NUR 167 CHP 26,30 Study Guide

define Distention

The stretching out of intestinal walls that accommodates fecal material as it moves through the sigmoid colon into the rectum, eventually leading to the defecation reflex.

When do you provide bowel training

When the patient arises each day After each meal Any time the patient says that his or her bowels have to move

True or false Nursing interventions for diarrhea include modifying food and fluid intake, providing probiotics, and administering prescribed medications.

True

True or false Fecal incontinence is the inability to control the bowels. Nursing interventions for this include treating the underlying cause if due to diarrhea, administering medications as ordered, bowel training, providing skin care, and providing emotional support.

True

what are the phases of the healing process?

inflammatory phase reconstruction phase maturation phase

What are the nursing interventions for fecal impaction?

it usually requires digital removal before administering a cleansing enema. This involves insertion of the gloved index finger into the anus to manually break the fecal mass into small pieces and remove them from the rectum. This procedure may be embarrassing as well as painful for the patient. To make the procedure less uncomfortable, it is helpful to instill an oil retention enema about 1 hour prior to digital removal. Some patients may even require mild pain medication to better tolerate the procedure.

What will you expect the health-care provider to order when you call to report signs of infection in a surgical wound?

vancomycin

Define laceration.

A laceration is an open wound made by the accidental cutting or tearing of tissue. Common sources of lacerations include knives and pieces of glass and metal. Unlike a surgical incision, it has jagged edges, often making closure of the wound more difficult and less aesthetically pleasing

define siphon enema

A sterile water enema used in a postsurgical patient to remove gas from the bowel.

what type of wounds are considered closed?

A wound in which the skin remains intact is considered a closed wound.

The nurse is preparing to collect a stool specimen ordered by the physician. Which client and reason defines the need for the specimen? 1. A client traveled outside the country and has lost weight since returning. 2. A client experiences bloating and flatus after consuming dairy products. 3. A client with hemorrhoids notices streaks of blood on the toilet paper. 4. A client is on iron therapy for anemia and the stools are dark in color.

ANS-A client traveled outside the country and has lost weight since returning. This is correct. The client who traveled outside the country and is now experiencing weight loss should be checked for parasites and/or parasite ova. The presence of either can be confirmed by microscopic examination of a stool specimen.

An older adult client is admitted to the hospital for a bowel obstruction, and part of the client's duodenum was surgically removed. Which condition does the nurse recognize as a potential problem for the client? 1. Limited stomach capacity 2. Duodenum-produced enzymes are not available 3. Poor absorption from shortening of the colon 4. A decreased ability to absorb nutrients

ANS-A decreased ability to absorb nutrients This is correct. Absorption of nutrients begins in the duodenum; without the duodenum, absorption of nutrients will decrease.

The nurse is assessing a client immediately after the placement of a colostomy. Which assessment finding does the nurse expect to see? 1. The presence of effluence in the colostomy appliance 2. A stoma that is red, shiny, moist, and beefy in appearance 3. A slight skin irritation found under the appliance wafer 4. Drainage of mucus and purulent liquid from the stoma

ANS-A stoma that is red, shiny, moist, and beefy in appearance This is correct. The nurse should expect to see a stoma that is red, shiny, and moist. The beefy appearance is related to edema and should diminish with time.

The nurse is discussing ways to help prevent constipation. Which information is most important for the nurse to share? 1. Do not ignore the defecation reflex. 2. Plan to defecate prior to the next meal. 3. Decrease fluids if fiber is increased. 4. Use laxatives to better time defecation.

ANS-Do not ignore the defecation reflex. This is incorrect. It is not accurate to expect defecation to occur before the next meal. It is more realistic for the client to expect the urge to defecate with 30 to 60 minutes after eating.

