Nurs 2002 Midterm

when is a straight catheter used?

when it is to be inserted and removed immediately

when is an indwelling catheter used?

when the catheter is to be left in place

what are the types of incontinence?

stress, urge, functional, overflow, and reflex

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

urge incontinence

involuntary leakage of urine with a sudden, strong desire to urinate

functional incontinence

urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation

overflow incontinence

involuntary loss of urine associated with overdistention and overflow of the bladder

reflex incontinence

emptying of the bladder without the sensation of the need to void

what nursing interventions help promote normal urination?

-maintaining normal voiding habits: schedule, urge to void, privacy, position, hygiene

-promoting fluid intake

-strengthening muscle tone

-assisting with toileting

what are some patient goals regarding urinary elimination?

-producing sufficient quantity of urine to to maintain fluid, electrolyte, and acid-base balance

-empty bladder completely at regular intervals without discomfort

-provide care for urinary diversion and know when to notify physician

-develop plan to modify factors contributing to current or future urinary problems

-correct unhealthy urinary habits

how might older age affect GI and GU health?

-risk for nutritional deficits: poor diet, living alone, social isolation, not preparing meals, etc

-dec appetite, leading to constipation

-lots of GI effects associated with many medications

-prostate pathologies in older men that may cause obstructions

how might race/ethnicity affect GI and GU health?

-certain populations at higher risk of diseases that can affect GI/GU health

-ex: African Americans and sickle cell disease, alcoholism in Native American populations, lactose intolerance has familial predisposition

what urine findings would require urgent assesment?

-blood in the urine

-cloudy/foamy urine

-foul odor

-low urine production (low GFR)

what urine is considered normal?

-straw yellow

-clear, transparent

-no sediment

-no odor

what patients are at high risk for UTIs?

-sexually active

-postmenopausal

-indwelling catheter

-diabetes

-elderly

-physical/cognitive impairment (inadequate self-care)

-women

what nursing interventions help prevent UTIs?

-avoiding bath tubs

-perineal hygiene

-increased fluid intake

-encouraging patient to void frequently

-administering antibiotics as prescribed

-educating patient on proper wiping

-hand hygiene

-proper catheter insertion/care

what are possible methods for collecting urine?

-bed pan

-commode

-toilet hat

-urinal

what are possible methods for collecting stool?

-hat

-bed pan

-commode

what components are included in a GI and GU health assessment?

-inspection: abdomen, urine, vomit, stool

-auscultation: listening for hyper/hypoactive/present bowel sounds

-light palpation: abdomen (overall impression), kidneys, liver, bladder

what nursing interventions promote improved GI outcomes?

-diarrhea: answering call bells immediately, removing cause (ex: meds), rectal examination if there is an impaction, giving special care to region around anus

-preventing food poisoning:

-encouraging recommended diet and exercising

-using medications only as needed

-using emptying methods such as enemas, rectal suppositories, oral intestinal lavage, digital removal of stool

what are some patient goals regarding bowel elimination?

-patient has a soft formed bowel movement every 1 to 3 days without discomfort

-the relationship between bowel elimination and diet, fluid, and exercise is explained

-patient should seek medical evaluation if changes in stool color or consistency persist

what patients are at risk for constipation?

-bed rest, immobility, post-op

-elderly

-reduced fluid

-depressed

-CNS dysfunction

what are the important patient teachings regarding colostomies?

-community resources are available for assistance

-initially encourage patients to avoid foods high in fiber

-avoid foods that cause diarrhea or flatus

-drink 2 quarts of water daily

-teach about medications

-teach about odor control (intake of dark-green vegetables)

-resume normal activity including work and sexual relations

how do ileum, ascending, transverse, descending, and sigmoid ostomies differ?

-different locations

-as you get closer to the rectum, the stool that is expelled will become more formed

what should a stoma look like? what would an abnormal stoma look like?

beefy red; flesh colored, cold, black

what are subjective data points relevant to the abdominal exam that you would ask your patient during an interview or assessment?

-BM habits: pain, odor, color, consistency, frequency, etc.

-medications: diruetic, narcotics

-pain

-urinary habits: continent?, frequency, pain/burning, color, odor

-medical and surgical history

-family history

-lifestyle: alcohol, exercise, obesity

what are some urgent assessment findings in the male reproductive assessment?

-acute scrotal conditions

-testicular torsia (twisting/rotating of testicles, can cause ischemia)

-trauma

-infectious conditions (ex: UTIs with indwelling catheters)

-inflammatory conditions

-rectal bleeding

what are some lifespan considerations of the male reproductive system?

