NSG 3009/ NSG3009 Exam 2 V2(2026/2027 Update) Principles of Assessment | Comprehensive Questions & Answers | 100% Accurate Solutions | – South University

NSG 3009/ NSG3009 Exam 2 V2(2026/2027 Update) Principles of Assessment | Comprehensive Questions & Answers | 100% Accurate Solutions | – South University Q. At what age should women begin getting yearly mammograms? ANSWER After age 40 Q. When should breast self-exams (BSE) be performed? ANSWER Monthly, 7 days after the menstrual period Q. What is the purpose of the PSA test? ANSWER To screen for prostate cancer in men, usually after age 50 Q. When should Pap smears begin? ANSWER At age 21, every 3 years Q. Who should get the HPV vaccine? ANSWER Boys and girls around age 11-12 Q. When should colon cancer screening begin? ANSWER At age 50, every 10 years Q. What does a DEXA scan assess? ANSWER Bone density for osteoporosis screening Q. What is a normal BMI range? ANSWER 18.5-24.9 Q. What order do you perform the abdominal assessment? ANSWER Inspect, auscultate, percuss, palpate Q. What are signs of appendicitis? ANSWER RLQ pain, rebound tenderness, positive Psoas/Obturator signs Q. What are abnormal breast findings? ANSWER Lumps, dimpling, nipple retraction or discharge Q. What are abnormal prostate exam findings? ANSWER Nodular, hard, enlarged, or soft prostate Q. What lung sound is associated with fluid, such as in CHF or pneumonia? ANSWER Crackles Q. What lung sound is a medical emergency? ANSWER Stridor Q. What is a normal pulse oximetry reading? ANSWER 95-100% Q. What does JVD indicate? ANSWER Right-sided heart failure or fluid overload Q. What happens to the heart during pregnancy? ANSWER Increased blood volume and heart rate; common systolic murmur Q. How are DTRs graded? ANSWER From 0 (absent) to 4+ (hyperactive) Q. What does the TUG test assess? ANSWER Fall risk; 12 seconds is high risk Q. What condition causes cloudy vision due to lens changes? ANSWER Cataracts Q. What condition is known for tunnel vision due to high IOP? ANSWER Glaucoma Q. What is the hallmark of macular degeneration? ANSWER Loss of central vision Q. What is clubbing of the nails a sign of? ANSWER Chronic hypoxia Q. What is the ABCDE rule for skin cancer? ANSWER Asymmetry, Border, Color, Diameter, Evolving Q. What are signs of PAD? ANSWER Cool, pale skin, weak pulses, pain with walking Q. What are signs of PVD? ANSWER Warm, red skin, swelling, varicose veins Q. What lung sound is caused by mucus in the airways? ANSWER Rhonchi Q. Which cranial nerve is responsible for facial expressions? ANSWER Cranial Nerve VII (Facial) Q. What is the grading scale for edema? ANSWER 1+ to 4+, based on depth and how long the indentation lasts Q. Which cranial nerve controls vision? ANSWER Cranial Nerve II (Optic) Q. What does LOC stand for in neuro assessment? ANSWER Level of Consciousness Q. What is a common symptom of diabetic retinopathy? ANSWER Blurry vision and floaters Q. Which condition is associated with rebound tenderness and RLQ pain? ANSWER Appendicitis Q. What is a normal heart rate range in adults? ANSWER 60-100 bpm Q. What is the technique for checking the jugular vein? ANSWER Head of bed at 45°, observe for pulsation/distention Q. What are normal heart sounds? ANSWER S1 and S2 (lub‑dub) Q. Which cranial nerve is responsible for smell? ANSWER Cranial Nerve I (Olfactory) Q. What causes cyanosis? ANSWER Low oxygen levels in the blood Q. What does the Romberg test assess? ANSWER Balance and proprioception Q. What causes peau d'orange appearance of the breast? ANSWER Blocked lymph drainage, often seen in breast cancer Q. How do you assess pain? ANSWER Using a 0-10 scale and asking location, quality, and duration What causes stridor? Upper airway obstruction What's a sign of preeclampsia? High blood pressure, proteinuria, edema What causes eclampsia? Preeclampsia with seizures What's a normal respiratory rate for adults? 12-20 breaths per minute What is the Snellen chart used for? Assessing visual acuity What is an abnormal mouth finding? Lesions, thrush, ulcers What are signs of lymphedema? Swelling, often in limbs, post‑surgery or radiation Which condition has high intraocular pressure? Glaucoma How do you test cranial nerve VIII? Whisper test, Weber, and Rinne What is an abnormal stool finding? Black/tarry (melena), bright red (hematochezia), clay‑colored What are 3 pressure related factors that contribute to pressure ulcer development? 