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191 Cards in this Set
- Front
- Back
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When is the best time to do the majority of your physical assessment?
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during hygiene care
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What do our activities of daily living promote, improve, and decrease?
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-promote comfort
-improve self-image -decrease infection and disease |
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What do self-care in ADLs promote?
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promotes increased activity, independence, and self-esteem.
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Name 6 factors that can influence a person's hygiene practices.
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-personal preferences
-body image -knowledge -socioeconomic status -cultural variables/social practices -physical condition |
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What are the 4 types of hygiene care?
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-early am care
-morning of after breakfast care -afternoon care -evening or "HS care" |
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What should you do if a pt is in pain when you need to do hygiene care?
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give pain meds and come back when pt. can tolerate care.
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How can cultural variables/social practices influence hygiene practices?
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-some cultures bathe less frequently and are not offended by body odor.
-Orthodox jews prohibit personal care by someone of the opposite sex -some religions require a cleansing bath after a women menstruates -some rel |
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How can socioeconomic status influence a client's hygiene practice?
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inadequate bathing facilities or lack of money can influence how frequently a person bathes.
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How can developmental level influence a client's hygiene practice?
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-parents perform childs hygiene
-preteens only bathe if forced -teens tend to bathe excessively -mature adults generally only need 2-3 bathes/week |
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How can knowledge level influence a client's hygiene care?
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-may not know how to floss correctly
-women may not know to wipe from front to back,etc. |
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What are 5 aspects of health status that can affect self-care ability?
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-pain
-limited mobility -sensory deficits -cognitive impairment -emotional disturbances |
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How can pain affect self-care ability?
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limits persons ability and motivation to perform hygiene and grooming.
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How can limited mobility affect self-care abilities?
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decreases ability to perform hygiene activities.
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How can sensory deficits affect self-care abilities?
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diminish a person's ability to perform hygiene measures safely and independently.
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How can cognitive impairment affect self-care abilities?
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may make it impossible for pt. to initiate own grooming. May be unable to determine need for hygiene.
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How can emotional disturbances affect self-care abilities?
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diminish person's ability to perform hygiene measures.
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What is the role of the nurse in maintaining the client's personal hygiene?
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you are responsible for providing the necessary assistance while also promoting as much self-care as possible.
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How can environment affect comm?
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comm is most successful in an environment that is quiet,private,free of noxious smells,comfortable temp.
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How can developmental variations affect comm?
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physical and cognitive development,language skills,level of education,and maturity influence comm
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How can gender influence comm?
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m and f comm diff. and may interpret same comm diff.
-men want to "be one up" -women want to "be connected" |
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How can personal space influence comm?
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people vary in ammt of physical space they are comfortable w/ when communicating
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What is intimate distance?
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a person's "private space" immediately surrounding them
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What is personal distance?
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18 inches to 4 feet.
interactions w/ clients and HC team usually occurs at this distance |
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What is social distance?
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4 to 12 feet.
used in formal interaction or communicating w/ group of individuals at same time |
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What is public distance?
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beyond 12 ft.
public speakers, large educational groups |
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How does territoriality affect comm?
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many clients consider everything within curtain boundary to be their territory.
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How can sociocultural factors affect comm?
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facial expressions,nonverbal comm, and selection of who to interact w/ are affected by culture.
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How can roles and relationships influence comm?
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relationships affect the choice of vocab,tone of voice,use of gestures, and distance assoc w/ comm.
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What are 7 things that can affect nonverbal comm?
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-personal appearance
-posture and gait:how you carry yourself -facial expression -eye contact -gestures -sounds -territoriality and personal space |
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What is the therapeutic relationship?
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focuses on improving the health of the client,whether an individual or a community.
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Explain active listening w/ regards to therapeutic comm.
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-maintain eye contact
-use a relaxed posture -lean forward -nods in acknowledgment |
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Explain sharing observations and using silence w/ regards to therapeutic comm.
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~Sharing observations
-"You look like you're in pain" ~Using silence -allows clients to think things thru |
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Explain how sharing hope,humor and feelings can promote therapeutic comm?
