funds exam 3
High gastric residual exceeds with tube feeding
Notify health care provider to determine if you need to hold feedings; Maintain patient in semi-Fowler's position (at least 30 degrees); Reassess residual volume 1 hour
complications with feeding tubes
The feeding tube becomes clogged; Patient develops nausea and vomiting; High gastric residual exceeds; hyperglycemia; Patient develops diarrhea three times or more in 24 hours; Aspiration of formula; Skin Irritation around tubing site
nasogastric tube
tube inserted through the nose into the stomach
impaction
unable to pass stool
Symptoms of lower UTI
urgency, burning, itching cloudy, foul smelling; in older adults: confusion
Sengstaken-Blakemore
used when tamponade is needed; do not aspirate or suction
Kidneys
remove waste from the blood to form urine
bladder
reservoir for urine until the urge to urinate develops
plan
set goals of care and desired outcomes and identify appropriate nursing actions
example of psychomotor
showing how they use insulin
Tap water enemas
stimulates evacuation, never repeated due to potential water toxicity
NG and NJ tubes upper digestion located in
stomach
esophagus
transports food to stomach
ileostomy
no colon; liquid stools; malnutrition and dehydration are likely
Decreasing drinking 2 hours before bedtime decreases risk of
nocturia
Pharynx
swallows
motivation to learn
the patient's desire or willingness to learn
Urethra
urine travels from the bladder and exits through the urethral meatus
A nurse is preparing to instill and enteral feeding to a client with a NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure?
verify the placement of the tube
when should teaching begin
on admission
stoma should be
red
Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care?
registered nurse
Descending Colostomy
right and left side of colon left; formed consistency stools
Ilius or bowel abstruction if you can hear on
right side but not left
ascending colostomy
right side of colon left; liquid stools
learning environment
safe environment that promotes learning
Normal saline enemas
safest due to equal osmotic pressure, volume stimulates peristalsis
If patient received an enema and then there is blood in their stool
this is emergent -> must bring to attention of physician
Orogastric
through the mouth and stomach
Nasointestinal
through the nose to intestine
ecoli
(from stool) most common form of UTI
Normal bowel sounds every
5-15 sec
Verifying Placement of Nasogastric Tubes
A pH between 0 to 4 is a good indication of gastric placement; chest xray
For a client with difficulty swallowing, the nurse should crush which medication?
Acetaminophen extra strength
Coping with impaired functions
Adaptive measures for patients with permanent health alterations
A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include?
Administering water after the feeding is completed
urine: odor
Ammonia in nature; Smell can change on what you eat or medication you take
UTIs
Bacteria in urinary tract; Can result from catheterization or procedure (if from catheter it is called catheter associated UTI); CAUTI
Double-barrel colostomy
Bowel is surgically cut and both ends are brought through the abdomen
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what?
Cause the device to pull away from the skin.
How can a nurse best evaluate the effectiveness of communication with a client?
Client feedback
invasive urinary examinations
Endoscopy-cystoscopy; Arteriogram (angiogram)
symptoms of upper UTI
Fever, chills, diaphoresis, flank pain, potential hematuria
assess
Gather information about the patient's condition
A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. Which type of stool should the nurse expect?
Moist and formed
Which is an abnormal finding of the urinary system?
Pain in the flank region upon hitting
which ng tubes can suction
Salem-sump and Levin
Data Documentation
The last component of a complete assessment; Legal and professional responsibility; Requires accurate and approved terminology and abbreviations
role play
affective
examples of restoration of health
anatomy and physiology of body system, medications, nutrition, diagnostic examinations, surgery
digestion ends in the
anus after you expel fecal material
Loose and liquid stools are associated with a colostomy that involves the
ascending colon
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?
assessment
hematuria
blood in the urine
pre-renal
decreased blood flow to and through kidneys
parenteral feeding
delivery of nutrients directly to the bloodstream
examples of coping with impaired functions
home care, self-care, physical therapy, occupational therapy, speech therapy, prevention of complications, and environmental alterations
r/t
how did it become
Aeb
what we are observing
Hyperactive bowel sounds
when you hear your stomach grumbling aloud
care of patient with urinary diversions
Never put foley bag on floor; Foley bag should never be above the bladder; Inspect the client's stoma regularly, keep it clean and dry;
Soapsuds enemas
Pure castile soap in tap water or normal saline, acts as an irritant to promote peristalsis
PEG tube
percutaneous endoscopic gastrostomy tube - feeding tube
implement
perform the nursing actions identified in planning
A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes
psychomotor learning
large intestine
reabsorbs some water, vitamins, and ions; forms and stores feces; primary goal elimination of waste
A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply.