1. Pressure Intensity 2. Pressure Duration 3. Tissue Tolerance How does pressure lead to tissue ischemia? If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time What occurs is tissue ischemia is left untreated? tissue death Does blanching occur in dark skinned patients? No, blanching does not occur but color, texture and temp may differ from surrounding area What does pressure duration assess? Low and extended pressures - Low pressure over a prolonged time causes tissue damage - Extended pressure occludes blood flow and nutrients causing tissue death What is tissue tolerance? the ability of tissue to endure pressure which is dependent on the integrity of the tissue and supporting structures What are risk factors of pressure injuries? ◦Impaired sensory perception ◦Impaired mobility ◦Alteration in LOC ◦Shear ◦Friction ◦Moisture What should the nurse look for when assessing a pressure injury? Wound location, staging, type and approximate percentage of tissue in wound bed, wound dimensions (sinus tracts and tunneling), exudate description and condition of surrounding skin stage 1 pressure injury Intact skin with nonblanchable redness stage 2 pressure injury partial thickness skin loss involving epidermis, dermis or both and, shallow abrasion or open blister looking stage 3 pressure injury full thickness skin loss extending to SQ, crater looking stage 4 pressure injury full thickness with exposed bone, muscle or tendon and may have eschar What characteristics does stage 3 and 4 pressure injuries share? They may have slough, undermining and tunneling present A nurse states slough is present in a stage 3 pressure injury. What should the student nurse expect to see? A yellow or white, stringy substance attached to wound bed A nurse states eschar is present in a stage 4 pressure injury. What should the student nurse expect to see? brown or black necrotic tissue Unstageable/Unclassified Pressure Ulcer Tissue loss but depth unknown because wound bed is obscured by slough and/or eschar A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its own". What education should the nurse provide? Slough and eschar must be removed by a clinician to determine the stage and in order for healing to occur suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Depth unknown A nurse is assessing a wound and notes the presence of granulation tissue. What should the student nurse expect to see? Red, moist tissue which indicates progression toward healing What should the nurse document when assessing exudate? Amount, color, consistency and odor The student nurse sees an excess amount of exudate in the wound bed. What does this indicate? The presence of infection What should the nurse look for when assessing the periwound area? Why is it important? Redness, warmth, signs of maceration and pain - presence of any of these factors indicates wound deterioration Why is wound classification important? Allows a nurse to understand the risks associated with a wound and implications for healing How does a partial thickness wound heal? Heals by regeneration How does a full thickness would heal? Heals by forming new tissue which takes longer What are the three components involved in the healing process of a partial thickness wound? Inflammatory response, epithelial proliferation and migration, and reestablishment of epidermal layers A patient states keeping his wound exposed to air while allow his wound to heal quickly. What education should the nurse provide to the patient? Wounds heal faster in moist environments because epidermal cells only migrate across moist surfaces. Reestablishment of the epidermal layers New epithelium is only a few cells thick. Cells slowly reestablish normal thickness and appear as dry, pink tissue What are the four stages involved in the healing process of a full thickness wound? Hemostasis, inflammation, proliferation and maturation Primary intention healing The skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly, with minimal scar formation, as long as infection and secondary breakdown are prevented Secondary infection healing Wound is left open until it becomes filed by scar tissue. It takes longer for a wound to heal by secondary intention increasing the chance of infection hemorrhage bleeding from a wound site is normal during and immediately after initial trauma A nurse suspects internal bleeding. How would the nurses assess the patient to confirm her findings? By assessing for distention or swelling of the affected body part, change in type and amount of drainage from a surgical drain r signs of hypovolemic shock Hematoma localized collection of blood underneath the tissue dihiscence partial or total separation of wound layers Evisceration protrusion of visceral organs through a wound opening What is the second most common health care associated infection? wound infection What are the signs and symptoms of wound infection? Fever, tenderness and pain at wound site Elevated WBC count Wound edges appear inflamed Drainage may be present: odorous and purulent (yellow, green, or brown) A student nurse is asked to perform a risk assessment of pressure ulcers on patient. How should the nurse determine the patient's risk? Using the Braden scale. Lower numbers indicates the patient is at a high risk for skin breakdown. What are the 6 components