The nurse is providing care for a client after surgery for repair for a penetrating wound to the abdomen. Which characteristic of the wound will make the nurse MOST vigilant for signs of infection? The object that entered the clients abdomen remained embedded until surgery The object was removed by the first responders and the wound flushes for foreign bodies The object inflicted no injury on the clients internal organs or boney structures The object was smooth nonporous mental, and a diameter less than one ince

ANS-The object that entered the clients abdomen remained embedded until surgery This is correct. The verity definition of a penetrating wound is that the object remains embedded in the tissue. The degree of damage depend son the characteristics of the penetrating object and any injury to internal structures. Because the object is left in place until surgery there is more time for pathogens to migrate into surrounding tissues. This scenario will make the nurse most vigilant for signs of infection.

The nurse is caring for multiple clients. The nurse recognizes which clients as being at greatest risk for development of pressure injuries? Select all that apply. 1. A 32-year-old client who is quadriplegic 2. A 59-year-old one day postoperative 3. A 66-year-old with diabetes mellitus 4. A 40-year-old with bilateral leg casts 5. An 80-year-old with thin and inelastic skin

1. A 32-year-old client who is quadriplegic 3. A 66-year-old with diabetes mellitus 4. A 40-year-old with bilateral leg casts 5. An 80-year-old with thin and inelastic skin This is correct. A client who is a quadriplegic is at high risk for pressure injury due to the total inability to move independently. In addition, decreased sensation contributes to the risk.This is correct. Clients who are at increased risk for development of a pressure injury includes persons who have chronic metabolic conditions such as diabetes mellitus, which impairs circulation and healing. This is correct. A client with bilateral leg casts is a risk for development of pressure injury because of the restrictive, and possibly irritating, nature of the client's treatment. This is correct. Clients who are at increased risk for development of a pressure injury include those who have very thin and inelastic skin, which is common among elderly clients.

define maturation phase

-begins on day 21 -can last for 1-2 yrs after injury also known as the remodeling phase, occurs when the wound contracts and the scar strengthens. Initially, a healing ridge develops just beneath the incision and approximately 1 cm on either side.

A client who is 3 days postoperative states a slight increase in pain level from the day before. Which additional assessment will the nurse make to determine the condition of the client's wound? Select all that apply. 1. Skin turgor 2. Color of drainage 3. Type of closure 4. Odor of drainage 5. Closed or open

2. Color of drainage 3. Type of closure 4. Odor of drainage 5. Closed or open This is correct. The color of any existing drainage from a wound is an important assessment and can indicate bleeding or infection. This is correct. The method used to close a wound is an important assessment. The condition of the closure method is also important. This is correct. The presence of drainage should be carefully assessed. The nurse needs to determine if the drainage is appropriate; i.e., sanguineous or purulent. All drainage should be assessed for odor. This is correct. It is important for the nurse to assess if the suture is open or closed. Poorly approximated wound edges can be an early sign of complications.

The nurse provides care to an obese client who is at risk for pressure injuries. The client's plan of care places the client on pressure injury prevention. Which actions should the nurse be implementing? Select all that apply. 1. Turning the client from side position to prone position every 2 hours 2. Maintaining a bed with clean, dry linens that are free of wrinkles 3. Encouraging an adequate fluid intake and a nutritious diet 4. Performing hygiene care as needed to keep skin clean and moist 5. Assessing the client's skin every 2 hours for indications of breakdown

2. Maintaining a bed with clean, dry linens that are free of wrinkles 3. Encouraging an adequate fluid intake and a nutritious diet 5. Assessing the client's skin every 2 hours for indications of breakdown This is correct. To reduce the risk for a pressure injury, the nurse should make sure the client's bed linens are clean, dry, and free of wrinkles. This is correct. To reduce the risk for a pressure injury, the client should be encouraged to be well hydrated and to consume a diet that is nutritious. The nurse should monitor that the client is being provided needed protein, vitamins, and minerals. This is correct. To reduce the risk for a pressure injury, the nurse should assess the client's skin every 2 hours for indications of breakdown.

The nurse is providing care for a client with a surgical wound exhibiting signs of delayed healing but no redness or drainage. The physician orders a culture of the wound. Which condition does the nurse understand the culture will reveal? 1. A necrotic wound 2. A colonized wound 3. An infected wound 4. A closed wound

A colonized wound This is correct. A colonized wound is one with a high number of microorganisms but without infection. The condition is suspected because of delayed healing. The culture will identify the microorganism so that the physician can order the most effective antibiotic to prevent infection from developing

define contusions

A contusion is a closed discolored wound caused by blunt trauma, better known as a bruise.

