CNF exam 2 - clinical foundations exam 2 review all chapters included PDF

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clinical foundations exam 2 review all chapters included ...

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Urine Specimens Routine urinalysis Clean-catch or midstream specimens Sterile specimens from indwelling catheter Urine specimen from a urinary diversion 24-hour urine specimen

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Promoting Normal Urination     

Maintaining normal voiding habits Promoting fluid intake Strengthening muscle tones Assisting with toileting Self-care responding as soon as possible to the urge to void and monitor use of caffeine, alcohol, medication schedules that promote voiding and that interfere with sleep

Maintaining normal voiding habits with schedule, urge to void, privacy, position and hygiene Types of Urinary incontinence Transient: appears suddenly, lasts 6 months or less Mixed: urine loss with features of 2 or more types of incontinence Overflow: over distraction and overflow of bladder Functional: caused by factors outside the urinary tract Reflex: emptying of the bladder without sensation of need to void Total: continuous, unpredictable loss of urine

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Caring for an incontinent patient More prevalent in women and increases with age o Being on bedrest, having dementia, and having difficulty walking to the bathroom higher risk Issues- odor, embarrassment, social isolation Treatment options o Behavior- Kegels, biofeedback, electrical stimulation o Pharmacological- medications, topical estrogen, collagen o Mechanical- pessaries, external barriers, urethral insert, surgical intervention

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Factors to consider with use of absorbent products      

Functional disability of the pt. Type and severity of incontinence Gender Availability of caregivers Failure with previous treatment programs Patient preference

Patients at risk for UTIs      

Sexually active women Women who use diaphragms for contraceptives Postmenopausal women- urinary stasis and decreased estrogen Individuals with indwelling urinary catheter Individuals with DM Older adults

Recommended to drink water even before sex, dry perineal area and observe urine, certain underwear’s, take showers not baths Types of catheters   

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Intermittent Urethral catheters “straight caths” Indwelling urethral catheter Suprapubic catheter o long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area External condom catheter o Urinary sheath prevent the tubing from kinking to maintain free urinary drainage “PureWick” female external catheter Hazards of urethral catherization o Sepsis- risk for bacteria to be introduced o Trauma- invasive procedure

ileal conduit: urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall continent urinary diversion (CUD): surgical alternative that uses a section of the intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma cutaneous ureterostomy: a type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin Patient Education for urinary diversion      

Explain reason for diversion and rationale treatment Demonstrate effective self-care behaviors Describe follow-up care and support resources Report where supplies may be obtained in the community Verbalize related fears and concerns Demonstrate a positive body image

Dialysis 

Hemodialysis- fistula, graft, central venous catheter

The nurse should auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration, and palpate over the access site, feeling for a thrill or vibration. If these are not present, the health care provider should be notified at once. An IV should not be started in the arm with the access. Peritoneal dialysis- abdominal cavity (peritoneum), diffusion and osmosis o

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KEY CONCEPTS 

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Factors affecting the amount and quality of urine produced by the body and the manner in which it is excreted include developmental considerations, food and fluid intake, psychological variables, activity and muscle tone, pathologic conditions, and medication use. Nursing assessment of urinary elimination includes collection of data about the patient’s voiding patterns, habits, and difficulties, along with a history of current or past urinary problems; physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; examination of the urine and measurement of urine volume; and correlation of these findings with the results of diagnostic tests and procedures for examining the urine and the urinary tract. Nurses use different techniques for collecting urine specimens. The nurse needs to understand the rationale for the specific test ordered, as well as the correct collection procedure associated with the required test in order to ensure obtaining the appropriate urine sample. Nursing interventions focus on maintaining and promoting normal urinary patterns, improving or controlling urinary incontinence, preventing potential problems associated with bladder catheterization, assisting with care of urinary diversions, and care of vascular access for hemodialysis and peritoneal dialysis.

Chapter 35: Comfort and pain Classification of Pain 

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Duration: acute and chronic o Acute- episodes of pain that lasts from seconds to less than 6 months o Chronic- “lasts 6 months or longer, may intermittent or continuous, can cause depression, withdrawal, dependency Source: cutaneous, somatic, visceral o Cutaneous- superficial pain usually involving the skin or subQ tissue o Somatic- pain originating in structures in the body’s external wall o Visceral- pain originating in the internal organs in the thorax, cranium or abdomen Mode of transmission: referred

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o Pain in an area removed from that in which stimulation has its origin Etiology: Nociceptive, neuropathic, intractable, phantom, psychogenic o Intractable is sever pain that is extremely resistant to relief measures o Psychogenic- pain for which no physical cause can be identified

The pain process involving nociception is transduction, transmission, perception and modulation of pain. Substances that stimulate nociceptors or pain receptors include bradykinin, prostaglandins and substance P. Neurotransmitters such as serotonin stimulates SM, inhibit gastric secretion and produce vasoconstriction.  