of the Braden Scale? sensory perception, moisture, activity, mobility, nutrition, friction/shear what did the Centers of Medicare and Medicaid Services (CMS) implement to help improve quality of care in regards to pressure ulcers? Hospitals no longer receive additional reimbursement for care related to stage 3 and 4 pressure ulcers that occur during hospitalizations Why is important for the admitting nurse to observe ALL areas of skin? Due to the CMS implements. So if the nurse misses an ulcer, the hospital will not be paid for the cost to care for it. What factors influence pressure ulcer formation and wound healing? ◦Nutrition ◦Tissue perfusion ◦Infection ◦Age ◦Psychosocial impact of wounds How many calories does a patient need to consume a day to maintain skin and wound healing? Patients need 1500 kcal/day How does tissue perfusion affect healing? Tissue perfusion occurs when tissue oxygenation fuels cellular function. Which patients are at risk for poor tissue perfusion? Patients who are in shock and who have diabetes mellitus What should be included in the assessment of pressure ulcer risk? ◦Predictive measures ◦Mobility ◦Nutritional status ◦Body fluids ◦Pain serous drainage clear, watery plasma sanguineous drainage containing or mixed with blood serosanginous drainage blood and serum red-pink purulent drainage comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria A nurse is assessing a surgical wound. While palpating the wound edges, the nurse feels extreme tenderness. What does this finding indicate? Excessive tenderness indicates infection The nurse is caring for a patient with a wound. What should be taken into consideration when planning interventions? ◦Risk for pressure ulcers ◦Type and severity of the wound ◦Presence of complications What is a nurse's major priority while providing wound care? Promotion of wound healing The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges are approximated What are the three major areas of nursing intervention for prevention of pressure ulcers? Skin care and management of incontinence; mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces; and education What are components of wound management? ◦Debridement ◦Education ◦Nutritional status ◦Protein status ◦Hemoglobin debridement Removal of nonviable, necrotic tissue; Methods include mechanical, autolytic, chemical, and sharp/surgical What are first aid interventions for traumatic wounds stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury. A patient is brought to the ER for a puncture wound. What interventions should the nurse implement? Allowing it to bleed to remove dirt and other contaminants such as saliva from a dog bite A patient is brought to the ER for a wound with a penetrating object. What interventions should the nurse implement? Do not remove the object. The presence of the object provides pressure and controls some bleeding When removing sutures, what should the nurse consider when pulling the suture? NEVER pull the visible portion of a suture through underlying tissues. Sutures on the surface of the skin harbor microorganisms and debris What should the nurse assess for before applying heat or cold therapies? Assess for temperature tolerance and skin integrity What are the local effects of heat application? Improved blood flow. However, if heat is applied for +1 hrs, reflex vasoconstriction occurs to control heat loss from the area What are the local effects of cold application? Diminishes swelling and pain but prolonged exposure results in reflex vasodilation What factors influence heat and cold tolerance? ◦Exposure time ◦Exposed skin ◦Temperature ◦Age ◦Perception of sensory stimuli What are the different types of heat and cold therapies? ◦Choice of moist or dry ◦Warm, moist compresses ◦Warm soaks ◦Sitz baths ◦Commercial hot and cold packs ◦Cold, moist, and dry compresses ◦Cold soaks ◦Ice bags or collars What is the purpose of dressings? ◦Protects from microorganisms ◦Aids in hemostasis ◦Promotes healing by absorbing drainage or debriding a wound ◦Supports wound site ◦Promotes thermal insulation ◦Provides a moist environment What type of dressing would the nurse use for wound healing by secondary intention? Dressing that supports a moist wound environment What equipment/supplies can be used to secure wound dressing? Tape, ties and binders Which type of wound requires sterile technique? Surgical wounds requires sterile technique to avoid introducing microorganisms into a healing wound What information does the nurse need to know before changing a wound dressing? ◦Know type of dressing, placement of drains, and equipment needed. How should the nurse prepare for a dressing change? Review previous wound assessments, evaluate pain and administer analgesics 30 mins prior if needed, describe procedure steps to lessen patient anxiety, gather all supplies, recognize normal