NUR 520 Exam 2 Questions With Complete Solutions
Impaction
Bowel cancer
Obstruction
Hardened feces
Causes constipation, incontinence, cramping, straining in
defecation
Bowel Training
Manipulate factors within the patient’s control: Food and
fluid intake, exercise, and time for defecation / Eliminate a soft,
formed stool at regular intervals without laxatives.
ostomy considerations/care
- Keep pt as free of odors as possible; empty frequently.
- Inspect the patient's stoma regularly: Note size, which should
stabilize within 6 to 8 weeks
- Measure I/O
Nasogastric tubes
- decompresses/drains the stomach
- allows the GI tract to rest before/after abdominal surgery
- monitor GI bleeding
- pull residuals, less that 200 discard (overfeeding = aspiration
risk)
I/O's
measurement of weight is a good indicator of fluid balance
,Factors Affecting Skin Integrity
genetics, age, underlying health conditions, activity, nutrition
Types of Wounds
- intentional (i.e. surgery, venipuncture)
& unintentional (trauma, pressure, skin tears)
- Classified according to how they are acquired or likelihood and
degree of contamination
Exudate
Serous: clear, watery with few cells; derived from serum of
blood or serous membranes of body
Sanguineous: large amounts of RBC, indicating damage to
capillaries
Purulent: thick, includes pus( leukocytes, liquified dead cells,
living bacteria)
Pressure Ulcers
*PREVENTABLE* Injury to skin &/or underlying tissue,
usually over bony prominence, as a result of ischemia due to
force and movement
- CMS & private insurance companies will no longer reimburse
for cost of treating health-care associated pressure ulcers
- Stage III, IV, or unstageable ulcers considered TJC sentinel
event
Risk factors for pressure ulcers
-friction and shearing
, -immobility
-inadequate nutrition
-fecal and urinary incontinence
-decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-presence of certain chronic conditions
Pressure Ulcers: Stage 1
nonblanchable erythema of intact skin
- Tissue may feel warmer/cooler than adjacent, Tissue swollen,
discomfort
Pressure Ulcers: Stage 2
Partial-thickness loss involving epidermis or dermis, Ulcer
visible with red-pink bed, No tissue sloughing or bruising
Pressure Ulcers: Stage 3
Full Thickness Skin Loss, subcutaneous tissue damage, Ulcer
extends down (but not through) underlying fascia, Shallow
crater, no tunneling, Drainage and infection common
Pressure Ulcers: Stage 4
Full Thickness Tissue Loss: Destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures, Sinus tracts,
tunneling, undermining, drainage
Impaction
Bowel cancer
Obstruction
Hardened feces
Causes constipation, incontinence, cramping, straining in
defecation
Bowel Training
Manipulate factors within the patient’s control: Food and
fluid intake, exercise, and time for defecation / Eliminate a soft,
formed stool at regular intervals without laxatives.
ostomy considerations/care
- Keep pt as free of odors as possible; empty frequently.
- Inspect the patient's stoma regularly: Note size, which should
stabilize within 6 to 8 weeks
- Measure I/O
Nasogastric tubes
- decompresses/drains the stomach
- allows the GI tract to rest before/after abdominal surgery
- monitor GI bleeding
- pull residuals, less that 200 discard (overfeeding = aspiration
risk)
I/O's
measurement of weight is a good indicator of fluid balance
,Factors Affecting Skin Integrity
genetics, age, underlying health conditions, activity, nutrition
Types of Wounds
- intentional (i.e. surgery, venipuncture)
& unintentional (trauma, pressure, skin tears)
- Classified according to how they are acquired or likelihood and
degree of contamination
Exudate
Serous: clear, watery with few cells; derived from serum of
blood or serous membranes of body
Sanguineous: large amounts of RBC, indicating damage to
capillaries
Purulent: thick, includes pus( leukocytes, liquified dead cells,
living bacteria)
Pressure Ulcers
*PREVENTABLE* Injury to skin &/or underlying tissue,
usually over bony prominence, as a result of ischemia due to
force and movement
- CMS & private insurance companies will no longer reimburse
for cost of treating health-care associated pressure ulcers
- Stage III, IV, or unstageable ulcers considered TJC sentinel
event
Risk factors for pressure ulcers
-friction and shearing
, -immobility
-inadequate nutrition
-fecal and urinary incontinence
-decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-presence of certain chronic conditions
Pressure Ulcers: Stage 1
nonblanchable erythema of intact skin
- Tissue may feel warmer/cooler than adjacent, Tissue swollen,
discomfort
Pressure Ulcers: Stage 2
Partial-thickness loss involving epidermis or dermis, Ulcer
visible with red-pink bed, No tissue sloughing or bruising
Pressure Ulcers: Stage 3
Full Thickness Skin Loss, subcutaneous tissue damage, Ulcer
extends down (but not through) underlying fascia, Shallow
crater, no tunneling, Drainage and infection common
Pressure Ulcers: Stage 4
Full Thickness Tissue Loss: Destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures, Sinus tracts,
tunneling, undermining, drainage
