesthesia
REGIONAL
client loses all seansation and consciousness
GENERAL ANESTHESIA
WHAT IS POCT
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
arterial samples are contraindicated in the following condition
anticoagulant therapy
clotting d/o
PVD
-allen test
Arterial puncture should not be performed if pt is?
hyperthermic, after breathing and suctioning treatment
if there have been changes in ventilator setting
when obtaining sterile urine from drainage bag, where should specimen not be ?obtained from
drainage bag-
USE aspiration port
normal fasting value is?
postrandial is
70-115
<120
cholesterol optimals
<200, <130, <250, >40
what are the ABG'S NORMAL RANGE
75-100
35-45 PCO2
7.35-7.45 pH
When is the best time to collect urine?
AM after st void
What is the most commonly performed test of feces is?
Occult Bld test
The GI tract can harbor what?
parasites
what type of test are used for patient with precancerous screaning
Pap test
Which one does not use radiowaves?
Radiography
What is the best explanation method for patient who has Angiography being done with contrast medium
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
what is doppler use for
reveals bld clots and peripheral disease
what should nurse monitor when patient had amniocentesis
vital sign, fetal heart tones, assess sign of labor
after 16th week 10-20 ml
When client is having a lumbar puncture done how does nurse assist
stands facing client with one hand across and the other hand over the buttocks; place the client in a lateral recumbent position
when obtaining sample from the port how much urine do you withdraw?
45 degreee 10 ml
clean with iodine swab
how many times do you clean patient vagina before obtaining urine
3 times
Asked the patient to fill the urine up to how many cc's
30-60cc
the passage of a drug from site of administration into the bloodstream is
absorption
medications such as nitostat are absorbed and patient should put under tongue
sublingual
refers to the mov't of drugs from the blood into various body fluids and tissues is
DISTRIBUTION
where is drug metabolize
in liver
the proces which drugs are eliminated from the body is
excretion
what is half life of 4 hr
8 hour is 25%
Time it takes for body to respond after meds is given
onset
The time it takes for a drug to reach the highest bld concentration after a plasma level
Peak plasma level
The lowest bld serum concentration immediately before the next scheduled dosage
trough
the time a drug remains in the system in a therapeutic concentration
Duration
bld concentration level maintained after a series of sceduled drug doses is
plateau
a patient is taking an androgen which is to given only bucally, where should patient place med at
superior posterior aspect of the internal cheek next to molar
what medication are designed quickly when placed under the tongue
Sublingual meds
which one is not a parenteral route?
ID SUBQ, IM, IV OR ORAL
oral
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
topical drugs- use gloves
abuse of antacids can lead to
osteomalacia
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
how to prep and administer meds , ensures the pt can safely and successfully administer their own meds
an order for a dingle dose of meds to be given immediately is
stat oder
what type of meds when the nurse judgement, and the clients condition requires it is -Make sure document time of administration
prn-nurse cannot give more frequently than the order indicated without consulting with the prescribing practitioner
used for estimating body surface is called
nomograms
when administering any meds the nurse compares the meds and nurse should check the label againsst the MAR
at least 3 times
what do you do when pt tell you that i will take pills later i will read for few more min
call me when your ready
clients have the right to refuse meds but
if clients understand the actions of the meds they may be willing to take the medication
what is your responsibility during change of shifts with regards to narc
each drug used must be accounted for on the narc record
what do you do when there's question about the medication orders
nurse withhold any drug until dr has been notified
during assestment of data, the nurse determine who should be inlcuded in teaching
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
when do you not use standard precaution
vaginal, rectal, oral or eye
oral
enteral tubes provide means of direct insillation meds into?
