NFDN 2003 MIDTERM STUDY GUIDE FINAL EXAM QUESTIONS AND ANSWERS 100% PASS

NFDN 2003 MIDTERM STUDY GUIDE FINAL EXAM QUESTIONS AND ANSWERS 100% PASS “What does SBAR stand for? - CORRECT ANSWER Situation Background Assessment Recommendation" "SBAR: Situation - CORRECT ANSWER a concise statement of the problem" "SBAR: Background - CORRECT ANSWER pertinent and brief info related to the situation" "SBAR:Assessment - CORRECT ANSWER Analysis and consideration of options (what you found/think)" "SBAR: Recommendation - CORRECT ANSWER action requested/recommended — what you want" "_______ can reverse decreased RR due to opioids - CORRECT ANSWER Narcan" "Which best describes continuous bladder irrigation (CBi therapy) - CORRECT ANSWER Removes clots after prostate or bladder surgery" "What size is the NS bag used for continuous bladder irrigation? - CORRECT ANSWER 3L (3000 ml)" "Proper method of calculating urine output during continuous bladder irrigation? - CORRECT ANSWER Calculate total output minus vol of irrigation fluid used" "Can infection travel from foley bag to the bladder? - CORRECT ANSWER yes" "A bronchoscopy permits visualization of what? - CORRECT ANSWER larynx, trachea, bronchi" "Blood accumulation in the pleural space - CORRECT ANSWER hemothorax" "fluid in the pleural space is called - CORRECT ANSWER pleural effusion" "Air that develops in the pleural space is termed - CORRECT ANSWER pneumothorax" "What kind of pressure is found in pleural space - CORRECT ANSWER negative" "Heavy sedation can cause a decrease in oxygen after surgery - CORRECT ANSWER true" "Emphysema results in - CORRECT ANSWER alveolar destruction" "Symptoms of COPD - CORRECT ANSWER History of progressive shortness of breath, excessive cough, and sputum production. Patients with predominantly emphysematous COPD may have dry cough and weight loss" "What is COPD? - CORRECT ANSWER chronic bronchitis, emphysema, and hyperactive airway dz -doesn't tend to get better" "Patients w COPD spo2 is usually between - CORRECT ANSWER 85-90" "abbreviation to record oxygen saturation and pulse - CORRECT ANSWER SPO2%" "Simple face mask - CORRECT ANSWER 6-8 L/min" "Hypovolemic shock - CORRECT ANSWER shock resulting from blood or fluid loss" "What isn't a nanda nursing diagnosis related to respiration - CORRECT ANSWER impaired respiration pattern" "Epidermis - CORRECT ANSWER several layers of epithelial cells" "dermis - CORRECT ANSWER inner layer of skin that provides tensile, strength, mechanical support, and protection to underlying muscles, bones, and organs)" "subcutaneous fatty tissue - CORRECT ANSWER (fat, blood vessels, connective tissue) regulates body and skin temperature and stores energy in the form of fat" "wounds - CORRECT ANSWER type of lesion, disruption of normal anatomical structure turn and function, classified by cause and descriptions" "Wounds are classified as either - CORRECT ANSWER open or closed" "open wound - CORRECT ANSWER break in the scene caused by knife, scalpel, bullet, accident" "closed wound - CORRECT ANSWER skin intact, trauma with blunt object" "acute wound - CORRECT ANSWER acute incident of skin breakdown" "chronic wound - CORRECT ANSWER ongoing skim integrity issues" "example of chronic wound - CORRECT ANSWER diabetes ulcer" "wound depth - CORRECT ANSWER deflects amount of tissue damage from break in skin and trauma to surrounding tissue, blood supply to site of injury" "superficial depth wound - CORRECT ANSWER Depressed lesion having depth less than 3mm - involves surface layers of skin or body" "deep depth wound - CORRECT ANSWER refers to deep layers of the skin, penetrating internal body organs" "Clean wound - CORRECT ANSWER created with clean instrumented and contains little or no debris ie. surgical wound" "pressure ulcer stages - CORRECT ANSWER Stage 1: non-blanchable redness Stage 2: partial thickness loss Stage 3: full thickness loss, w/o undermining, see fat Stage 4: 3+ undermining, see tendon, muscle" "Atelectasis - CORRECT ANSWER collapsed lung" "Pleural effusion - CORRECT ANSWER abnormal accumulation of fluid in the pleural space" "Hemothorax - CORRECT ANSWER blood in the pleural cavity" "pneumothorax - CORRECT ANSWER air in the pleural cavity" "Pneumoconiosis - CORRECT ANSWER abnormal condition of dust in the lungs" "Pneumonia - CORRECT ANSWER inflammation of the lungs" "Asthma - CORRECT ANSWER episodes of breathing difficulty due to narrowed or obstructed airways" "Emphysema - CORRECT ANSWER a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness." "Tuberculosis - CORRECT ANSWER chronic lung inflammation" "Usually caused by trauma or rupture from an inflammatory process like pneumonia or TB - CORRECT ANSWER pneuthorax" "phases of wound healing - CORRECT ANSWER inflammatory proliferative maturation (remodelling phase)" "inflammatory phase of wound healing - CORRECT ANSWER edema, erythema, heat and pain at wound sign (classic s&s of infection) - blood clot develops forms a fibrin matrix scab forms - prevents contamination histamine is released and causes increase in blood and nutrients to the wound neutrophils move into wound and ingest debris and bacteria macrophages clean there wound by phagocytosis and prepare it for healing" "proliferative phase of wound healing - CORRECT ANSWER lasts 3-24 days granulation tissue fills wound bed, contraction (inward movement of the edges) of the wound and resurfacing of the wound by epithelialization wound closes by epithelialization **EPITHELIAL CELLS CAN ONLY MIGRATE ACROSS A MOIST ENVIRONENT THEREFORE WOUND NEEDS TO BE MOIST TO FACILITATE WOUND CLOSURE" "infection - CORRECT ANSWER watch for fever, drainage, swelling, tenderness, increased WBC, general malaise" "inflammation - CORRECT ANSWER edema, heat, pain" "What factors affect skin integrity - CORRECT ANSWER LIFESTYLE FACTORS: Hygiene, nutrition and fluid status, exercise, smoking substance abuse DEVELOPEMENTAL FACTORS: skin disease PHYSIOLOGICAL FACTORS: age, incontinence, hypoxemia, diabetes, infections, neurological impairment, medications" "Incontinence with skin integrity - CORRECT ANSWER contamination of wound from urine/stool. - bacteria" "Hypoxemia with skin integrity - CORRECT ANSWER impaired blood flow and oxygen = decreased nutrients to wound = decreased healing time" "Diabetes and skin integrity - CORRECT ANSWER may have vascular disease hyperglycaemia inhibits leucocyte activity and infection can set in - promotes growth of yeast and fungi" "medications commonly affecting skin integrity - CORRECT ANSWER steroids, antinflammatory meds, chemo" "environment and skin integrity - CORRECT ANSWER dryness, mess, perspiration, incontinence - skin becomes wet, macerated and softened can lead to breakdown" "CBC - CORRECT ANSWER Complete Blood Count hematocrit tells number of circulkating cells hemoglobin tells oxygen carrying capacity of the blood if hemoglobin is low = hematocrit is low WBC increase if infection present RBC carries Hgb" "Pulmonary function diagnostic test - CORRECT ANSWER to assess respiratory function (amount of air moving in and out of the lungs) - tests include: measurement of lung volumes, ventilatory function and mechanics of breathing, diffusion, gas exchange" "ABGS diagnostic test - CORRECT ANSWER measures blood pH and arterial O2 and CO2 levels" "Pulse oximetry - CORRECT ANSWER oxygen saturation of hemoglobin should be above 90%" "Sputum cultures - CORRECT ANSWER culture bugs too test for sensitivity could be TB" "Interventions