Fundamentals Exam 3

Bowel Elimination Wound Care Sensory Perception

Common bowel elimination problems

• ____

• ____

• ____

• flatulence

• ____

constipation

gas

incontinence

hemorrhoids

____ causes abdominal distention and severe, sharp pain if intestinal motility is reduced because of ____, ____ ____, abdominal surgery, or ____.

flatulence, opiates, general anesthesia, immobilization

Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease frequently cause ____.

hemorrhoids

A person with a ____ colostomy will have more formed stool.

sigmoid

The output from a ____ colostomy will be thick liquid to soft consistency.

transverse

With an ileostomy, the fecal effluent leaves the body before it enters the ____, creating frequent, ____ stools.

colon, liquid

In order to enhance bowel movement,

• provide privacy

• increase the head of the bed at least __ degrees

• encourage a diet with ____ and increase ____ intake

• increase ____ by moving around

• use ____ pan for ____ and ____ fractures

30

fiber, fluid

peristalsis

fracture, hip, femur

_____ have a stronger and more rapid effect on the intestines than laxatives.

cathartics

When performing an enema, patients should be placed in ____ ____ position.

Cleansing enemas include ____ water, normal ____, ____ solution, and low- volume ____ ____.

left sims

tap, saline, soapsuds, hypertonic saline

Tap water is ____ and exerts an osmotic pressure lower than fluid in ____ ____.

hypotonic, interstitial spaces

Physiologically, ____ ____ is the safest solution to use for an enema because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the ____.

normal saline, bowel

____ solutions inserted into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces. The ____ fills with fluid and the resultant distention promotes defecation.

hypertonic, colon

Digital removal of stool must be ordered by a provider, involves using a finger to manually ____, ____ ____, and bring down stool. It is used if ____ fail to remove an impaction and is the last resort in managing severe ____ as it is very uncomfortable for the patient.

feel, break up, enemas, constipation

Conditions that sometimes require special interventions to decompress the GI tract include ____, absence of ____, ____ to the GI tract, or ____ of the GI tract often caused by ____.

surgery, peristalsis, trauma, obstruction, tumors

NG tubes may be used for

• ____: removal of secretions and gaseous substances from GI tract; prevention or relief of abdominal distention

• ____ ____: installation of liquid nutritional supplements, medications, or feedings into stomach or small intensine for patients with impaired swallowing

• ____: internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage

• ____: irrigation of stomach in cases of active bleeding, poisoning, or gastric dilation

decompression, enteral feeding, compression, lavage

Stomas should be ____ /____ and healthy. Alert provider immediately if ____ or ____.

pink/ red, dark, purple

If a patient has cardiac disease or is taking cardiac or ____ medication, obtain a ____ ____ because manipulation of rectal tissue stimulates the ____ nerve and sometimes causes a sudden decline in ____ ____.

hypertensive, pulse rate, vagus, pulse rate

As adults age, ____ becomes thinner, ____ is lost, ____ fat becomes thinner, ____ ____ is more sluggish, and the skin becomes less hydrated.

Therefore, ____, ____, and ____ can cause problems.

skin, elasticity, subcutaneous, blood supply

shear, friction, pressure

Risk factors for wounds includes

• poor ____

• ____

• incontinence

• immobility

• long term ____ use

• ____, ____, moisture

• ____ or ____

circulation

diabetes

steroid

shear, friction

IV, port

Factors influencing wound healing: DIDNT HEAL

D: ____

I: ____

D: ____

N: ____

T: ____

H: ____

E: ____

A: ____

L: ____

diabetes

infection

drugs

nutritional problems

tissue necrosis

hypoxia

extensive tension

another wound

low temperature

A ____ ____ is localized damage to the skin and underlying soft tissue, usually developing over a ____ prominence or related to ____ from a medical device or other device.

This injury can present as ____ skin, a ____ to open ____ and may be painful.