Dynorphins- most potent analgesic effect Enkephalins- reduce pain sensation by inhibiting the release of substance p form neurons

Responses to pain:   

Behavioral (voluntary): grimacing, moaning, crying, guarding the area, restlessness Physiological (involuntary): Inc/Dec BP, Inc RR, Inc/Dec pulse rate, pupil dilation, muscle tension, N/V, fainting Affective (psychological): anxiety, depression, fear, anger, anorexia, hopelessness, fatigue

Factor affecting pain experience: culture, ethnicity, family, gender, age, religious Factors affecting pain experience: environment and support, anxiety and other stressors, past pain experience NURSING PROCESS FOR PAIN: Assessment- psychological, emotional, sociological, physiologic  

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COLDSPA- physiologic indicators of pain, behavioral responses, effect of pain on activities and lifestyle Assessment Tools o Wong-Baker FACES  Adults and children (>3 yr) o Beyer oucher pain scale  Actual people face on scale o CRIES pain scale  Neonates (ages 0–6 months), 10 point like the APGAR o FLACC scale  Face, legs, activity, cry, consolability  Infants and children 2 mo. -7 years who are unable to sense severity of pain o COMFORT scale  Infants, children, adults who are unable to use the numeric rating scale or WB faces Diagnosing

Type of pain, etiologic factors, behavioral, physiologic, other factors affecting pain process Planning/Implementation o Establishing trusting nurse-patient relationship o Manipulating factors affecting pain experience o Initiating nonpharmacologic interventions o Complementary and alternative relief measures o Teaching patient about pain Nonpharmacologic pain relief measures: distraction, humor, music, imagery, relaxation and cutaneous stimulation, acupuncture, hypnosis, biofeedback, therapeutic touch, animal-facilitated therapy o Cutaneous stimulation relieves pain often using the gate control therapy  Massage, application of heat or cold, acupressure, transcutaneous electrical nerve stimulation (TENS) Pharmacologic pain relief measures: nonopioid analgesics, opioids analgesics (misconceptions), adjuvant drugs o Adjuvant analgesics (anticonvulsants, antidepressants…) o Possible sedation with opioids, more important than lowered respiratory rate o The Pasero Opioid-induced sedation scale used to assess respiratory depression  S = sleep, easy to arouse: no action necessary  1 = awake and alert; no action necessary  2 = occasionally drowsy but easy to arouse; requires no action  3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose  4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone o Physical dependence, tolerance, addiction Special considerations: chronic/cancer pain, children, older adults o Breakthrough pain with cancer Alternative administration methods: patient-controlled analgesia (PCA), epidural analgesia, local anesthesia Evaluation (reassess after implementation) the pain experience, management regimens, pt. and family response o

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PREPU QUESTION REVIEW     

Tolerance- body becomes accustomed and needs a larger dose Sympathetic response- pupil dilation, muscle rigidity, increased pulse rate, pallor Kidney function would be temporarily suppressed by acute pain Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage The gate theory appears to explain why mechanical and electrical interventions or heat and pressure may provide effective pain relief.

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Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Teaching self-management techniques that activate closing the gate may also minimize the experience of pain. Pain medication and epidural anesthesia are not a part of gate theory interventions. Stretches and active exercises may cause further injury to the client.

Ch 30 Perioperative Nursing Three phases of Perioperative nursing   

Perioperative: begins with decision to have surgery, lasts until pt is transferred to operating room or procedural bed Intraoperative: begins when the patient is transferred to the OR bed until transfer to the postanesthesia care unit (PACU) Postoperative: lasts from admission to recovery room to complete recovery from surgery and last follow-up physician visit

Classification of Surgical Procedure   

Urgency: elective, urgent, emergency Risk: minor or major Purpose: o Diagnostic- to make or confirm a diagnosis  Breast biopsy, laparoscopy, exploratory laparotomy o Curative o Preventive o Ablative- to remove a diseased body part  Appendectomy, amputation, resection, partial/subtotal o Palliative- to relieve or reduce intensity of an illness, is not curative  Colostomy, nerve root resection, debridement of necrotic tissue, balloon angioplasties, arthroscopy o Reconstructive- restoring function to traumatized or malfunctioning tissue, to improve self-concept  Scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction o Transplantation- to replace organs or structures that are diseased/malfunctioning  Kidney, cornea, heart, joint, liver o Constructive- to restore function in congenital anomalies  Cleft palate repair, closure of atrial septal defect

Types of Anesthesia 

General: administration of drugs by inhalation or intravenous route

Major risks w/general is circulatory and respiratory depression, postop N&V and alterations in thermoregulation (possibly bronchospasm) o Three phases of general anesthesia:  Induction: from administration of anesthesia to ready for incision  Maintenance: from incision to near completion of procedure  Emergence: starts when pt. emerges from anesthesia and is ready to leave operating room Moderate sedation/analgesia (conscious sedation/analgesia): used for short-term, minimally invasive procedures o Maintains cardiorespiratory function and responds to verbal commands Regional: anesthetic agent injected near a nerve or nerve pathway or around operative site o Types of Regional anesthesia: nerve blocks, spinal anesthesia, caudal anesthesia, epidural anesthesia o Effects include reduction or loss of reflex action and localized loss of sensation Topical and local anesthesia: used on mucous membranes, open skin, wounds, burns o Local- Injection of an anesthetic agent such as bupivacaine, lidocaine or tetracaine o