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~sharing hope
-encouragement and positive feedback ~sharing humor -improves pt outcomes -helps nurses w/stress ~sharing feelings -can validate client's feelings -share your feelings w/ your client |
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What is sharing feelings AKA?
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self-disclosure.
-telling pt something about yourself |
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What are 5 aspects of therapeutic comm?
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~providing info.
-helps pts make informed decisions ~self-disclosing -revealing personal experiences w/ the intent of helping the client ~confronting -improves client self-awareness -can be positive if done in a matter-of-fact way ~open ended ~assertive |
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How can giving personal opinions cz nontherapeutic comm?
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-can be interpreted as pro advice
-legal implications |
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How can changing the subject cz nontherapeutic comm?
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-blocks further comm
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How can false reassurance cz nontherapeutic comm?
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"Don't worry everything will be fine" <--don't know that
-may have good intentions -can block further comm/trust |
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How can asking for explanations cz nontherapeutic comm?
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"Why did you stop taking meds!?"
-"Why" questions can be seen as accusations |
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How can approval or disapproval cz nontherapeutic comm?
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-don't impose your own attitudes or beliefs
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How can defensive responses cz nontherapeutic comm?
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-don't ignore criticisms
-criticisms can promote discovery |
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How can arguing cz nontherapeutic comm?
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-don't challenge your clients perceptions
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Explain SCORE concerning therapeutic comm.
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Silence
Clarify Open ended Reflect what pt said back Empathy |
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Explain NJAWS concerning nontherapeutic comm.
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Don't:
No advice to pt. Judgmental Argue Why Sympathy |
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What are the prerequisites for a helping relationship?
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-open,honest congruent comm
-empathy (vs sympathy) -respect .no judgmentalness .believe in pt strengths .actively listen .be consistent in verbal&non-verbal comm .pacing .offer assistance as needed |
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What characteristics define a helping relationship?
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-client needs are met
-purpose is to enhance client growth -interactions are goal directed and planned -comm is therapeutic -includes periodic eval of goal achievement -has defined end |
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What char. define a social relationship?
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-mutual needs are met
-purpose is friendship,socialization enjoyment,or accomplishment of a task -interactions are spontaneous -comm may include giving advice -no or little emphasis on the eval of interaction -no defined end |
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What are the 4 stages of the helping relationship?
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~Preorientation phase
-be prepared,ask questions ~orientation phase -establish helping relationship -address who you are;what you will do;when you will leave ~working phase ~termination phase |
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Give examples of some clients who have special needs concerning comm?
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-speaking difficulties
-hearing deficits -cognitive impairment -unresponsive clients -non english speaking -developmental concerns |
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What do we value as nurses?
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-health
-independence -believe in autonomy |
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How can you manage the comm process?
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-be aware of what is motivating you and your values/beliefs and perceptions
-think about about what may be the perceptions of the receiver -consider the verbal &nonverbal aspects of the comm -use as many diff channels as possible -solicit feedback -actively listen -manage the environment |
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How can you actively listen?
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process what they're saying,don't be thinking about what you're going to say next
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What factors do you look for when assessing care of the skin?
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-ability to tolerate care
-physical cond of the skin -developmental changes -self-care ability: independent or need assistance and what degree of assist do they need? |
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What factors can cz a risk for skin impairment?
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-immobilization
-reduced sensation -nutritional alteration -secretions or excretions -vascular insufficiency -external devices:casts,etc. |
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What are 3 general nursing diagnoses concerning skin care?
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-bathing/hygiene;self care deficit
-dressing/grooming; self care deficit -toileting;self care deficit |
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What should you consider in the Plan for skin care?
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-method:often overlap w/plans for other probs.
-client's preference -client's cond: may need home care,may have to arrange it w/family members,etc. -time |
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Cleansing bath?
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for hygiene purposes
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Therapeutic bath?
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for treatment purposes
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Explain intervention concerning skin care.
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-cleansing or therapeutic bath
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What guidelines should nurse follow no matter what intervention used conc skin care?