to clear the airways - CORRECT ANSWER DEEP BREATHING AND COUGHING INCENTIVE SPIROMETRY POSITIONING INHALED BRONCHODILATORS SUCTIONING CHEST PHYSCI SOB: ELEVATE HOB, APPLY AND CHECK O2, DB AND C, GET HELP" "Assessment of chest tubese - CORRECT ANSWER tidying in water seal noted with breathing no tidying - lungs expanded or tubing is kinked intermittent bubbling is ooko **NO EXCESSIVE BUBBLING = INDICATES LEAK *notify doc if greater than 100ml/hr never clamp tubing - if going for tests may discontinue suction but leave suction vent open" "Urinalysis and culture sensitivity - CORRECT ANSWER shows kidney function helps diagnose disease determines if bacteria are present and if so, what kinda ndhowmuch" "Nursing interventions to reduce risk - CORRECT ANSWER monitor client cleanse skin mooisturizing providing nutrition positioning client every 2 hours encouraging client to maintain ADLS teaching" "Interventions to promote wound healing - CORRECT ANSWER debridement = removal of dirt foreign matter dead tissue sharp-removal of necrotic tissue using scalpel scissors laser mechanical-apply mechanical force like scrubbing (can lead to removal of healthy tissue as its non selective) enzymatic-enzymes break down necrotic tissues without targeting viable tissue autolytic-body ability to digest devitalized tissue - applying moisture retentive dressing to woundd bed creating occlusive seal and macrophages and neutrophils eliminates the necrotic tissue" "types of wound drains - CORRECT ANSWER open/closed & passive/active" "hemovac - CORRECT ANSWER self suction and collection of drainage often secured with suture" "penrose - CORRECT ANSWER open flat tube (passive)" "Jackson-pratt - CORRECT ANSWER closed bulb self-suction and collection of drainage - secured w suture" "drain care to promote healing - CORRECT ANSWER maintain patency secure drain monitor drainage for color, consistency and quanitity empty fluid from drain- measure and record maintain dressing around drain" "Non-pharmalogical interventions for wound healing - CORRECT ANSWER apply heat or cold ice pack on for 20 min and off warm pack, warm blanket" "factors that impair wound healing - CORRECT ANSWER infection malnutrition age obesity impaired oxygenation smoking drugs vascular disease radiation wound stres" "alginates - CORRECT ANSWER absorbs excessive moisture - used when large amounts of drainage" "foams - CORRECT ANSWER absorbs exudates and debris while maintaining mooisture" "wound vac - CORRECT ANSWER assists in wound closure" "Cleansing a surgical wound - CORRECT ANSWER cleanse least contaminated to moist (wound to surface edge) gentle friction when irrigating allow solution to flow from least contamination to most clean to dirtty" "restrictive respiratory disorder - CORRECT ANSWER restrictive to lung expansion or obstructive to movement of air in/out of lungs reduced lung volume" "obstructive respiratory disorder - CORRECT ANSWER decreased size of airway; increased resistance, decreased ability to expand lungs" "hypoxemia - CORRECT ANSWER decrease in arterial oxygen in the blood - changes in mental status, dyspnea, increase BP, changes in HR, dysthymia, central cyanosis (late sign)" "hypoxia - CORRECT ANSWER decrease in oxygen supply to the tissues" "inadequate ventilation - CORRECT ANSWER anxiety restlessness or confusion use of accessory muscles for breahing change in cognition hypoxia hypoxemia" "factors affecting respiration - CORRECT ANSWER lifestyle environmental developemenmtal physiological any condition that might affect cardiovascular system directly affects bodies ability to meet oxygen demands" "absent breath sounds - CORRECT ANSWER could mean consolidation in that area (pneumonia or mass)" "crackles - CORRECT ANSWER auscultated in right and left lung bases; caused by random sudden re-inflatino of groups of alveoli" "fine crackles - CORRECT ANSWER high pitched, fine, short, end of respiration not cleared with coughing sounds like rubbing hair together" "coarse crackles - CORRECT ANSWER loud, bubbly sounds during inspiration, not cleared with coughing" "wheezes - CORRECT ANSWER heard over all lung fields; high velocity air flow through severely narrowed bronchus; high. pitched musical" "pleural friction rub - CORRECT ANSWER heard over. anterior. lateral lung field; caused by inflamed pleura" "honcho - CORRECT ANSWER heard over trachea and bronchi" "stress incontinence - CORRECT ANSWER dribbling of urine with increased abdominal pressure" "urge incontinence - CORRECT ANSWER sudden desire to urinate" "functional incontinence - CORRECT ANSWER unpredictable, involuntary passage of urine in the pre scene of normal bladder and uretheral function" "reflex urinary incontinence - CORRECT ANSWER unexpected voiding without awareness of need to void" "total incontinence - CORRECT ANSWER inability to control urination - due to cognitive impairment or non functional urinary sphincter" "urgency - CORRECT ANSWER feeling need to urinate immmediately" "dysuria - CORRECT ANSWER pain or difficult urination" "hesitancy - CORRECT ANSWER difficulty initiating urination" "polyuria - CORRECT ANSWER voiding large amounts of urine" "oliguria - CORRECT ANSWER DECREASED URINARY OUTPUT COMPARED TO INTAKE - MOST COMMON CLINICAL SITUATION SEEN IN ACUTE RENAL FAILURE" "ANURIA - CORRECT ANSWER SUPPRESSION OR ARREST OF URINE - OBSTRUCTION" "nocturia - CORRECT ANSWER frequent urination at night" "dribbling - CORRECT ANSWER leakage of urine despite voluntary control of urination" "hematuria - CORRECT ANSWER blood in urine" "retention - CORRECT ANSWER accumulation of urine in bladder; unable to empty bladder fully" "residual urine - CORRECT ANSWER volume of urine left in bladder after voiding" "conduit - CORRECT ANSWER channel for the passage of fluid" "ileal conduit - CORRECT ANSWER piece of ileum is resected and used to create a conduit or passage for redirecting urine - bladder damaged or removed so alternative way is created for urine to drain outside of the body" "indwelling catheter (retention/foley) - CORRECT ANSWER continuous bladder drainage, gradual decompression of over distended bladder ballon 2 or 3 lumen" "intermittent caheter - CORRECT ANSWER drains bladder for short periods of time obtain sterile specimen single lumen no balloon" "suprapubic catheter - CORRECT ANSWER continuous drainage inserted above pubic area may or may not have ballooon" "insertion of catheter - CORRECT ANSWER advance catheter additional 5 cm once urine starts to drain" "regional anesthesia - CORRECT ANSWER nerve blocked with local anaesthetic" "spinal anesthesia - CORRECT ANSWER increased risk of headaches" "general anaesthesia - CORRECT ANSWER patient put to sleep with drugs given either by inhalation or IV" What is the purpose of concept maps and clinical critical pathways? - CORRECT ANSWER Care plans that use visualisation to organize the relationship between the interventions and issues involved." "How do clinical pathways and concept maps support clinical decision making for nurses? - CORRECT ANSWER By providing an organized way to provide evidence based nursing care plans and daily interventions." "What are the impacts of hospitalization on the med/surg client's determinants of health? - CORRECT ANSWER loss of income, employment issues, ability to buy nutritional food, stressful and unsafe employment, accessibility to social services, culture and gender Everyone could be struggling, do not assume." "How does infection