-adolescents: use tanner's stages of maturation to assess,

-older adults: dec testosterone (affect libido and sexual function), loss of muscle tone (incontinence), stool retention, dysfunction from medications, erectile dysfunction

what are some common symptoms of the male reproductive system?

-pain

-problems with urination

-erectile dysfunction

-penile lesions, penile discharge

-scrotal enlargement

what are some risk factors for developing STIs?

-engaging in sexual relations with a new partner or with multiple partners

-personal history of STIs or engaging in sexual activity with a partner with a history of STIs

-engaging in a relationship with a partner who has several partners

-failure to practice safe sex*

what are some lifespan considerations for the female reproductive system?

-tanner staging for development

-pregnant women: cervical changes

-older adults: menopause, vaginal infections, UTIs, dyspareunia (genital pain before/during/after sex), diminished libido, cancers

what are urgent assessment findings for the female reproductive system?

-severe pain

-excessive vaginal bleeding

-ectopic pregnancy

-late period, menstrual flow different than usual

what are common breast/axillary symptoms?

-breast pain

-rash

-lumps, swelling

-nipple discharge

-trauma

what are lifespan considerations for the breast/axillary exam?

-pregnant women: changes in breast, lactation

-adolescents: tanner staging, gynecomastia in males

what are urgent assessment findings for the breast/axillae?

-a new breast lump or mass

-swelling of all or part of a breast (even if no distinct lump is felt)

-skin irritation or dimpling

-breast or nipple pain

-nipple retraction (turning inward)

-redness, scaliness, or thickening of the nipple or breast skin

-nipple discharge (other than breast milk)

what are the normal findings related to the breast and axillae when performing inspection? what are abnormal findings?

-normal: color appropriate for skin tone, linear stretch marks, round/oval everted nipples, symmetry, contour, no signs of rashes, infection, texture changes, or unusual pigmentation

-abnormal findings: erythema (redness), hyperpigmentation, peau d'orange, retractions, discharge, any change in color/size/symmetry/contour

what are the normal findings related to the breast and axillae when performing palpation? what are abnormal findings?

-normal: skin is smooth, elastic, and firm, softer and less tone after pregnancy, engorgement prior to menstruation, no lumps, no tenderness, movable

-abnormal: masses, tenderness, dimpling, retraction

what are important points for teaching the self-examination of breasts?

-using soft, medium, and firm pressure to feel entire breast in up and down pattern

-look at breasts in mirror with hands atop of head: should be fairly equal in size, shape, and color w/o swelling, discoloration, dimpling, or drainage from nipple

-examine underarm w/ arm slightly raised

what are important points for teaching the self-examination of the testes?

-examine each testicle with both hands; should not feel pain with gentle rolling of testicle

-cancerous lumps are usually on side of testicle

-know location of epididymis

-make appointment with provider if any concerns arise

what is the role of the nurse in a nutritional assessment?

-determining adequate and appropriate caloric and nutrient intake

-accurately complete nutritional assessments

how might culture influence nutrition/findings on a nutrition assessment?

-differences in what is considered edible

-how food is prepared

-what food combinations are permitted

-income level and availability of food

-religious beliefs

what are lifespan considerations related to a nutrition assessment?

-pregnant women: weight gain, GI changes, increase in nutritional needs to support growth (inc caloric needs)

-older adults: dec energy expenditure, difficulty chewing/swallowing, dec in peristalsis, dec thirst, social isolation, unintentional weight loss

-infant/children: rapid growth, need adequate nutrition

what are urgent assessment findings for a nutritional assessment?

-clear nutritional deficits

-trauma or stress = inc caloric need

what are risk factors for nutritional deficit?

-surgery

-trauma

-infection

-head injury

-burns

what factors can affect nutrition and nutritional status?

-age

-biological sex

-state of health

-alcohol abuse

-medications

-nutrient supplements

-socioeconomic factors

-culture/religion

-decreased/increased food intake

how does nutrition influence growth and development?

-body needs adequate energy and nutrients to develop and grow properly

-nutrition essential during periods of crucial development, such as childhood/adolescence

what is normal BMI?

18.5-24.9

what developmental considerations are important in the HEENT assessment of children?

fontanels/dec visual acuity in infants, assessing for red eye reflex in kids

what developmental considerations are important in the HEENT assessment of older adults?

-bony structures more pronounced

-skin lesions more likely

-carefully assess for possible cancers

-hypothyroidism

-eye structural changes

-vision loss

-decreased tear production

-diabetic retinopathy

-cataracts

-decreased hearing d/t age and structural changes

-inc auditory reaction time

-decreased olfactory sensory fibers, saliva production, and taste buds

-loss, discoloration, and loosening of teeth

-receding gums

-smooth/shiny tongue, fissures

what are important cultural considerations of the HEENT assessment?