"I should drink at least six glasses of water every day."; "I can include bran muffins in my breakfast daily."; "I will walk every day as part of my exercise regimen."
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse "why the water is necessary." Which of the following is an appropriate response by the nurse?
"Water helps clear the tube so it doesn't get clogged."
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?
"Wear cotton underpants."
The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen?
"With the enclosed towelettes, wipe your labia from front to back before collecting the specimen."
concept mapping
A visual representation that allows nurses to graphically illustrate the connections between a patient's health problems; Allows nurses to obtain a holistic perspective of health care needs
Factors that influence Bowel Elimination
Age; Diet; Fluid intake; Physical activity; Psychological; pregnancy; Surgery and anesthesia; medications
Continuous tube feeding
Allow formula to be admin at lower rates, usually 1.5 ml/min over a longer time usually 12-24 hours. delivered by gravity flow system or an electronic feeding pump; patients bed at 30-35 degrees so they dont aspirate
urinary retention
An accumulation of urine due to the inability of the bladder to empty; Bladder scan to check PVR- Less than 50cc is normal in adults
Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed?
Aspirate for a residual volume
When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?
Aspiration pneumonia
Care of Ostomies
Assessing the ostomy; An ostomy requires a pouch to collect fecal material; Maintenance of skin integrity; Nutritional considerations; Fluid intake; Psychological Considerations
A nurse is caring for a client in a long term care facility who is receiving enteral feedings via an NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding?
Auscultate bowel sounds; Assist the client to an upright position; Test the pH of the gastric aspirate
Medication Administration in a feeding tube
Begin and end with a 30 mL tap water flush; Flush -> Med -> Flush; Administer one medication at a time and flush in between each medication
A client has a surgically created colostomy. What is the most effective nursing intervention initially to help the client accept the colostomy?
Begin to teach self-care of the colostomy by introducing equipment.
Noninvasive urinary examinations
Bladder scanner; Abdominal x-ray (KUB); CT scan abdomen; IVP (intravenous pyelogram); Renal US
Guaiac Fecal Occult Blood tests
Checking for blood in stool bcuz it may be indicative of a GI bleed; if it turns blue its positive; if test is positive Xray or CT if they don't show anything then colonoscopy and relay to physician immediately
The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?
Checking for residual stomach contents
affective
Deals with expression of feelings and acceptance of attitudes, opinions, or values
Specific diseases that affect urination
Diabetes mellitus, multiple sclerosis, BPH, Alzheimer's disease, Parkinson's disease, and degenerative joint disease.
urinary diversions
Diversion of urine to external source
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus (gas) from the stoma. What is the nurses initial action?
Document assessment
A client has surgery for an abdominal cholecystectomy and returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first?
Ensure that all tubes are attached to collection devices
After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention?
Evaluating the client's ability to care for the ileostomy
A client recently had surgery to create and ileostomy. The nurse assesses the client 3 days post-operative for which most frequent complication of this type of surgery?
Fluid and electrolyte imbalance
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
Fresh Fruit and whole wheat toast
restoration of health
Helping injured or ill patients regain their previous level of functioning - Teaching of family
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings?
Hypotension; Fever; Poor skin turgor
diagnose
Identify the patient's problems
cognitive
Includes all intellectual behaviors and requires thinking
bedside commode
Needs to be clean tub, these are for collection
A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?
Institute measures to prevent constipation.
A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error?
Interpreting
urinary incontinence
Involuntary leakage of urine; Cognitive or behavioral decline; Kegel exercise to help fix it; women more likely; likely when pregnant; in men BPH can cause this; mobility, stroke, and medications may cause this; not a normal part of aging
psychomotor
Involves acquiring skills that require integration of mental and muscular activity
pyelonephritis
Kidney infection; UTI going long periods of time without being treated
Which nursing action is a part of the evaluation phase of the critical thinking process?
Looking at all the situations objectively; Using several criteria to determine the effectiveness of a nursing intervention
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
Lower the enema fluid container bcuz it will more slowly go in; Stop it if cramping doesn't get better after lowering the enema fluid container
Hyperglycemia with tube feeding
Measure finger-stick glucose every 6 hours, until maximum administration rate is attained and tolerated for 24 hours
insertion of nasogastric tube
Measure from tip of nose to ear and then down to xyphoid process document in cm
different types of enteral feeding
Orogastric; Nasogastric; Nasointestinal; Gastrostomy; Jejunostomy
When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?
