another funds exam 2 study set

normal age related changes in the GI tract

the strength of the striated external sphincter muscles decreases, leading to decreased sphincter control, which increases the possibility of fecal incontinence. Weakened pelvic muscles and decreased activity level also contribute to constipation in older adults.

lack of fiber in diet

less frequent bowel movements and stools with less bulk and may experience some difficulty in bowel elimination.
Sources; fruits, vegetables, grains

how fluids affect bowel elimination

Decreased fluid intake causes constipation. Water is absorbed through the L.I., if there's not enough water the stool gets hard and dry making it difficult to defecate

benefits of physical activity on the GI tract

Increases muscle tone and stimulates peristalsis. Strong abdominal and perineal muscles are needed to increase intra-abdominal pressure during defecation.

factors that influence bowel elimination

Nutrition, Fluid intake, Activity and exercise, Body position, Ignoring the urge to defecate, Lifestyle, Pregnancy, Medications, Diagnostic procedures, Surgery, Fecal diversion

four factors that place a patient at risk for constipation

inactivity, decreased fluid intake, limited mobility, perioperative anesthesia

signs of contipation

distended abdomen, hypoactive bowel sounds, straining with bowel movements, blood streaked stool, unsatisfactory defecation, bloating

fecal impaction

Stool that is firmly wedged in rectal fault that can't be passed

signs and symptoms of fecal impaction

Oozing diarrhea around impaction, bloating, urge to defecate but inability to pass stool, loss of appetite, vomiting

diarrhea

Frequent evacuation of watery stools

fecal occult blood testing

evaluates stool for blood that is not apparent upon visual examination

factors to promote normal defecation

diet- assist patient with planning a high fiber diet, fluids- 1,500-2,000 mL/day, discuss patients' fluid preferences, activity and exercise- encourage walking, isotonic, isometric, contraction/relaxation of abdominal muscles

cathartics and laxatives

promotes evacuation of hardened stool

antidiarrheals

acts on intestine to slow bowel motility or absorb excess fluid in the bowel

Enemas

a. installation of a fluid rectally to stimulate peristalsis and evacuation of the lower bowel

Measures included in a successful bowel training program

Aims to maintain soft stool consistency and develop a routine method of stool evacuation. Routine is repeated at the same time each day with the same techniques. Includes the use of stool softener twice a day, bulking agent, and suppository.

factors that influence urination

fluid intake, loss of body fluids, diet, body position, cognition, psychological factors, obstruction of urine flow, infections of urinary tract, hypotension, neurological injury, decreased muscle tone, pregnacy

dysuria

difficult, painful urination

polyuria

Formation and excretion of large amounts of urine in the absence of a concurrent increase in fluid intake(\>2000ml/day)

anuria

absence of urine (

oliguria

a. Formation and excretion of less than 500 mL of urine in 24 hours (

urgency

a. sudden, forceful urge to urinate

nocturia

voiding during sleeping hours

frequency

a. urinating more frequently, without an increase in amount

hematuria

presence of blood in urine

pyuria

presence of pus in urine

urinary retention

inability to pass urine completely

urinary incontinence

involuntary passage of urine

enuresis

a. Involuntary voiding with underlying pathophysiologic origin after the age that bladder control is usually achieved; nocturnal enuresis is bedwetting

signs and symptoms of a UTI

Painful voiding, more frequent voiding, urine contains pus and blood.

stress incontinence

increased abdominal pressure causes involuntary loss of small amounts of urine

urge incontinence

random involuntary passage of urine after a strong urge to void

reflex incontinence

involuntary loss of urine, occurring at somewhat predictable intervals when a specific bladder volume is reached overcoming sphincter control

functional incontinence

inability of a normally continent person to reach the bathroom in time to avoid unintentional loss of urine

random urine specimen

a. used when sterile urine is not required, collected in a urinal, bedpan, hat, or directly into specimen cup, urine should not be contaminated with toilet paper or feces

clean voided or midstream urine specimen

a. a specimen relatively free of microorganisms is required. A sterile specimen cup or sterile bedpan or urinal is used to collect the urine specimen.

specimen from a catheter

may be necessary if a patient is unable to void or already has a catheter in place. Urine collected in this manner is sterile. When obtaining urine from a catheter, always maintain strict asepsis to prevent microorganisms from entering the bladder.