GI of pt who cannot ingest orally

answer=never attempt to give whole or undissolve meds through an enteral tube
when should you not administer the medication of enteral tube
until the placement in the stomach is verified
what type of syringe use for insulin
u-100 syringe
hypodermic is used ost often when a med is ordered in
ml 2, 2.5, 3 ml
what do you after you obtain from ampule
change the needle and use filter needle because irritate the sub q
vials
glass single multi dose rubber cap drug containers-change needle because it can dull the needle
what are the angles of IM, subq,IV,ID
90,45,25, 10-15
what should nurse avoid using in infants and children
deltoid and dorsogluteal
an obese client usually requires
21 g 2"
when doing IM what do you do
aspirate
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
for subq needle size and gauge
0.5-3 ml with 25-29 g 3/8 to 1/2 inch needle
normally use 25 g 5/8 inch needle
what is the primary site for client over 7 monsth old
VG site
which should topical not used with
moist skin;;;use it with applicator, follicle, and use a steril tongue depressor to remove the medication the container
when instilling medication on patient eye you should not
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
pinna adult down children is
up eye, eear and nose use gloves
What is the correct position of giving enema
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
what is ventilation
the movement of air into and out of the lungs
what is stimulated and ventilation regulated by
CO2
a decrease in bld oxygen is
hypoxemia
the vast majority of oxygein in the bld is carried bound to
heme
what are the factors affecting oxygenation
age-older have barrel chest
loss of alveolar gas and susceptible to respiratory infection becasuse of decreased cilia
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
opd
what is the end result of opd
impaired exhalation, air trapping and dificulty bringin air into the alveoli
what is the most common OPD
asthma, emphysema, COPD, cystic fibrosis
impair the ability of the chest wall and lungs to expand during the inspiratory phase of ventilation
restrictive pulmonary disease
impaiment cause
incrase the work of breathing and reduce airflow to the alveoli
what is the most common disease in RPD
pneaumonia
what are the risk factors of pneumonia
WISE ON
alveolar collapse caused by pleural defects due to tumore or by occlusion of the small airways by secretion is
aterlectasis
collection of fl between the pleural layers is
pleural effusion
nurse are responsile for teaching pt to self administer med before their discharge pt education incluedes
demonstration a and observe of pt perfomance by performance that ensure pt can saffely and successfully give their own meds
a single order of meds to be given immediately is called
stat
prn is when the
Nurse judgement and patient condition requires it
when administering a drug what is the nurse responsibility
right drg and check 3 times
nurse correctly identify patient by asking
to identify and state full name and check id band
client state i will take sleeping pill later, i will read for few more minutes what do you do
tell pt to call you when your ready
clients have the right to refuse meds however, what will make pt be willing to take meds
if pt undertand the action of meds
what is your responsibility as anurse during shift change with NARC
each drug used must be accounted on the narc record
what do you do when an order is unclear
meds in ques is not given
hold meds and call dr
one teaching plan is developed assestment est pt history help nurse to determine who should be includede in teaching session of drug therapy
an older pt living alone is physically cable of self administering by may have short term memory loss
then include family and friends
with ampule what do you use to open it with
use gauze to help prevent it from being cut on hagged edge of broken ampule
what positiom is pt with rectal meds administration
side lying p with upper leg drawn up toward
with patient taking meds under the tongue what do you tell the pt
sublingual- allow to dissolve completely
instilling meds in the nose how
tilt head slightly and instruct the pt to keep head tilted for 2-3 minutes
rectal suppository is contraindicated because
cardiac because stimulate vagus nerve and use lubricant with h20
what phase start on 3rd and 4th day after injury and last 2-3 weeks
reconstructive phase
after surgery what normal wound should look like
scant serous(clear)
composed primary of serym watery appearance or blister is
serous exudate
79yo taking steroid and is not eating right what intervention
decadron and nutrition
when do you assess for PU
on admission
what occur when pt viscera protryde through the disrupted wound
evisceration
what nutrient enhance wound healing -food
orange juice
first to second degree wound that involve the epdermis and upper dermis is called
partial thickness
pt black wound contain what type
necrotic
pt complain f wound irritation what type of nursing dx
