Foundations Exam 3 Questions

1. Why are drains used in wounds?

If there is a large amount of drainage, promote healing.

What is an enema?

Installation of a solution into the rectum and sigmoid colon.

What are some important things to assess prior to giving enemas?

Last bowel movement, normal bowel patterns, hemorrhoids, mobility, abdominal pain, external sphincter control

How does an oil retention enema work?

Oil retention- lubricate the rectum and colon. Feces absorb the oil and become softer and easier to pass.

What is the greatest risk related to having a feeding tube?

the patient aspirating (getting food or stomach fluids in their lungs)

What are prevention strategies for pressure ulcers?

turn patient often use positioning devices HOB at low degree of elevation clean skin when soiled elevated heels off bed avoid massaging red areas moisturize dry skin

What part of the intestine are ostomies usually created?

Ileum, colon (ascending, transverse, sigmoid)

1. What are advantages for IVs?

Allows for direct access to vascular system. This means quick access to administer therapy to patients. Able to give patients therapy without giving a shot, or PO medications.

How does a normal saline- infusion work?

Normal Saline-Infusion of saline stimulates peristalsis. Safest solution to use.

1. What are factors that influence the healing of wounds?

Nutrition, tissue perfusion, infection, age

1. What are the 4 different IV devices discussed in class?

Peripheral line, central line, PICC line, port a cath.

What are some ostomy complications

Peristomal skin damage, fungal infection, stoma becomes necrotic, circulation issues at stoma or other organs involved in the ostomy construction.

How to you control the rate of administration of an enema?

Raise and lower the bag to decrease or increase rate of flow.

How does a soap suds enema work? what type of soap is used?

Soap Suds-creates the effect of intestinal irritation to stimulate peristalsis. What type of soap is used? Pure castile soap

1. What is infiltration? .

When IV fluids enter the subcutaneous tissue around the site. Edema, coolness, pallor.

While changing a patient's dressing, you noticed a foul odor and yellow drainage, what's happening?

Possibly an infection. Prepare to assess for signs and symptoms of infection and administer antibiotics

define hemorrhoids

-dilated, engorged veins in the lining of the rectum. Internal or external.

Why are enemas used?

Promote defecation by stimulating peristalsis

What is a cleansing enema?

Promote the complete evacuation of feces from the colon. Stimulate peristalsis through infusion of large volume of solution or irritation of colon's mucosa. Include tap water, NS, soapsuds, hypertonic saline.

What is the correct volume for a cleansing enema for an adult?

750ml-1000ml

What can the nurse do to promote normal defecation of a patient?

Allow patient to use toilet in the sitting position. Help position patients comfortably on a bedpan. Give patient privacy. Encourage fluids, proper diet

1. What is a saline lock and what are the advantages to a saline lock?

Also called heparin lock or J loop; able to administer medications or fluids without having to have IV tubing connected at all times; increased mobility, safety, and comfort for patient.

1. What locations would you want to avoid placing an IV?

Any signs of infection, infiltration, or thrombosis; Extremities on same side as a mastectomy; Extremities that are flaccid.

How does a carminative enema work? what are the ingredients of this enema?

Carminative - improve ability to pass flatus, provide relief from gaseous distention. What are the ingredients of this enema? Magnesium, glycerin, water

When assessing a patient, what are the characteristics used to describe feces?

Color, odor, consistency, frequency, amount, shape, constituents

Differentiate between the following: Colostomy- Ileostomy- Urostomy-

Colostomy-surgical opening created in the colon Ileostomy-surgical opening created in the ileum Urostomy-surgical opening created in the ureters

1. What can you do to treat infiltration or phlebitis?

D/C IV line and most likely insert another line in a different location, raise extremity to promote venous drainage and decrease edema, heat therapy, call health care provider, document.

1. What are challenges or considerations for IVs?

Direct access to vascular system means quick acting, therefore, reactions to infusion occur quickly. Infection. Pain.

Why is skin integrity important around the stoma?

Effluent can irritate the skin around the stoma.

1. What types of things can be administered through an IV?

Fluids, medication, total parenteral nutrition (TPN), blood.

1. What are some complications of wound healing?

Hemorrhage (hematoma), infection, dehiscence, evisceration.

How does a hypertonic enema work?

Hypertonic- Pulls fluid out of interstitial spaces. Most beneficial to clients unable to tolerate large volumes of fluid. Colon fills with fluid and distention promotes defecation. Contraindicated in clients who are dehydrated and young infants.

How does the location of the ostomy affect the consistency of the stool?

Ileostomy bypasses the entire large intestine, therefore stools are frequent and liquid. Same for colostomy of ascending colon. Transverse colostomy more solid, formed stool. Sigmoid colostomy near-normal stool.

What patients would a cleansing enema be contraindicated? I

Increased intracranial pressure, glaucoma, recent rectal or prostate surgery.

Once an enema is given and the patient has had a bowel movement, what observations should the nurse make (concerning the patient and the feces)?

Inspect color, consistency and amount of stool and fluid passed, amount of flatus expelled. Assess patient for abdominal cramping, rigidity, or distention.

Differentiate between (don't need to know lots of details, just understand how alternative ostomies can vary from traditional ostomies): Kock or Indiana pouch Ileoanal pouch anastomosis

Kock or Indiana pouch-small intestine, creates a spherical reservoir, continent stoma drained with a catheter. Ileoanal pouch anastomosis-removal of colon, pouch created from end of small intestine, attach pouch to anus, continent.

1. What is the difference between primary and secondary intention?

Little tissue loss, surgical incision, skin edges approximated, infection risk low. Secondary is loss of tissue, burn, pressure ulcer, severe laceration, left open until it becomes filled with scar tissue.