affect wound healing? - CORRECT ANSWER Prolongs inflammatory phase. Change in volume, odor, viscosity, fever and pain. Purulent.. Never pus." "How does malnutrition affect wound healing? - CORRECT ANSWER Impairs all phases of healing. Protein, carbs, vitamins and minerals. Look at the client's diet." "How does age affect wound healing? - CORRECT ANSWER Alters all phases of healing. Reduce liver functions and slowed inflammatory responses." "How does obesity affect wound healing? - CORRECT ANSWER Fatty tissue will have less adequate blood supply. Observe wounds for infection. Dehiscent (characterized by splitting or bursting open) pops open." "How does smoking affect wound healing? - CORRECT ANSWER Causes excessive clotting. Necrosis/infection." "How do vascular diseases affect wound healing? - CORRECT ANSWER Impaired oxygenation. Prevent and instruct patients to avoid breaks in skin" "What are some pharmacologic processes that promote wound healing? - CORRECT ANSWER antibiotics, antihyperglycemics, vitamins, debridement agents ( silver), antipyretics." "What are some non-pharmacologic processes that can promote wound healing? - CORRECT ANSWER turning patients, promoting ambulation, high protein diet, appropriate and competent wound care, early detection of infection, compression and mobilization, elevation and wound irrigation." "What is an acute wound? - CORRECT ANSWER heal with the first line of treatment. Trauma or surgical wounds." "what is a chronic wound? - CORRECT ANSWER recurring wounds, wounds that are non-healable, wounds that do not respond to the first line treatment, wounds that progress slowly in the healing process, wounds that happened due to underlying chronic disease." "What are the 3 healing intentions? - CORRECT ANSWER Partial, Secondary, and tertiary intention." "What is the healing process for partial intention? - CORRECT ANSWER usually at the 24 hour mark it will clot." "What is the healing process for secondary intention? - CORRECT ANSWER it heals from the bottom up" "What is the healing process for tertiary intention? - CORRECT ANSWER are bringing together 2 opposing granulation surfaces, resulting in deeper wider scar. Deep wounds break down and are sutured later. Higher risk for infection because you are leaving it open, can take weeks to months. Lots of wound contraction." "What is a partial thickness wound and its healing time? - CORRECT ANSWER loss of epidermis and possibly partial loss of dermis. Ex a paper cut. Heating time: left open-6-7 days, covered/moist-4 days" "what is a full-thickness wound and its healing time? - CORRECT ANSWER loss of epidermis and possibly partial loss of dermis. Ex a paper cut. Heating time: left open-6-7 days, covered/moist-4 days" "What is serous wound drainage? - CORRECT ANSWER clear, watery plasma" "What is sangiuneous wound drainage? - CORRECT ANSWER bright red-active blood" "What is serosanguineous wound drainage? - CORRECT ANSWER mixture of plasma and red blood cells; pale and watery" "What is purulent wound drainage? - CORRECT ANSWER thick, yellow, green/tan, and brown" "Which diagnostic tests are used to access wounds? - CORRECT ANSWER Biopsy, Doppler ultrasound, and CT or MRI." "What are some common complications associated with treatment and healing of wounds? - CORRECT ANSWER Dehiscence, diabetics have slow wound healing, chemotherapeutics suppress immune response which will heighten infection risk, malnutrition, age." "What is the technique for collecting wound cultures? - CORRECT ANSWER Clean the wound with normal saline PRIOR to taking the culture. Rotate the swab in 1 cm area with slight pressure ( give analgesic prior if needed). Swab the healthiest looking tissue or take a culture from the sinus tract or undermining Clean the wound with normal saline PRIOR to taking the culture, rotate the swab in 1cm area with slight pressure, swab the healthiest looking tissue OR take a culture from the sinus tract or undermining." "What is COCA? - CORRECT ANSWER Colour, odour, consistency and amount." "What are the 7 principles of the sterile technique? - CORRECT ANSWER -A sterile object remains sterile only when touched by another sterile object. -Only sterile objects may be placed on a sterile field. -A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. -A sterile object or field becomes contaminated by prolonged exposure to air. -When a sterile surface meets/contacts a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. -Fluid flows in the direction of gravity. -The edges of a sterile field or container are considered contaminated." "What is the medical asepsis clean technique? - CORRECT ANSWER Clean gloves Does not have to be "sterile to sterile" Objects may have one "contaminated/ dirty end" and one sterile end. Ex: subcutaneous infections, simple wound dressing." "What is the surgical asepsis sterile technique? - CORRECT ANSWER Sterile Gloves Following the 7 sterile principles Object are either sterile or containment end. Ex: surgical wound dressing, foley catheters, wound vacs." "What is the principles and rationales for wound cleansing? - CORRECT ANSWER closed wound: check physician orders, wipe clean to dirty, follow principles of sterile technique, one gauze per swipe, dry the wound and peri wound, same order you cleansed with a sterile dry gauze." "What is the principles and rationales for wound irrigating? - CORRECT ANSWER used in more complex wounds, but can also be used in closed wounds. Flush with consistent low pressure. Bottle of saline or 30 ml syringe. Fluid flows directly onto the wound, do not irrigate when base cannot be determined, and dry the periwound." "What is the principles and rationale for wound dressings? - CORRECT ANSWER ordered by doctor, nursing responsibility to assess appropriateness, maintain sterility while applying, wrinkles or folds provide a path of entry for microorganisms and should be avoided, use non-adhesive gauze wrap if patient at risk for skin tears due to adhesive, assess for allergies to adhesive." "What is the principles and rationale for a non-adherent contact layer dressing? - CORRECT ANSWER place overtop wound and periwound, can remain on skin while outer layer changed, allows moisture to pass through it. Made with tulle, and infused with petrolatum or silicone." "What is the principles and rationale for soft silicone dressings? - CORRECT ANSWER float above the wound surface, does not interfere with wound healing, used on fungating wounds or wounds with fragile skin, requires an absorbent layer on top." "What is the principles and rationale for hydrocolloid dressings? - CORRECT ANSWER used on wounds with-minimal drainage, no evidence of infection, with slough on wound bed. Shallow deep wounds, autolytic debridement, "liquify slough", does not affect healthy skin, adhesive and occlusive, left on for 5-7 days." "What is the principles and rationale for transparent film dressings? - CORRECT ANSWER used to secure IV's, provides an occlusive barrier-does not allow fluid to escape and can lead to maceration, self adhesive- difficult to remove, do not use on fragile skin, utilize a lateral pull to remove." "What is the principles and rationale for hydrogel dressings? - CORRECT ANSWER helps provide a moist wound environment, promotes autolytic debridement." "What is the principles and rationale for foam dressings? - CORRECT ANSWER non-adhesive or adhesive, comes in a multitude of shapes and sizes, absorbs moderate to large amount