signs of healing and answer questions about the procedure or wound What is the first step in packing a wound? assess its size, depth, and shape Why should a nurse avoid overpacking a wound? Overpacking causes pressure on the tissue in the wound bed negative pressure wound therapy (NPWT) application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid Vacuum-assisted closure (V.A.C.) device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together When should NPWT be used? To treat acute and chronic wounds What are the different types of dressing? ◦Gauze ◦Transparent film ◦Hydrocolloid ◦Hydrogel ◦Foam ◦Composite What dressing technique should the nurse use to avoid causing damage to the periwound skin? Avoid dressing techniques that cause excessive moisture What is the purpose of self adhesive, transparent film? Traps moisture over a wound providing a moist environment Hydrocolloid dressing Forms gel as wound exudate is absorbed and maintains a moist healing environment; supports healing in clean granulating wounds and autolytically deride necrotic wounds Hydrogel dressing gauze or sheet dressings impregnated with water or glycerin based amorphous gel; hydrates wounds and absorbs small amounts of exudate What type of wounds should a nurse use hydrogel dressing? partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin. foam and alginate dressings wounds w large amounts of exudate and that need packing; used around drainage tubes to absorb drainage calcium alginate dressings highly absorbent dressing that forms a soft gel when in contact with wound fluid and does not cause trauma when removed from the wound composite dressings Combine two different dressing types into one dressing A patient developed a pressure injury that was deep with the presence of exudates. Which type of dressing would the nurse use? Hydrogel A patient is admitted for a burn injury and is experiencing moderate drainage fluid. Which type of dressing would the nurse use? Calcium alginate A nurse is going to perform a dressing change and the patient mentions her pain level is 5/10. How should the nurse proceed? Administer analgesic medications 30 to 60 mins before dressing changes What comfort measures should be taken for dressing changes ◦Administer analgesic medications 30 to 60 minutes before dressing changes ◦Carefully remove tape ◦Gently clean wound edges ◦Carefully manipulate dressings and drains to minimize stress on sensitive tissues ◦Turn and position patient carefully Laceration a deep cut or tear in skin Abrasion the process of scraping or wearing away contusion a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise What are three important principles when cleaning an incision or the periwound skin? ◦Clean from least contaminated to the surrounding skin ◦Use gentle friction ◦When irrigating, allow the solution to flow from the least to most contaminated area How should a nurse clean a drain site? By cleaning around the drain moving in a circular rotation How would a nurse perform irrigation on a open wound? Requires sterile technique, use a 35 mL syringe w/ a 19 gauge soft angiocatheter. Never get close the wound opening with the syringe to avoid the introduction of irrigating fluid into a closed space Which way should fluid flow during wound irrigation? The fluid should flow directly into the wound and not over a contaminated area before entering the wound when drainage interferes with healing, ___________ is achieved by using a drain alone or a drainage tube with continuous suction evacuation What is the purpose of bandages and binders? creating pressure over a body part, immobilizing a body part, supporting a wound, reducing or preventing edema, securing a splint and securing dressing Before applying a bandage or binder, what should the nurse assess? Inspect the skin for abrasion, edema or discoloration What should the nurse frequently assess for apply applying a bandage? Assess, document and immediately report changes in circulation, skin integrity, comfort level, temperature, sensation changes and body function Critical thinking the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process What are characteristics of a critical thinker Open-minded, continual inquiry and perseverance Recognition of an issue, analysis of related information and formation of conclusions Imagination and exploration of alternatives, consideration of ethical principles and informed decision making What are the levels of critical thinking in nursing? Basic, complex and commitment Basic level of critical thinking The learner trusts that experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles. Complex critical thinker begin to separate themselves form authorities. Analyze and examine choices more independently. look beyond expert opinion. Weighs benefits and risks of decisions Commitment level of critical thinking Anticipate