When the pressure applied over a capillary exceeds the normal ____ pressure and the vessel is occluded for a prolonged period, ____ ____ occurs.

____ occurs when the normal red tones of the light- skinned patient are absent.

pressure injury, bony, pressure

intact, blister ulcer

capillary, tissue ischemia

blanching

Loss of ____ ____ is caused when skin and underlying soft tissue are compressed between a bony prominence and external surface.

tissue integrity

If a pressure ulcer has dead skin in it then it is ____ (____).

unstageable, necrosis

Stage I pressure ulcer is a ____ area that does not fade after __ minutes of taking away ____. Often over ____ areas.

reddened, 30, pressure, bony

Stage II pressure ulcer is when the ____ ____ of skin is lost. It may be a ____ or little crater. It is often ____ and ____.

top layer, blister, pink, painful

Stage __ pressure ulcer is deeper and goes into the subcutaneous tissue. It can look like a deep crater. The tissue may be ____, ____, or both.

III, black, infected

Stage IV wound extends deep into the tissue and often affects the ____, ____, and ____.

muscles, tendons, bones

Stage _ pressure ulcer is intact skin with localized area of non-blanchable redness/ ____.

I, erythema

Stage _ pressure ulcer is partial- thickness skin loss involving epidermis, ____, or both.

Wound bed is ____, pink or red, and ____.

May look like intact or ruptured ____- filled ____.

II, dermis

viable, moist

serum, blister

Stage _ pressure ulcer is full- thickness tissue loss with adipose (____) visible in the ulcer.

____ tissue and rolled wound edges are often present.

Slough and ____ may be present.

III, fat

granulation

eschar

Stage _ pressure ulcer is full-thickness tissue loss with exposed bone, muscle, or tendon.

May have slough or eschar.

Rolled edges, undermining, or ____ may be present.

IV

tunneling

If you detect ____ or suspicious looking drainage, a specimen of the drainage may need to be obtained for ____ ____.

Never collect a wound culture from ____ drainage.

purulent, wound culture, old

Serous drainage is ____, ____ plasma.

clear, watery

Purulent drainage is ____, ____, green, tan or brown.

thick, yellow

____ is pale, pink, watery; mixture of clear and red fluid.

serosanguineous

____ is bright red; indicates active bleeding.

sanguineous

Complications of wound healing include

____: bleeding from a wound site is normal during and immediately after trauma. ____ occurs within several minutes unless large blood vessels are involved or a patient has poor clotting function.

____: microorganisms infect surgical wound though various forms of ____; such as touch of a contaminated HCP or surgical instrument, through the air, or through contact on or in a person’s body then spread into the wound

____: partial or total separation of wound layers

____: protrusion of visceral organs through a wound opening

hemorrhage, hemostasis

infection, contact

dehiscence

evisceration

____ occurring after hemostasis indicates a dislodged surgical suture, a clot, infection, or erosion of a blood vessel by a foreign object (ex. ____).

hemorrhage, drain

The local clinical signs of wound infection include ____, increased amount of wound drainage; change in appearance of a wound drainage (____, ____ change, presence of ____); and periwound ____, ____, or ____.

A patient may have a ____ and an increase in ____ count.

Laboratory tests such as a ____ ____ or tissue biopsy assist in determining presence of wound infection and the causative microorganism.

erythema, thick, color, odor, warmth, pain, edema

fever, WBC

wound culture

In the first stage of wound healing; ____ or ____ stage, the damaged tissue releases ____ which trigger hemostasis; blood ____ and the wound starts to heal.