Ileostomy

A diversion created in the ileum portion of the small intestine, type of stoma is created at the end of the ileum due to the complete removal of the colon. Effluent from an ileostomy is liquid because the majority of the water is not absorbed until it reaches the colon, continually drains from the stoma, which requires that the patient constantly wear a pouch and empty it often

A client arrives at a clinic with a wound received by an ax two days ago while cutting firewood. The client states that initial wound care was performed at home. The nurse assesses a deep open wound on the lower leg, which will need surgical closure. Which complication does the nurse recognize is a probability for this client? 1. Delayed healing because of the passage of time before surgery 2. The possibility of lower limb amputation due to muscle damage 3. A high risk for infection from Staphylococcus aureus contamination 4. A wound that will be treated by using a secondary intention closure

A high risk for infection from Staphylococcus aureus contamination This is correct. Because of the passage of time, the description of the wound, and the fact that initial wound care occurred at home, this client has a high probability of developing an infection from Staphylococcus aureus. Because this bacterium is present on everyone's skin, wound contamination is likely.

define Constipation

A state of having less-frequent, hard, formed stools that are difficult to expel.

Define Guaiac test

A test used to determine the presence of occult blood in the bowel.

define Kayexalate enema

A type of enema administered for the purpose of lowering a very high potassium

Colostomy

A will have a single opening, termed a single-barreled or end stoma, if the distal colon is permanently removed, as with cancer of the descending or sigmoid colon, he distal portion of the colon may not need to be removed, only allowed time to rest and heal the diseased portion, the colon may be completely incised, or cut into two pieces. Both ends of the dissected colon are brought to the surface and two stomas are formed, a proximal and a distal stoma

Which types of wounds are considered open?

A wound in which the skin integrity has been breached is an open wound.

A nurse explains to a client that it is wise to avoid taking a laxative every day because of the problems it can cause. The client demonstrates understanding by saying laxative abuse can result in which condition? Select all that apply. 1. Fluid and electrolyte imbalances 2. The need for increasing dosages of laxative 3. Loss of natural contractility in the bowel 4. Increased risk for an impaction 5. Development of irritable bowel syndrome

ANS- Fluid and electrolyte imbalances The need for increasing dosages of laxative Loss of natural contractility in the bowel Increased risk for an impaction This is correct. Laxative abuse can result in diarrhea, thus increasing the risk for fluid and electrolyte imbalances. This is correct. Laxative abuse leads to the need for increasing dosages of laxatives. This is correct. Dependence on laxative-induced bowel movements results in the loss of natural contractility of the bowel, which can increase the risk for development of an impaction. This is correct. Dependence on laxative-induced bowel movements results in the loss of natural contractility of the bowel, which can increase the risk for development of an impaction.

In response to a nurse's question about bowel function, a client shares that sometimes the feces are greenish black in color. Which answer by the nurse is correct? 1. "Large amounts of dairy products can cause your stools to turn green." 2. "If you take iron tablets, your stools can become greenish black." 3. "Typically our diet has very little to do with the color of our stools." 4. "Eating green foods, such as spinach, can cause your stools to have greenish black streaks."

ANS-"Eating green foods, such as spinach, can cause your stools to have greenish black streaks." This is correct. Eating dark green vegetables, such as spinach, can cause greenish-black streaks in the stool.

The nurse is caring for a client with diabetes mellitus who has a non-healing wound on the bottom of the foot. Which assessment finding causes the nurse to conclude that the wound is likely infected with Clostridia? A crackling sensation under the skin can be felt when palpating around the wound The area surrounding the wound is dark red, swollen, and draining yellow exudate The infected area around the wound appears to be expanding to surrounding tissue The wound drainage has a strong smell of rotten grapes and appears green in color.