the need to make choices without assistance from others, accountability What are the five steps of the scientific method? identify the problem, collect data, formulate a question or hypothesis, test the question or hypothesis evaluate results of the test or study problem solving Evaluating the solution over time, identifying possible solutions, and trying a solution over time to make sure that it is effective Diagnostic reasoning analytical process for determining a patient's health problems clinical decision making makes a decision that identifies the problem, reducing the severity of the problem or resolving the problem completely What are the components of a critical thinking model for clinical decision making? Competence Specific knowledge base Experience The nursing process competency Attitudes for critical thinking Standards for critical thinking concept mapping A visual representation of patient problems and interventions that illustrates an interrelationship and leads to a nursing diagnosis During stressful situations, what is disrupted due to continued SNS stimulation? Autonomic control of decision making Error detection Speech Memory Emotions Assessment The gathering and analysis of information about the patient's health status Diagnosis Clinical judgements from the assessment to identify the patient's response to health problems Plan setting goals and expected outcomes for your care and selecting interventions individualized to each patient's diagnosis Implement Involves performing the planned interventions Evaluation evaluate the patient's response and determine whether the interventions were effective What is the purpose of the nursing process? to diagnose and treat human responses to actual or potential health problems What are the two stages of assessment? 1. Collection and verification of data 2. Analysis of data A nurse states that they gathered the assessment information from a primary source. How did the nurse obtain the information? From the patient A nurse states that they gathered the assessment information from a secondary source. How did the nurse obtain the information? From family, HCP and medical records Cue information obtained through use of senses Inference your judgement or interpretation of cues Patient centered interview conducted during a nursing history Periodic assessment Conducted during ongoing contact with patients Physical examination Conducted during a nursing history and at any time a patient presents a symptom What are the foundation for creating nurse-patient relationships? •Trust building •Presence •Rounding motivational interviewing used often in counseling that allows you to become a helper in the change process effective communication requires courtesy, comfort, connection, and confirmation Interview Preparation Review medical records. Were problems identified that perhaps need clarification or follow-up? Does the patient's admitting diagnosis or other diagnoses suggest lines of questions for you to ask? Hand-off information may frame a clinical problem about which you want to learn more. What are the phases of an interview? Orientation/setting an agenda Working phase - collecting assessment or nursing health history Terminating an interview How should a nurse terminate an interview? Summarize discussion and check for accuracy. Give clue that the interview is coming to an end. Tell patient when you will return to provide care During an interview, what components of the patient's health history should the nurse learn about? Biographical information, patient expectations, reason for seeking health care, present illness or health concerns, health history, family history, psychosocial history, spiritual health, ROS What cultural considerations does should the nurse have when caring for patients? Be respectful and understand the differences, have a genuine curiosity, avoid making stereotypes, do not make assumptions and it you are unsure about what a patient is saying, ask for clarification What types of questions would the nurse to assess a patient's psychosocial history? Support system? Spouse? Children? Friends? Family members? Stress coping mechanisms? diagnostic and laboratory data Results provide further explanation of alterations or problems identified during the health history and physical examination Interpreting and validating assessment data Ensures collection of complete database Leads to second step of nursing process data documentation Use clear, concise appropriate terminology Becomes baseline for care How should a nurse document subjective data? Record any subjective information by using quotation marks What are the three types of nursing diagnoses? Problem-focused, risk diagnosis and health promotion Problem focused diagnosis identify an undesirable human response to existing problems or concerns of a patient; supported with defining