concepts final

unexpected findings of abdomen

hyper/hypoactive bowel sounds
abdominal distention
enlarged organs (palpated)

abdominal distention causes

obesity (fat)
air/gas (fart)
ascites (fluid)
ovarian cyst (fluid cyst)
pregnancy (fetus)
feces
tumors (f word)

factors affecting bowel elimination

age, fluid intake, diet, physical activity, pain, surgery, anesthesia, medications, pregnancy, stage fright, position, baby formula, stress

constipation

a symptom, not a disease, infrequent and/or hard, dry, small stools that are difficult to eliminate

diarrhea

an increase in the number of stools and the passage of liquid, unformed feces

impaction

results from unrelieved constipation
a collection of hardened feces wedged in the rectum that a person cannot expel

hemorrhoids

dilated, engorged veins in the lining of the rectum (frank bright red blood in stool, metallic smell)

incontinence

inability to control the passage of feces and gas to the anus

flatulence

accumulation of gas in the intestines causing walls to stretch

valsalva maneuver

pressure exerted to expel feces through voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway (drops blood pressure, elderly)

paralytic ileus

when the bowels don't wake up after surgery

bowel changes (aging)

poor fluid intake, limited access to consistent meals, swallowing/chewing difficulties-->constipation, risk of colorectal cancer

bowel changes (immobility)

weakened abdominal and pelvic floor muscles--> ineffective in increasing the intraabdominal pressure during defecation which leads to constipation

bowel changes (opioids)

depress GI motility and slow colonic action

nursing interventions for bowel elimination

establish a regular pattern (laxatives, skin care, warm liquids, weigh daily), preventative screenings, diet (fiber, fluids), exercise (ambulate, ROM, aerobic)

normal urine characteristics

dilute or very concentrated, sterile, contains fluids, salts, and waste products, doesn't contain bacteria, viruses, or fungi, can be produced in small or large amounts
clear, not cloudy, no sediment, odorless

urinalysis

screens for UTI, kidney disease; nitrates (infection), proteins (not supposed to be there) keto diet, specific gravity (balance of solutes and waste), glucose (shouldn't be there), ketones (Atkins diet)

culture and sensitivity

performed to diagnose a UTI, performed if organisms grow in a culture to determine what antibiotic to use, Urine culture = for nitrates

factors influencing urinary elimination

development, psychosocial, food and fluid intake, medications, muscle tone, surgical or diagnostic procedures, pathological conditions, UTIs, urinary diversion

stress incontinence

loss of urine control during activities that increase intraabdominal pressure (coughing, sneezing, laughing, exercise)

urge incontinence

sudden strong urge to void, followed by rapid bladder contraction

mixed incontinence

combination of stress and urge

functional incontinence

lack of urine control in absence of any abnormalities of urinary tract

overflow incontinence

unable to empty the bladder completely, constant dribbling or urine or increased frequency of urination

temporary incontinence

associated with severe constipation, infections in urinary tract, medication use

normal urine output

60 mL/hour
1400 mL/day

anuria

failure of kidneys to excrete more than 50 to 100 ml of urine in 24 hours

oliguria

greater than 100 and less than 5000 ml

nocturia

excessive urination at night

dysuria

painful urination

polyuria

excessive production and excretion of urine

hematuria

blood in the urine

urinary retention

inability to empty bladder fully caused by an obstruction or neuro disorder

diabetes and urination

urine can have sweet, fruity odor, elevated BUN, glucose in urine, ketones

BPH and urination

nocturia

nursing interventions - urinary elimination

Promoting adequate fluid intake, teaching self-care activities, and assisting with voiding, providing privacy, offering a bedpan every hour
Proper hand hygiene can prevent the spread of infection
Proper perineal care can prevent cross-contamination

UTI prevention

cotton lined underwear, avoid tight clothes, drink 8 ounces of water per day, urinate when urge is felt, wipe front to back, shower instead of bathing, avoid scented products

nursing interventions - catheters

cleansed twice daily, catheter bags kept below bladder, should be emptied when 2/3 full

cognition

knowing influenced by awareness and judgment
it comprises skills that include language, calculation, memory, attention, reasoning, learning, problem solving, and decision making.

sensation

a feeling, within or outside the body, of conditions resulting from stimulation of sensory receptors.

sensory needs

needed for survival, growth, and development and bodily pleasure, give meaning to events in the environment

sensory adaptation

stimulus must be variable to create a response, otherwise it is gradually ignored

cataract

the clouding of the lens of the eye, causes blurring of vision.

glaucoma

a serious condition of the eye, causes increased intraocular pressure, putting pressure on the optic nerve, which leads to loss of peripheral visual fields and possibly blindness.

diabetic retinopathy

complication of diabetes mellitus in which the blood vessels of the retina become damaged.

macular degeneration

the leading cause of visual defects in the United States, is the loss of vision in the central visual fields.

peripheral neuropathy

nerve damage away from the center of the body, is caused by damage to sensory nerve fibers in the arms and legs

anosmia

complete loss of sense of smell

presybycusis

age related hearing gloss, is usually sensorineural in nature

meniere's disease

vertigo, tinnitus, Progressive hearing loss

vertigo

sensation that objects are moving around the person

tinnitus

ringing sound in the ear

cerebrovascular accident

stroke, is an avascular injury to the brain, causing damage to an area of the brain

ischemic stroke (clot)

narrowing a blood vessel and blocking blood flow

ischemic stroke (embolus)

breaks from a clot in the systemic circulation and lodges in a small cerebral blood vessel, blocking blood flow

hemorrhagic stroke

with bleeding in the brain from a burst aneurysm or an injury.