24-hour urine specimen

a. required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day.

Reagan strip

a. available to measure the amount of certain substances such as glucose, protein, or ketones in the urine

urinalysis

a. provides data about the color, turbidity, pH, and specific gravity of the urine and detects protein, glucose, ketones, red blood cells, white blood cells, bacteria, or casts.

urine culture

allows bacteria to grow and multiply over a period of at least 48 hours. The laboratory is able to make a preliminary identification of the organism within 24 hours

techniques used to stimulate voiding

turning on running water, pouring water over perineal area, place the patient's hand in warm water, stroke the inner thigh

ileal conduit

Connects the distal ureters to resected portion of terminal ileum which is used to form a stoma

Kock pouch

Segment of ileum used to form a pouch to hold urine. Drained by catheterization

cutaneous ureterostomy

distal end of ureter brought to surface to form a stoma.

Vesicostomy

opening made directly into bladder, forming a stoma

Nephrostomy

tube placed into renal pelvis

Stoma

pouch attached to the skin to collect urine. SKIN CARE IS CRUCIAL!!

nursing measures to prevent infection when inserting a catheter

hand hygiene and maintaining sterile asepsis throughout the procedure

still used in learning

using critical thinking skill, taking examinations, practicing reflections, stimulation, and developing expertise

subjective data

symptoms collected by patient vocalizing feelings and thoughts, ex; itching, nausea

objective data

signs collected via senses, nonverbal, ex; temperature, respiratory rate

sources of data

physical examination, clinical record viewing, primary source (patient), secondary source (supplement info from patient reference, family or records), tertiary source (from outside patient reference, textbooks)

Gordon's 11 functional health patterns

Health perception and health management, Activity and exercise, Nutrition and metabolism, Elimination—excretory function (bowel, bladder and skin), Sleep and rest, Cognition and perception, Self-perception and self-concept, Roles and relationships, Coping and stress tolerance, Sexuality and reproduction, Values and beliefs

medical diagnosis

Identified disease or pathologic process; treatment focuses on correcting or preventing specific pathology of specific organs or body systems

collaborative problem

Problems based on medical diagnoses, medically ordered treatments, or other related problems that require interdependent standards and activities to be addressed

actual nursing diagnosis

An existing human response to a health problem the nurse identifies that is amenable to nursing intervention

risk nursing diagnosis

State of being at risk for the development of a health problem amenable to nursing intervention

diagnostic label

a. word/phrase that is based on a pattern of connected data

descriptors

words used to give additional meaning to a nursing diagnosis. They describe changes in condition, state of the patient, or some qualification of the specific nursing diagnosis

definition

each nursing diagnosis that NANDA-1 approves for clinical use has a definition that describes the characteristics of the human response under consideration

defining characteristics

a. identifies clinical indicators (s&s) that support diagnostic label
b. Related factors: situations, events, or conditions that precede, cause, affect, or are associated with diagnostic label

related factors

situations, events, or conditions that precede, cause, affect, or are associated with diagnostic label

risk factors

they are environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event

process of identifying a problem

- Clustering, interpreting, and validating cues to determine patterns. New cues and new cue clusters can change patterns.

health promotion nursing diagnosis

diagnostic statement that is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.

goals

broad, nonspecific statements about the status one expects a patient to achieve

outcome

identifies a specific change in a patient's condition as a result of nursing interventions

7 types of intervention

assisting with ADL's, teaching, responding to life threatening events, implementing health promotion and illness prevention, performing technical skills, pschosociocultural interventions, recording and documenting nursing interventions and patients response

Independent nursing interventions

a. Rns can legally order and implement these, ex; assessment, diagnosing needs, nursing care, assisting with ADL's, advocating for patient

Dependent nursing interventions

requires order/ prescription from HCP, ex; administering oxygen, meds, activity orders, catheters, providing diet, irrigation

