What are somethings to consider during preoperative preparation?
Assessment
Preadmission testing
Preoperative teaching
Informed Consent
Patient preparation
Emergency Surgery
Edit
2
A patient that has been admitted into your unit has a scheduled surgery for the following day.
The patients states he is allergic to latex. What, as the caregiver, must you do next?
Inform the Physician and the surgical unit to prepare for preventative actions.
Edit
3
Prior to surgery what should the TPCN assess for regarding history?
General health & Physical status
Allergies
Current Meds
Nutrition
Understanding of scheduled procedure
Psychosocial/spiritual needs
Educational Needs
Edit
4
If a patient drinks a six pack of beer a day are they an alcoholic?
Yes, poss risk for Delirium Trimmers if restricted from continuous us for surgical procedures.
Edit
5
Why does obesity affect clients in surgery?
Adipose tissue does not heal as well or fast
Edit
6
Why is it important to assessment the patient for ETOH and Tobacco use?
Liver problems doesn't cause coagulation, malnutrition, or metabolism. (Delays wound Healing)
Edit
7
Chemo therapy aids and/or leukemia is important to know about a patient prior to surgery
because this indicates what?
Immunocompetence
Edit
8
What are preadmission testing performed based on?
Patient History
Procedure
General Health Status
Medication Use
Edit
9
Patients H/H are indicated to be low. Patients O2 level is still low after putting them on 4 liters of
oxygen. Why?
With Decreased Heme comes decreased O2
Edit
10
Why is it good to assess the thyroid level of a patient?
Hormone that Regulates Metabolism
Edit
11
TCDB stands for what and should be done when and in what increments?
Turn, Cough, Deep Breath should be done after surgery once every hour?
Edit
12
What is the deveice that assists in the expansion of the alveoli and diffuses the anesthesia outside
of the body and decreases the chances of pneumonia?
Incentive Spirometer (IS)
Edit
13
What are some actions taken postoperatively to decrease secondary problems?
TCDB/IS
Early Mobilization
Pain Management
Edit
14
THis is the patients voluntary agreement to participate in a particular cure or treetment. It must
be provided in words that are understood by the patient by the surgeon.
Informed Consent
Edit
15
What is required on a written consent?
Name and details of procedure
Name of Patient, Surgeon, and Anesthesiologist
Time and Date of signature
Will/Will not receive blood
Risks and Hazards
Name and Qualifications of the surgeon performing this procedure.
Edit
16
Patient is admitted into the unit and is informed they will need to have surgery to remove their
gallbladder. The patient is 17 years old and you are in need to get a consent signed. Who do you
get to sign?
You would get the parents/guardian.
(Confused, sedated, mentally incompetent, and minors can not sign.)
Edit
17
Your patient is to be preped for surgery. You notice the site of surgery, on the chest, has hair.
Why would you not shave?
Because it is evidence based practice that shaving prior to surgery increases risk for infection.
Instead, clip with scissors.
Edit
18
Your patient is admitted on your unit to have surgery that same day. Your patient is 69 year old
female with a perm, make up, manicure with nails, dentures and jewelry. What do you do to
prepare them for surgery.
Ask the patient to allow you to place valuables with security, Remove atleast (if not all) one fake
nail for O2 monitoring, wash face free of make-up to reduce risks for complications of the eyes,
remove dentures and last but not least use the rest room before departure.
Edit
19
These are three stages of Anesthesia.
Conduction
Maintainance
Emergence
Edit
20
This is used on minor short term surgical procedures.
Topical Anesthesia
Edit
21
Versed, valium is given while patient retains respiratory function while awake during these
procedures.
Conscious Sedation
Edit
22
Surgery begins with administration until patient is taken to PACU.
Intraoperative Care
Edit
23
Perioperative Nurse can be an LVN. T/F
False: can only be RN and up.
Edit
24
What is the average stay in PACU?
2hours with an assessment every 10-15 min.
Edit
25
This is the score used for assessing the 5 areas of activity, respiration, consciousness, and O2 sat
for patients safety prior to returning to unit. Must be scored between 8-10.
Alderete Score
PARS (Postanesthesia Recovery Score)
Edit
26
EBL means? and what's important about this?
Estimated Blood Loss. Possible need for blood transfusion.
Edit
27
What is linked to increased risk for surgical site infection?
Hypothermia
Edit
28
What is the purpose for the surgical site drains?
To prevent from blood coagulation to increase chances of infection and dehesence.
Edit
29
Jackson Prat
JP Drain
Edit
30
Serous Fluid is....
Cell Break down. Clear Fluid
Edit
31
Where do the most of the nerves reside?
On the surface of skin.