Paralytic ileus
A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report?
Projectile vomiting
Skin Irritation around tubing site with tube feeding
Provide a skin barrier for any drainage at the site; Monitor the tube's placement
health promotion and illness prevention
Providing information to allow patients access to healthier lifestyle
End colostomy
Proximal end forms stoma and distal end is removed or sewn closed; Patient can have it reversed if there is enough intestine left
A healthcare provider prescribes intermittent nasogastric tube feedings to supplement a client's oral nutritional intake. Which hazard associated with a nasogastric tube feeding will be reduced if the nurse administers this feeding over 30 to 60 minutes?
Regurgitation
After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube to negative pressure. What does the nurse explain is the purpose of this tube?
Removing fluids and gas from the upper gastrointestinal tract
A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?
Rise of formula in the tube
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?
Sequence of steps used to meet the client's needs
A nurse is caring for a client who is receiving continuous tube feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feedings?
Stop the feeding
Can hinder bowel movements
Surgery; Stress; immobility
Loop colostomy
Temporary in the transverse colon; To give body a break; Not enough bowel
During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which reply by the nurse is best?
To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours."
urine: clarity
Transparent unless pathology is present
Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter?
Tubing luer-lok port
most common health care-acquired infections
UTI
Indications for Use of Bladder Scanner
Urinary frequency; Absent or decreased urine output; Bladder distention; Inability to void; Establishing intermittent catheterization schedule
The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care?
Urinary tract infection
What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen?
Urinate small amount, stop flow, fill half of cup
Intermittent urethral catheters
Used to drain the bladder for shorter periods (5 to 10 minutes)
indwelling urethral catheter
Used when a catheter is to remain in place for continuous drainage; Designed using an inflated balloon so that it does not slip out of the bladder; Should not stay longer than necessary
Bowel Assessment
Usual elimination pattern; Description of stool; Changes in appetite; Diet hx; Intake; Hx of surgeries; Medication hx
removal of an indwelling catheter
Want to remove catheter ASAP - Nurse sensitive indicator; Removal of the catheter should not cause any patient discomfort; Increase fluid intake; Monitor voiding
Fleet
a commercially prepared hypertonic enema
Jejunostomy
a tube that is placed surgically or by laparoscopy through the abdominal wall into the jejunum for long-term nutritional support; long term
Problem-oriented approach
honing into the problem
Pancreas
hormones regulate blood glucose levels; bicarbonate neutralize stomach acid
Which step in the nursing process would involve promoting a safe environment for the client?
implementation
Dobhoff
is mostly used for enteral feedings in patients who are at increased risk for aspiration, such as those with absent or diminished gag reflex or severe gastroesophageal reflux disease (GERD); do not aspirate or suction
Post-void residual (PVR)
is the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization
Hypoactive bowel sounds
longer than 15 sec
Hypertonic solutions enemas
low volume, good for clients that cannot tolerate high-volume enemas; Good for smaller patients
Oil retention enemas
lubricates the rectum and colon for easier passage of stool
Transverse Colostomy
middle of colon missing; liquid stool
digestion begins in the
mouth with breakdown of food
levin
must be connected to suction to low suction to prevent gastric irritation; also drains fluid and gas from stomach; can suction
24 hour urine collection
must be kept on ice or in frig
If you can't hear bowel sounds
must notify physician
Salem-Sump
nasogastric small vent tube within a large suction tube for decompressing the stomach; most common; can suction
sodium affects
nervous system
sputum
not spit, more hearty than spit
Indications for Enteral feeding
Critical illness/trauma; Neurological and muscular disorders; GI disorders; Muscular disorders; Cancer that affects head, neck, or GI tract; Inadequate oral intake
demonstration
psychomotor
Patient develops diarrhea three times or more in 24 hours: indicates possible intolerance with tube feeding
notify health care provider; one of the biggest side effects of tube feeding
anus
opening for elimination of feces
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
planning
different types of ng tubes
salem-sump, duo, dobhoff, levin, Sengstaken-Blakemore
salivary glands
saliva moistens and lubricates food, amylase digests carbohydrates
stomach
stores and churns food; HCl activates enzymes, breaks up food, kills germs; mucus protects stomach wall; limited absorption
The best indicator if whether or not a patient is tolerating tube feeding is
the amount of residual
Fecal Incontinence
the inability to control the passage of feces and gas through the anus; if someone is super sick or cognitive deficient
Palpate bowel sounds
right lower, right upper, left upper, left lower
steps for collecting urine culture from indwelling catheter
1.Kink off tubing that goes into bag 2.After you see urine is backed up you wipe port with alcohol wipe 3.Empty 10cc of urine into collection typically you need 30cc 4.Rewipe the port with alcohol wipe
If patient is suspected to have TB you need to
collect 3 samples of sputum
small intestine
completes digestion; mucus protects gut wall; absorbs nutrients, most water; Primary location of nutrients and water absorbtion
A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client?