factors affecting alterations

Lifestyle (smoking, obesity, high cholesterol diet, excessive alcohol use, stress)
Environment (toxins, loud noises, safety)
Medical conditions
Medications

delirium definition

a reversible state of acute confusion characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition

delirium symptoms

Fluctuating awareness, impairment of memory and attention, disorganized thinking, hallucinations, and disturbances of sleep

delirium causes

drug or alcohol use, the side effects of medication, infections, fluid and electrolyte imbalances, low oxygen level, and pain

depression

a mood disorder characterized by a sense of hopelessness and persistent unhappiness
Rapid onset, usually reversible

depression symptoms

Loss of interest, sadness for an extended period of time, decreased self-esteem, sleeping too much, insomnia, changes in eating patterns (symptoms on most days for 2 weeks)

depression causes

medication side effects, social circumstances, isolation

dementia

permanent decline in mental function, subtle onset characterized by the decline in many cognitive abilities, including reasoning, use of language, memory, computation, judgement, and learning
Not reversible and worsens overtime

sensory deficits

Deficit in the normal function of sensory reception and perception (one sense may become more acute to compensate for deficit, at risk for sensory overload)

sensory deprivation

Inadequate quality or quantity of stimulation (too little stimuli, isolation, impaired ability to receive or send data, inability to cognitively process stimuli)

sensory overload

Reception of multiple sensory stimuli (pain, dyspnea, anxiety, noise, intrusive procedures, contact with many strangers, medications)

expressive aphasia

(Broca's), a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. Understanding/reading still intact.

receptive aphasia

(Wernicke's) is the inability to understand written or spoken language.

mini-cog

Mini-mental state examination: screening tool to test patient's cognoitive orientation, attention, calculation, recall, language, and spatial orientation

acute confusion

dementia, a reversible state of confusion, develops over 1 to 2 days and is caused by a medical condition

chronic confusion

Alzheimer's, occurring over a long period of time, not reversible

nursing interventions-visually impaired

adequate lighting and minimize glare, eyeglasses or contacts in use, use large print or clear handwriting, use photos, pictures or diagrams
If the patient is living independently, care is taken to rid the home of safety hazards. Furniture is placed to allow wide passageways. Throw rugs are removed. Nonskid mats are used in bathrooms and kitchens. Grab bars and stair railings are kept in good repair

nursing intervention-cognitive alterations

If 24-hour supervision and assistance with care are needed, provisions are made with loved ones or a day care service or placement is arranged in a long-term care facility.

nursing interventions-tactile alterations

A simple kitchen thermometer is used to verify that bath-water temperature is approximately 37.8°C (100°F)
Hot-water heaters are set so that scalding is not possible.

nursing interventions-olfactory alterations

The home should be checked for safety of gas stoves, hot-water heaters, and furnaces
Carbon monoxide detectors

nursing interventions-equilibrium alterations

Installation of a secure grab bar in the tub or shower at home gives the patient stability when getting in and out of the tub.

nursing interventions-sensory deprivation

Use of sensory aids such as glasses and hearing aids promotes social interactions

stress appraisal

process of interpreting the threat (stage 1 threat assessment, stage 2 coping options)

general adaptation syndrome

(GAS): physical response to stress-alarm, resistance, exhaustion (normally in alarm or resistance)

distress

negative stress (can't adapt to it, takes a toll on our system)

eustress

positive stress (temporary, acute, something good coming from the end, can't anticipate)

local adaptation syndrome

(LAS): inflammation, reflexive response to pain, hypoxia secondary to catecholamine release

sense of coherence

(SOC): characteristic of personality that references one's perception of the world as comprehensible, manageable and meaningful
Strong SOC: likely to recognize and utilize resources
Low SOC: likely to be overwhelmed

problem-focused coping

aimed at altering or removing the stressor

emotion-focused coping

work to ease the emotional distress associated with a stressful condition

defense mechanisms

unconscious, protective coping methods that people may apply in response to a perceived threat

compensation

focusing on strengths rather than perceived weakness

denial

ignoring aspects of reality that induce anxiety or contribute to a loss of self-esteem

displacement

redirecting negative emotions perceived as unacceptable or threatening to a safer emotion

intellectualization

overthinking a challenging situation or impulse to avoid dealing with emotions it elicits

projection

attributing one's own motives, values, desires, situational responses, and personality traits to another person

reaction formation

responding to negative thoughts or feelings by demonstrating opposite emotions and actions

regression

reverting to behavior associated with an earlier stage of development when challenged by thoughts and stressor

repression

blocking unacceptable thoughts and feelings from consciousness

sublimation

channeling unacceptable thoughts and feelings from consciousness

factors affecting coping

Chosen on the basis of personal experience of success with various mechanisms, the degree of the threat, and the availability of social resources
How well someone manages stress

factors affecting stress

Personality factors (resilience, hardiness, and SOC)
Moral compass, realistic optimism, religion, spirituality

five rights of delegation

right task
right circumstances (not TAPE)
right person
right direction/communication (need to tell specifically what you want done)
right supervision (evaluate what was done after)

TAPE

teaching, assessment, planning, education (things that cannot be delegated)