Edit
32
What are some common nursing diagnoses for postoperative care?
Acute Pain
Decrease Cardiac Output: AEB Incr HR & Decr BP
Impaired Skin Integrity: AEB surgical incision
Risk For (many)
Anxiety
Knowledge Deficit
Edit
33
Post-operatively, what is the limit for patient who is due to void?
8HRs post-op
Edit
34
Atelectasis is caused by what post operatively?
Not performing some essentials such as TCDB & IS.
Edit
35
When should a patient be able to eat or drink?
When the Gag Reflex occurs
Edit
36
The occurrence of a broken clot that is moving, ex DTV is called ___.
Thombosis Phlebitis
Edit
37
When is staph seen in a surgery incision?
45 day after surgery
Edit
38
What medications go with a PCA pump?
Morphine, Demerol, Phentonyl, Diluadid
Edit
39
Along with PCA what alternatives are give to relieve pain?
Muscle Relaxant and PO meds
Edit
40
How long do PCA's usually stay with a patient after surgery?
24 hrs, after that PO meds are administered.
Edit
41
What are some nursing interventions for Pain relieve for postoperative care?
Encourage early mobilization
Pomote cardiac output, wound healing, bowel/bladder function
Provide emotional support
Education
Edit
42
What is the lowest the diastolic pressure needs to be to insure proper blood flow to the brain?
Diastolic pressure needs to be atleast 50and above
Edit
43
How does a patient adapt to an illness or loss?
Denial or disbelief; Anger; Bargaining; Resolution; Acceptance.
Edit
44
What is the difference between active and passive participation?
Active is reading the material given to them for the better of their health.
Passive is disposing of all info given to them and not participating.
Edit
45
What are the different types of Sutures?
A) Individual/Interrupted
B) Continuous Sutures
C) Blanket Sutures
D) Retention Sutures
Edit
46
This is the act of a wound that opens along the joined edges.
Dehiscence
Edit
47
This is the removal of internal organs from an opened wound.
Evisceration
Edit
48
These sutures are used in surgical incision that prevent dehiscence and ultimately prevent
evisceration.
Retention Sutures
Edit
49
What is the largest organ in the body?
skin
Edit
50
What is a break in the skin with disruption of the normal continuit of structures from a physical
means?
Wound
Edit
51
This type of cleanliness consists of GI, uninfected operative outside of resp, genital, and urinary
tract.
Clean-Closed
Edit
52
This type of cleanliness consists of operation wounds in respiartion, GI, genital or uninfective
urinary tract.
Clean-Contaminated
Edit
53
This type of cleanliness is an Open, fresh, accidental, oper. c brk in sterile technique or GI
spillage, nonpurulent inflammation.
Contaminated
Edit
54
This type of Cleanliness is in old wounds with dead tissue, infection, or perforated viscera.
Dirty/Infected
Edit
55
This is the tearing of tissue.
Laceration
Edit
56
This is the scraping of skin off surface.
Abrasion
Edit
57
This is a closed wound: bruise.
Contusion
Edit
58
This is a small, deep wound.
Puncture
Edit
59
This is an intentional cut into tissue.
Incision
Edit
60
This is a clean surgical incision with well defined edges and has minimal tissue loss during
healing process (occuring by epithelialization)
Primarily Healing Process
Edit
61
This healing process a wound without proximate edges such as a pressure ulcer. (Great tissue
loss, open wound)
Secondary Healing Process
Edit
62
This type of wound is the result of debridement of a large necrotic wound. Requires management
of infection. Delayed suturing and grafts.
Tertiary Healing process
Edit
63
The bodies reaction towards wounds and begins within minutes of the injury and can last up to
three days.
Inflammatory Phase
Edit
64
Injury occurs---3min-->swelling, redness, heat & Pain---> Bleeding controlled by hemostasis--->
WBC's ingest bacteria & prepare for tissue repair
Inflammatory Phase
Edit
65
Damaged tissues & Mast cells creates histamine resulting in _____.
Basal dilation
Edit
66
New granulation tissue is generated producing a red, beefy, shiny tissue with a granular
appearance is known as what phase of healing?
Proliferative Phase
Edit
67
What stimulates production of collagen; epithelialization with scar formation?
Fibroblasts
Edit
68
Collagen fibers reorganize, mature and gain tensile strength of a healing wound. This phase is
known as?
Maturation Phase
Edit
69
Scar tissue is regains the skin's original strength and more. T/F
False: Scar tissue regains 70-80% of skins original strength.
Edit
70
This is new, healing tissue, very fragile at first and is red. What is this wound classified as?