characteristics Related factor an etiological or causative factor for the diagnosis; not a cause-and-effect statement risk diagnosis Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication; contains risk factors such as environmental, physiological, psychological, genetic or chemical elements Health promotion diagnosis Identify the desire or motivation to improve health status through a positive behavioral change Data cluster a set of cues, the signs or symptoms gathered during assessment; compared with standards to reach a conclusion about a patient's response to a health problem Clinical criterion an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion NANDA-I classification Provides the standards for the patterns of data for each nursing diagnosis; standards are the defining characteristics or risk factors diagnostic label the name of the nursing diagnosis as approved by NANDA-I; describes the essence of a patient's response to health conditions in as few words as possible Most settings use a two part format in labeling which types of nursing diagnoses? Health promotion and problem focused What is included in a three part nursing diagnosis? Problem Etiology or related factor Symptoms or defining characteristics When does diagnostic errors occur? During data collection, clustering, analysis and interpretation of data, and diagnostic statement What does planning nursing care involve? Setting priorities based on patient diagnoses and collaborative problems Identifying patient-centered goals and expected outcomes Prescribing nursing interventions appropriate for each diagnosis High priority nursing diagnoses Emergent; if untreated will result in harm to a patient intermediate priority nursing diagnoses nonemergent, nonlife-threatening needs Low priority nursing diagnoses affect that patients future well being, not always directly related to specific illness or prognosis What should the nurse consider when determining the priority of the nursing diagnoses? Maslow's hierarchy of needs, always assign priority on the basis of good nursing judgement and avoid classifying only physiological nursing diagnoses as high priority What are examples of high priority nursing diagnoses? Those related to airway status, circulation, safety and pain Priority setting begins when you identify and prioritize a patient's main diagnosis and then prioritize the specific nursing intervention planned to achieve desired goals and outcomes What should a nurse do if ethical issues makes priorities less clear? Have an open discussion with patient, family, and other HCP When should the nurse review priorities? Each time you see the patient Patient centered goal Outcomes and goals reflect the patient behavior and responses expected as a result of nursing interventions Nursing Outcomes Classification (NOC) Resource that can be used in selecting goals and outcomes for your patients. For each NANDA-I nursing diagnosis there are multiple NOC suggested outcomes What is required for patients to participate in goal setting? Be alert and have some degree of independence in completing activities of daily living, problem solving and decision making What does mutual goal setting include? Includes the patient, family when appropriate in prioritizing the goals of care and developing a plan of action What should each goal and outcome address? It should address only one behavior, perception or physiological response Short term goal An objective behavior or response that you expect a patient to achieve in a short time, usually less than a week Long term goals An objective behavior or response that you expect a patient to achieve over a longer period usually over several days A patient is suffering from SOB. What goal statement would the nurse document? The patient will breath unlabored at 14-18 per minutes by the end of the shift What does the nurse need to know when planning nursing care? Know the scientific rationale for the intervention Possess the necessary psychomotor and interpersonal skills Be able to function within a setting to use health care resources effectively SMART goals Specific, Measurable, Attainable, Realistic, Timely nurse-initiated intervention Independent -action that a nurse initiates that requires no order; such interventions benefits a patient in a predicted way related to nursing diagnoses and patient goals Health care provider initiated interventions Dependent—Require an order from a physician or other health care professional collaborative interventions Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes. The NIC model includes three levels: domains, classes, and interventions for ease of use What does a five column format for student care plans include? (1) assessment data relevant to corresponding diagnosis, (2) goals/outcomes identified for the patient, (3) implementation of the plan of care, (4) a scientific