impaired skin integrity with moisture and irritaion
what is the purpose of wound dressing
keep wound moist and enhance epitheliazation
what promotes and therapeutic effects of heat therapy
improves bld flow
nuse should monitor the nutritional status of pt at risk for PU, nutrient help decresease incidence of pU and contribute healing process
protein and increase fl intake
when irrigating a wound what do you use
normal saline
how do you irrigate a wound
from clanest to dirtiest area
cutrure only where and avoid
granulation tissue
avoid wound edge and eschar
a wound with tunneling how do you determine dept
insert a stterile cotton swab into the deepest point of the wound and mark at the skin surface level
how often does nurse must empty the reservoir
when half full closed drainage
to prevent breakdown what should be applied
moisture barrier
with dry dressing how do you change
clean skin with warm wet washcloth if suture require cleanindg use 1/2 hydrogen peroxi
serum
water appearance
purulent
pus
hemorrhagic
bright red
what is granulation tissue
red moist tissue which progress toward wound healing
what should be removed first in the wound bed before it can heal and how
slough-yellow tissue viad debride
necrotic tissue which must be remove before wound healing is called
eschar-black
material and cell dc from bld vessel
exudate
blister is what type of drainage
seous
thisck yellow tan or braoen drainage is called or mucus
purulent-pus suppuroation
pale red watery mix with clear and red -surgical incision is
serosanguinous
bright red is
sanguinouse
with yello or sloght or purulent need to
flean and remoe nonviable
with black need
debridement with necrotic or exar
name the external barriers
environmental and sociocultural
intrerruptions
lack of privacy
stimuli

language
value system
educational backgorund
internal barriers includes
psych:anxiety, fear, anger depression and inability to comprehend
Physiological: pain, fatigue, sensory deptivation and oxygen deprivation
what are the primary health maintenance of care
disease prevention, health care, growth and development, first aid nutrition, hygiene
Secondary and dx and treatment
disease process, methods of care and health care setting
Tertiary or follow up
care at home, meds, dieraty mod, activity, rehab, safety, preventionand recurrence
what age group benefit from the use of art materials and medical supplies with medicine cups and putting bandages on dolls is
older children-school age
older adults how do you assess
assess for reading skills, frequent repetitio, demonstration, discussion, and assess learning style
when is client teaching may be indicated when a client
express need for info to make decisions
Has a need for new skills
desires to make modifications in lifestyle
is in an unfamiliar environment
The nurse assesses the client for characteristics that will hinder or facilitate learning waht are some characterisci base on developmental stage
Age is not synonymous with developmental level;
Observation of behavior provides the clearest clue to developmental level
When do you expect the client readiness to learn?
when client ask questions
Participate in learning
During Nursing Diagnosis,a pt who does not undertand how to use crutches for assisted ambulation may have dx of
Deficient knowledge:crutchwalking r/t inexperience AEB multiple questions and heitancy to walk=FINAL
WHEN IS THE BEST TIME TO DO TEACHING
WHEN CLIENT ASK QUESTION-FINAL
WHAT raethe specific learning goals include
measurable behavior change
time frame
methods and intervals for eval
IT MUST BE REALISTIC
for hearing impaired
face pt directly when you speak
use short sentence
use signals to reingore verbal information, gesture
eliminate distracting noises or activities
when evaluating the teaching what are used to evaluate teaching effectiveness
feedback from the learner, colleagues, situational, self evaluation
play immtiation is what stage
children
teach the pt during the time of day in which pt is better ablt to concentrate
older adults
identify and build on positive qualities
adolescents
prep print based material at an appropriate reading skill level
older adults
in order to determine someone discheage plannning needs what is the priority if pt has hypertensive
his ability to purchase his meds-i think similar to final with diabetes
what is the largest organ of the body
skin
what is vesicular sound-final
soft breezy low pitch sounds heard longer on inspiration than expiration over lungs
wht is bronchial
loud and hight picth heard longer on ex than ins though trachea
what is crackles
heard predominantly on ispiration over the base of the luns sound like a piece of hair being rolled
rhonchi is
heard predominantly on expiration all over the lungs as continous
when there's absent on breath sound is considered
abnormal such empyemam hemotho or pneumothorax
are pulses equal
yes equal in rate andrythm listen for 1 full min in apical and 30 sec in peripheral
what is cystocele
bulging in the anterior wall throug hthe all of vagina
what do you intruct pt about tse