ANS-A crackling sensation under the skin can be felt when palpating around the wound Wounds infected with Clostridia develop a condition called gas gangrene, which causes a crackling that can be felt when the area around the wound is palpated. Gangrene is n anaerobic infection and most often occurs in the areas of poor circulation such as the lower extremities of a client with diabetes mellitus

The nurse is caring for a client who is postoperative for abdominal surgery. On assessment, the nurse notes the presence of hypoactive bowel sounds. Which nursing intervention does the nurse need to include on the client's plan of care? Select all that apply. 1. Ambulation four times a day in the hall 2. Intake of 8 ounces of water four times a day 3. Movement to a chair for meals 4. Laxative administration at bedtime 5. Encouragement to pass flatus

ANS-Ambulation four times a day in the hall Movement to a chair for meals Encouragement to pass flatus This is correct. Physical activity, such as getting up in a chair and ambulating, stimulates peristalsis and helps the client regain bowel function.This is correct. Physical activity, such as getting up in a chair and ambulating, stimulates peristalsis and helps the client regain bowel function.This is correct. The client is likely to have flatus following bowel surgery and passing the flatus will promote normal bowel peristalsis. The nurse knows that clients often need to be encouraged to pass flatus.

The nurse is assigned to provide client care to multiple clients. Which client does the nurse recognize as being at greatest risk for a fecal impaction? 1. An older adult client with poor fluid intake and a history of laxative abuse. 2. A client who is four days postoperative receiving an opioid drug for pain. 3. A client admitted for dehydration related to vomiting, receiving IV therapy. 4. A client ordered on bedrest for a pulmonary embolus who eats a regular diet.

ANS-An older adult client with poor fluid intake and a history of laxative abuse. This is correct. The older adult client with a history of laxative abuse and a poor fluid intake is at greatest risk for fecal impaction. The client has three risk factors: age, decreased colon tone, and deficient fluid intake.

While providing care for an older adult client, the nurse learns that the client has had only small, watery stools for several days. Which is the nurse's priority in providing care for this client? 1. Assess the client for an impaction. 2. Call the primary care physician and get an order for a laxative. 3. Administer medication to slow the diarrhea. 4. Collect a stool specimen for analysis.

ANS-Assess the client for an impaction. This is correct. Older adult clients are at risk for development of constipation and an impaction; small amounts of liquid stool seeps around an impaction, so the client should first be checked for an impaction.

The nurse is caring for a client admitted through the emergency department (ED) following an accident. The clients injuries include an i open fracture of the leg and multiple bruises. Which terminology will the nurse use to document the clients wounds? Close the leg injury with multiple cuts Massive bruising with broken bones Compound leg fracture with multiple contusions Puncture leg wound with surface skin scrapes

ANS-Compond leg fracture with multiple contusions This is correct . An open fracture is correctly reffered to as a compund fracture . Contusions is the terminology use for brussing, this entry is an ecample of using correct meidcal tereminiolgy

The nurse is caring for a client who has fecal incontinence. The symptoms include intermittent periods when small amounts of liquid stool are passed, followed by periods of severe constipation requiring the use of enemas to resolve. Which intervention should the nurse perform first? 1. Assess for readiness to participate in a bowel training program. 2. Teach the client about increasing fiber and fluids in the daily diet. 3. Examine the client and check for the possibility of fecal impaction. 4. Inform the client of the multiple types of incontinence products available.

ANS-Examine the client and check for the possibility of fecal impaction. This is correct. The periodic passage of small amounts of liquid stool is a cardinal indication that the client may have a fecal impaction. The alternating periods of constipation are expected. The nurse needs to first assess for this condition.

The nurse assists a client to the bathroom, and notices that the client's stool is clay colored. The client tells the nurse that this has occurred off and on for the last month or two. Which condition does the nurse suspect? 1. Poorly balanced diet 2. Gallstones or liver problems 3. History of gastrointestinal (GI) bleeding 4. Poor fluid intake

ANS-Gallstones or liver problems This is correct. Gallstones or liver disease can prevent bile from entering the small intestine, and bile gives feces color.