-snellen chart can be used for non-english speakers

-ethnic variations found in the sclera (whites of eyes)

-inc risk of certain conditions, such as glaucoma

-racial variations in skin color, eye/nose/lip shape

-environmental risk factors associated with socioeconomic status

-gingivitis, cleft lip/palate, bifid uvula, oral and pharyngeal cancers, sleep-disordered breathing

what are urgent assessment findings of the head/lymphatics assessment?

-"BE FAST" for stroke: balance/HA/dizziness, eye issues (blurred/loss of vision), facial drooping, arm weakness/numbness, slurred speech

-acute head injuries and neurologic changes (stabilization of head/neck, trauma assessment)

-neck pain (muscle tension/spasms, check for fever/headache)

-lymphatics (fixed, irregular, hard, or rubbery mass)

-hyperthyroidism (thyroid storm/crisis)

what are common head/neck symptoms?

-headache

-neck pain

-limited neck movement

-facial pain

-lumps or masses

-hypothyroidism

-hyperthyroidism

-sleepiness

what subjective data is collected during the head/lymphatics assessment?

-risk factors: personal history, medications, family history

-risk reduction/health promotion: reducing injury risk, preventing thyroid disorder complications, early detection of masses or malignant lymph nodes

what objective data should be collected regarding the face?

-inspection: expression, appearance, symmetry, skin color

-palpation: temporal arteries, TMJ, sinuses

-neuro, CN VII: smile, frown, puff cheeks, close eyes tight, raise eyebrows, taste

-neuro, CN V: facial sensation

what objective data should be collected regarding the head?

-inspection: size, symmetry, and shape of head, hair distribution, scalp

-palpation: palpate scalp looking for deformities or tenderness, fontanelles

what objective data should be collected regarding the neck?

-inspection: abnormal masses/swelling, mobility/ROM, thyroid, neck vessels

-palpation: cervical vertebrae, tracheal cartilage, thyroid, neck vessels (carotid/jugular)

-auscultation: carotids (listen for bruit with bell)

-neuro, CN XI: trapezius and sternocleidomastoid muscle strength by having client turn head/shrug shoulders against resistance

what objective data should be collected regarding the lymph nodes?

-inspection: redness or discolored

-palpation: feel for swelling/masses

-concerning lymph nodes: >1 cm, hard, fixed/immobile, painless

what are urgent assessment findings of the eye assessment?

-sudden vision loss

-eye trauma/injuries

-foreign bodies, lacerations, hyphema (blood in eye)

-acute glaucoma

what subjective data should be collected during the eye exam?

-assessment of risk factors: past medical history (eye conditions, surgeries, health, allergies, corrective prescriptions), medications, family history, nutrition, environmental exposures

-risk reduction: control of diabetes, sunlight exposure, diet, visual health goals

what are common eye symptoms?

-pain

-trauma or surgery

-visual change

-blind spots, floaters, halos

-discharge

-change in ADLs

what objective data should be collected during the eye exam?

-inspection: eye position, eyelids, eyelashes, palpebral fissures, conjunctiva and sclera, cornea, anterior chamber, lacrimal apparatus, iris

-PERRLA: pupils equal, round, reactive to light and accommodation

-pupil size, regularity, equality, and accommodation

-EOM function: 6 cardinal gazes, corneal light reflex, peripheral vision, ocular deviation, cover/uncover test

what are urgent assessment findings of the ears?

-outer ear foreign object

-foul-smelling drainage

-chronically draining ears

-ear trauma; tympanic rupture

what subjective data should be collected during the ear assessment?

-assessment of risk factors: personal history, medications, family history, risk factors

-risk reduction: assessment for general hearing loss and providing protective equipment, skin cancer prevention, ear cleaning

what are common ear symptoms?

-hearing loss

-vertigo

-tinnitus

-otalgia

what objective data should be collected during the ear assessment?

-inspect: shape, position, discharge

-palpate: pinna, tragus, mastoid process

-otoscopic examination of inner ear: pull pinna back and up for adults, back and down for children

-whisper test

-weber and rinne test

what are urgent assessment findings of the nose, sinus, mouth, and throat?

-ludwig angina: edema pushing tongue up and back (leading to airway obstruction; infection of the mouth floor)

-aspiration

-abrupt loss of smell

-bacterial sinus infection

what subjective data should be taken during the nose, sinus, mouth, and throat assessment?