montley for early detection of, during warm shower
increase in muscle size due to fiber
hypertrophy
reduction in muscle size and shape
atropy
increase muscle tone
hypertonicity
readiness to produce drug effect is
bioavailability
what is pharmakokinetics
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
what is absorption
the passae of drug fr site of administration into the bloodstream
refers to the movement of drugs from the bld into various body fl and tissues is
distribution
what is metabolism
the physical and chemical processing of drug
what is the pirmary source of biotransformation
liver
define half life
the time it takes for the bodu to eliminate hafl fr original dose
onset means
the time it takes the body to respond to a drug after administration
the highest bld concentration
peak plasma before elimination
the lowest ble serum of a drugh-FINAL
through
duration
the time a drug remains in the system in a concentration great enough to have a therapeutic effect
what is plateua-final
bld concentration level maintain after series of scheduled drugs
chewable tablets enhaces
gastric absorption
buccal and sublingual meds must be allowed to dissolve completely before pt
eat and drink
waht do u do with emulsion and suspension
shake it first
trasdermal is
topical or nitroglycerin change patch 24-7 days
adverse reachtioj is
drug other than those therapeutic
what is anaphylaxis
life theatining characterized by respiratory distress, bronchospasm and cario collapse
drug tolerance
body is accustomed to it cancer pt may req larger dose bec body builds up tolerance
single dose order
one time meds
standing order are
routine
the nurse should correctly identify pt by- -FINAL
checkin armband
FINAL-WHAT IS A UNIT DOSE FORM
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
STOCK SUPPLIED IS
DISPENSED AND LABELED IN LARGE QUANTITY
WHAT IS ADDICTION
defined a psychological and physiologival dependence on sybstance
dependence is
continual or periodic use of drug-reliance on or need to take a drug
nurses who are addicted may display
suspiciou behacior such as insisting on carrying narc keys
pharmacognosy
study of herb
before administering drug what should nurse establish first
clients baseline or normal status
ie inspect insulin and heparin should be carefully inspected with pt make sure their doing proper tech
planning for safe administration of drug
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
nursing dx of ineffective breathing patter r/t decreased energy may have aclient outcome
demoonstrate correct use of metered dose
before meds administration of oral what should be assess first
gag reflex
loc
present of nausea and vomiting

aspiration-to prevent confirm pt gag reflex and ability to swallow
what should be assess with bucal
mm and integrity
what should nurse asses before NG
bowel sound and check tube for patency before giving meds
check by aspirating and ph or x ray
when dr order drug in tablet for for NG what should be done
dissolve crushe tab in 15-30 of warm water before instillation
dont immerse in cold-cause abdominal cramps
what is max vol in well developed for IM injections
4 ML
primary site for 7 mos or older on IM is
VG
nuse must avoid using
d and dorso
normal for sub q is
25-5/8"
IV IS FOR
rapid drug effect or med irritating to tissue
what should nurse assess the patency of infusion and condition of site and sighn of complication of ? and ? and define
infiltation-final=swelling and discomfort at IV site
phlebitis inflammation of vein
with intermitten infusion device-using IVPB inserted in to a peropjer or cath in the clients vein commonly referred to as
heparin lock or saling lock-provide continous access to venous circulation increase pt mobility
how often do you flush
8 house to maintain patency heparin or normal saling

heparin must be flushed with normal saling
what is the potential problem with eye drop
cross contaminatin
before instilling meds to ear whan should be instected
drainage
how to give meds via ear
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
what do you do with nose
clear nostril and be in upright position with head tilted back slighlty

aerosols
shake occlde and keep head 2-3 min
posiotion for rectal
sims and reamain for at least 15 min use water soluble lubricant
what fingle should be use with suppository
index
before the instillation of drops or the use of a ninhaler what do you ask pt to do
blose nose and clear nostril have pt exhale and close one nostril
who has larger urethra
male have longer female is shorter
The Gi system begins in the
mouth and ends at the anus
what is the primary fnx of colon
collet, concentratite, transport and eliminate waster materials
initial awareness to defecate start
150 ml the urge is stonger at 400 ml
failure to heed the call to defecate can cause?
lead to overdistention of the rectum with hardening of the stooll and CONSTIPATION
IF THE PERSON POSTPONES DEFECTION RECTAL ACCOMODATION CCCURS AND
DESIRE TO DEFECATE IS POSTPONES
WHAT FACTORS AFFECT WITH DEFECATION WITH INCREASE WITH AGE?