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-provide privacy
-maintain safety -maintain warmth -promote client independence |
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What should you doc. concerning evaluation during skin care hygiene?
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doc. how well tolerated the bath and what % they could do themselves.
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Explain Implications concerning care of feet and nails.
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-If nails get too long,could tear skin.
-be careful about trimming nails in someone w/decreased circ. Usually need a podiatrist to care for in that case. |
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What are you assessing for concerning care of feet and nails?
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-physical assessment:edema,swelling,cracking of nails
-developmental factors:dryer skin w/ aging,decreased circ. -footwear:fits correctly -knowledge |
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What might you need to do concerning Plan of care of feet and nails?
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may need to consult w/podiatrist
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Explain intervention relating to care of feet and nails.
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prevention of inf,odor,trauma.
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What are the 5 main functions of the skin?
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1.protection
2.sensation 3.regulation 4.secretion/excretion 5.formation of vitamin D |
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What comprises total personal hygiene?
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taking a bath or shower,washing hair,brushing and flossing teeth,etc.
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What are some types of therapeutic baths?
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-oatmeal and coal tar treat specific skin cond.
-warm sitz cleanses perineum and soothes infl of that area |
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What are some Implications concerning oral hygiene?
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-mucous membranes provide moisture:dry or cracked lips can be an area for inf.
-saliva aids digestion -tongue tastes:could lead to a decreased sense of taste which usually leads to decreased nutrition. -teeth chew -smile displays sense of well being |
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What is our main nursing care responsibility concerning oral hygiene?
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maintenance and prevention
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What are we assessing concerning oral hygiene?
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physical cond:any sores,radiation can make more prone to lesions,O2 and feeding tube can dry mouth out
-hygiene practices -common problems:halitosis,dental caries,gingivitis,etc. |
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What do we need to be aware of concerning special oral hygiene?
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-unconscious client:suction so they don't aspirate
-stomatitis: infl. of mouth -oral infections -fluoride needs ~Denture care |
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What are the implications of hair care?
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-self image
-alopecia -elevating spirits ~when ill,hair care is usually first to go. |
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What could it mean if a lot of hair is falling out?
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Anemia
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Assessment of Hair?
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-physical assessment
-self-care ability -hair care practices |
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What type of Interventions should be considered for Hair care?
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-brushing and combing
-shampooing -shaving -mustache and beard care |
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What are some things you should consider concerning pts comfort?
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-room environment
-temp,ventilation,noise and odors -overbed table and nightstand -chairs -bedmaking |
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What are some Implications concerning care of the skin?
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-function
-physical changes -skin intact and healthy |
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What are some common myths concerning pain?
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-comfort is the absence of pain
-pain is universal -pain is objective -If a pt is in pain,you'll know it -bc pain is subjective,there is no good way to assess it |
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What is the most common reason for seeking medical care?
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Pain
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What are 4 factors that influence pain perception and pain response?
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-emotions
-age -sociocultural factors -comm and cognitive impairments |
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How can sociocultural factors influence pain perception?
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boys taught not to show;some cultures see it as a punishment from God
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How can emotions influence pain perception?
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many common emotions assoc w/pain are: fear,guilt,anger,helplessness,loneliness.
-emotional response to pain is affected by previous pain experiences. |
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How can comm and cognitive impairments influence reaction to pain?
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-need to consider behavioral cues
-facial expressions,vocalizations,changes in physical activity -physiological cues(elevated BP and pulse) |
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What is nociceptive pain?
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-most common
-occurs when pain receptors respond to potentially damaging stimuli -may occur as a result of trauma,surgery,infl. |
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What is visceral pain?
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czed by stimulation of deep internal pain receptors.
-most often experienced in abdominal cavity,cranium,thorax. |
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What is somatic pain?
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-originates in ligaments,tendons,nerves,bld vessels,and bones
-can be czed by fracture,arthritis,bone cancer |
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What is neuropathic pain?
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-complex and often chronic
-arises when injury or more nerves results in repeated transmission of pain signals even in absence of painful stimuli ex:stroke,tumor |
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What is referred pain?