The nurse is preparing to administer an ordered enema to a client. Which intervention by the nurse is correct for this procedure? 1. Warm the water to a temperature between 115°F and 125°F. 2. Insert the tip of the enema tube approximately 3 to 4 inches into the rectum. 3. Give the enema while the client is in a sitting position on the toilet. 4. Have the client lie on the right side to facilitate the instillation of fluid.

ANS-Insert the tip of the enema tube approximately 3 to 4 inches into the rectum. This is correct. Inserting the tip of the enema tubing farther than 3 to 4 inches could damage the intestinal mucosa or perforate the colon.

While inspecting a client's stool, a nurse notices a small amount of black, tarry blood with a distinctive old-blood odor that appears to have been partially digested. Which term does the nurses use to describe the client's stool? 1. Melena 2. Occult blood 3. Frank blood 4. Steatorrhea

ANS-Melena This is correct. Smaller amounts of blood that come from higher in the digestive tract, such as the stomach, having been partially digested, will have a distinctive old-blood odor and a black, tarry appearance known as melena.

A client has undergone diagnostic tests of the gastrointestinal (GI) system. The client, who has chronic constipation, tells the nurse the physician is concerned about peristalsis, and asks why it is important. Which information will the nurse include? 1. Peristalsis counteracts gravity to prevent food from being propelled through the GI tract too swiftly. 2. Peristalsis is movement triggered by enzymes causing food to digest quickly and prevent constipation. 3. Peristalsis is contractions of circular and longitudinal muscles that propels food through the GI tract. 4. Peristalsis is an abnormal movement of the bowel which causes intractable nausea and vomiting.

ANS-Peristalsis is contractions of circular and longitudinal muscles that propels food through the GI tract. This is correct. Peristalsis is the contraction of circular and longitudinal muscles that propels food from the esophagus to the rectum. Constipation can be a result of slow peristalsis.

A client with a known history of diverticulosis who is experiencing severe cramping and diarrhea is admitted to the hospital during the night with a diagnosis of diverticulitis. The client's pain increases, and the abdomen is distended and hard. The client has spiked a fever of 102.4°F. The nurse concludes the client may be developing a life-threatening complication and notifies the physician. Which possible complication concerns the nurse? 1. Crohn disease 2. Irritable bowel syndrome (IBS) 3. Fecal incontinence 4. Peritonitis

ANS-Peritonitis This is correct. Peritonitis is a life-threatening complication that can occur as a result of infected diverticula that perforate, allowing fecal material and bacteria to enter the sterile peritoneum.

The nurse is admitting a client and performs a focused assessment. Which techniques will result in the nurse acquiring objective data related to bowel function? 1. Ask when the client last had a bowel movement. 2. Use the diaphragm of a stethoscope to hear bowel sounds. 3. Inquire about the characteristics of feces. 4. Ask the client to describe past abdominal pain.

ANS-Use the diaphragm of a stethoscope to hear bowel sounds. This is correct. When the nurse listens with the diaphragm of the stethoscope for bowel sounds, the nurse is gathering objective data.

The nurse is providing care for a client with a newly placed ileostomy. Which comment by the client indicates a lack of acceptance for the alteration in body function? Select all that apply. 1. "I don't want to look at anything right now while it is so fresh." 2. "I know that you know what to do, so I will be quiet during care." 3. "I am still having some intense pain; I think that I need medication." 4. "I guess that I will need to ask about any dietary changes I need to make." 5. "Please teach my spouse how to perform all the care; I don't need to know."

ANS-"I don't want to look at anything right now while it is so fresh." "I know that you know what to do, so I will be quiet during care." "Please teach my spouse how to perform all the care; I don't need to know." This is correct. The client is showing a lack of acceptance by refusing to look at the stoma. The delay until healing occurs is a sign of an unhealthy attitude; there is much for the client to learn in regards to healing. This is correct. The client's willingness to allow the nurse to perform care without any participation is an indication that the client lacks acceptance.This is correct. The client is showing a lack of acceptance by refusing to look at the stoma. The delay until healing occurs is a sign of an unhealthy attitude; there is much for the client to learn in regards to healing. This is correct. The client's willingness to allow the nurse to perform care without any participation is an indication that the client lacks acceptance.

what should you avoid until after you assess the bowel sounds?