Granulation
Edit
71
"Moist scab" necrotic tissue with yellow color. This wound is classified as?
Slough
Edit
72
"Dry Scab" Necrotic tissue known as what wound classification?
Eschar
Edit
73
You examine a patients wound. You notice the wound appears smooth, velvety texture with a
dark red color with bumpy texture. What type of wound tissue is this?
Granulation Tissue
Edit
74
Angiogensis & collagen deposition is found in ____
Granulation tissue
Edit
75
You find a patients wound appear creamy white, stringy, loosely adhering to wound. What type
of wound is this?
Slough Tissue
Edit
76
Black fibrinous network of platelets, cells (scab), which becomes food for bacteria, delaying the
healing process. Needs to be removed.
Dead Tissue/Eschar
Edit
77
(Internal) decreased Blood Pressure, increased pulse, increased respirations, diaphoresis and
restlessness. These are complications of what type of wound?
Hemorrhage
Edit
78
Purulent Drainage can be the cause of _____ creating a complication of wound healing.
Infection
Edit
79
If a patients abdominal incision eviscerates what must you do as a nursing intervention?
Apply moist saline and sterile gauze, notify surgeon/physician and do not attempt to reapply
organs internally.
Edit
80
The partial/total separation of layers usually occurring 3-11 days after injury is known as what?
Dehiscence
Edit
81
The total separation of wound layers; protrusion of visceral organs through a wound opening.
Evisceration
Edit
82
A clear drainage (water plasma liquid portion of the blood)
Serous
Edit
83
Thick yellow green tan or brown drainage, that contains white blood cells and bacteria
Purulent
Edit
84
Pale red watery mixture of clear and red fluid drainage
Serosanguineous
Edit
85
Bright red drainage (bleeding)
Sanguineous
Edit
86
If a wound is infected what must be present?
Purulent drainage
Edit
87
Redness, edema, heat, pain, loss of function are all cardinal signs of ____.
Inflammation
Edit
88
P&P:PAGE 654
Table 34-35
KNOW WBC COUNT
Edit
89
You are changing a patient's wound dressing. There is an increased amount of exudate, pallor of
wound bed, and a delay in healing. What is this signs of?
Infection
Edit
90
Contaminated or traumatic wounds usually show signs of infection when?
2-3 days
Edit
91
Surgical wounds show signs of infection when?
4-5 days post-op
Edit
92
When obtaining a culture of wound drainage what is the procedure?
Cleanse first
Collect form wound base, not drainage
Differentiate aerobic v anaerobic
Use Sterile technique (swab tip touches ONLY area to be cultured and inside of culturette)
Edit
93
Why is nutrition essential for wound healing?
Protein: essential in wound healing and cellular growth
Tight Glucose control:
**Diabetes**
Edit
94
Body build is essential because...
For the slightly fluffy type, excess skin/adipose tissue may be of a complication to heal quickly
and efficiently.
Edit
95
Why is oxygenation essential for wound healing?
Anygiogensis and epithelialization
Edit
96
When assessing a wound, what should one take note of?
Location, size
Amount of drainage, color, consistency
Wound base- type tissue
Any tunnel or undermining
Wound margins
Surrounding tissues
Signs of infection
Progress toward healing
Edit
97
For wound cleansing, Hydrogen Peroxide is the best solution to use in homes and clinical
settings. T/F
False: Hydrgen Peroxide is a cytotoxic solution. Complicates wound healing.
Edit
98
What are the four methods of debridement?
Autolytic
Enzymatic
Mechanical
Sharp
Edit
99
When an enzyme is placed on top of a necrotic tissue.
Enzymatic
Edit
100
Nurse using a wet to try dressing to remove the necrotic tissue
Mechanica
Edit
101
When a physician uses the assistance of a scapule to physically remove necrotic tissue from a
wound.
Sharp
Edit
102
What is the purpose of a dressing over a wound?
Protect; aid in hemostasis; promote healing (absorb drainage, debridement); Support/splint;
protect pt from visualization; promote thermal insulation; Provide moisture between wound &
dressing; and remove excess moisture.
Edit
103
What is a good dressing?
It will remove excess exudate from a wound, won't allow wound to dry by keeping moist
enviroment. Allows proper gas exchange, and thermoregulation. Minimize contamination, be
non-traumatic and not adhere to the wound.
Edit
104
DIABETES
Mellitus
Edit
105
This is a group of conditions characterized by relative or complete lack of insulin. It can also be
characterized by defects in insulin cell receptors as a result in disturbances in metabolism of
carbs, proteins, & lipids.
Diabetes Mellitus
Edit
106
What type of Diabetes is most abundant in adults and children?