of exudate. Left in place for up to 7 days, helps keep peri wound area healthy by wicking moisture away from healthy skin, very commonly used dressings for stage 2 or small 3 pressure ulcers." "What is the principles and rationale for alignate and hydrofiber dressings? - CORRECT ANSWER alginate-manufactured from seaweed, absorbs moderate to large amount of exudate, for partial and full thickness wounds or infected wounds, CAN NOT be used on dry wounds, can be infused with antimicrobial medications such as silver, placed underneath other dressing materials such as gauze, can be packed into wounds." "What is the principles and rationale for wound packing? - CORRECT ANSWER Completed AFTER size, depth, shape and assessment has been completed, packing not required if less than 5cm needed,physician will order what type of material is used to pack the wound. Material must be moistened prior to packing(normal saline or physician ordered solution), entire wound surface to touch part of moist packing, periwound/surrounding skin kept dry, loosely pack undermining and tunneling, do not over pack/tightly pack, amount placed in wound needs to be documented." "What is the principles and rationale for sutures? - CORRECT ANSWER thread or metal used to sew body tissues together, reduces scar formation, controls bleeding, minimal trauma and tension to tissues, types of suturing methods-intermittent, continuous, blanket continuous, retention. superficial(non absorbable) or deep (absorbable), are foreign bodies and may cause local inflammation. Removal:check unit policy on when and what you can remove, assess incision site, cleanse and remove, never pull visible suture through underlying tissue, recleanse and steri-strips or dress as per order, record and report anything out of the ordinary." "What is the principles and rationale for staples? - CORRECT ANSWER metal, place staples on gauze so that you can count after procedure, after removal steri-strip or redress incision Removal:check unit policy, assessment, medicate, gather equipment, cleanse site, remove staples as per unit policy, dress if necessary, record and report anything out of ordinary." "What is the principles and rationale for steri strips? - CORRECT ANSWER clean and dry around wound, peel back package, grasp end of skin enclosure with forceps or gloved hand, start at the middle of the wound, rest of strips should be ⅛ inch apart from one another." "What is priority information when documenting and reporting skin integrity to your team? - CORRECT ANSWER What kind of wound is it. Stage 1 or 2. How long has it been there for, look at previous charting and what it use to look like last dressing change, baseline if it has gotten worse, infection, how painful is it (administer analgesic 30-45 min before)." "What are factors that increase the risk of altered oxygenation? - CORRECT ANSWER Environmental Factors: second hand smoke, poor air quality, mold, asbestos, lack of knowledge for barriers (masks) Behavioural: Smoking, bed rest, sedentary lifestyle Development: Asthma, diabetes, heart disease, renal disease, COPD, pneumonia." "What is an arterial blood gas test used to determine? - CORRECT ANSWER used to determine how well lungs exchange oxygen and carbon dioxide." "What is a pulmonary function test used to determine? - CORRECT ANSWER used as an ongoing test to monitor disease and lung conditions. It is non-invasive. Nurse educated client on test." "What is a tracheal ariway? - CORRECT ANSWER Cuffed trach ( balloon is blocking the rest of the airway. Only air coming through is through the trach), Assess tie but do not change by yourself. High risk for infection and airway injury." "What is a nasotracheal airway? - CORRECT ANSWER alled a nasal trumpet. Use water based lubricant. Measure tip of nose to ear lobe. Flange rests against nasal opening." "What is an endotracheal airway? - CORRECT ANSWER Not in the LPN scope. Requires manual ventilation. Forcing them to breathe in and out. High risk for infection and airway injury." "WHat is an oxymyzer? - CORRECT ANSWER Specialized nasal cannula. Consist of O2 reserve. Can eat with mask on.. More comfortable, cheaper, reduces anxiety, humidification not required." "what is a CPAP and BPAP machine? - CORRECT ANSWER CPAP for life sustaining measures; hard decision, respect wishes, family has the right to remove it." "what is mechanical ventilation? - CORRECT ANSWER Supported by a machine. Invasive (trach/ endotracheal). Non invasive ( face or nasal mask)." "What is end-tital? - CORRECT ANSWER Amount of CO2 in body after expiration 35-45. If it is too high, ventilation is to low.... Ventilating too fast." "What is the PN responsibility when caring for a client with an oraltracheal and nasotracheal suctioning? - CORRECT ANSWER Completed over max of 15 sec. Nose is preferred. Have O2 ready and allow rest between passes." "What is the PN responsibility when caring for a client with - CORRECT ANSWER " "What is the PN responsibility when caring for a client with tracheal suctioning? - CORRECT ANSWER Rotate the catheter while removing. 100-120 pressure. Check facility standards. High risk for bodily fluid contact, creating droplets ( wear PPE)" "What is the PN responsibility when caring for a client with a tracheostomy? - CORRECT ANSWER Use sterile technique for caring and maintaining airway. O2 to be given before suctioning. 10 sec suctioning rule. When changing dressing or ties make sure you have a buddy. Clean skin around the trach site to prevent build up of dried secretions and skin breakdown. Assess and clean the stoma under the face plate." "What is the PN responsibility when caring for a client with chest drainage systems? - CORRECT ANSWER nsure no kinks or clots in tubing. Make sure all tubing is plugged in. Make sure the machine and also suction is turned on. Mark hourly or at the beginning of shift what level the chamber is at. Intermediate bubbling is ok, but do not want continuous. Check dressing to be dry and intact. Keep machine lower than patient (do not attach to bedrail), water rises with inhalation." "What is the nursing process and proper diagnosis when caring for clients with a UTI? - CORRECT ANSWER Confirm a possible UTI by testing a C&S. Second most common bacterial disease. Most commonly found in women. Due to poor hygiene, increasing catheter use" "What are the risk factors for the development of altered skin integrity? - CORRECT ANSWER aging skin, dehydration, poor nutrition, prolonged use of corticosteroids, impaired sensory perception, cognitive impairment, and adhesive dressings." "What are some interpreted assessment findings common to clients with altered oxygenation? - CORRECT ANSWER -SPO2 will be increased, decreased then normal -BP will be altered -difficulty with inspiration/expiration -hypoxemia -hypercapnia" "What are some pharmacologic therapies commonly used for clients with altered oxygenation? - CORRECT ANSWER Inhalers, oxygen masks, corticosteroids," "What are some NON-pharmacologic therapies commonly used for clients with altered oxygenation? - CORRECT ANSWER Sitting upright, deep slow breaths, relaxing" "What is the importance of collab with client, family, and interdesciplincary tesm to optimize client outcomes? - CORRECT ANSWER -increase the pts well being -provides link to personal life to enable more holistic care -POA -can help decrease risk factors/triggers -traditional healing practices consideration -encouraging family