Avoid palpating the abdomen until after you have assessed the bowel sounds because palpation may stimulate bowel sounds that were not there naturally

Define E. Coli

Bacteria normally found in the bowel are referred to as enterococci. One specific bacterium from this group helps to break down food for digestion When the intestines are opened during surgery, the bacteria from the bowel can easily infect the surgical wound

The nurse is providing discharge teaching to a client who had surgery to remove a growth on the tongue. The nurse understands that the surgery site is identified as a clean-contaminated wound. Which teaching will the nurse provide? 1. The wound is considered to have been grossly contaminated during surgery. 2. Due to the location of the wound, the presence of purulent drainage is expected. 3. Mouth wounds are known to heal quickly and usually without complications. 4. Because of the normal flora in the mouth, the wound is at risk for infection.

Because of the normal flora in the mouth, the wound is at risk for infection This is correct. Because the normal flora will naturally invade a mouth incision, the surgical wound is considered clean-contaminated. The wound is also likely to be exposed to microbes from food and fluids. The wound is at risk for infection and client teaching should focus on this possibility.

Can you delegate administration of an enema to a UAP or a CNA?

Because you are held responsible for safe and competent administration of the enema, it is very important that you verify that the UAP or CNA has received specific training and is competent in performance of the skill, documented in writing for your best protection, assess the patient's condition and determine whether it is safe to have the UAP or CNA perform the skill, Make certain that the UAP or CNA clearly understands the vagal response, including the signs and symptoms and the actions to take if signs or symptoms are noted, and specifically to notify you immediately. It is also your responsibility to determine that the UAP or CNA understands appropriate steps to take to decrease the risk of perforating the intestinal wall.

which of the following describes third intention wound care? A. The wound is clean with little tissue loss .B. There is greater tissue loss and the wound edges are irregular. C. The wound is left open for a time to allow granulation tissue to form, then it is sutured closed .D. The edges are approximated and the wound is sutured closed.

C. The wound is left open for a time to allow granulation tissue to form, then it is sutured closed. An example of this is a draining wound, which is left open until the drainage ceases and then is sutured closed.

anastomosed

, surgically reconnected, and placed back into the abdominal cavity, and the abdominal wall closed

How often should you change the faceplate and appliance bag?

The faceplate is changed every 3 to 5 days or sooner if the adhesive backing begins to loosen from the skin

define Fecal incontinence

The loss of voluntary control of the rectal sphincters.

how do you keep pressure injuries from occurring?

Reposition the patient at least every 2 hours to prevent pressure and compromise of circulation to the area Keep the skin clean and dry. Assess an incontinent patient's incontinence pads or linens every hour. Keep linens free of wrinkles, which can cause further areas of increased pressure. For immobile patients, apply lotion to dry skin and assess pressure points for erythema every 1 to 2 hours. Lift patients who cannot move themselves with a draw sheet or mechanical lift rather than pulling them across the bed or chair. Remove linens from underneath a patient by rolling him or her to one side and folding the linens to the center of the bed. Then the patient is rolled to the other side and linens are removed to prevent shearing. Encourage adequate fluids and nutrition. Protein, mineral, and vitamin drink supplements may be given when patients fail to consume adequate meats, fruits, and vegetables at mealtimes. Use specialty beds and devices to help decrease pressure injuries, such as foam eggcrate mattresses, gel-filled pads and mattresses, air-filled mattresses and overlays, and beds that pump air through mattresses filled with tiny beads, known as air-fluidized beds

What is meant by laxative abuse?

The patient may use laxatives so often that he or she is no longer able to have a bowel movement naturally. If the patient does not or cannot take laxatives as frequently as usual, he or she may become severely constipated or develop a fecal impaction.