Electrolyte imbalances
enemas
Never do enemas more than once; Need order for enemas; patients should lie on side
Which features distinguish nursing diagnoses from medical diagnoses?
Nursing diagnoses involve the client when possible; nursing diagnoses involve the sorting of health problems within the nursing domain; Nursing diagnoses involve clinical judgment about the client's response to health problems.
enteral feeding
Nutrients supplied to the gastrointestinal tract orally or by feeding tube.
A client has a nasogastric feeding tube inserted, and the healthcare provider prescribes the feeding to be instituted immediately. What should the nurse do first?
Obtain an x-ray to verify that the tube is in the stomach.
A nurse obtains daily stool specimens for a client with chronic bowel inflammation. What does the nurse determine is the reason these stool examinations were prescribed?
Occult blood
Aspiration of formula - into lungs instead of stomach with tube feeding
Stop the feeding; Turn client to the side; Suction the airway; Provide O2 if indicated; Monitor for elevated temp; Monitor for decreased O2 or increased respiratory rate; Auscultate breath sounds; Notify the provider; Obtain a chest x-ray
Bowel Diversions
Temporary or permanent artificial opening in the abdominal wall
What should the nurse include in dietary teaching for a client with a colostomy?
The diet should be adjusted to include foods that result in manageable stools.
who are at the greatest risk for low health literacy
The elderly, minorities, immigrants, persons of low income, and people with chronic mental and/or physical health conditions
A school nurse is asked to develop a program for teachers about infection control, especially focusing on hand washing technique. What is the most effective way for the nurse to evaluate what the teachers have learned?
Watch the teachers demonstrate infection control techniques.
A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client?
Weight gain
if a Patient develops nausea and vomiting on a feeding tube
Withhold tube feeding, and notify physician or health care provider
liver
breaks down and builds up many biological molecules; stores vitamins and iron; destroys old blood cells; destroys poisons; produces bile to aid digestion
mouth
breaks up food particles, assists in producing spoken language
Ileostomy or colonoscopy
can possibly be reversed
other enemas
carminative and Kayexalate (can also be used if patients have higher levels of potassium)
clean catch
clean self start to urinate and then catch it in the middle bcuz women have short urethras so more bacteria will be in the beginning so the midstream will come from the bladder
discussion
cognitive
ability to learn
depends on physical and cognitive abilities, developmental level, physical wellness, thought processes
evaluate
determine if goals and expected outcomes are achieved
Gastrostomy
directly into the stomach
renal
disease condition of the renal tissue
duo ng tube
do not aspirate or suction
examples of Maintenance and promotion of health and illness prevention
first aid, smoking/alcohol/substance abuse, stress management, nutrition, exercise, health screenings
sigmoid colostomy
formed stool; full colon besides rectum
If patient leaves sample of urine on back of toilet and its been sitting their for more than 30 min
get rid of it and get a new sample
Common Bowel Elimination Problems
constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids
intermittent or bolus feeding
gradual instillation of liquid nourishment four to six times a day
post-renal
obstruction in the lower urinary tract that prevents urine flow from the kidneys
gallbladder
stores and concentrates bile
rectum
stores and expels feces
Hemorrhoids
swollen, twisted, varicose veins in the rectal region; usually larger people or women who just gave birth
if stoma is blue or purple
that is emergent; call physician immediately
if patient has a urinary catheter
they must void before being discharged
nasogastric
through the nose to the stomach
Ureters
transport urine from the kidneys to the bladder
Never collect urine from
urinary catheter unless it is a new bag
Common urinary problems
urinary retention, UTIs, urinary incontinence, urinary diversions, hematuria, pyelonephritis
Nursing dx
what is diagnosed