LOSS OF MUSCLE TONE -FINAL
WHAT IS THE PRIMARY CAUSE OF CONSTIPATION
INADEQUATE INTAKE OF FL AND CERTAIN DAIRY
DIARRHAR AND ______ DISCHARGE OF GAS FROM THE RECTUM IS DIRRECT RESULT OF FOOD INGESTED
FLATULENCE
WHAT IS URINARY INCONTINENCE
CAN'T CONTROL LOSS OF URINE AND CONSTITURE SOCIAL OR HYGIENIC
THE INABILITY TO COMPLETELY EVACUTE URINE IS
URINARY RETENTION
DUE TO UTI, VAGINITIS, IMMOBILITY SEDATION-FINAL WHICH INCONTINENCE OCCURS
UTI
WHAT ARE THE 4 CHRONIC URINE LOSS
SUI, INSTABILITY, FUNCTIONAL, AND EXTRAURETHRAL
WHAT IS SUI- INCREASE WITH AGE, AFTER MENOPAUSE`
cant controll urine due to physical exertion and absent DM contration- related to urethral hypermobility and intrinsic sphincter def.
obese pt who sneeze is WHAT incontinence
SUI
SUI URETHRAL HYPERMOBILITY
ab movt of bladder and uretha during physical exertion due to
vaginal delivery, estrogen. obesity
intinsic SPHINCTER DEFICIENCY is due to
muscular spincted is compromised and leakage is severe defined as TOTAL INCONTINENCE
INSTABILITY ONCONTINECE
LOSS OF URINE CAUSED BY PREMATURE OR HYPERACTIVE CONTRACT OF DETRSOR
WITH NORM SNSATION IN INSTABILITY
unstable det contraction -desire to pi and leak to follow if bathroom not available

urge incotinence and reflex
functional incotinece
altered mobility, dexterity and access to toilet, change in mentation
hospital setting, women in second floor
confusion -dementia when signals to toilet become unclear
extraurethral
sphincter is bypassed or total incontinence same as severe sui cause
ectopia, fistula, surgery
varies from DRIBLING LEAKAGE
URINARY RETENTION IS DUE TO BLADDER
OUTLET OBSTRUCTION AND DEFICIENT DETRUSOR MUSCLE CONTRACTION
BLADDER OUTLET EVACUATION CAUSES
INCOMPLETER BLADDER EVA BY BLOCKING THE OUTFLOE OF URIN THEROUG SPINCTER
DEFICIENT DETRUSOR OCCUR
WHEN CONTRACTIONS ARE INSUFFICIENT TO MAINTAIN URETHRAL OPENING LONG ENGOUGH TO MAINTAIN URETHRAL
WHAT IS CONSTIPATION
FINAL=INFREQUENT AND DIFFICULT PASSFE OF HARDENED STOOL
WHAT DIETRARY FACTORS THAT CONTRIBUTE TO CONSTIPATION
DEHYDRATION- DEUROPATHIC CONDITION
WHAT FUNCTIONAL LIMITATION PREDISPOSE OLDER ADULT CLIENT TO CONSTIPATION
PROLONGED COLONIC TRANSIT TIME
RECTOCELE
HERNIATION OF THE RECTUM AND SORROUNDING TISSUE INTO THE SPACE OF THE VAGINAL CAUSE OBSTRUCTION TO DEFECTION AND SUBSEQUENT CONSTIPATION
THE PASSAGE OF LIQUEFIED STOOL BECAUSE OF ITS INCREASED FREQUENCY IS
DIARRHEA
WHAT IS THE PRIMARY CAUSE
MALABSOPTION
INFLAMMATORY DISEASE
DRUGS
ENEMA MISUSE
WHAT INFECTIOUS DISAHHEA OCCUR WITH
OVERGROTHE PATH E COLI, SALMONELLA, SHIGELLA AS WELL MULTIPLE ANTIPMIC CAN PROMOTE OVERGROWHT
INVOLUNTARY LOSS OF STOLL IS
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
SUDDEN URGE TO URINATE IS DUE TO -LARGE VOLUME OF LEAK
URGE INCONTINENCE
LEAKAGE WITH NO SENSATION
OR WARNING IS GENERALLY ASSOCIATED WITH BYPASSING SPHINCTER
EXTRAURETHAL
LOW COMPLIANCE OF THE RECTAL VAULT OR RECTAL URGENCY IS ASSOCIATED WITH
DIARRHEA
SMALL VOL DUE TO PHYSICAL EXERTIO
SUI
HOW IS MOBILITY MAY BE EVALUATER?