Type 2 Diabetes (90%)
Edit
107
This is a chronic condition that often results in damage to organs and other pathological/disease
states. (Silent Killer)
Diabetes Mellitus
Edit
108
What are the diagnosis criteria for type 1 Diabetes Mellitus?
1) Present with symptoms of 3 P's
2) Causal plasma glucose >200mg/dL
3) Flasting plasma glucose >/= 126mg/dL & confirmed by repeat on another day+1 P's is
preferred method
4) 2 hr plasma glucose >/= 200 mg/dL during OGTT
Edit
109
What are the 3 P's?
Polydipsia
Polyuria
Polyphagia
(Sudden weight loss)
Edit
110
In this type of diabetes, there are damage caused to the beta cells of pancreas that's thought to be
result of autoimmune response caused by Genetic predisposition, viral infections, environmental
stimuli, and islet cell autoantibodies are present.
Type 1 Diabetes
Edit
111
a naturally occurring polypeptide hormone secreted by the beta cells of the islets of Langerhans
in the pancreas in response to increased levels of glucose in the blood as well as the
parasympathetic nervous system and other stimuli.
Insulin
Edit
112
characteristic signs of diabetes mellitus, including increased desire to eat, excessive thirst,
increased urination, and eventually lethargy and weight loss
Insulin
Edit
113
How does one manage type 1 diabetes?
Intensive therapy; admin of insulin>3xday; dietary intake; anticipate exercise.
Conventional therapy: Admin of insulin 1-2xday, self monitoring of urine or blood glucose 1x
day, client education on diet & exercise.
Edit
114
This is an abnormal accumulation of ketones in the body caused by excessive breakdown of fatty
acids.
Ketosis (develops in the absence of adequate metabolism of carbs...as in diabetes Type 1)
Edit
115
The diagnosis criteria for type 2 diabetes in adults is?
2hr plasma glucose >/=200mg/dL OGTT (or any other tests as for Type 1)
Edit
116
What is the diagnosis criteria in Type 2 diabetes in children?
Overweight & any of the following:
1) Family history of type 2 in 1 or 2 relatives
2) Native American, African American, Hispanic American, Asian-American/Pacific Islander
3) Signs of insulin resistance or conditions associated w/insulin resistance; acanthosis nigricans,
HTN, dyslipidemia, or PCOS.
Edit
117
A patient states he is at the clinic at least 3-4times a week due to UTI they are always thirsty and
urinate frequently. What are these clinical symptoms of?
Type 2 diabetes
Edit
118
Hyperpigmentation, thickening of the skin and
PCOS
Edit
119
What is the number 1 factor for type 2 diabetes in children?
Obesety
Edit
120
Who is more susceptible to diabetes?
Girls (ratio is 1.7-1)
(Maturity Onset Diabetes of the Young; Type 2)
Edit
121
Cells do not accept insulin; increased resistance r/t altered cellular metabolism & intracellular
postreceptor defect
Insulin resistance
Edit
122
Insulin secretion may be normal or decreased
Insulin secretory defect in Type 2
Edit
123
Are islet cell antibodies present in Type 2 diabetes?
No
Edit
124
What is the conventional therapy for managing type 1 diabetes?
Admin of insulin 1-2xday; self monitoring of urine or blood glucose 1xday; client education on
diet & exercise.
Edit
125
If blood sugar is greater than 300 or if there is presents of ketose in the urine output should a
diabetic exercise?
No, <300mg/dL. (body is not taking sugars in to provide for the strength to exercise)
Edit
126
This is a risk factor for type 2 diabetes that produces insulin resistant states causing beta cells to
produce excessive amounts of insulin.
OBESITY
Edit
127
How can Type 2 diabetes be managed?
Oral agents, exercise, insulin, and diet.
Edit
128
What are the criteria for the use of insulin?
Severity f diabetes: degree of hyperglycemia & presence of physical symptoms
Comorbidities: severity of other diseases may make noninsulin options less successful
Client: preference/compliance
Edit
129
Risk for distrubed thought process, for impaired skin intregrity, for infection and for injury are
all nursing diagnosis for?
diabetes
Edit
130
You notice your diabetic patient's change in behavior as more erratic, confused and trembling,
shaking with cool clammy skin and a pale skin tone. You find the patient's food tray on the floor.
What are these signs of?
Hypoglycemia
Edit
131
What are the signs and symptoms of Hyperglycemia?
Polyuria, polydipsia, and headache.
Edit
132
Life threatening insulin deficiency
Diabetic Ketone Acidosis
Edit
133
In management of a chronic condition of diabetes, what lab test is done to evaluate progress?
