Week 4 WCU GI, Urinary, Tissue Sealy

Tissue Integrity is?

the ability of the human body to regenerate and maintain normal physiologic functioning.

What act as defense mechanisms for the body?

The skin, cornea, subcutaneous tissue, and mucous membranes

What is the largest organ system of the body accounting for about 15% of the total body weight.

The skin

What is the main function of the skin?

Main function is protection, providing a barrier from injury, infection, ultraviolet radiation (UV), and heat.

The skin plays a crucial role in?

sensory perceptions such as touch, pain, pressure, and vibration.

What does the skin help regulate?

Regulates temperature and protects the body against temperature changes.

Fill in the blank: The skin helps eliminate________ and supports the underlying structures and synthesis of ___________

Waste, Vitamin D

Skin frailty refers to?

at-risk, vulnerable skin.

What are the risk Factors for the Development of Pressure Injuries and Wounds?

-Age

-Mobility issues

-Weight

-Conditions such as spina bifida and cerebral palsy, and other chronic conditions such as liver, renal diseases, cancer, and malnutrition

What is a pressure injury?

A localized damage to the skin and/or underlying tissue as a result of a pressure or pressure in combination with shear.

What are the most susceptible areas for pressure injuries?

over bony prominences, such as the heels, toes, sacrum, hips, elbows, shoulders and back of the head.

What medical devices can cause pressure injuries?

urinary catheters, oxygen tubing, endotracheal tubing, or drains.

Skin redness is usually referred to as

blanchable or non-blanchable erythema

Non-blanchable erythema is?

redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin.

What are the 4 stages of pressure ulcers?

Stage 1: nonblanchable erythema of intact skin

Stage 2: Partial-thickness skin loss with exposed dermis

Stage 3: Full-thickness skin loss

Stage 4: Full-thickness skin and tissue loss

3 multiple choice options

Aside from the 4 stages of Pressure Ulcers, what is the unstageable stage?

Obscured full-thickness skin and tissue loss

What is a Deep Tissue Pressure Injury (DTPI):

persistent nonblanchable deep red, maroon, or purple discoloration

What are the 3 types of wound healilng?

1. Primary healing or first intention

2. secondary healing or second intention

3. delayed primary closure

3 multiple choice options

What is primary healing or first intention?

Occurs in clean lacerations and surgical incisions; closed with skin adhesives or sutures

What is secondary healing or second intention?

wound healing that happens when the wound is left open to heal

What is delayed primary closure?

a combination of primary and secondary healing, where the wound is left open for 5-10 days before it is closed with sutures

Wounds are classified as acute or chronic based on what?

origin and healing progression.

Acute wounds develop as a result of what?

injury and typically are a result of trauma

What type of wound develops over time from acute wounds that do not progress in healing?

Chronic wounds

3 multiple choice options

What are the major complications of wounds?

infections, dehiscences, eviscerations, hematomas/seromas, and fistulas

Alterations in urinary elimination and bowel elimination are usually

treatable or manageable.

Nurses can assist clients with urinary elimination by

helping them make lifestyle changes, provide bladder training, and instruct clients how to perform pelvic floor muscle exercises.

Nurses can assist clients with bowel elimination by

helping them lifestyle changes, provide bowel training, and provide the client with agents to stimulate a bowel movement.

The gastrointestinal (GI) tract is composed of

the liver, pancreas, gallbladder, and a series of hallow organs that originate at the mouth and terminate at the anus.

The GI tract is made up of the

mouth, esophagus, stomach, small intestine, large intestine, and anus

What system is the GI tract part of?

Digestive system

What is the small flap that prevents food and liquid from entering the airway and allows it to continue into the esophagus?

Epiglottis

3 multiple choice options

The GI tract works with the organs of the digestive system to?

digest food and drink

What does peristalsis do?

moves food downward toward the stomach

2 multiple choice options

Once in the stomach, food and liquid is mixed with

digestive secretions before slowly being emptied into the small intestine.

3 multiple choice options

Everyone needs to have a fully functional

urinary and gastrointestinal tract to maintain the proper elimination of bodily waste and to remain healthy.

What is the primary function of the urinary tract?

to eliminate waste and excess fluid from the body in the form of urine.

The urinary tract regulates?

levels of electrolytes

The urinary tract produces hormones that are?

important for blood pressure regulation

The urinary tract helps our bones with what?

keeps bones strong

3 multiple choice options

The urinary tract develops what type of cells?

red blood cells

3 multiple choice options

Where does urine travel?

through the urinary system or urinary tract, which consists of the kidneys, ureters, bladder, and urethra.

What does the urinary tract consist of?

kidneys, ureters, bladder, and urethra

Where are the kidneys located?

located below the ribcage, each adjacent to the spine.

On average, how many quarts of blood are filtered by the kidneys to produce how many quarts of urine?

120-150 quarts of blood to produce about 1-2 quarts of urine

3 multiple choice options

From the kidneys, urine is transported

to the bladder by ureters

What are ureters?

thin tubes of muscle

Normally, how much urine can the bladder hold?

up to 2 cups of urine

how many ureters does each kidney have?

one

3 multiple choice options

Antidiuretics minimize fluid loss by

preventing urine production in the kidneys.

Diuretics increase urination by

increasing urine production in the kidneys.

What are the 6 types of Urinary Incontinence?

1. Stress incontinence

2. Urge incontinence:

3. Reflex incontinence

4. Overflow incontinence

5. Functional incontinence

6. Bedwetting

What type of urinary incontinence causes coughing, sneezing, laughing, or physical activity that increases pressure on the bladder?