Define peristalsis

The propulsion of a bolus of food through the GI tract is due to the rhythmic wavelike movements that begin in the esophagus and continue to the rectum

The nurse is preparing to irrigate a clients wound with a syringe and sterile saltine. Which action by the nurse demonstrates correct procedure? The irrigation of th)

The solution flow is directed from the least contaminated to the most contaminated area. This is correct. The purpose of irrigating is to cleanse the wound of debris; therefore, the irrigation solution should be directed from the least to the most contaminated areas. Commonly, the flow of the solution is from the superior to inferior areas, which uses gravity to help remove the debris

define reconstruction phase

This phase occurs when the wound begins to heal and lasts for about 21 days after the injury. It is also referred to as the proliferation phase. The process of initiating healing begins with the presence of fibroblasts in the wound

TRUE OR FALSE When the vagus nerve is stimulated, it can drop the heart rate as low as 30 to 40 beats per minute (bpm) and cause constriction of the bronchioles of the lungs. As you know, a heart rate of 30 or 40 bpm is insufficient to support adequate blood pressure and circulation for longer than a few minutes, making it important to know the signs and symptoms to watch for

True

True of False If an impaction is not relieved, obstruction or perforation of the bowel wall can occur.

True

True or False A patient have to exhibit all of the signs and symptoms for you to stop administering the enema or removing the impaction

True

True or False May you delegate fecal impactation to a CNA or UAP? False Most hospitals do not allow delegation of this procedure to a CNA or UAP.

True

True or false Alternative bowel elimination is necessary as a result of tumors, cancer, damage to the intestines, and intestinal diseases such as Crohn's and ulcerative colitis.

True

True or false Enemas are ordered to cleanse the bowel (tap water, normal saline, soapsuds, sodium phosphate, high enema, or milk and molasses), soften feces (oil retention), deliver medications (steroids or Kayexelate), and relieve gas (Harris flush, return flow, or siphon).

True

True or false Fecal impaction occurs when a very hard mass of stool blocks movement of feces through the intestines. Nursing interventions for this include administering an oil retention enema to soften it and then digitally removing the hard mass.

True

True or false Colostomy irrigation is done to relieve constipation and for bowel training when the stoma is in the descending or sigmoid colon. The colon may be trained to empty once per day with an irrigation so the patient doesn't have to wear a bag all day.

True

True or false Diarrhea is defined as loose or water stools occurring three or more times in a day that may be accompanied by cramping. It may be due to lactose intolerance, intestinal infections, certain medications, anxiety, stress, diverticulosis, inflammation and infection of the intestines, and food allergies.

True

True or false Enemas should not be given to patients with rectal conditions, excessive bleeding potential, and certain heart conditions. Complications of enemas include a vagal response, which causes a slowed heartbeat and other symptoms, and perforation of the colon.

True

True or false Nurses may be specially trained to care for ostomies (enterostomal therapists), but all nurses must know how to empty, clean, and change an ostomy appliance.

True

True or false Nursing interventions for constipation include increasing activity, increasing fiber and fluid intake, providing privacy, and assisting with positioning to help facilitate a bowel movement. In addition, the health-care provider may order medications and enemas if necessary

True

True or false The normal healthy stoma is pink to red in color, shiny, and moist. The skin around it (peristomal skin) should be free of irritation, excoriation, and erythema.

True

True or false Typical stools are soft, formed, light yellowish-brown to dark brown, slightly odiferous, and in a slightly curved shape. Abnormal characteristics include a variety of colors; foul odors; and a hard, dry consistency or a very loose to watery consistency.

True

True or false Various colors of bowel movement can be very significant. It may simply be due to foods the patient has eaten or can be indications of bleeding in various locations in the intestines.

True

True or false When performing a focused assessment of the bowels, ask about frequency, normal number of stools per day, normal color and consistency of stools, and if constipation or diarrhea is a current problem. Then auscultate bowel sounds and palpate the abdomen for firmness, distention, and pain.