presence during invasive proced." "what are the health education needs for a client with oxygenation? - CORRECT ANSWER lifestyle behaviour changes (smoking, 2nd hand exposure, adequate nutrition and hydration, exercise, immunizations, reduce cold outdoor exposure, limiting caffeine and alcoholic bevies, use filtration masks around chemicals and pollutants, deep breath techniques.)" "What is pertinent information is required to accurate documentation and reporting regarding the client with altered oxygenation? - CORRECT ANSWER exactly what is going on, any interventions, assessments done, teachings done, evaluations, interventions," "What is the nursing process of pyelonephritis? - CORRECT ANSWER usually starts as a lower UTI, or an obstruction of the lower GU tract from BPH or renal calculi." "What is the nursing process of cancer? - CORRECT ANSWER chronic/recurrent stones or infections, findings are weight loss, weakness, anemia, hematuria, flank pain, palpable masses, lung or liver or long bone mets." "What is the nursing process of acute kidney disease? - CORRECT ANSWER abrupt decline in kidney function, potentially reversible, increased creatinine and BUN, oliguria, ELIMINATE cause, monitor vitals, In/Out, cardiac assessment." "What is the nursing process of chronic kidney disease? - CORRECT ANSWER progressive, irreversible, deterioration of renal function. 5 stages. High creatinine, BUN, anuria, ADVANCED STAGES require dialysis or transplant, nutritional restrictions." "What is the nurses responsibility in the prevention/identification of complications related to altered elimination? - CORRECT ANSWER Maintain an open caring attitude and provide bladder health education to those seeking information." "what are the legal and ethicaal principles that apply to the care of the med/surg client? - CORRECT ANSWER Advanced directives, estate planning, taxation issues and appeals for denied services. Power of attorney." "what is the nurses role in providing culturally competent care for diverse populations for the med/surg patient? - CORRECT ANSWER Providing effective language support, care, cure, caregiving and healing systems. Families roles and relationships. Knowing about spirituality and religion, migration and settlement," "what is the nursing process to treat pressure injury wounds? - CORRECT ANSWER measuring the wound, documentation, irrigation, local care and ambulatory care" "What is the nursing process for cystitis? - CORRECT ANSWER used to describe inflammation or infection of the urinary bladder. Most common is a bacterial infection (uti). Symptoms: freq urination, urgency, pain or burning, cloudy or smelly urine, lower abdominal discomfort, mild fever." "How are diagnostic tests used for clients with altered elimination to facilitate accurate nursing assessments? - CORRECT ANSWER Use to diagnose, understand and manage urinary conditions. Common tests include: urinalysis, creatine, C&S, ultrasound/bladder scan, xray, cystography." "what are some non-pharmacologic therapies commonly used for the prevention and treatment of the client with altered urinary elimination? - CORRECT ANSWER lifestyle modifications (hydration, reduce caffeine), pelvic floor muscle rehabilitation (good for everyone), anti-incontinence devices, containment devices." "What is a radiography used for? - CORRECT ANSWER Abdominal view used to show the renal outline, shadow and a full bladder. Used to detect stones and foreign bodies, abscesses, tumors and cysts." "what is a pyelogram used for? - CORRECT ANSWER Presence, position, size and shape of the kidneys, the ureters and the bladder. Uses contrast medium. Assess for allergies and an allergic response to injection site and after affects of anaphylaxis." "what is urodynamic testing? - CORRECT ANSWER combination of tests for urinairy incontinence. Urine flow study and a cystometrography." "What is bladder irrigation? - CORRECT ANSWER May require if catheter becomes occluded by sediment and enrustation. Only used when deemed harmful to remove and reinsert. Two styles; intermittent bladder irrigation, continuous bladder irrigation." "what is hemodialysis? - CORRECT ANSWER A machine acting as an artificial kidney to remove waste from the blood." 5 Star solution - CORRECT ANSWER - do it yourself - influence others - assign someone - do nothing - combine knowledge" "Qualities of Good Decision Makers - CORRECT ANSWER - Self confident - Proactive - Flexible - Focused - Always accountable for their actions - Current knowledge - Works w/ resources - Competency" "Mentorship - CORRECT ANSWER - To have a knowledgable/competent/ reliable person to learn/understand from - Informal/Formal relationship for the purpose of educating a jr. nurse" "Mentorship -- Benefits - CORRECT ANSWER - support for new grad - faster growth of future generation - creates long term connections - role models - incluse on curriculum vitae - feeling of empowerment" "Mentorship -- Downfalls - CORRECT ANSWER - Personality conflict - Imposing their style on you - Social issues" "Clinical Pathway - CORRECT ANSWER - Support team - Client population - Time frames - Interventional categories of Rx plans - Meet expected outcomes - Variance record" "SBAR - CORRECT ANSWER - S [situation] - report clearly the situation and give the facts - B [background] - give background info about the client - A [assessment] - give details of your assessment - R [recommendations] - suggests recommendations that you would like to see done" "Metaparadigm Concepts - CORRECT ANSWER - PERSON/CLIENT- centre of all nursing process - ENVIRONMENT - person is a part of and interacts w/ a complex environmental system - HEALTH - more than the absence of disease, ideal health, optimal health or total wellbeing - NURSING - see individual as a whole" "Wound Care Nursing Roles - CORRECT ANSWER - proper assessment: gather history, physical examination, determine priority ND" "Skin - CORRECT ANSWER - Primary line of defence, protection of the body [alteration of skin allows bacteria/pathogen can move in/further into the body], a disruption results in loss of body fluids and risks for infection" "Wound classification - CORRECT ANSWER - Cause: intentional/unintentional - Skin integrity: open, closed [hematoma], acute [cellilitis], chronic [bowel related] - Depth: partial thickness, full thickness - Cleanliness: clean, clean-contaminated, contaminated - Duration: acute vs. chronic" "Wound Color Classification - CORRECT ANSWER - Red: healing wound, granulation tissue, inflammatory, proliferative, or maturation phase of healing, needs to be kept clean and moist* - Yellow: fibrous slough or exudate, infected and not ready to heal, require removal of slough - Black: presence of eschar [necrotic tissue], not ready to heal, must remove eschar for healing to happen - Combination Color: use most severe colour treatment" "Pressure Ulcer - CORRECT ANSWER - Lesion caused by unrelieved pressure that leads to damage of underlying tissue - Localized area of necrosis - Causes: friction, shearing force, moisture, impaired mobility, altered LOC, impaired sensory" "Pressure Ulcer Stages - CORRECT ANSWER - Stage 1: nonblanchabe erythema of intact skin [increase circulation - rub red spot to move blood around] - Stage 2: partial-thickness skin loss involving the epidermis, dermis, or both [abrasion/blister, insentience] - Stage 3: full-thickness skin loss involving damage to or necrosis of subq tissue that may extent to