Hemoglobin A1C
Edit
134
This term is used broadly to include the stomach, duodenum and jejunum. "within the small
intestine"
Enteral.
Edit
135
Decompression of the stomach through removal of contents using intermittent suction is known
as what action?
Apsiration
Edit
136
What would cause you to aspirate enteral tubes?
Remove stomach contents due to obstruction in intestine, or after abdominal surgery to allow
bowel to function and anesthesia to wear off. (Rational for both is to prevent aspiration into
lungs)
Edit
137
Why is it essential after surgery to allow bowel to start passing gases and even movement?
Anesthesia has caused bowels to stop and should wear off to prevent patient aspiration into lungs
and decrease pressure on a surgical site.
Edit
138
What is the process of lavage of the stomach to stop gastric/esophageal bleeding?
Iced normal saline is placed into the tube using a 50-60cc catheter tipped syringe, and then
removed. Repeat his process until bleeding stops
Edit
139
The process of lavage of the stomach to remove poisonous medications from the body?
Normal saline is placed into the tube using a 50-60cc catheter tipped syringe, and then removed.
Repeat.
Edit
140
This is the use of a special ballooned enteral tube to stop hemorrhage from gastric ulcers or
esophageal varices.
Compression of Stomach or Esophagus
Edit
141
This is the use of an enteral tube to provide adequate nutrition & insure medication delivery
directly into the stomach or small intestine when individuals are unable to eat in the usual
manner.
Feeding & Medication Administration
Edit
142
What are the reason for the use of an Enteral Tube?
1) Decompression of the stomach through removal (aspiration) of contents using intermittent
suction
2) Lavage of the stomach
3) Compression of Stomach/esophagus
4) Feeding and Medication Administration
Edit
143
Salem Sump, and Levine tubes are what type of enteral tubes?
Nasogastric Tubes
Edit
144
When sterile objects touch another clean object it still remains sterile. T/F
False: ONLY sterile to sterile
Edit
145
When you lose range of vision of sterile objects/field what have you done?
You have "contaminated that object/field.
Edit
146
What happens to sterile object/field the longer it is exposed to air?
It becomes contaminated
Edit
147
When removing staples from a patient, you notice the TPCN cleans the site then remove the
staples away from the skin from top to bottom, one after the other. What do you take note of?
The TPCN should have removed everyother staple for proper precautions toward possible
dehiscence.
Edit
148
After removal of staples what should be documented?
Sutures removed
Objective description of incision line
Instructions
Patient response
Edit
149
When removing Interrupted sutures you should cut beneath the knot and pull with forceps at the
opposite end of the knot. T/F
False: Grasp the knotted end with forceps. Snip the suture close to the skin surface opposite the
knot and in one smooth pull, remove the suture.
Edit
150
The function of this organ plays a role in immune function, internal organ protection,
temperature control of the body, provides sensory perception, assists in maintenance of fluid and
electrolytes and communication of feelings (body image).
Skin
Edit
151
What are the classic signs of inflammation?
Redness
Edema
Heat
Pain
Loss of Fxn
Edit
152
What must be present for an infection to have occurred?
Purulent drainage must be present
Edit
153
Your patient is running a temperature of 102.5. You've administered ASA as ordered and start
with a dressing change on an abscess on the left hip. You notice tenderness as you remove
dressing and also a foul odor. What do you expect to see after the removal of dressing?
Purulent drainage due to an infection.
Signs:
Tenderness
Fever
Foul odor
Edit
154
This is a complication of wound healing that is an abnormal passage between 2 organs or
between an organ & the outside of the body.
Fistula
Edit
155
This is a complication of wound healing that is an abnormal passage away from wound base that
is not connecting to another wound, organ or outside.
Tunnel
Edit
156
What are some factors impairing wound healing?
Nutrition, Age, Body Build, Impaired O2, smoking, diabetes, drugs, radiation, wound stress,
psychosocial impact
Edit
157
Nutrient availability, moisture level, cleanliness, skin integrity, comorbidities, txmts, cause and
severity of injury are all an influence for _______.
Wound Healing.
Edit
158
When assessing a wound what should you note?
Location, size
Amount of drainage, color, consistency
Wound base – type tissue
Granulation, slough, eschar
% Red, yellow, black
Moisture content – moist, wet, dry
Any tunnels or undermining
Wound margins
Surrounding tissue
Signs of infection?
Progress toward healing
Edit
159
This assessment tool helps you assess the size, depth, undermining, necrotic tissue type &
amount, exudate type & amount, peri-wound color, edema, induration, granulation and
epithelialization.
Bates Jensen Wound Assessment Tool
Edit
160
This is the removal of necrotic material/tissue.