-assessment of risk factors: personal history, meds/supplements, family history, dental health, psychosocial history, environmental exposure

-risk reduction: tobacco use, sleep disorders, cancer, oral health, chronic nose bleeds

what are common symptoms of the nose, sinus, mouth, and throat?

-facial pressure, pain, headache

-snoring, sleep apnea

-nasal congestion

-halitosis, anosmia

-cough, pharyngitis

-dysphagia, dental pain

-voice changes, oral lesions

what objective data should be collected regarding the nose and paranasal sinuses?

-examining nasal mucosa with penlight

-palpating frontal and maxillary sinuses for tenderness

-test sense of smell (test each nostril)

what objective data should be collected regarding the mouth and thorat?

-inspect color, condition, and lesions of: lips, gums, teeth, buccal mucosa, sublingual area, tongue, hard and soft palate, oropharynx, and tonsils

-observe movement of soft palate as client says "AHH" (CN IX, X)

what are the rights of medication administration?

-right drug

-right reason

-right dose, route, preparation

-right patient

-right time

-right assessment data

-right education

-right to refuse

-right documentation

-right response

what questions would you ask to ensure the right drug? what action would you take?

-has the patient been given this medication before?

-given the patient's symptoms and diagnosis, does it make sense for the patient to have this medication?

-determine if the patient has any known drug allergies or sensitivities

-assess the patient's other medications to detect possible contraindications

-make sure it is the right medication; packaging, labeling, and spelling of some drugs look alike—watch for visual cues on packing or in how the drug name is written

-have another person double-check medications and mathematical calculations (per policy)

what question would you ask to ensure the right reason? what action would you take?

-do the patient's condition, symptoms, and health status warrant receiving this medication?

-determine if the patient has the condition the medication is used for

what questions would you ask to ensure the right dose, route, and preparation? what action would you take?

-is the correct dose being administered?

-how is the medication administered?

-does administration require med math to calculate the dose?

-is it appropriate to administer the medication orally, intravenously, by injection, or other route?

-check the original orders to verify the route of administration

-ensure that labeling is legible and clearly understood

-follow institution medication protocols as written.

what question would you ask to ensure the right patient? what action would you take?

-is this the right patient to receive this medication?

-verify the identity of the patient using at least two identifiers: name and date of birth (check wristband, ask patient to state name)

what question would you ask to ensure the right time? what action would you take?

-is this the correct time for the medication to be administered?

-check when the medication was last administered; if the drug is new, document when it is first given

what question would you ask to ensure the right assessment data? what action would you take?

-is it appropriate to administer the medication, based on the specific data collected?

-collect appropriate assessment data related to mechanism of action and/or therapeutic effect

what questions would you ask to ensure the right education? what action would you take?

-is the patient familiar with the medication?

-does the patient understand the purpose, dosing, and administration information, as well as other information specific to medication?

-assess patient's level of knowledge, provide patient education as necessary

what questions would you ask to ensure the right to refuse? what action would you take?

-has the patient verbally agreed to take the medication?

-has the patient expressed any concern with the medication?

-acknowledge the patient's right to self-determination; provide education, then verify, document, and notify the provider about the refusal as needed

what question would you ask to ensure the right documentation? what action would you take?

-has the correct documentation been completed according to facility policy?

-complete documentation according to facility policy immediately after administering any medication

-document and communicate to the appropriate health care provider any signs and symptoms indicative of any adverse effects

what question would you ask to ensure the right response? what action would you take?

-how is the patient responding to the medication?

-monitor the patient to determine the efficacy of the drug, detect and prevent complication, and evaluate and document changes in health status

-when applicable, assess the patient's laboratory values to detect changes

-provide patient education, when possible, so patient is alert to adverse effects and changes in how he or she feels

what are the principles used to safely prepare and administer oral medications?

-use crusher, cutter, etc. depending on patients needs

-follow five rights

-can be capsule, pill, tablet, extended release, elixir, suspension, or syrup

what are the principles used to safely prepare and administer parenteral medications?

-selecting correct needle/syringe

-using aseptic/sterile technique to prevent infection

-careful recapping needles

-adhering to 5 rights

what are the principles used to safely prepare and administer topical medications?

-should not share

-cleaning skin thoroughly before administration to enhance absorption

-follow specific instructions of the medication

-5 rights

what are the subQ and IM injection sites?

-IM: deltoid, ventrogluteal, vatus lateralis, less commonly dorsogluteal

-SubQ: outer aspect of upper arm, abdomen, anterior aspects of thigh, upper back, upper ventral/dorsogluteal area