foundations of nursing exam 4 FINAL

RUQ

includes the pylorus, duodenum, liver

LUQ

includes the stomach and spleen

RLQ

includes the cecum and appendix

LLQ

includes the sigmoid colon

along the midline

where is the urinary bladder located?

stretch marks

what does striae mean?

swelling

what does ascites mean?

inspection, auscultation, percussion, palpation

what is the order of abdominal assessment techniques?

when an internal organ or tissue, like the intestine or fat, pushes through a weak spot ot opening in the surrounding muscle or tissue wall, creating a bulge

what is a hernia?

swelling of the abdomen

what is ascites?

after abdominal surgery, late bowel obstruction

what could hypoactive BS indicate?

diarrhea, early bowel obstruction

what could hyperactive BS indicate?

indicating peritonitis or paralytic ileus

what does absent BS indicate?

partial bowel obstruction

what can high pitched BS indicate?

diarrhea

passing liquid with increased frequency

infection, malabsorption, inflammatory process, meds

what can cause diarrhea?

constipation

infrequent passage of hard stool

diet, dehydration, diverticular disease, neuropathy, immobility, meds, gynecological problems

what can cause constipation?

fruits, veggies, coffee, chocolate

what foods have laxative effects?

located in RLQ, stool consistency is liquid to semi-liquid, almost continuous output, high risk for dehydration

what is an ileostomy?

located in various quadrants, stool more formed and predictable

what is a colostomy?

• stoma should be pink/red

• assess for cuts, ulcerations

what are some important things to note with ostomy care?

0.5 cc/kg/hr (approx. 30cc/hr for an adult)

what is normal urine output?

false- it usually excludes feces/wound drainage on dressing

t/f: I&O documentation includes feces/wound drainage on dressing

one ounce = 30 cc

ounce to cc calculation for I&O

third space

the nonfunctional area between cells

when too much fluid moves from intravascular space (blood vessels) into the interstitial or “third” space

when does third spacing occur?

ascites, edema, hypotension, reduced CO

what can third spacing cause?

give pt. IV albumin to pull fluid back into vessels

what can you do if a Pt. is dehydrated intervascularly?

anal sphincter dysfunction, compromised rectal function, anatomical defects

what are some causes of fecal/bowel incontinence?

• indwelling rectal tube

• external anal pouch

what can you do for fecal/bowel incontinence?

liver

produces clotting factors, main source of protein (albumin)

increase fluid loss (makes you pee)

what is the effect of diuretics?

to treat HTN, CHF, edema

why would a pt be prescribed diuretics?

the removal of excess salt (sodium) and fluid from the body through increased urination

what is the expected effect when a pt takes diuretics?

steroids

what causes sodium and water retention?

intracellular fluid (ICF)

fluid inside the cell (67%)

extracellular fluid (ECF) - 3 types

fluid outside the cell

• interstitial (25%)

• intravascular (7%)

• transcellular (1%)

what are the three types of ECF?

interstital (a type of ECF)

fluid around/between cells

intravascular (7%) - type of ECF

plasma- fluid in the cells

transcellular (1%) - type of ECF

CSF, synovial fluid

pushes water

does hyrdostatic pressure PUSH or PULL water?

pulls water

does osmotic pressure PUSH or PULL water?

painful urination (UTI, STI)

what is dysuria?

cloudy urine (UTI)

what is pyuria?

• not making urine ; or less thann 100 cc/24 hrs

• ESRD

what is anuria?

• dec urine output (100-400 cc/ 24 hrs)

• renal disease

what is oliguria?

• inc urine output

• diluted urine

what is polyuria?

sugar in urine

what is glycosuria?

• inc frequency to pee in the night

• has to due w/ enlarged prostate

• FALL RISK!!

what is nocturia?

indwelling cathedar

in this type of cathedar, a balloon port tells you how much to put in and take out

infection

what is the biggest risk of an indwelling cathedar?

false

t/f: you can delegate foley cathedar removal

straight cathedar

this type of cathedar is not a foley because there is no balloon

no becaise it isnt in the bladder

can you do 30 cc/hr with an external cathedar?

• careful not too tight on males

• check esp if pt without feeling

two main things to watch for when pt. has an external cathedar

true.

t/f: CAUTI can be prevented

UTIs. 75% are cathedar related

what is the most common HAI?

• inc LOS

• inc costs

• higher morbidity and mortality 

CAUTIs are associated with what pt. outcomes?

5-20

normal BUN levels

0.5-1.5

normal Cr levels

• looks at kidney function

• always report together

what does BUN and Cr look at?

renal disease

what does inc BUN indicate?

liver failure, malnutrition, over-hydration

what does dec BUN indicate?

Cr

excreted from the body by the kidneys

3.5-5.0

normal K+ levels

135-145

normal Na levels

seizures

hyponatremia puts you at high risk for what?

diabetes insipidus (polyuria)

what does inc Na levels indicate?

kidney problems

what does dec GFR indicate?

monitor drainage of a post op site

what does JP drains do?

seizures

dec sodium levels lead to…

hyperosmotic

if you have hyperglycemia your body is in a ________ state

1

1,000 mL = ___ kg

• 2-3 lb/day

• 5 lb/week

what is considered significant weight gain?

dehydration

are infants more prone to dehydration or over-hydration?

reduced thirst sensation- encourage them to drink

do older adults have increased or reduced thirst sensation?

liver disease > low albumin > H20 leaks from vessels > edema

how does liver disease cause edema?

spirituality

anything that pertains to a persons relationship with a nonmaterial life force ir higher power

faith

a belief in something for which there is no proof or material evidence

agnostic

one who holds that nothing can be known about the existence of a higher power

atheist

person who denies the existence of a higher power

jehovahs witnesses

which religion opposes the “false teaching” of other sects, which often extends to modern science, including medicine?

• need for meaning and purpose

• need for love and relatedness

• need for forgiveness

3 spiritual needs underlie all religious traditions and are common to all people

roman catholicism

fasting from meat on ash wednesday and good friday

judaism

may decline to have health care intervention on the sabbath

no pork or shellfish

kosher diets (jewish)

• mental health

• physiologuc health

• emotional health

deficiences in rest/sleep have negative impact on:

insomnia

difficulty falling or staying asleep

obstructive sleep apnea

• use CPAP to put pressure on airway

abscense of breathing during sleep

hypersomnia

excessive daytime sleepiness that isnt attributed to another sleep disorder

narcolepsy

inadvertent daytime lapses into sleep

shift-work sleep disorder

results from working on a rotating schedule of days and nights against the bodys normal circadian rhythm

• the ANA highlighted the importance of “compassionate presence” by nurses through our care

• facillitating healing and alleviating suffering

what is meant by “nursing prescence?” how do we convey this in the care of our patients?

stage 2

in which one of the following stages of NREM sleep does the person fall into a stage of sleep but can be aroused with relative ease?

narcolepsy

in which of the following sleep disorders does the pt have an uncontrollable desire to sleep?

true

t/f: somnambulism is a parasomnia in which the person walks in his or her sleep