Fundamentals Test 6

given to remove feces, to relieve constipation or fecal impation, prevent involuntary escape of fecal material during surgery, promote visualization fo the intestinal tract, help establish regular bowel function during training
usually larger volume and retention is for as long as possible 5-15 min.

are large-volume enemas that result in rapid colonic emptying (500-1000mL adults; 150-250mL infants)

available commercially in smaller volumes (70-130mL adults); draws water into the colon which stimulate the defecation reflex.

retain in the bowel for a prolonged period

lubricate the stool and intestinal mucosa (150-200 mL/adult); have patient retain the oil for at least 30 min.

help expel flatus and relieve gaseous distention; milk-and-molasses enema (equal parts) and the mag-sulfate-glycerin-water enema; (30:60:90mL adult)

provide meds that absorbed rectally

destroy intestinal parasites

admininster fluids and nutrition rectally

occassionally to expel flatus (100-200mL adult)
the solution is instilled and then the container is lowered so the solution flows back into the container.

decompress or drain the stomach of fluid or unwanted stomach contents (poison, medication, and air), and when peristalsis is absent, or when the tract needs to rest before or after surgery, or to monitor bleeding

require irrigation with 30 to 60 mL saline to maintain patency

oral hygiene q 2-4 hr., frequent mouth rinsing, lubricate lips, keep nares clean and use lubricant after cleaning, offer analgesic throat lozenges or sprays from throat placement, ensure tubing is secured to nose and gown.

sign/symptoms: becoming light headed or fainting when rising from a reclined position
Prevention: Implement leg exercises and turn Q2H/ROM
Nursing Intervention: have pt. move legs in bed prior to sitting on edge of bed, put the head of the bed up and allow pt. to adjust to new position, have pt. move legs back and forth as they sit on the edge of the bed before standing (dangling), allow pt. to stand prior to walking, if pt. experiences dizziness pt. should return to bed and be placed in a supine position which will restore blood flow to the brain

sign/symptoms: pain and cramping in the calf or thigh of the involved extremity, redness, swelling or warmth in the affected area
Prevention: implement leg exercises and turn Q2H/ROM, ambulate with assistance at least 3-4 times per day, antiembolism stockings/sequentials, avoidance of leg message,avoid positions that impede circulation, monitor fluid balance (maintain hydration), administer prophylactic anticoagulants as ordered
Tx/nursing interventions: administer anticoagulants, maintain bed-rest (with limb elevated) as ordered, use external heat application as ordered, measure bilateral calf or thigh circumference daily

signs/symptoms: dyspnea, chest pain, cough, cyanosis, rapid respiratons, tachycardia, anxiety
Prevention: prevent DVTs
Tx/Nursing Interventions: may be life threatening (notify MD STAT), maintain bed rest with pt. in semi-fowler's position, administer oxygen, maintain IV fluids, administer anticoagulants, avoid Valsalva's maneuver

signs/symptoms: decreased lung sounds over the affected area, dyspnea, cyanosis, crackles, restleness, apprehension
Prevention: C&DB, incentive spirometry Q2H, ambulate with assistance at least 3-4 times a day, avoid position that decrease ventilation, maintain hydration
Tx/Nursing Interventions: position in semi or full-Fowler's, administer oxygen as ordered, maintain fluid and nutritional status, continue deep breathing and incentive spiromety, ensure rest and comfort

signs/symptoms: elevated temp., chills, productive cough (rust or purulent sputum), crackles and wheezes, dyspnea, chest pain
Prevention: C&DB, incentive spirometry Q2H, ambulate with assistance at least 3-4 times a day, avoid positions that decrease ventilation, maintain hydration
Tx/Nursing Interventions: position pt. in semi or full Fowler's position, administer oxygen as ordered, maintain fluid and nutritional status, administer antibiotics, administer expectorants, continue deep breathing and incentive spirometry, provide frequent oral care, teach proper disposal of tissues and sputum, ensure rest and comfort

signs/symptoms: pt. may describe symptoms of bloating or feeling of rectal fullness, stools are less frequent, small and hard, stools may be difficult to pass
Prevention: ambulate wit assistance 3-4 times a day, encourage fluid 8-10 glasses a day intake, encourage high fiber foods, encourage fruit juices (prune)
Tx/Nursing Interventions: maintain privacy when toileting pt., administer suppositories, enemas, stool softeners as ordered,

signs/symptoms: severe flank pain radiating into the groin area, blood in urine, N/V
Prevention: ambulate with assistance at leat 3-4 times a day, drink plenty of fluids
Tx/Nursing Interventions: Narcotics for pain control, attempt to flush stone out of system by hydrating pt. with solutions, strain all urine to collect stone for analysis, lithotripsy for lg. stones