Debridement
Edit
161
?
Gauze, nonstick dressing
Edit
162
?
Film dressing
Edit
163
?
Hydrocolloids dressing
Edit
164
?
Foam dressing
Edit
165
What must you do prior to changing a dressing?
ALWAYS Check doctor’s order
Explain procedure to patient
Establish what equipment is needed
Provide privacy and Provide comfort
Use sterile technique (in hospital or for all acute wounds)
Wash hands before & after
Assess wound as previously discussed
Document
Edit
166
Hourly urine output of 30cc/hr is considered ___.
Abnormal
(poor kidney fxn may result in anemia and impaired calcium absorption.
Edit
167
What is the normal output of urine per day?
1500-1600cc
Edit
168
This is composed of the glomerulus, Bowman's capsule, proximal convoluted tubule, loop of
Henle, distal tubule and collecting duct.
Nephron
Edit
169
Name the Location, Size, Fxn, Secretions, and what it Regulates.
One On each side of vertebral column, lower back.
Approximately 2inches in length
Fxn: filters water, glucose, amino acids, urea, creatinine, and major elevtrolytes in blood forms
urin in the nephron.
Secretes:erythropoietin which stimulates production of RBC's in the bone marrow and it
regulates calcium and phosphate.
Edit
170
The kidney is perfused by what artery/vein?
Renal Artery
Edit
171
This connects kidney to bladder and is approximately 5 inches in length and transport sterile
urine to bladder.
Ureters
Edit
172
How do the ureters enter the bladder?
Obliquely which reduces potential for urine reflux into the kidney.
Edit
173
Urine moves in a continuous drip. T/F
False: Urine moves in peristaltic waves
Edit
174
This organ is located in the pelvic cavity behind the symphysis pubis and its function is to act as
a receptacle for urine.
Bladder
Edit
175
What is the normal volume held by the bladder?
Normal volume 600mL and decreases with age to 250mL
Edit
176
What is the difference in location of the bladder between a man and a woman?
In men, it rests against the anterior wall of the rectum, whereas a woman's rests against the
anterior walls of the uterus and vagina above the deltrusor muscle.
Edit
177
The size of the bladder is in comparison to the size of ___.
you fist.
Edit
178
This is located in the inferior aspect of the bladder and its function is to as a conduit connecting
bladder to outside of the body.
Urethra
Edit
179
What's the difference in the size of a woman's urethra to a man's?
Women 1.5-2.5inches in legnth.
Men 8 inches in legnth.
Edit
180
What assists in the removal of bacteria from the urethra?
Turbulent Flow
Edit
181
Explain the process of urination.
(The brain may inhibit the urge to void or allow voiding)
Bladder contracts--> Relaxation of the urethral sphincter--> Contraction of the deltrusor muscle.
Edit
182
When assessing a patients urine what should you note?
Color, Clarity, Odor, & Amount
Edit
183
UA, Specific Gravity of Urine, C&S, 24hr Urine, BUN, Cr are all lab assessments related to
____.
Renal System
Edit
184
Classification of diseases that affect the renal system by decreasing blood flow to and through
the kidney is ...
Pre-renal disease
Edit
185
Renal disease is a classification of diseases that affect the conditions of ____.
The Kidney
Edit
186
Classification of diseases that affect the renal system with obstruction that occurs below the
kidney preventing urine flow through the system is ...
Postrenal disease
Edit
187
While Assesing this factors influence on Urination you will find that it is associated with the
development of end stage renal disease (ESRD) and uremic syndrome.
Diabetes Mellitus
Edit
188
Multiple sclerosis is an example of what disease condition that influences urination?
Post Renal Disease
Edit
189
Heart Failure is an example of what disease process that influences Urination?
Pre-Renal
Edit
190
This is the spectrum of symptoms that accompany uremia such as blood in the urine.
uremic syndrome
Edit
191
Benign Prostatic Hyperplasia is an example of this disease condition that influences Urination.
Post Renal Disease
Edit
192
This is a nonmalignant, noninflammatory enlargement of the prostate, most common among men
over 50 yrs of age. Progressive and may lead to urethral obstruction and to interference with
urine flow, urinary frequency, nocturia, dysuria, and UTI.
Benign Prostatic Hyperplasia
Edit
193
This disease decreases cognitive awareness of a full bladder resulting in overflow incontinence.
Alzheimer Disease
Edit
194
What are some common renal system diagnostic tests?
Renal Ultrasound
Intravenous Pyelogram (IVP)
Abdominal Xray (KUB0
Post Void Residual
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These are some other Nursing Assessments to Consider for Urination Elimination.