rationale (the reason that you chose a specific nursing action, based on supporting evidence), and (5) a section to evaluate your care. In the implementation section, you select interventions appropriate for the patient. Would a nurse design a care plan in community based settings? •(1) educate the patient/family about necessary care techniques and precautions, •(2) teach the patient/family how to integrate care within family activities, and • (3) guide the patient/family on how to assume a greater percentage of care over time. Direct care interventions Treatments nurses provide through interaction with patients Indirect care interventions Treatments performed away from the patient but on behalf of the patient or group of patients Clinical practice guidelines and protocols a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations Standing orders a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems Nursing Interventions Classification (NIC) interventions Differentiates nursing practice from that of other health care disciplines by offering a language that nurses use to describe a set of actions in delivering nursing care Standards of Practice Used as evidence of the standard of care that registered nurses (RNs) provide their patients Five preparatory activities for the implementation process: Reassessing the patient, reviewing and revising that existing nursing care plan, organizing resources and care delivery anticipating and preventing complication and implementing nursing interventions What should occur during the initial phase of implementation? Reassess that patient to be sure that you have selected appropriate interventions. The reassessment helps you decide if the proposed nursing actions are still appropriate for patient's level of wellness Cognitive skills includes critical thinking and decision making skills described earlier. Always use good judgement and sound clinical decision making when performing any intervention interpersonal skills develop a trusting relationship, express a level of caring and communicate clearly with patients and families Psychomotor skills require the integration of cognitive and motor activities. For example, when giving an injection you need to understand anatomy and pharmacology (cognitive) and use good coordination and precision to administer the injection correctly (motor) how to maintain fluid balance fluid intake must equal fluid output Fluid output normally occurs through which four organs: Skin, lungs, GI tract and kidney What factors affect bowel elimination? Age Diet Fluid intake Physical activity Psychological factors Personal habits Position during defecation Pain Pregnancy Surgery and anesthesia Medications Diagnostic tests What is the recommended fluid intake for each gender? 3 L per day for men and 2.2 L per day for women ileus temporary loss of peristalsis with resulting obstruction of the intestines how does physical activity affect BM? promotes peristalsis How does prolonged emotional stress affect bowel elimination? Digestive process is accelerated and peristalsis is increased Constipation infrequent stool and/or hard, dry, small stools that are difficult to eliminate; a symptom not disease fecal impaction Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel diarrhea An increase in the number of stools and the passage of liquid, unformed feces incontinence Inability to control passage of feces and gas to the anus flatulence Accumulation of gas in the intestines causing the walls to stretch hemorrhoids Dilated, engorged veins in the lining of the rectum What are causes of hemorrhoids? Diarrhea Constipation Pregnancy Prolong sitting and standing Cirrhosis of the Liver stoma Temporary or permanent artificial opening in the abdominal wall What is the stool consistency in a sigmoid colostomy? More formed stool location of sigmoid colon left lower quadrant location of transverse colon positioned horizontally over the small intestine What is the stool consistency in a transverse colostomy? Thick liquid to soft consistency location of ileum RLQ What is the stool consistency in a ileostomy? Liquid stool bc it leaves body before it enter colon loop colostomy Surgeon pulls loop of intestine (ileum or colon) into abdomen and it has 2 opening through the stoma •Proximal: drains fecal effluent •Distal: drains mucous End colostomy Piece of intestine brought out through surgical opening and turned down like a turtleneck A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: constipation Pouching ostomies An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. What nutritional considerations is associated with ostomy care? •Consume low fiber for the first weeks •Eat slowly and chew food completely •Drink 10-12 glasses of water daily •Patient may choose to avoid gassy food What can occur is the skin is constantly exposed to liquid stool? Skin breakdown