OBSERVING THE CLIENT UNDRESS OR MOVE ONTO A TABLE CHAIR OR BED
HOW IS DEXTERITY ASSESSED
OBSERVING THE PT REMOVE CLOTHING, PARTICULAR ATTN IS PAD TO THE MANIPULATION OF ZIPPER, BUTTONS OR SHOW
WHAT IS THE PERINEUM INSPECTED FOR
SKIN INTEGRITY
WHAT IS IMPORTANT TO ASSESS THAT IS ASSOCIATED WITH SUI
ATROPHIC VAFINAL CHANGES
BULGING OF THE ANTERIOR WALL INDICATES A
CYSTOCELE OR LOSS OF SUPPORT OF THE BLADDER BASE
HEMORRHAOIS IS
PERIANAL VARICOSITIES OFTHE HEMORRHOIDAL VEINS AND MAY LAOS BE IDENTIFIED
WHEN URINARY INCONTINENCE EXISTS WHAT TYPE OF ANALYSIS SHOULD BE DONE
PYURIA
HEMATURIA IS
BLOOD IN THE URINE
REFLEX URINARY
INVOLUNTARY LOSS OF URINE AND NO AWARENESS OF BLADDER FILLING NO URGE TO VOID OR FEELING OF BLADDER FULNESS-NEUROLOGIC IMPARMENT-REFLEX OF ARC
URGE URINARY INCONTINECE
STATE IN WHICH A INDIVIDUAL EXPERIENCE INVOLUNTARY PASSAGE OF URING AFTER
STRONG SENSE OF URGENCY TO VOID MORE THAN EVERY 2 HOURS
FUNCTIONAL URINARY INCONTINENCE
URGE TO VOID DUE TO SENSORY COGNITIVE OR MOBILITY
TOTAL URINARY INCONTINECE
IS THE STAE IN WHICH ITS CONTINOUS AND UNPREDICTABLE LOSS OF URINE
URINARY RETENTION
BLADDER DISTENTION, FREQUENT VOIDING, HIGH URETHRAL PRESSURE CAUSED BY WEAK DETRUSOR, INHIBITION OF REFLEX ARC
PERCIEVED CONSTIPATION
A DAILY BOWEL MOVEMENT
WHAT IS THE PROBLEM WITH AN INCREASE IN FIBE
MAY PRODUCE BLATING AND ABDOMINAL DISCOMFORT
WHAT IS THE CONDOM CATH FOR
CONNECTED TO A DRAINAGE BAG VIA LEG OR BED SIDE FOR URINARY CONTAINEMNT- RESERVED FOR SEVERE SUI
WHAT CAN THEY EXPERIENCE WITH SIGNIFICANT DIAHHERA
SEVERE DEHYDRATION AND EELECTROLYTE IMBALANCE
PARALYZE SHOULD BE GIVEN
BISACODYL OR MINI EENMA SCHEDULED VIGOROUSLY TO AVOID IMPACTION AND FECAL INCONTINENCE
WHAT IS USED WITH URINARY RETENTION
INTERMITTENT CATH
CLEINT WITH DIARHHEA MONITOR
SKIN FOR INTEGRITY AND TREATED WITH PECTIN POWDER FOLLOWED BY SEALANT
ONLY WOMEN WITH SEVERE LEAKAGE ARE ADVISED TO USE
INCONTINENT BRIED-SEVERE SUI
INITIATE DIET AND FL THEAPHY AND IF UNWILLING MAY BE GIVEN
BULK LAX
MANAGE DIARRHET ELEIMINAT FOOD MALABSORBED, GIVE ANTIMICROBIAL AND
BULKING AGENT WATERY STOOL
PROVIDE ORAL FL RICH IN ELECTROLUTES RECTAL POUCH
CONSTIPATION
BOWEL EVAC ORAL LAX OR PIEE OR BULK FOR