Sociocultural
Psychological
Fluid Balance
Surgical Procedures
Medications
Diagnostic Examinations
History of Pregnancy
Limitations in Mobility
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What are some good health promotional interventions you could teach the patient about
regarding urinary elimination?
Teach the Patient about Risk Factors r/t Disease
Teach the Patient about prescribed medications
Maintain Hydration to flush bladder of pathogens
Reduce Caffeine in Diet (tea, coffee, colas and chocolate) that prompts diuresis
Insure Hygiene to reduce pathogen access
Teach Kegel exercises to strengthen muscle tone
Maintain Mobility to get to the bathroom
Ingestion of Cranberry or Blueberry Juice
Timely Toileting
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Give me examples of Nursing Diagnoses for urinary elimination.
impaired, related to incontinence as evidenced by dribbling urine, frequent trips to the bathroom
at night and history of an enlarged prostate.
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What are some common alterations in Urinary elimination?
Urinary tract infections
Urinary retention
Urinary incontinence
Urinary diversions
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Renal System Equipment Guidelines for Procedures
(REVIEW PPT)
Strict handwashing before and after procedure
Use gloves when in contact with body fluids
Place patient in position of comfort before starting procedure
Check date on outside of equipment packaging to insure it is sterile
Do not use packaged items that have been opened
Explain to the patient what you are going to do before starting the procedure
If you contaminate your sterile field-start over.
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200
What is the purpose for NG intubation?
Decompression through aspiration of gastric contents
Lavage with normal saline for gastric bleeding or removal of poisonous substance
Hypokalemia,
Enteral feeding or medication administration for a short period of time, usually 1-2 weeks
Who is able to perform an NG Tube placement and what is required to do so?
RN or LVN is able to place one with a Dr.'s Order
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When measuring the length of an NGT for placement one should ...
Use the tip (end of the catheter with vents), measure from the tip of the patients nose to the
earlobe.
Hold your fingers on the measurement above, then add measurement from earlobe to xiphoid
process.
Add six (6) inches to this measurement for stomach location.
Mark the NG tube with tape or sharpee pen as indicator for individual patient placement.
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You should add 6inches of length to the NGT from the Auxillary Process. T/F
False: Add 6inches from the Xiphoid process.
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You have successfully placed the NG tube without complications. You check the pH of the
aspirated fluids and find a result of 7.0. What do you do next?
Remove the NG tube. A pH of 7 indicates the tube is placed in the lungs. (pH of 4.0 is gastric
contents
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What is the most adequate way to check placement of an NGTube?
X-ray
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If patient starts coughing or gaging in the process of placing the NG tube you should?
stop pull back then proceed after they stop coughing.
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Your patients meds are about time to be given but they now have an NG tube. You notice on the
med the markings SR. What do you do next?
You call the doctor and request for another form of that medicine to give either liquid or
injection form. SR is a slow release med that can not be crushed. (TR, SR, ER, ER)
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What are some common nursing Diagnoses related to NG Tube?
Nausea related to gastric distention (secondary to pancreatitis) as evidenced by refusal of food,
report of gagging sensation
Risk for deficient fluid volume related to vomiting (secondary to GI bleed)
Imbalanced Nutrition: less than body requirements related to inadequate food intake (secondary
to anorexia nervosa) as evidenced by 900 calorie intake on calorie count, albumin of 2.5.
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The clinical manifestations of this disease is gradual onset of polyuria, polydipsia, easily
fatigued, and frequent infections (UTI). Often discovered w/diagnosis of comorbidity.
Type 2 DM
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Why is obesity a risk factor for DM Type 2?
Obese people produce insulin resistant states causing beta cells to produce excessive amounts of
insulin.
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What are some medical diagnoses associated with enteral nutrition?
Cerebrovascular Accident (stroke) resulting in dysphagia
Esophogeal Cancer requiring surgery
Head and neck cancers requiring radiation treatments
Facial trauma from a motor vehicle accident
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This Enteral tube enters into the stomach. It is a hard plastic, usually used no longer than 2
weeks, and is inserted by RN or LVN. Residual should be checked before any feeding or
medication administration and document amount. Check pH for placement (pH 4.0)
Nasogastric Tube (salem Slum, Levine)
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This Enteral tube enters through abdomen into stomach. It's held in place by a balloon/water
combo. Inserted by physician under flouroscopy. Residual checked before any feeding or
medication administration and document amount. (pH 4.0)
Gastrostomy Tube
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This Enteral tube enters into duodenum through nose or mouth. Soft plastic, weighted at the end,
x-ray for placement. Inserted by physician. No residual check, collapses with manipulation.