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States of Anesthesia: loss of consciousness, analgesia, relaxed skeletal muscles, and depressed reflexes Informed Consent Information:       

Description of procedure and alternative therapies Underlying disease process and its natural course Name and qualifications of person performing procedure Explanation of risks and how often they occur Explanation that the pt. has the right to refuse treatment or withdraw consent Explanation of expected outcome, recovery, rehabilitation plan and course of treatment Witnessing a pt. signature on an informed consent form: option of nontreatment, underlying cause and its natural course, name and qualifications/explanation of the risks and benefits of the provider of the procedure or treatment

Advance directives: living wills, durable power of attorney for health care, DNR status Outpatient/Same-day surgery  

Reduces length of hospital stay and cuts costs Reduces stress for the pt.

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May require additional teaching and home care services for certain pt. (older adults, chronically ill pt., pt. with no support system)

Outcomes for the surgical pt.      

Receive respectful and appropriate care Be free from injury and AE, infection and DVT Maintain fluid and electrolyte balance, skin integrity, normal temp. Pain managed Demonstrate understanding pf physiologic and psychological responses to surgery Participate in rehabilitation process

Surgical Risks of medications     

Anticoagulants: precipitate hemorrhage Diuretics: electrolyte imbalances, respiratory depression from anesthesia Tranquilizers: increase hypotensive effects of anesthetic agents Adrenal steroids: abrupt withdrawal may cause cardiovascular collapse Antibiotics in mycin group: respiratory paralysis when combined with certain muscles relaxants

*Some medications may be given the morning of the surgery with water such as pt. with heat or cardiovascular problems or DM Nutritional status- both malnutrition and obesity increase surgical risk  

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Malnourished- greater risk for alterations in fluid and electrolyte balance, delay in wound healing and wound infections Obese- Inc. risk for respiratory, cardiovascular, positional injury, DVT, and gastrointestinal problems o may have sleep apnea for respiratory o may have GERD putting them at risk for aspirating stomach contents o fatty tissue has poor blood supply and has less resistance to infection o WOUND HEALING Smokers are at risk for hypoxia and postop pneumonia and it also compromises wound healing by constricting blood vessels, impairing blood flow to healing tissues

Nurse’s role in presurgical testing: ensure that tests are explained to the pt., appropriate specimens are collected, results are recorded in pt. records before, and abnormal results are reported Nursing Interventions for surgical pts. 

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Hygiene and skin preparation o Minimize skin contamination and decrease risk for postop surgical site infection- clean skin and leaving or removing hair in area Elimination

Insertion of Foley may be prescribed before surgery usually with pelvic surgery, if not then pt. must empty bladder before surgery Nutrition and fluids o Pt. must be well nourished and hydrated before to counterbalance fluid, blood, and electrolytes lost during surgery; to facilitate anesthesia delivery; promote tissue healing after surgery o Pt. can drink clear liquids up to 2 hr. before surgery Rest and sleep Preparation and safety the day of the surgery o

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Nursing Interventions to meet psychological needs of surgical pt.    

Establish therapeutic relationship and allow pt. to verbalize fears and concerns Uses active listening skills to identify anxiety and fear Use touch to demonstrate genuine empathy and caring Be prepared to respond to common pt. questions about surgery

Preparing the pt. through teaching: surgical events and sensations, pain management, and physical activities (deep breathing, coughing, incentive spirometer, leg exercise, turning in bed and early ambulation); taught in preop period but required in postop. Deep breathing prevents alveoli from collapsing, improve lung expansion and volume and helps to expel anesthetic gases and mucus, and oxygenate tissues. TJC protocol to prevent wrong site, wrong procedure and wrong person surge   

Preoperative pt. identification verification process Marking the operative site Final verification just prior to beginning the procedure, referred to as the time-out

Postoperative assessments and interventions (every 10 to 15 min)        

Respiratory status (airway, pulse oximetry) Cardiovascular status (BP) Temperature Central nervous system status (level of alertness, movement, shivering) Fluid and wound status Gastrointestinal status (N/V) Pain management General condition

Interventions to prevent respiratory complication     

Monitoring VS Implementing deep breathing Coughing Incentive spirometry Turning in bed every 2 hr.

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Ambulating Maintain hydration Avoiding positioning that dec. ventilation Monitoring responses to narcotic analgesics

END OF CHAPTER QUESTION REVIEW 

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A responsibility of the nurse is the administration of preoperative medications of pt. Sedatives, such as diazepam, midazolam, or lorazepam, are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate–droperidol are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine and ranitidine, are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent A thoracic incision makes it more painful for the patient to take deep breaths or cough. Shallow respirations and ineffective coughing increase the risk for respiratory complications. Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse rate are assessment findings that indicate hemorrhage. Thrombophlebitis is an inflammation of a vein associated with thrombus (blood clot) formation. Thrombophlebitis is typically superficial and, in patients without an underlying condition, is often related to IV catheters. Manifestations ...