Differentiate between (don't need to know lots of details, just understand how ostomies can be designed differently): Loop colostomy- End colostomy Double barrel colostomy

Loop colostomy-temporary large stoma, transverse colon, plastic rod or bridge used, bowel sutured to skin, two openings through one stoma. End colostomy-one stoma formed from proximal end of bowel, with distal portion of GI tract removed or sewn closed. Double barrel colostomy-surgically severed, two ends brought out to abdomen, two stomas.

How does a medicated enema work?

Medicated- contain drugs (antibiotics, electrolytes)

What assessments should be made when pouching an ostomy?

Observe stoma for color, swelling, trauma, healing. Assess protrusion of stoma. Measure the stoma, observe effluent, assess skin for irritation. Assess contour of abdomen, presence of scars, incisions.

1. How do the devices differ from one another? Peripheral-short term Central line-long term, surgery; PICC Port-long term

Peripheral-short term, increased complications, RN can place; Central line-long term, surgery; PICC-long term (usually less than central line), can be placed at bedside by special trained RN; Port-long term, surgery, less maintenance than above.

What should the nurse document after an enema administration?

Record type and volume of enema given and characteristics of results. Report failure of client to defecate to health care provider.

What color should a "good" stoma always be?

Reddish pink and moist

1. What is the SASH method?

S=Saline A=Antibiotic or other medication (I like to think administer med) S=Saline H=Heparin

1. List and describe the various types of wound drainage.

Serous-clear watery plasma; Serosanguineous-pale, red, watery, mixture of clear and red; Sanguineous-bright red, indicates active bleeding; Purulent-thick, yellow, green, tan or brown

What is effluent?

Stool that is discharged from an ostomy.

How does a tap water enemas work? what is the potential hazard of this enema?

Tap water-Water escapes from the bowel lumen into interstitial spaces. The infused volume stimulates defecation before large amounts of water leave the bowel. What is a potential hazard of this enema? Water toxicity or circulatory overload if the body absorbs large amounts of water.

Define ostomy

Temporary or permanent surgical opening created where the ends of the intestine are brought through the abdominal wall to create a stoma.

What is a "skin barrier"?

Used to minimize chance of skin damage around the stoma from effluent. Also used to aid adherence of ostomy pouches to the skin. Includes wafers, pastes, powders, and liquid film.

What are some unexpected outcomes of enema administration and what should the nurse do?

a. Abdomen becomes rigid and distended-stop enema if still instilling; Notify the health care provider, and obtain vitals. b. Abdominal pain or cramping-slow rate of instillation. c. Bleeding occurs-Stop enema administration, notify health care provider, and obtain vitals.

What is an appropriate nursing action to prevent a complication of NG tube feedings?

administer feedings at an appropriate rate that doesn't cause the patient discomfort

Define stoma

artificial opening in the abdominal wall.

What should you do a drain stops draining?

check to make sure the auction on the drain is activated check tubing for clot & notify the doc

Why are transparent dressings used?

clean wounds with little to no drainage small superficial wounds, protection of high risk skin

What is a wound vac?

device that assist in wound closure by applying localized negative pressure to draw the edges of a wound together evacuates fluid

What are the risk factors to pressure ulcer formation?

elderly immobilized malnourished obese unresponsive incontinent restrained surgery longer than 3 hrs immunosuppressed neuro deficits

define flatulence

gas accumulates in the lumen of the intestines, bowel wall stretches, and distends.

The patient begins to cough and choke as the nurse is inserting the NG tube. What is the best action for the nurse to take at this time?

give the patient water or ice chips to try and swallow.

If the feeding tube has migrated what assessment findings would you expect to find?

if it had migrated to the lungs the patient might be turning blue,

The patient is receiving a continuous enteral feeding. What assessment finding would require follow-up?

if the patient is absorbing the food. and having good weight gaini

define incontinence

inability to control passage of feces and gas from the anus.

Define Diarrhea-

increase in the number of stools and passage of liquid, unformed feces. Intestinal contents pass through intestines to quickly to allow for usual absorption of fluid and nutrients.

1. What is phlebitis? How does it differ from infiltration?

inflammation of the vein. Pain, edema, erythema, increased skin temp, redness along path of vein.

If the nurse suspects the NG feeding tube has migrated, what should the nurse do?

inform the physician and document the length at which it is at now. There should be an xray to confirm where the tube is

define constipation & causes

infrequent bowel movements, difficulty passing stools, excessive straining, inability to defecate at will, and hard feces. i. Causes-improper diet, reduced fluid intake, lack of exercise, medications. Impaction-collection of hardened feces, wedged in the rectum i. Causes-dehydration, debilitated patients, confusion. ii. Treatment-digital examination and removal of impacted mass.

The student nurse is preparing to administer medication through a feeding tube, what things would you need to keep in mind about medication administration through a feeding tube?

keep 6 rights. never directly add meds to tube. mix them with a solution. check for residual. flush, administer, flush

The nurse is going to administer an intermittent tube feeding. Since the patient's feeding tube has been in place for 3 days, what should the nurse do prior to administering the feeding?.

make sure it Is in proper position?

What are the reasons dressings are used?

protects a wound from contamination aids in hemostatis promotes healing by absorbing drainage support or splints the wound site protects client from seeing the wound promotes thermal insulation of the wound surface provide moist healing environment

Why is it important to have the tube feeding at room temperature?

so that it doesn't burn the patient or cause discomfort

What are the stages of pressure ulcers?

stage 1: nonblancable erythema of intact skin stage 2: partial thickness loss involving epidermis and/or dermis stage 3: full thickness skin loss, damage to subcutaneous tissue stage 4: full thickness skin loss, extensive damage to muscle or bone

Why are moist to dry dressings used?

wounds require deriding dressing dries and sticks to underlying tissue and debridement occurs during removal