End Stoma
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One end of intestine is brought to surface
3 pressure related factors that contribute to pressure injuries
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1. intensity of pressure
2. duration of pressure
3. tissue tolerance; shear, friction, moisture, nutrition, age, dehydration, low
BP can all increase risk
reflex urinary incontinence
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Involuntary loss of urine occurring at somewhat predictable intervals when
patient reaches specific bladder volume related to spinal cord damage
between C1 to S2
Example: constipation R/T surgery, pain, medication, and decreased mobility. AMB
hard dry stools. what is the priority nursing diagnosis?
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Priority (primary) should be the pain because the pain is what is causing the
constipation and decreased mobility and increased medication.
functional incontinence
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, loss of continence because of causes outside the urinary tract
Usually related to functional deficits such as altered mobility and manual
dexterity, cognitive impairment, poor motivation, or environmental barriers
Diagnostic examinations (bowel)
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Radiologic imaging, endoscopy, ultrasound, CT, or MRI
When planning
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Set priorities based on assistance required, extent of problems, and nature
of the diagnosis.
Interventions with nutrition
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Education, early identification of the problem, meal planning, weight loss
plans, food safety like choking hazards and proper storage, advancing
diets so progressively increasing intake, promote appetite, assist with oral
feedings
, classification of pressure ulcers
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stage 1: intact skin with nonblanchable redness
stage 2: partial thickness skin loss involving epidermis, dermis or both
stage 3: full thickness tissue loss with visible fat
stage 4: full thickness tissue loss with exposed bone, muscle or tendon
What is important to preserve during hygiene of a patient?
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Their independence.
What are the 11 functional health patterns
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Give this one a try later!
One end of intestine is brought to surface
3 pressure related factors that contribute to pressure injuries
,Give this one a try later!
1. intensity of pressure
2. duration of pressure
3. tissue tolerance; shear, friction, moisture, nutrition, age, dehydration, low
BP can all increase risk
reflex urinary incontinence
Give this one a try later!
Involuntary loss of urine occurring at somewhat predictable intervals when
patient reaches specific bladder volume related to spinal cord damage
between C1 to S2
Example: constipation R/T surgery, pain, medication, and decreased mobility. AMB
hard dry stools. what is the priority nursing diagnosis?
Give this one a try later!
Priority (primary) should be the pain because the pain is what is causing the
constipation and decreased mobility and increased medication.
functional incontinence
Give this one a try later!
, loss of continence because of causes outside the urinary tract
Usually related to functional deficits such as altered mobility and manual
dexterity, cognitive impairment, poor motivation, or environmental barriers
Diagnostic examinations (bowel)
Give this one a try later!
Radiologic imaging, endoscopy, ultrasound, CT, or MRI
When planning
Give this one a try later!
Set priorities based on assistance required, extent of problems, and nature
of the diagnosis.
Interventions with nutrition
Give this one a try later!
Education, early identification of the problem, meal planning, weight loss
plans, food safety like choking hazards and proper storage, advancing
diets so progressively increasing intake, promote appetite, assist with oral
feedings
, classification of pressure ulcers
Give this one a try later!
stage 1: intact skin with nonblanchable redness
stage 2: partial thickness skin loss involving epidermis, dermis or both
stage 3: full thickness tissue loss with visible fat
stage 4: full thickness tissue loss with exposed bone, muscle or tendon
What is important to preserve during hygiene of a patient?
Give this one a try later!
Their independence.
What are the 11 functional health patterns
Give this one a try later!