Collaborative nursing interventions:

a. work in collaboration with HCP to implement dependent nursing interventions, ex; order says "...as tolerated"

structure evaluation

focuses on the attributes of the setting or the surroundings where healthcare is provided. It deals with environmental aspects that directly or indirectly influence the quality of care provided

process evaluation

focuses on the nurse's performance and whether the nursing care provided was appropriate and competent

outcome evaluation

focuses on the patient and the patients function, determines the extent to which the patient's behavioral response to the nursing intervention reflects the desired patient goal and outcome criteria

factors that influence personal preference for hygiene

environment, motivation, mental health, cognitive abilities, energy, acute illness and surgery, pain, neuromuscular function, sensory deficits

how environment effects hygiene

lack of access to facilities or proper resources for self-care may affects a person's ability for adequate self-care

how motivation effects hygiene

Even though a person is physically capable of self-care, they must be motivated to perform self-care and must believe that self-care is important.

how mental health effects hygiene

a. Mental health issues can result in self-care deficits. The inability to perceive reality because of psychosis or schizophrenia may cause inattentiveness to the need for personal care.

how cognitive ability effects hygiene

Those with limited or altered cognitive abilities may be unaware of the need for self-care, may not know appropriate methods of achieving it, or may be unable to assess what they can perform safely and independently.

how energy effects hygiene

Compromised respiratory or cardiac function reduces the body's ability to provide sufficient oxygen to the cells, limiting the patient's ability to participate in self-care without fatigue.

how acute illness or surgery effects hygiene

Analgesics, fluid and electrolyte imbalance, and hypoxemia can lead to drowsiness and confusion. Nausea and vomiting contribute to general malaise and may lessen motivation to perform self-care. Casts, IVs, incisions, catheters tubes, and anxiety may limit the ability to perform self-care

how pain effects hygiene

Patients experiencing pain may be unable to care for themselves because their ability or willingness to move may be significantly curtailed.

how sensory deficits effects hygiene

a. loss of sights and hearing make self-care difficult for the patient, but devising alternate methods of cuing and communicating instructions can help them perform self-care independently.

manifestations of altered self-care

poor hygiene and grooming, inability to demonstrate self-care activities, verbalization of reluctance to perform self-care

risk factors of altered self-care

pain, immobility or limited use of extremity, neuromuscular impairment, mental confusion or deceased mental alertness, deceased visual acuity or other sensory deficits, inability to control bowel or bladder function, decreased energy levels or fatigue, socioeconomic factors

complete bed bath

bath administered to totally dependent patient in bed, a. washing of every body area starting with the face, then arms, chest, legs, perineal area, back, and bottom

partial bed bath

a. "hot spots" (places that get dirty easily- face, hands, armpits, perineal area) or patient does part and nurse does part

bag bath

a. wipes, use different cloth for each area

Sitz bath

a. To cleanse, soothe, and reduce inflammation of perineal or vaginal area after childbirth, vaginal or rectal surgery, or from local irritation of hemorrhoids and fissures

patients at risk for skin breakdown in the perineal area

Infants- incontinent of urine and stool, have fragile easily injured skin, can't provide their own care, frequent diaper changes needed to manage skin breakdown
Older adults- have fragile, easily injured skin, may be unable to provide their own care, may be incontinent, lack of mobility

benefits of a back rub

given to patients to enhance the blood supply to the skin and muscles, to promote comfort, and to promote relaxation.

guidelines to include when advising patients with diabetes or peripheral vascular disease about foot care

feet should be inspected daily, cleaned thoroughly with warm water and mild soap, carefully dried, especially between the toes, avoid lotion between the toes, toenails cut straight across, edges filled with an emery board, avoid soaking the feet in water, use of lotion on the tops and bottoms of feet

caries

cavities in tooth enamel

cerumen

earwax

gingiva

oral mucosa

halitosis

bad smelling breath

self-care

A person's ability to perform primary care functions in the four areas of bathing, feeding, toileting, and dressing without the help of others

normal skin changes in older adults

The skin becomes drier, less elastic, and less resilient because glands reduce oil production. May develop brown discolorations.

factors that effect skin function

moisture, dehydration, edema, inadequate nutrition, shearing forces