but not through underlying fascia - Stage 4: Full-thickness skin loss w/ extensive destruction, tissue necrosis or damage to muscle or bone/supporting structure" "Complex Wound - CORRECT ANSWER - Wounds that do not heal well - Edges not approximated [gaping, infected, necrotic, granulating] - may need to pack with saline soakeds" "Phases of Wound Healing - CORRECT ANSWER - Inflammatory: begins w/n minutes and lasts up to 4 days - edema, erythema, heat, pain, clots develop - Proliferation: 3-24 days - granulation tissue fills the wound bed, contraction of edges - Maturation: may take place for more than a year - collagen fibres undergo remodelling or reorganization before assuming their normal appearance" "Wound Healing - CORRECT ANSWER - Primary: edges of wound are brought together and closed using sutures, staples, clips or adhesive strips -- occurs quickly w/ minimal scarring - Secondary: edges cannot approximate, wound left open until filled w/ tissue arising from base, takes longer for wound to heal, infection chance high, scarring generally occurs - Tertiary: used for deep wounds that have either not been sutured or breakdown and are restored later" "Drainage Assessment - CORRECT ANSWER - Serous: clear watery plasma [normal] - Sanguineous: bright red [bad - indicates a vein/artery has been cut] - Serosanguineous: mixture of plasma and RBC, pale red & watery - Purulent: necrotic tissue, pus, thick, yellow, green, tan, brown, or black" "Wound Healing Complication - CORRECT ANSWER - Inflammation: edema, heat & pain - Infection: elevated temp - Hemorrhage: bleeding - check platelet & clotting factor - Fistula: destruction of tissue, enzymes eat away tissue - Dehiscence and Evisceration" "Infection - CORRECT ANSWER - Watch for fever, wound drainage, swelling, tenderness, increased WBC, general malaise" "Hemorrhage - CORRECT ANSWER - Can occur post-op or post-injury - Clotting occurs quickly - Apply pressure dressing - Watch for distention, swelling, obvious bleeding, increased drainage, assess v/s" "Fistula - CORRECT ANSWER - Abnormal passage between 2 organs or between organ and the outside of the body - Complicated to heal" "Undermining - CORRECT ANSWER - Tunnelling that may occur from one wound to another underneath the epidermis" "Dehiscence & Evisceration - CORRECT ANSWER - Dehiscence: refers to partial or total separation of wound edges - Evisceration: protrusion of internal organs through the incision" "Skin Integrity Risk Factors - CORRECT ANSWER - Lifestyle: personal hygiene, nutrition, fluid status, activity and exercise, smoking, substance abuse - Developmental: skin disease, age - Physiological: age, incontinence, hypoxemia, diabetes, infections, neurological impairments - Medications: steroids, anti-inflammatory, chemotherapy - Environment: skin dryness, frictions, moisture, perspiration, emesis" "Skin Diagnostic Tests - CORRECT ANSWER - CBC's - Pre-Albumin and Albumin Levels [plasma proteins] - Glucose levels - Radiological studies [osteoblasts/osteoclast]" "Braden Scale - CORRECT ANSWER - Sensory perception - Moisture - Activity - Mobility - Nutrition - Friction and Shear -- Total score: lower the score, higher the risk" "Wound Assessment - CORRECT ANSWER - Type: Penetrating (wound broke through the epidermis, dermis, underlying tissue), Abrasion (superficial injury caused by injury, scraping), Laceration (open wound w/ jagged edges, penetration), Contusion (closed wound, painful, swollen, bruise) - Location - Size (L x W x H) - Color - Surrounding skin - Odor - Drainage/drains - Temperature - Wound closures - Pain/tolerance - Dressing removed/applied" "Drain Purposes - CORRECT ANSWER - Removes blood, serum, lymph, other fluids that accumulate in wound beds after procedures - Left in place for 24 hr-7 days - Prevents accumulation of fluid which builds pressure, decreases perfusion and delays healing" "Drain Complications - CORRECT ANSWER - Painful - Pathway for infection - Mechanical damage (to local tissue) - Foreign body (body starts to wall off it by encasing it in granulation tissue) - Not draining - Excessive drainage" "Skin Integrity Teaching - CORRECT ANSWER - Current knowledge level and skill level - Readiness to learn - Learning ability, needs, preferences - Resistance to change - Learning style (visual, auditory, kinetic) - Resources available" "Skin Integrity Nursing Diagnosis - CORRECT ANSWER - Risk for infection - Imbalanced nutrition: less than body requirements - Pain - Impaired skin integrity - Impaired tissue integrity" "Skin Integrity to Promote Healing - CORRECT ANSWER - Providing adequate nutrition - Cleanse the wound - Maintain a moist wound bed - Dress wound - Drain the wound - Drain care to help promote healing - Debridement - Removal of sutures or staples - Non-pharmacological (apply heat/cold) - Pharmacology (DRUS***)" "Skin Wound Care Products - CORRECT ANSWER - Gauze: absorbent & wick away any drainage - Non-adherent gauze: does not stick to wound and drainage can pass through - Transparent film: maintains moisture in wound, protects from friction - Hydrocolloid: adhesive & occlusive, maintains a moist environment, liquify necrotic tissue - Hydrogel: hydrates & absorbs, soothing, provides moisture, derides by softening necrotic tissue - Alginates: absorbs excessive moisture, made from seaweed - Foams: absorbs exudate & debris while maintaining moist environment - Wound vac: assist in wound closure by applying negative pressure to draw edges inward" "Sterile Technique - CORRECT ANSWER - Sterile object remains sterile only when touched by another sterile object - Only sterile objects maybe placed on a sterile field - Sterile object or field out of range of vision or an object below a persons waist is contaminated - Sterile objects become contaminated after prolonged exposure to air - Sterile surfaces cannot come in contact with wet, contaminated surfaced - Fluid flows in the direction of gravity therefore a sterile object becomes contaminated by gravitational flow - Edges of a sterile field or container are considered to be contaminated" "Aseptic Technique - CORRECT ANSWER - Free of pathogenic micro-organisms - Purposeful prevention of the organism transfer from person to person" "No Touch - CORRECT ANSWER - Changing contact surface dressings without directly touching the wound or any surface that might come into contact with the wounds" "Clean Technique - CORRECT ANSWER - Free of dirt, marks or stains - Reduce the overall number of overall number of micro-organisms or person to person transmission" "ABG's - CORRECT ANSWER - Hemocrit - Hemoglobin - pH - Electrolytes - O2 - CO2 - HCO3" "Nurse's Role in Oxygenation - CORRECT ANSWER - Need to know normal and abnormalities of respiratory problems - Complete proper assessments to formulate a nursing diagnosis, goals & outcomes" "P.E.E.P - CORRECT ANSWER - Positive end expiratory pressure - "double breathing" - Increased lung expansion - Decrease lung Atelectysis [aveoli fill with fluid]" "Inadequate Ventilation - CORRECT ANSWER - Hypoxemia: decreased O2 in arterial blood (demand problem) - Hypoxia: decreased supply of O2 in tissue (supply problem) - Anxiety: increased CO2 cause acidosis - Restlessness or confusion - Use of accessory muscles for breathing - Change in cognition" "Common Respiratory Disorder - CORRECT ANSWER - Restrictive: to lung expansion or obstructive to movement of air in/out of lungs, i.e. muscle dysfunction; nerves dysfunction ; decreased