Stress Incontinence

What type of urinary incontinence causes a strong urge to urinate, but leaking occurs before getting to the toilet?

Urge Incontinence

What type of urinary incontinence causes urinary leakage as a result of nerve damage?

Reflex Incontinence

What type of urinary incontinence causes a physical inability to reach the toilet in time?

Functional Incontinence

What type of urinary incontinence causes a incomplete bladder emptying which results in the bladder overfilling when full?

Overflow Incontinence

What occurs when the bladder is not able to fully empty?

Urinary Retention

What are symptoms of urinary retention?

inability to urinate, pain, abdominal distention, urinary frequency, urinary hesitancy, weak or slow urine stream, and urinary leakage

If a urinary tract infection is left untreated, it may result in?

kidney infection called pyelonephritis

A urinary tract infection is caused by?

bacteria entering the urinary tract

are urinary tract infections more common in men or women?

More common in women than in men because women have a shorter urethra

What are the risk factors for a UTI?

Risk factors include sexual activity, menopause, urinary retention, urinary obstruction, frequent urinary catheter use, diabetes, or urinary tract abnormalities.

What are the symptoms of a UTI?

Symptoms include burning or painful urination and frequent urgency to urinate despite not having a lot of urine to pass.

How does food and liquid travel in the small intestine?

food and liquid continue to mix with digestive secretions from the pancreas, liver, and small intestine as peristalsis continues to aid in the transport of food through the GI tract.

Then the digested products continue into the large intestine.

Once in the large intestine, liquid is?

absorbed from the waste byproduct and stool begins to form

Peristalsis continues to move the forming stool out of the body through the?

anus during a bowel movement

What is the accidental passing of stool also known as accidental bowel leakage?

fecal incontinence

Alcohol

Caffeinated beverages and foods

Dairy

Foods that are high in fat or are highly greasy

Beverages that contain fructose

Spicy foods

Apples, peaches, and pears

Products that contain sweeteners, such as sorbitol, mannitol, xylitol, and maltitol

are known to increase the risk of?

diarrhea

3 multiple choice options

Constipation occurs when?

a client has infrequent bowel movements

How many bowel movements per week are considered "abnormal" for a diagnosis of constipation?

fewer than 3

3 multiple choice options

The stools from a person with constipation are?

hard, lumpy, and difficult to pass

What are some interventions to treat constipation?

high fiber diet

staying well hydrated

exercise

bowel training

medication to soften stools

3 multiple choice options

Diarrhea causes

excess fluid loss causing dehydration

What are some findings that are indicative of constipatiion?

cramping, abdominal pain, inability to pass stool or very thin segments of stool, only passing liquid

3 multiple choice options

Cystostomy is

similar to urinary catherization but is more invasive. a catheter is inserted directed into the bladder and attached to a drainage bag outside the client's abdomen

What are the conditions that alter bowel elimination patterns?

Diverticulitis, Irritable Bowel Syndrome, Ulcerative Colitis, Crohn's disease

What diseases can cause blood in the stool?

Ulcerative Colitis & Crohn's Disease

3 multiple choice options

What test is used to check if there is blood in the stool?

stool guaiac test

3 multiple choice options

What is a temporary or permanent fecal diversion that uses the terminal end of the small intestine called the ileum?

Ileostomy

What is a colostomy?`

a fecal diversion in which part of the colon is used to form a stoma through the abdominal wall

What are complications of fecal diversion?

skin irritation, stoma issues, hernias, prolapse, narrowing, blockages, diarrhea, bleeding, electrolyte imbalance, and leaking

What are the nursing interventions to facilitate bowel elimination patterns?

lifestyle changes

enema

medications

rectal tube

bowel training

What are the 6 types of urinary diversions?

Urinary catheterization

Ureteral Stent

Urostomy

Nephrostomy

Continent Urinary Diversion

Cystostomy

What is a surgically created diversion that uses part of the small intestine?

Urostomy or ileal conduit

What is urinalysis?

a lab test commonly used by health care providers to evaluate for a variety of disorders.

What is a urine culture?

sterile or clean voided sample of urine and can report bacterial growth(yeast) in 24-48 hours

What is the name of the diagnostic test where urine is collected over a 24-hour period, placed in a special container, and refrigerated?

24-Hour Urine Collection

What is clean catch urine collection?

a method used for collecting a urine sample for urinalysis and/or urine culture to evaluate for UTIs. This method requires male/female to use a sanity wipe on their genitals to wipe off any contaminants. The client will urinate a little before stopping, place the sample cup under them, and voiding into the cup until the sample is collected.

catheterization requires?

a doctor's orders

what is urine catheterization?

procedure that involves the passage of a catheter(hollow tube) into the urinary bladder to withdraw urine. the process requires sterile technique to avoid infecting the client with bacteria and causing a UTI or kidney infection

What is a bladder scanner used for?

a bladder scanner tells us how much urine a client has in their bladder. It helps nurses determine the need for catheterization

What is dermatitis?

a red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound secretions

What is loss of top layer of the skin caused by mechanical forces?

skin tears

What is cellulitis?

An infection of the superficial layers of skin.

What are traumatic wounds?

lacerations which are usually caused by blunt or sharp objects.

What are surgical wounds?

acute wounds that are created intentionally during surgery

Surgical wounds are classified as?

clean, clean-contaminated, contaminated or dirty

What is a form of dermatitis that forms when the skin is exposed to irritants like feces, urine, stoma content, and wound exudates?

moisture-associated skin damage (MASD)

To avoid pressure injury to a client we should?

pad bony prominences, use barrier cream and turn the patient over every 2 hours