signs/symptoms: frequency and urgenty of urination, burning sensation in urethra during urination, suprapubic discomfort, constant pressure feeling, dark cloudy or odorous urine, fatique and anorexia, possible blood in urine
Prevention: drink 8-10 glasses of water daily, always wipe from front to back, take showers rather than baths, void immediately after sexual interrcourse, wear underwear with a cotton crotch, avoid tight and restrictive clothing on lower half of body
Tx/Nursing Interventions: urine cluture and sensitivity test, administer antibiotics as ordered, continue preventive measures, drink 2-3 glasses of cranberry juice a day (or pills)

can happen within only a couple of days
Signs/symptoms; muscle wasting (decrease in size) or muscle weakness
Prevention: ambulate with assistance at least 3-4 times a day, ROM daily and muscle activities against resistance, weight bearing position on a tilt table if needed, body postitions should always be in correct anatomical alignment, change position at least every 2 hours
Tx/nursing interventions: physical therapy, prevention measures

sign/symptoms: joint remain permanently i contracted positions, limit mobility, can begin only within a few days of immobility
Prevention: ambulate with assistance 3-4 times a day, daily ROM and muscle activities against resistance, body positions should always be in correct alignment (use rolls or pillows), change positions at least every 2 hours
Tx/Nursing interventions: prevention is the key because it may be irreversible, physical therapy

signs/symptoms: plantar flexion of foot, difficulty walking
Prevention: foot support (boot) while in bed, keep top bedding off the patients lower extremities (cradle),
Tx/nursing interventions:prevention is the key (may be irreversible), physical therapy

signs/symptoms: none until fracture occurs
Prevention: weight bearing activities, tilt table if needed for weight bearing, calcium supplements
Tx/Nursing Interventions: preventive measures, treat fractures if they occur

Nursing interventions: if possible move pt. to sun room, cafeteria, or a change of scenery, have volunteers visit pt., provide entertainment, encourage as much self-care as possible, encourage pt. to shave, apply make-up, wear glasses etc., maintain night sleep hours

intact skin with non-blanched rednesss of a localized area, keep pressure off that area

partial thickness loss of dermis presenting as a shallow open ulcer with red, pink wound
this will probably need a dressing

full thickness loss, fat maybe visible but bone, tendon, and muscle is not exposed

full thickness loss with possible bone, tendon, or muscle exposed or damage, slough or eschar maybe present as well as undermining or tunneling

full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, brown) and/or eschar (tan, brown, or black) in the wound bed
until this has been removed the true depth/stage cannot be determined

purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue.
The area may be preceded by tissue that is painful, firm, mushy, boggy, warm or cool, as compared to adjacent tissue

mobility, nutrition, hydration, moisture on skin, mental status, age

turning/repositioning, adequate nutrition and hydration, hygiene, frequent skin assessment, monitor casts, braces closely, pads, pillows

assess daily (norton, braden scale), measure depth, width, length, monitor drainage and odor, and color of wound bed and surrounding tissues, monitor for eschar and for improvement or deterioration

use pressure relieving devices, dressing changes, debridement, antibiotics, nutrition

daily (Q shift or as ordered), width, depth, length, drainage and odor, wound bed color, and type of dressing

blanchable reddening (becomes pale and white when pressure is applied then returns to red) of the skin that occurs when pressure is removed.
It is not a pressure ulcer because once pt. has been repostioned any reddened area should fade within 60-90 minutes

risk factors: sexually active women, use of diaphragms for contraception, postmenopausal women, indwelling catheter, diabetes mellitus history, elderly people
Prevention: drink 8-10 glasses water, wipe front to bakc, take showers not baths, drink 2 glasses before and after sex, void immediately after sex, wear cotton crotch underwear, avoid tight and restrictive clothing on lower half or body, can drink cranberry or blueberry juice daily

types: stress, urge, mixed
Prevention: kegel, lose weight, avoid heavy lifting, timing associated with drinking

involuntary loss of urine related to an increase in intra-abdominal pressure: cough, sneeze, laugh, some physical activity, childbirth, menopause, obesity, straining due to constipation

involuntary loss of urine that occurs soon after feeling an urgent need to void, pt. urinate before getting to the toilet and an inabilty to suppress the need to urinate

risk factors: secondary to anesthesia, urethral obstruction (stones, tumors, prostate), surgical or childbirth trauma, innervation alterations, medication side effects, anxiety
Prevention: limit amount of time pt. has a catheter, monitor for small (50 mL) frequent voids, treat underlying cause

involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel, usually permanent and urinates through a stoma, it cannot be voluntarily controlled, uses a bag

uses a section of the intestine to create an internal reservoir that holds urine, external outlet must be catheterized at regular intervals to drain the urine, no bag

the bladder neck is closed and the appendix is used to gain access to the bladder from the skin surface. One end of the appendix is brought to the surface and used as a stoma, the other end is tunneled into the bladder. must intermittently cath. the bladder via the stoma. No bag