intrathoracic space; change in lung compliance [ Atelectasis-collapsed lung, pleural effusion-fluid, hemothorax, pneumothorax, pneumoconsiosis (fibrotic lung)] - Obstructive: decrease size of airway, increased resistance, decreased ability to expand lungs, i.e. muscle weakness/fatigue; increased mucous; inflammation; tumour; foreign body; sputum [Pneumonia, Asthma, Emphysema, Tuberculosis, Lung Cancer]" "_ _ _ _ - Thorax - CORRECT ANSWER - Pneumothorax: air enters pleural space, the loss of intrepleural pressure causes lung to collapse S&S: pain as atmospheric air irritates the pleura, dyspnea - Hemothorax: bleeding in the pleural space between the parietal and visceral pleurae, produces counter pressure and prevents the lung from fully expanding S&S: pain, dyspnea, shock - Tension pneumothorax: air in pleural cavity from bronchus and gets worse until it collapses" "Oxygenation Risk Factors - CORRECT ANSWER - Lifestyle: smoking, exercise, nutrition, genetics, substance abuse - Environmental: quality of air - Developmental: infants/children (decrease surfactant, increased in reps infection, asthma) - Physiological: respiratory disease (COPD)" "Assessing Respiratory Status - CORRECT ANSWER - Health history: pain, fatigue, smoking, dyspnea, cough & lung sounds, environmental exposure, history of allergies & reps. infection, medications - Respiratory exam: orientation, LOC, behaviour, v/s, inspection (skin & mucous membrane, clubbing of nails), breathing patterns, lung auscultation, abdominal assessment" "Abnormal Breath Sounds - CORRECT ANSWER - Diminished or absent: consolidation in that area - Fine crackles: high pitched, fine, short, interrupted crackling sounds heard during end of inspiration, not cleared with coughing, sound alike rubbing hair together - Coarse crackles: loud, bubbly sounds heard during inspiration, not cleared with coughing - Wheezes: heard over all lung field, high pitched continuous musical sounds like squeak heard continuously during inspiration or expiration - Pleural Friction rub: heard over anterior lateral lung field, caused by inflamed pleura, parietal pleura rubbing against visceral pleura - Rhonchi: heard over trachea and bronchi, caused by muscular spasm, fluid or mucus in larger airways" "Recognizing Hypoxia - CORRECT ANSWER - S&S: change in mental status, LOC, restlessness, confusion, agitation. v/s change (resp. rate increases initially then drops), changes in skin (cyanosis)" "Common Diagnostic Test - CORRECT ANSWER - CBC - Pulmonary function test: assess reps. function - ABG's: measures blood pH, arterial O2 and CO2 level - Pulse oximetry - Sputum culture - Imaging studies (x-ray, Ct, lung scan) - Endoscopy (Bronchoscopy, Thoracoscopy, Thorancentesis) - Biopsy" "Sputum Abnormalities - CORRECT ANSWER - Normal (clear/white) - Profuse amount of purulent sputum - Thin, mucoid, sputum may indicate viral bronchitis - Gradual increase of sputum over time may indicate chronic bronchitis - Pink-tinged mucoid sputum may indicate a lung tumor - Profuse, frothy, pink material may indicate pulmonary edema - Foul smelling sputum may be caused by an infection" "Nursing Measures for Alteration in Oxygenation - CORRECT ANSWER - Chest/respiratory assessment - Oxygenation saturation - Vital signs - Choice of masks - Positioning in bed - Comfort - Pain relief - chest physiotherapy (postural drainage) - Nasopharyngeal suctioning - Oxygen therapy vis mask - Artificial airways (oral airway, endotracheal tube, tracheostomy)" "Interventions for Alteration in Oxygenation - CORRECT ANSWER - Positioning - Giving O2 - Opening airways - Improving efficiency (chest physiotherapy, suction) - Reduce anxiety - Assisting client to cough - Suctioning - Liquefying & mobilizing sputum - Reducing sputum production" "Indications for suctioning - CORRECT ANSWER - Increased reps. rate - Wet lung sounds - Oral & nasal secretions - Drooling - Visual assessment [breathing] - Auditory assessment [gurgling sounds] - Tactile assessment [vibrations of loose secretions] - Auscultation [crackles] --- Only suctions for 10 seconds MAX!! - obstructing airway" "Oxygen Therapy - CORRECT ANSWER - Normal ABG PaO2: 80-100mmHg SaO2: 95-100%" "Assessment of Chest Tubes - CORRECT ANSWER - Tidaling in water seal noted with breathing - No tidaling-lungs expanded or tubing kinked - Intermittent bubbling is ok - Should not be excessive bubbling - indicates a leak - May need to refill water seal chamber" "Altered Airways - CORRECT ANSWER - Endotracheal: catheter passed through nose or mouth into trachea - Tracheostomy: tube inserted through an opening in the trachea -- by passes upper airway obstruction - Opening is made in 2-3rd tracheal ring cuffed tube inserted and inflates" "Tracheostomy Assessment - CORRECT ANSWER - Ineffective airway clearance as the tube is a foreign object in airway and increases production of mucus - Client is unable to cough to clear airway - Frequent respiratory assessment and suctioning required" "Oxygenation Client Teaching - CORRECT ANSWER - Purpose of O2/Hazards of O2 - Deep breathing and coughing - Using a metered dose inhaler - Using an incentive spirometer - Diaphragmatic breathing - Pursed-lip breathing" "Urinary Risk Factors - CORRECT ANSWER - Lifestyles: amount of fluid consumed in 24hr (6-8 glasses) - Cultural: privacy issues, perspiration, urine, respiration, diarrhea, vomiting - Developmental: volume is gradually increased as children age. Women- pregnancy changes. Middle/Older- menopause - Physiological: cognitive impairment - Psychosocial: mentally handicapped, brain injury, cognitive impairment" "GU Assessment Data - CORRECT ANSWER - Health history: pattern of elimination, duration, colour, clarity, amount, increased/decreased, difficulty urinating - Physical assessment: urinalysis, skin condition, sleep patterns, edema contributed to nocturia, abdomen assessment, bladder distention" "Urine Examination - CORRECT ANSWER - Color [clear - light yellow] - Clarity - Odor - pH - Specific gravity [ kidneys ability to concentrate urine] - Protein, glucose, ketones - microscopic exam [detects presence of RBC, WBC, pus, bacteria, crystal" "Urinalysis - CORRECT ANSWER - Kidney function - Diagnosis disease - Presence of ketones, bacteria, proteins - Culture & Sensitivity - Urea: by product of protein - Creatinine: by product of muscle break down [Creatinine Clearance: profession of renal disease, Serum clearance: effectiveness of renal function, Blood Urea Nitrogen: index of renal function] -- too high = renal failure -- too low = dehydration or kidney disease" "Urinary Diagnostic Testings - CORRECT ANSWER - X-ray [kidney, bladder, ureter] -- detects the presence of stones, kidney enlargement, tumours - Ultrasounds [bladder scan] - CT/MRI - Nuclear scan [evaluates acute and chronic renal failure] - IVP [intravenous pyelograms (dye through kidneys)] - Retrograde pyelography [x-ray providing detailed view of ureter] - Endoscopic - cystoscopy - Biopsy [kidney, bladder lining] - Urodynamics [voiding problems]" "Types of Urinary Incontinence - CORRECT ANSWER - Stress incontinence: dribbling of urine w/ increased abdominal pressure - Urge incontinence: sudden desire to urinate - Functional incontinence: unpredictable, involuntary passage of urine in the presence of normal bladder and urethral function - Reflex urinary incontinence: unexpected voiding w/o awareness of the need to void - Total incontinence: inability to control urination [cognitive