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49 Cards in this Set
- Front
- Back
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Nutritional - Metabolic
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Describes the clints pattern of food and fluid consuption relative to metabolic need and pattern indicators of local nurient supply
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Elimination Patterns
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Desctribes the patterns of excretorary function (bowel, bladder & skin)
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Sexuality - Reproduction
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Describes the clients patterns of satisfaction & dissatisfaction with sexuality pattern and describes reproductive pattern.
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Post-Operative phase
Pain |
Pain Level- assess need for pain medication based on clients level of discomfort
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Post-Operative phase
Airway |
Air way obstruction - Anesthesia relaxing Tongue
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Post-Operative phase
Vital signs |
Monitor and compare that there are no major flutuations from prior to surgery and check q4h
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Post-Operative phase
Surgical dressing |
Assess dressing for appearance and presence of abnormalities
(if exudent straight after surgery check again in 1 hour then report to doctor) |
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Post-Operative phase
elimination |
measure all sources of fluid intake and output (including estimated blood/voiding loss during surgery)
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Hydration status indicators
4 |
skin integrity - pale and warm and tugor
Mucous membranes - dry and stick saliva Tachycardic - fast heartrate sunken eyes - oliguria - little or no urine output |
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Ped responsibilities
1. |
maintain tube and position (care of site)
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Peg Tube Maintenance 2
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around site maintance (cleaned with warm soapy water to avoid conteamination
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Peg Tube Maintenance
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Flush regularly - Rotate and migrate
Avoiding blockages & skin adherance |
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Peg Tube Maintenance
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Monitor regulare while feeding - fast rate of delivery to avoid dumping syndrome
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5 indicators of Teaching patient effective
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Patient verbally acknowledge
demonstrates procedure nurse ask for feedback acts confident client involed in procedure |
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How does a nurse assess Elimination patterns
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More that analyzing and quantifying, evaluation of structures, rish factors, contributing factors patients perceptions to elimination
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what factors influences elimination the nurse needs to know?
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physiological
psychological environmental cultural concerns that effect the clients self esteem and physical well being |
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Assessment of elimination
describespatterns |
describes the persons bowel & bladder elimination patterns for frequency, amount and usual bowel habits.
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Assessment of elimination
describes risk and cause |
Identify risk can causative factors associated with altered elimination
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Assessment of elimination
describes self care practices |
identifies the persons self care practices and knowledge about elimination
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Assessment of elimination
describes variations of elimination problems |
differentiating between various elimination problems
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Diagnoses
NANDA 2007 Constipation, Diarrhoea |
percieved constipation
bowel incontinence |
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What is imparied unrinary elimination
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stress Incontinence
reflux Incontinence urge Incontinence functional Incontinence total Incontinence urinary retention |
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what are some of the related diagnoses or elimiation problems
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body image
fluid volume imbalance hopelessness ineffective coping self care deficit altered sexualtiy patterns impaired skin integrity risk for skin integrity imparied |
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what are influencing factors to elimination problems
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Diet
age activity exercise stress drugs pathology |
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Physiology of bowel elimination
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Absorbtion Colonic function
peristalis " " defecation " " |
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Physiology of Urinary elimination
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Mictrition Urine
Vioding " Urination " |
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Factore the influence elimination
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Activity
nutrition pathology medications environmental factors injury |
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symptoms of bowel elimiantion problems
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Pain
weakness rectal fullness bloating bleeding |
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what are self care practices for elimination patterns
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fluid intake
activity and exercise prevention of UTI self treatment of urinary retention Urinary incontinence |
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factors influencing urinary elimination
environmental Psychological and physiological |
stress
history of prolonged urinary catheterization medicatins pathology |
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Nam some Urinary diversion
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ileal conduit
ureterosigmoidostomy cuteneous ureterostomy nephrostomy |
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diagnostic evaluations
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barium enema
proctosigmoidoscopy and colonoscopy intravenous pyelogram cystometrogram electromyography bulocavemous reflex |
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what do we focus on as nurses
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individual
family community |
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what are the physical examination signs of bladder function
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bladder and bowel destention
screening for functional and pathophysiological causes identifying adverse effects |
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what does the nurse pay attention to when looking for elimination problems
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general appearance
abdomen anus and rectum genitourinary structures neurologic and musculoskeletal systems integumentary system |
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faecal examination looks for
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colour
consistency and shape volume odour composition |
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Urinary examination looks for
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colour
transparency odour volume specific gravity ph cells, casts and crystals electrolytes |
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what are 2 diagnostic studies for elimination
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Cystometrogram - radiographic study of bowel and urinary system urodynamic.
Electromyuopgraphy - pressure flow studies postvoid residual volumes |
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reasons for use of indwelling urinary catheters
short term |
short term - allow accurate measurement or output.
to keep bladder empty while surgery or after surgery to prevent PO retention |
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reasons for use of indwelling urinary catheters
long term |
used in cases of chronic retention and incontinence
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UTI symptoms
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frequency, urgency, dysuria, hesitancy or difficult initiating urine streem, low back pain, nocturia, incontinence, retention, suprapubic tenderness or fullness,, feeling of incmplete emptying of bladder.
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features of UTI
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fever, chills, nausea, vomiting, malaise, flank pain.
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what is a ureterostomy
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diver uring directly to the skin surface though a ureteral STOMA a puch must be worn
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what is a condults
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collects uring in a part of the intestine, then open to the skin as a STOMA must wear pouch.
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What is sigmoidostomies
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Diverts urine to the large intestine no stoma required, the urine goes with bowel movements.
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what is a Ileal reservoir
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divert urine into a surgically created pouch, functions as a bladder, the stoma is continent client removes urine by self catherization
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What do you do to prevent UTI
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drink 2-3 l of fluid a day
cranberry juice enough sleep clean perineum from back to front avoid irritation nylon underwear, scented toilet tissue, emtpy bladder when urge to urinate |
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factors contributing to urinary incontinence medications
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medications central nervous system depressants - opiod analgesics
Diuretics change in mental status medications |
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factors contributing to urinary incontinence
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depression - decreases energy,
self esteem - no importance to maintain continence. Inadequate resources - clients with glasses or walking difficulties afraid to ambulate products clients manage incontinence are costly. not enough help for some to ambulate regularly or help with incontinence. |