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occurs in an area that is distant from the original site.
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What is phantom pain?
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pain that is perceived to originate from an area that has been surgically removed
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What is pyschogenic pain?
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pain that is believed to arise from the mind. pt perceives it but no physical cz can be id'ed
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Explain the transduction pathway of pain.
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nociceptors become activated by the perception of potentially damaging mechanical,thermal,and chemical stimuli.
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Explain the Transmission pathway of pain.
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peripheral nerves carry the pain message to the dorsal horn of the spinal cord.
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Explain A-delta fibers. (pain)
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transmit fast pain impulses from acute,focused mechanical and thermal stimuli.
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Explain C fibers (pain)
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fibers that transmit slow pain impulses.
dull,diffuse pain impulses that travel at a slow rate. |
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What is perception? (pain)
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recognition and definition of pain in the frontal cortex.
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What is the pain threshold?
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pt at which the brain recognizes and defines a stimulus
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What is pain tolerance?
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duration or intensity of pain that a person is willing to endure
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What is modulation? (pain)
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pain signals can be either facilitated or inhibited , and the perception of pain can be thereby changed.
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Onset,duration,purpose of Acute pain?
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Onset-rapid
Duration-short,UP TO 6 mo. Purpose-warning something wrong |
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Localization,clinical signs,prognosis of Acute Pain?
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localization-confined,generally well ID'ed
clinical signs-inc. pulse,inc. BP,sypathetic overactivity prognosis-good once prob resolved |
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Onset,duration,purpose of Chronic pain?
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onset-sudden or develop insidiously
duration-longer than 6 mo. purpose-meaningless |
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Pattern,localization,clinical signs,prognosis of Chronic pain?
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pattern-continuous or intermittent
localization-less well defined,indistinct clinical signs-normal vitals bc body adapts to pain prognosis-complete relief not possible |
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Physiological(involuntary)responses for Acute Pain?
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-incr. systolic BP
-incr. heart rate and force of contraction -incr. respiratory rate -dilated bld vessels to brain,incr. alertness -dilated pupils -rapid speech |
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Physiological responses for Deep or Prolonged Pain?
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-decr.systolic BP,possible syncope
-decr. pulse rate -changeable breathing patterns -withdrawal -constricted pupils -slow,monotonous speech |
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Behavioral responses(voluntary) to Pain?
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-withdrawing from painful stimuli
-moaning -facial grimacing -crying -agitation -guarding |
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Psychological responses to Pain?
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-anxiety
-depression -anger -fear -exhaustion -hopelessness -irritability |
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How often should you assess pain?
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every time vitals are taken
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What should you assess on admission conc. pain?
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-pain characteristics
-mgmt strategies -relevant medical history -psychosocial history -impact of pain on clients daily life(how affects,work,chores etc.) -clients expectations/goals |
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Explain PQRST conc. pain assessment.
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Provoking-precipitating factors:what brought on pain
Quality:burning,stinging,throbing stabbing? Region/radiation/location Severity-intensity:keep same pt on same scale Time-onset,duration,frequency |
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Explain numerical pain scale.
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0-5,0-10,etc.
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What is NIPS?
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Neonatal Infant Pain Scale
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FACES pain scale?
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smiley to sad,crying faces
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Explain FLACC pain scale.
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-based on assigned pts
-used for cognitively impaired pts unable to use other scales or infants -bold print for adults,regular print for infants |
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Explain points for FLACC pain scale.
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Scale from 1-10
Face>0-2 Legs>0-2 Activity>0-2 Cry>0-2 Consolability>0-2 |
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Give 5 basic nursing diagnosis for pain.
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-Acute pain R/T...
-Chronic pain R/T... -fatigue r/t chronic arthritis pain -impaired mobility r/t pain in right foot -knowledge deficit r/t pain mgmt strategies |
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Explain Interventions r/t pain.
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-pain therapy requires an individualized approach
-interventions are not exclusive -interventions that work in some situations may not work in others |
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Explain pt goals r/t pain.