CONSTIPATION INCREASE FIBER AND FL, LIGHT EXERVISE
INDWELLING CATH IS FOR
REFLEXCONTINENCE
TWHAT IS PURPOSE OF ENEMA
TO CLENSE THE LOWER BOWEL AND ASSIST TO GET RID OR STOLL
EXTRAURETHRAL INCONTINENCE IS MANAGE BY A POUCH A
AN ILEAL CONDUIT
STOMA
EVACUATION OF FECAL CONTENTS AND END STOMA IS CREASTED PROXIMAL TO AB WALL
LOOP STOMA
CREATED BY OPENIGN THE ANTERIOR ASPECT OF THE BOWEL EITHER longtudinally or transverse
ileostomy
loop in an ileoanal reservoir by ascending colon
colostomy
temp fecal diversion created from the TRANSVVERSE COLON OR FROM THE CECUM
WHAT SHOULD YOU ELEVATE THE BED WHEN YOUR PUTTING BED PAN
45 DEGREES
ATTACHE THE DRAINAGE AFTER CONDOM CATH AND MAKE SRE THE TUBE
LAYS OVER THE CLIENTS LED TO THE SIDE OF THE BED OF CLIENT LADDER OR THE CLIENT LEG
HOW DO YOU HOLD PENIS
PERPENDICULAR
IF ITS INDWELLING WITH RETENTION BALLOON CONTINUE INSERTING ANOTHER
1 TO 3 INCHES
ENEMA IS GIVEN AT WAHT TEMP
POSITION
105-110 BODY TEMP
KNEE CHEST OR SIMS
SPRAYING THE back of the throat with lidocain is what type of anesthesia
local
laparoscope for tybal serilization is what type
regional
what is allen test for
assess the pt for bleeding of occclusion bleeding-pressure minimun of 5 min
symptoms of imparired circulation in clude
numbness tingling
blui color
absent peripheral pulse-final
central lin
treatment and to withdraw bld for analysis
random collection
collection anutime with clean cup
RBC,WBC and platelets
4.0-5.2 to the 12
5.0-20 to 9th
140-400 x 3
how many wbs
6
funx of rbc
transpor ox , co2 and acid base
platelets maintain
vascular repair
ptt measure
blood clot
pt
measure effectiveness of coumadim
sicle cell
clumping of rbc
type and crossmatch
identify the pt blood type and donor is compatible
how manyy bld tupe
8
RBC
4.0-5.9
HB
120-163
HCT
36-53 FINAL
MCH
26-34
MCHC-FINAL
310-370
WBC
5-10
NA
135-148
,G
1.3-2.1
PHOS
2.7-4.5
HCO3
22-26
PCO2
35-45
PH
7.35-7.45
SAT
94 AND UP
GLUCOSE
70-120
2 HR <120 LOW BLD GLUCOSE
PO2
75-100
ASCITESC
ACCUMULATION OF FL IN THE ABDOMEN
ANGIOGRAMS
USED TO EVALUATE SIZE SHAPE AND PATENCY OF VEINS
VENIPUNCTURE
COLLECT SPECIMENS
PORT A CATH
INSERTERD INTO THE SUPERIOR VENA CAVA OR RITHGHT ATRIUM UNDER THE SKIN