____ also leaks into surrounding tissue causing swelling.

hemostasis, inflammatory, cytokines, coagulates, plasma

In the ____ stage of wound healing, the proliferative stage, new ____ fibers are formed, a new ____ bed is created, and ____ start growing. The wound edges begin pulling ____ and new ____ tissue grows.

second, collagen, wound, capillaries, closer, granulation

In the final stage of wound healing, the ____ stage, stronger ____ replaces the soft ____ collagen, however, this tissue is much ____ than the original tissue and is susceptible to injury.

remodeling, collagen, gelatinous, weaker

____ healing or first intention occurs in clean ____ and ____ ____; closed with ____ ____ or ____. Edges are ____.

primary, lacerations, surgical incisions, skin adhesives, sutures, approximated

_____ _____ or _____ _____: wound healing that happens when the wound is left open to heal.

secondary healing, secondary intention

Sensory perception on the Braden scale is graded from 1-4:

1. ____ limited

2. ____ limited

3. ____ limited

4. ____ ____

completely

very

slightly

no impairment

Moisture on the Braden scale is graded from 1-4:

1. ____ moist

2. ____ moist

3. ____ moist

4. ____ moist

constantly

very

occasionally

rarely

Activity on the Braden scale is graded from 1 -4:

1. ____

2. ____

3. ____ occasionally

4. walks ____

bedfast

chairfast

walks

frequently

Mobility on the Braden scale

1. ____ ____

2. ____ limited

3. ____ limited

4. ____ ____

completely immobile

very

slightly

no limitations

Nutrition on Braden scale

1. ____ ____

2. ____ inadequate

3. ____

4. ____

very poor

probably

adequate

excellent

Friction & shear on Braden scale

1. ____

2. ____ problem

3. no apparent problem

problem

potential

When assessing the skin in relation to wound healing, continually assess for signs of ____ and/or ____ development.

breakdown, ulcer

Health promotion for wound healing includes ____ and ____ the patient, using ____ skin care and ____ management, support surfaces, and prevention of ____ ____.

positioning, turning, topical, incontinence, pressure ulcers

Implementation in acute care of wound healing includes management of ____ ulcers and wound management: ____, education, ____ status, ____ status, ____, and ____.

pressure, debridement, nutritional, protein, hemoglobin, albumin

With hemostasis, control ____ by allowing ____ wounds to bleed and do not remove a ____ object.

bleeding, puncture, penetrating

The purpose of wound dressings is to protect from ____, aid in ____, promote healing by absorbing ____ or ____ a wound, support wound site, provide ____ insulation, provide a ____ environment.

microorganisms, hemostasis, drainage, debriding, thermal, moist

Clean wounds from ____ to ____ contaminated.

least, most

Acute wounds develop as a result of ____ and are typically a result of ____.

Chronic wounds develop ____ ____ from ____ wounds that do not progress in ____.

injury, trauma

over time, acute, healing

Extent of ____ injury depends on the depth of destruction.

Degree of burns is the degree of ____.

burn, thickness

Phases of burn injury are ____ (resuscitiation), ____ (healing), ____ (restorative).

emergent, acute, rehabilitative

Types of burns

• ____

• ____

• ____

• ____-related

• ____ (heat-related)

chemical

electrical

radiation

smoke

thermal

Reception: stimulation of a receptor such as ____, ____, or ____.

light, sound, touch

____: integration and ____ of a stimuli.

perception, interpretation

____: only the most important stimuli will elicit a reaction.

reaction

Sensory deficit is a deficit in the normal function of ____ ____ and ____.

sensory reception, perception

Sensory deprivation is ____ ____ or ____ of stimulation.

inadequate, quality, quantity

____ ____ is reception of multiple sensory stimuli.

sensory overload

Factors influencing sensory function

• ____

• ____ stimuli

• ____ of stimuli

• ____ interaction

• environmental and cultural factors

age

meaningful

amount

social

Nursing diagnoses that apply to patient with sensory alterations include risk for ____, ____-____ deficit, risk for ____, impaired ____ communication, impaired ____, and impaired ____.

injury, self- care, falls, verbal, socialization, mobility

Health promotion for sensory perception includes ____, preventive measures, use of ____ devices, and promoting ____ ____.

screening, assistive, meaningful stimulation