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-mutually acceptable level of pain that will allow return of function.
ex: can ambulate to nurse's station while maintaining pain level of 3 -using pain relief measures safely and effectively |
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What are some nonpharmacological pain interventions?
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-Gate control theory
-relaxation and distraction -accupressure -TENS -biofeedback -hypnosis -humor |
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What is Gate control theory?
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looks at CNS as switchboard, can block pain by using other kinds of stimulation
-heat,cold,touch |
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Accupressure?
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fingertips provide firm,gentle pressure over various points
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What is TENS?
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transcutaneous electrical nerve stimulator.
-portable device that stimulates A-delta sensory fibers. |
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Who are non-pharmacological pain interventions best for?
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those who:
-are receptive -express anxiety or fear -might benefit from avoiding or reducing drug therapy -experiencing a prolonged interval of pain -incomplete relief w/ meds |
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What are non-opioid pain meds?
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-nonsteroidal anti-infl drugs(NSAIDS)
-acetaminophen -aspirin |
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Examples of opioid pain meds?
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morphine,oxycodone,hydromorphone
-if pt on for too long,will get constipated,make sure also has laxative order |
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Examples of adjuvants?
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antiemetics,antihistamines
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What are some pharmacological interventions for pain?
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-WHO analgesic ladder
-24 hour dosing -little chance(<1%)of addiction |
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What is 24-hr dosing?
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next dose is administered b4 last dose wears off.
-prevents pt from experiencing severe pain several times a day, better than PRN dosing for pain. |
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What are methods of delivery for pain meds?
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oral,IM,IV,transdermal,nasal,spinal,PCA pumps
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How can anesthesia be used as a pain intervention?
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can be placed directly into wound or in epidural IV line.
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What are 2 surgical interventions for pain?
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1.rhizotomy-interrupts anterior or posterior nerve route that is loc bw the ganglion and the cord
2.cordotomy-interrupts pain and temp sensation below the tract that is severed. |
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What are the nursing considerations conc. comfort and pain?
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-assessments
-interventions -eval -teaching |
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What is the purpose of documentation?
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-communication re pt status and care
-legal record of care |
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What are the essential components of the clients chart?
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-admission data
-advance directive -history and physical -doc's orders -progress notes -diagnostics(lab/x-ray) -interdisciplinary section |
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What is the source-oriented record?
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members of each discipline record their findings in a separately labeled section of the chart.
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What is a problem oriented record? It's 4 parts?
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organized around pts probs.
1.database 2.problem list 3.plan of care 4.progress notes |
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What are some ex of charting by exception?
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-client refuses meds
-lung sounds are abnormal -clients oxygenation status is deteriorating |
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What is Focus/DAR charting?
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-focus charting highlights the client's concerns,problems,strengths
1st column:time and date 2nd column:ID's focus or prob 3rd column:charting in DAR format |
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What is DAR format?
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-Data:doc subj and obj data
-Action:docu interventions performed -Response:decribe pts response |
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What is charting by exception(CBE)?
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designed to streamline docu.
uses preprinted flowsheets |
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Things to remember concerning computerized charting?
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-maintain confidentiality:don't display data where others can see it
-correct errors as per protocol -never leave terminal unattended after you log on -dont give your password or sign on info to anyone |
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What are some legal Dont's of documentation?
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DON'T:
-use negative language or include inappropriate info in pt record -use labels to describe pt,be objective -don't record staff conflicts -don't record staffing probs -don't mention incident reports -dont use words assoc w/errors -don't name a 2nd pt -don't chart casual convos w/ co-workers |
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What should you do if make an error?
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-draw single line thru it
-write "mistaken entry" -initial,date, and time |
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If chart is unavailable...
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-add info on first available line
-start w/current date and time -write "late entry" and reason -document care indicating time care occured -sign the entry |
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What are legal issues concerning confidentiality and documentation?
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-never leave in public areas
-never remove client info from facility -dispose of confidential papers properly |
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Legal issues regarding access to records and documentation?