which is why ostomy care requires meticulous skin care Ileoanal pouch anastomosis •Removes colon, creates pouch from end of small intestine and attach pouch to anus •Continent of stool because stool evacuated via anus continent ileostomy •Creates pouch in small intestine created with a valve that can be drained when patient places large catheter into stoma •Empties pouch several times a day •Rarely done antegrade continence enema (ACE) •Done in children with fecal soiling associated with neuropathic ot structural abnormalities •Continence valves created in intestine so tube can be inserted, and enema is given What are factors for elimination? Elimination pattern Surgery or illness Stool characteristics Medications Routines Emotional state Bowel diversions Exercise Appetite changes Pain or discomfort Diet history Social history Daily fluid intake Mobility and dexterity What assessment tool would the nurse use to determine stool characteristics? Bristol Stool Form Scale What should be included in physical assessment •Mouth, abdomen, and rectum •Inspect for lesions, discoloration, inflammation and hemorrhoids What laboratory test can be ordered for bowel assessment? Fecal specimens such as the fecal occult blood test (FOBT) What diagnostic examination can be ordered to assess the GI system? Direct visualization (endoscopy), indirect visualization (Anorectal manometry, XR, US, CT, MRIs) and boweal preparation What are examples of risks for constipation? Opiate containing meds Decreased fiber intake Decreased fluid intake Recent anesthesia Stress Inactivity (immobility) Eating a large amount of dairy products What should the nurse focus on when creating goals and outcomes for bowel elimination? •Incorporate elimination habits or routines •Reinforce routines that promote health •Consider preexisting concerns What can be implemented for health promotion related to bowel elimination? Routine, screening for colorectal cancer and promotion of normal defecation (sitting position, privacy and positioning on bedpan) How should a nurse position a patient for a bedpan? Prevent muscle strain and discomfort Elevate head of the bed 30 to 45 degrees Wear gloves when handling bedpans If immobile, rolls onto bedpan Enema instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis oil retention enema lubricates and softens the feces in the rectum and colon carminative enema provide relief from gaseous distention Digital removal of stool Use if enemas fail to remove an impaction. This is the last resort for constipation. A health care provider's order is necessary to remove an impaction To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: mass colonic peristalsis occurs at this time. How would a nurse evaluate the effective of the care plan for bowel elimination? Develop a therapeutic relationship Evaluate a patient's level of knowledge Determine the extent to which the patient accomplishes normal defecation Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health Which terms described the process of bladder emptying? Urination, micturition and voiding micturition complex interaction between the bladder, urinary sphincter and CNS How much fluid can the bladder hold? 400-600 mL urinary retention •An accumulation of urine due to the inability of the bladder to empty urinary tract infection usually caused by E. Coli urinary incontinence Involuntary leakage of urine postvoid residual (PVR) the amount of urine remaining in the bladder immediately after voiding overflow incotinence associated w/ chronic retention of urine; pressure in the bladder exceeds the ability of the sphincter to prevent the passage of urine and the patient will dribble urine Catheter associated UTI associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs Stress UI involuntary loss of urine associated with effort or exertion on sneezing or coughing overactive bladder urinary urgency, often accompanied by increased urinary frequency and nocturia Functional UI caused by factors that prohibit or interfere with a patient's access to the toilet or other acceptable receptacle for urine A health care provider may suspect that a patient is experiencing urinary retention when the patient has small amount of urine voided 2-3 times per hour What growth and developmental considerations should the nurse keep in mind in regards to urine elimination? Determine the patient's ability to control the act of urination across life span and pregnancy causes changes to urinary tract What psychosocial implications considerations should the nurse keep in mind in regards to urine elimination? micturition should be private and incontinence can be devastating to self-image and self-esteem Successful critical thinking requires a synthesis of •Knowledge •Experience •Information gathered from patients •Critical thinking attitudes •Intellectual and professional standards