Considered lower risk for aspiration from this location. Moved into duodenum by peristalsis.
Position for advancement of tube.
Duodenal Tube (Dobhoff)
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This enteral tube enters into jejunum through abdominal approach, then sutured in place. Soft
plastic. No residual check as there is only a small space in intestine for pooling of contents.
Considered lowest risk for aspiration into lungs from this location. Inserted by physician under
flouroscopy.
Jejunostomy Tube
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This is the use of a pump to deliver nutrition over 12 hrs or 24hrs. Ordered by physician as cc/hr
x number of hours.
Continuous feeding
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This is method, a nurse administers using gravity (bolus) and 60cc syringe. Liquid feeding is
poured into the syringe, plunger is removed. The higher syringe is held, the faster the flow.
Intermittant
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A patient is on tube feeding and you noticed the patient is soiled so you act to clean them. What
do you do?
You turn off tube feeding and lower the head to proceed with cleaning. After you've completed,
raise patient to fowlers position from 30-45degrees than start feeding. (prevents patient from
aspiration)
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What is the pH of the gastric, intestine, and lung content in exact order?
4.0; 5.0; 7.0;
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When should you check the residual of a patient with a enteral tube?
You should check residual every 4hrs and before meds are give.
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When should you hold tube feeding?
When lowering patient below 30 degrees and if residual is >100mL or double hourly infusion
than you should hold feeding
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If output of enteral tube decreases due to thick secretions, what should you us to dislodge
obstruction?
Cola or cranberry juice
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After checking the residual on your patient you notice there is 200mL more than the last time
you have check. What should you do with the fluids?
return residual to prevent electrolyte imbalance
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224
_____ Commercial formula is specific for patients on enteral feedings with respiratory
conditions while _____ is for renal conditions.
Pulmocare / Nepro
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This nutritional product for enteral feeding adds calories or proteins, but is not intended to
provide entire caloirc intake.
Supplements
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This enteral nutritional feeding usually is prepared by family when patient is living in home
setting.
Blenderized
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This occurs with hyperosmolar solutions-formulas high in electrolytes and carbohydrates. Fluids
are drawn into the formula from the vascular system through osmosis rapid distention of location
in GI tract resulting in cramping and diarrhea.
Dumping Syndrome with Enteral Feedings
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How do you prevent dumping syndrome from occurring due to enteral feedings?
Assess patient to rule out other reasons for diarrhea
Slow down formula administration (may be issue in intermittent feedings performed by nurse)
Administer feeding at room temperature
Consider amount of enteral flushes used by nurse administering the feeding
Report dumping syndrome and discuss continuous versus intermittent feedings with
dietician/MD.
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What are some gastrointestinal strategies one could implement to minimize complications of
Enteral Feeding?
Room temperature formulas to prevent gastric cramping
Monitor gastric residual to prevent vomiting/aspiration
Appropriate fiber & water content to promote hydration and bowel function
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What are some mechanical strategies one could implement to minimize complications of Enteral
Feeding?
Check tube placement to reduce aspiration risk
HOB elevated 30-45 degrees to reduce aspiration risk
Check residual q 4 hours, and before feeding/meds
Prevent kinks in tubing to insure delivery of feeding/meds
Insure pump is set correctly to deliver nutrition as ordered and prevent fluid overload
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What are some metabolic strategies one could implement to minimize complications of Enteral
Feeding?
Monitor blood glucose levels daily to insure patient safety
I&O every shift to prevent dehydration or fluid overload
Assess feeding rates/formulation and document every shift
Provide oral hygiene every four hours
Monitor breath sounds every four hours
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When gastrointestinal tract cannot be accessed for an extended period of time, what is the
alternative route for delivery of nourishment?
(TPN) Total Parenteral Nutrition or (HAL) Hyperalimentation
(requires Central line access)
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What should be monitored while a patient is on TPN or HAL?
Based upon daily blood draws for electrolytes, liver studies, renal panel, albumin, glucose
Requires accuchecks every 4-6 hours to monitor glucose (TPN/HAL utilizes 10-50% glucose
solution)
More expensive, more invasive, than enteral feeding
High glucose content places patient at high risk for infection-monitor for signs and symptoms
May not add any other fluids, medications or blood products through this “dedicated”
intravenous line
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What are some common nursing diagnoses associated with enteral tubes?
Imbalanced Nutrition, less than body requirements related to difficulty swallowing as evidenced
by prolonged length of time food is in the mouth without swallowing, coughing while eating,
loss of 10 pounds in two weeks.
Nausea related to gastointestinal irritation as evidenced by report of vomiting at home, potassium
(K+) of 2.5, and inability to consume food and fluids.