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-property of facility or agency
-only those w/ "need to know" per facility policy -expect changes w/ electronic records |
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Incident reports...
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-completed by staff who witnessed or found the incident
-not included in your notes -internal record only(not discoverable) |
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In person verbal orders?
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-doc should write order on chart
-repeat order back to doc -ask for any clarification immediately |
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Over the phone verbal orders?
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-repeat order back to doc
-doctor should sign-off on order when on unit |
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Legal issues of orders?
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~know what order to question
-any order a pt questions -any order if pts cond has changed -standing orders if inexperienced and have questions -ambiguous orders you can clarify/discuss an order w/ your supervisor |
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Giving change-of-shift report...
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~prepare
-gather/organize data ~present individual client info. -name/age/sex -room # -attending doc -diagnosis -surgical procedures |
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What should change-of-shift report focus on?
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-pertinent assessment info.
-event that occurred in previous 24 hrs:changes in orders/conds,lab studies,dx tests,specimens -pt response to care -unfinished nursing activities to meds,tests,txs -special equip needed -personalization of nursing care -pertinent interdisclipinary plans |
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Computer printout?
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-individual client info
-may include all current orders -nursing specific activities .frequency of VS .dressing changes -most recent la results |
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What is oliguria?
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urine output of less than 400 mL is 24 hrs.
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What is dysuria?
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painful or difficult urination. May be assoc w/ inf or partial obstruction of urinary tract
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What is hematuria?
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blood in the urine. May be due to trauma,kidney stones,inf.
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What is urgency?
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A sudden,almost uncontrollable need to urinate
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What is frequency?
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the need to urinate at short intervals
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What should you be looking for when assessing urinary elimination?
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~pt interview/history:fluids they drink?diet?normal urinary pattern?looks like?recent changes in pattern or urine itself?Meds on?
~physical exam:percuss kidneys for CVA tenderness,palpate bladder,look at skin,perineum for irritation,breakdown ~urine exam. |
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What should you record for urine intake?
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-oral
-IV -enteral -irrigations -bld and bld products -anything on a full liquid diet |
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What are some nursing diagnoses for urinary eliminaton?
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-impaired urinary elimination
-urinary incontinence:can be etiology for other conds>anxiety,stress,etc. .funtional overflow,reflex,stress,total,urge -risk for urge urinary incontinence -urinary retention -readiness for enhanced urinary elimination |
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What are some planning/goals related to urinary elimination?
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-client will resume his normal urination pattern by..
-client will respond to the urge to void in a timely manner by... -client will have a postvoid residual vol of < 150 mL by.. -client will perform toileting activities independently by... |
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What is reflex urinary incontinence?
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involuntary loss of urine at somewhat predictable intervals when a speific bladder vol is reached
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What is reflex urinary incontinence r/t?
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-tissue damage(radiation,radical pelvic surgery)
-neurological impairment(paralysis) |
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What are interventions for reflex urinary incontinence?
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-determine schedule for emptying bladder
-self-catheterization or collection devices |
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What are contributing factors for UTI's?
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-residual urine
-pH:acidify urine to prevent UTI,also helps w/kidney stones -instrumentation -contaminated hands -poor perineal hygiene -catheterization -intercourse -kinked catheter drainage tubing czing back flow of urine:keep Foley bag lower than bladder |
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What are S/S of Bladder Inf?
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-pain,burning(dysuria)
-frequency,urgency -hematuria -cloudy urine -fever,chills,N/V,malaise |
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What are S/S of kidney inf?
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-CVA tenderness
-chills and fever |
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What are interventions for UTI?
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-meds
-antibiotics:for bladder inf,usually output -analgesics:help w/bladder spasms,usually change color of urine -education to prevent recurrence |
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Explain drugs which stimulate urination.
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-stimulate cholinergic receptors
-cause contraction of bladder -for use when person can't void as in postoperative situations -would not use if obstruction present -PNS innervaes other vital organs,ex:heart and lungs(bronchospasms,slow heart rate) |
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2 examples of drugs which stimulate urination?
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-bethamechol
-urecholine |
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Explain urinary antispasmodic drugs.