impairment or non-functional urinary sphincter]" "Symptoms of Urinary Alteration - CORRECT ANSWER - Incontinence: involuntary loss of urine - Urgency: feeling the need to urinate immediately - Dysuria: painful or difficult urination - Frequency: voiding frequently (2) - Hesitancy: difficulty initiating urination - Polyuria: voiding large amounts - Oliguria: decreased urinary output compared to intake - Anuria: supression or arrest of urine - Nocturia: voiding at night - Dribbling: leakage of urine despite voluntary control of urination - Hematuria: blood in urine - Retention: accumulation of urine in the bladder, unable to empty bladder fully - Residual urine: volume of urine left in the bladder after voiding" "Urinary Catheterization - CORRECT ANSWER - Relieve urinary retention & obstruction - Empty the bladder pre/post surgery - Obtain a sterile urine specimen - Measure amount of PVR urine in bladder - Accurately monitor output in acutely ill patients" "Types of Catheters - CORRECT ANSWER - Indwelling [retention/foley]: gradual decompression of an over-distended bladder, continuous bladder drainage -- 12-16 french, balloon - Intermittent [straight]: drains bladder for short periods of time [5-10 sec], used to obtain sterile specimen - Suprapubic: continuous drainage, inserted through small incision above pubic area - Condom: external urinary catheter, soft pliable rubber sheath that slips over the penis, may be worn at night or continuously" "Urinary Nursing Assessments - CORRECT ANSWER - When did the client last void - Palpate bladder distention - Has client had surgery - Perform bladder scan prior to catheterization - Encourage voiding through non-invasive actions [running h2o]" "Assessment with Catheter - CORRECT ANSWER - Tubing free of obstructions or kinks - Free of tension - Ensure gravity drainage bag will be lower than the bladder - Drainage system is sealed & closed - Monitor flow of urine every 2-3 hour - Check amount, colour, odour, presence of blood clots & mucus shreds" "Catheter Complication - CORRECT ANSWER - Infection: caused by non sterile tech, direct route for micro-organism. S&S: frequency, urgency, dysuria, nocturia, unwell - Trauma: caused by improper insertion, catheter forced through strictures or at incorrect angle, ballon inflated in while foley in incorrect position. S&S: bleeding, swelling, pain, tenderness, discharge" "Autonomic Dysreflexia - CORRECT ANSWER - Spinal cord injuries - Reflex of autonomic system in response to stimulation of bladder/bowel - Full bladder/impacted bowel - Vasoconstriction & increased BP, headache, sweating, flushing, goose bumps" "Urinary Client Teaching - CORRECT ANSWER - Drink fluids - Perform catheter care - Teach how to transfer self - Teach S&S of UTI - Kegal exercises - Tubing care - Abnormal urine output - Do NOT use powders or lotions" "Bladder Irrigation - CORRECT ANSWER - Solution hung at 24-26 inches above the bladder - Irrigate 30-50 mLs to clear clots [intermittent] - Bladder spasms*" "Hemodialysis - CORRECT ANSWER - Circulation of the pts. blood through a dialyzer to remove waste products and excess fluid" "Dialysate - CORRECT ANSWER - Chemical bath that is used to draw fluids and toxins out of the blood stream also can supply electrolytes to the blood stream [osmosis]" "Peritoneal Dialysis - CORRECT ANSWER - Cleansing the blood and waste products using osmosis & diffusion but using the pts. own peritoneum for the semi permeable membrane - Dialysis is instilled into their peritoneal cavity by gravity through a surgical placed catheter - Dialysis is left in the cavity for a period of time and then drained taking accumulated wastes and excess fluid" "Peritoneal Dialysis Complications - CORRECT ANSWER - Peritonitis: inflammation of peritoneal membrane S&S: cloudy dialysis discharge, abdominal pain, rebound tenderness - Leakage: leakage through the catheter site may occur immediately after insertion and normally stops if dialysis is held until the incision can heal - Bleeding: common after the first few exchanges of new catheter insertion" "Surgical Experience - CORRECT ANSWER - Perioperative: holding area, pre-admission clinic, clinical exam room - Preoperative: invasive procedure area, anaesthetic room, operating room - Intraoperative: OR, recovery, ICU, general unit, outpatient dept - Postoperative: perioperative nursing" "Perioperative History - CORRECT ANSWER - Surgical pts. cared for in specific areas w/n the hospital - pre-admission, health history, preparation for OR, diagnostic, lab - Pre-anaesthetic medication prior to surgery may be ordered" "Perioperative Nurse's Role - CORRECT ANSWER - Teaching - Stress reduction techniques - Gather history - Assess pt. knowledge - Get signed consent - Explain pre-op procedures - Explain operating room - Explain post-op procedures - Post op care" "Preoperative Assessment - CORRECT ANSWER - Baseline V/S - Routine hygiene - Ensure client in gown - Remove nail polish - Remove dentures - Check allergy & ID band - Remove ALL jewellery - Consent form signed - Charts prepared & ready to go - Focussed Client assessment: anxiety, anger, anticipatory grieving [loss of body part], latex allergy, knowledge deficit" "Admission Process - CORRECT ANSWER - Initial contact to health care - Data collection - Physical exam/hospital gown - Baseline lab - Check valuables/meds - Prioritize plan of care" "Factors Affecting Surgery - CORRECT ANSWER - Lifestyle: nutrition, malnourished, obesity, use of herbal medication, exercise/activity, use of drugs/alcohol/smoking - Culture & religion: allow pt. to pursue their beliefs - Developmental: neonate - adult blood loss, difference in body size - Socioeconomics: may need to return to work after, discharge planning is necessary - Physiological: past hospitalization, medications, previous surgery - Psychological: anxiety, beliefs, coping strategies" "Latex Allergy Risk Factors - CORRECT ANSWER - History of anaphylactic reaction - Food allergies - Job w/ daily exposure to latex - Conditions requiring continual or intermittent catheterization - History of reactions - Allergy to poinsettia plants - History of allergies or asthma" "Perioperative Diagnostic Test - CORRECT ANSWER - Blood work, CBC, electrolytes, crossmatch, creatinine, clotting - Urinalysis - X-ray - MRI, CT scan - ECG" "Informed Consent - CORRECT ANSWER - Pts. legal right to receive accurate & adequate information about their medical condition and treatment - Surgeon required to ask client to sign - Nurse may be asked to witness clients signature - Students cannot sign as witness" "Anesthetics - CORRECT ANSWER - General: inhalation or IV injections - Spinal: local anaesthetic inserted btwn L4/5, goes right into spinal fluid - Epidural: local anaesthetic injected in epidural space [pura matter, dura matter, epidermal matter] - Regional: nerve block - Local: specific part of body" "Surgical Risks - CORRECT ANSWER - Chronic Respiratory Disorders - Cardiovascular disorder - Diabetes Mellitus - Renal & liver disease - Malnutrition - Obesity - Alcoholism - Nicotine abuse - Certain medications - Drug abuse" "Postoperative Assessment - CORRECT ANSWER - Receive client & report condition - Relevant preoperative status [v/s, labs, allergies] - Assess ABG - LOC, neurovascular assessment - Pain - Head to Toe - Type fo surgery - Medications given - Estimated blood loss & replacement fluid - Presence of tubes, drains, catheters, wound status, surgical complications