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-decrease spasmolytic action of smooth muscle of GU tract
-decreases pain of bladder spasms -these drugs are anticholinergic -could cz inf,blurred vision |
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4 examples of anticholinergic drugs?
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-flavoxate hydrochloride
-oxybutynin -urispas -ditropan |
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Explain urinary analgesics.
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-exert a local anesthetic effect on urinary mucosa
-relieve urinary tract pain. -available OTC -colors urine red-orange,stains clothes -take w/ meals -should seek treatment for underlying conds czing pain |
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3 examples of urinary analgesics?
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-phenazopyridine hydrochloride
-pyridium -azo standard |
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What are some factors that affect defecation?
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-development:aging,decr. muscle tone,less activity
-diet:fiber,fluids -activity:walking helps bowel peristalsis -psychological:embarrasment -habits -medication -anesthesia and surgery -pain:if hurts,ppl will try not to go>hemorrhoids,etc. |
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Assessment for bowel elimination?
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-normal bowel habits:how often?when normally go? stool consistency?diet?any constipation,diarrhea?
-risk factors -stool assessment |
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What should look for in stool assessment?
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-old bld will be dark/balckish:melena
-iron may cz black colored stools -sometimes can see bright red bld in stool: stress ulcers in very ill ppl,cancer or lesion in GI tract |
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Other things to look for in stool assessment?
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-white or clay colored:no bile,bile gives stool its pigment
-pale w/ fat:malabsorption -mucus or bloody mucus -worms |
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What are some reasons stool may be tested for?
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-ova and parasites
-culture -culture and sensitivity -occult bld |
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Occult blood?
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-GUAIAC:test for occult bld>get specimen from inside of stool,smear on paper and put guaiac liquid on it.
-order guaiac all stools or guaiac stools X 3 -screening for colon cancer |
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Nursing diagnoses for bowel elimination?
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-bowel incontinence
-constipation -risk for constipation -perceived constipation -diarrhea |
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Planning/Goals for bowel elimination?
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-maintain/restore normal bowel elimination pattern by.
-maintain/regain normal stool consistency by... -prevent(assoc. risks) -fluid & electrolyte imbalance:diarrhea -skin breakdown:if incontinent of bowel,have ostomy |
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Interventions for Bowel elimination?
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-promote regular defecation
-privacy:promote bc may hold if ppl in room,etc. -timing -nutrition and fluids -exercise:helps move peristalsis -positioning:sitting up in bed -meds:enemas |
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What is constipation?
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-infrequent bowel mvmts,difficult evacuation of stool,inability to defecate at will and hard feces
-the longer stool stays in the intestine,the more H2O is absorbed and the harder the stool |
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Causes of Constipation?
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-meds:NARCOTICS
-ASA,antihistamines,aluminum antacids -hypnotics,tranquilizers -irregular bowel habits/changes in routine schedule -bedrest:decr. mobility -elderly:slowed peristalsis -neurological conds that block nerve impulses -illness such as hypothyroidism,hypocalcemia,hypokalemia -depression -eating disorders -low fiber diets -stress -laxative abuse |
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How can constipation cz harm?
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-straining can cz increase in intraocular pressure and intracranial pressure
-ppl who have had an MI:dysrhythmias stimulation of vagus nerve -surgery and childbirth:hemorrhoidectomy and sutures -hemorrhoids |
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Preventening and Intervening for Constipation?
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-fluids:adequate amt
-fiber:incr fiber in diet,fruits and veggies -activity -stool softeners to prevent,sometimes laxative if on narcotics -laxatives or enemas to treat -privacy -positioning -bedside commode |
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What is best position to place client in to administer an enema?
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Left Sims
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Impaction?
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-Czed by unrelieved constipation
-hardened feces collects and becomes so wedged in rectum that it cannot be passed |
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Assessment for Impaction...
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-debilitated,confused,unconscious,dehyrated client:most common
-look for oozing of diarrhea as sign:may not always be present -loss of appetite -nausea -ab distention,cramping -rectal pain |