True

The nurse is preparing to clean a surgical wound that is closed with staples. Assessment reveals that the incision is clean, dry, well approximated, and without redness or tenderness. Which wound cleaning procedure will the nurse use? 1. Use antiseptic swabs and clean from the inferior end of the incision to the superior end. 2. Use antiseptic swabs and clean around the wound using a wide circular motion. 3. Use forceps with a sterile antiseptic swab and move from the superior to the inferior end. 4. Use an antiseptic swab to cleanse the left side, right side, and then the center of the incision.

Use forceps with a sterile antiseptic swab and move from the superior to the inferior end. This is correct. To clean a long incision that is stapled closed with approximated edges, the nurse should use a sterile antiseptic swab held with forceps, using a clean swab for each pass across the incision. The accepted order is distal side, proximal side, and then the center of the incision.

what should you focus on when assessing bowel movement?

Shape of abdomen-shape should be rounded or flat, but not distended or inflated. Distention related to the GI tract may be a sign of excessive gas, fluid, or stool. Auscultate the bowel sounds-Bowel sounds should be assessed at least once per shift and more often as indicated

The nurse is providing care for a client readmitted to the hospital following a modified mastectomy. The nurse notes that the primary surgical wound is inflamed, painful, and edematous. Under the client's arm, the nurse notices a small open area draining a moderate amount of green drainage. Which condition does the nurse identify? 1. Infection in a contaminated surgery wound 2. Skin breakdown caused from migrated drainage 3. Stasis ulcer from decreased arm movement 4. Sinus tract between infected and healthy tissue

Sinus tract between infected and healthy tissue This is correct. A sinus tract (fistula) is when a pathway forms between infected and healthy tissue. The tract opening is located away from the original site and will usually drain yellow to green drainage if the tract is open. The location of a sinus tract may be influenced by gravity or the path of least resistance.

When you assess a wound, you should be sure to include what aspects of the wound.

Site: anatomical location Wound type: open or closed Wound closure: sutures, staples, Steri-Strips, approximation Size: width, length, depth Condition of wound bed: color, texture, eschar, sloughing, presence of granulation tissue, undermining, sinus tracts Condition of skin surrounding wound: color, texture, maceration Pain: rate discomfort/tenderness using pain scale Drainage: amount, type/color, odor

When you observe possible signs of infection in a wound, notify the health-care provider of your findings immediately. Before calling, be sure to have all of what appropriate information at hand?

Vital sign readings Laboratory results Amount and type of drainage Description of the wound, including observed signs of infection Patient's rating of incisional pain

A patient has signs of infection in his left shoulder incision—erythema, warmth, and a small amount of purulent drainage. You prepare to report this to the health-care provider. Which information will you have ready when you call? Vital signs Name and dosage of pain medication currently ordered Appropriate laboratory results Patient's rating of incisional pain Description of the wound and drainage Names of all staff who have changed his dressing since surgery Signs of infection you observe Name and dosage of antibiotics currently ordered, if any

Vital signs Appropriate laboratory results Patient's rating of incisional pain Description of the wound and drainage Signs of infection you observe Name and dosage of antibiotics currently ordered, if any

The nurse is caring for a client admitted with chronic venous insufficiency. The nurse assesses the client's lower extremities, which are edematous and discolored. Which additional finding should the nurse expect to find during assessment? 1. Sinus tract development on the ankles 2. Skin wounds known as stasis ulcers 3. Pressure injuries where the knees touch 4. Contusions from unsteady ambulation

Skin wounds known as stasis ulcers This is correct. Stasis ulcers develop when the venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins.

define Melena

Small amounts of blood that come from higher in the digestive tract, such as the stomach, that have been partially digested and that have a distinctive "old blood" odor and a black, tarry appearance.

Describe the differences between the six classifications of pressure injuries.

Stage 1 A stage 1 pressure injury is indicated by erythema of intact skin, generally over a bony prominence, that will not blanch, or turn white, when you gently touch it with your fingertip Stage 2 A stage 2 pressure injury occurs when there is a partial-thickness loss and exposed dermis. Stage 3 The stage 3 pressure injury is a full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue but not involving muscle or bone. Undermining and tunneling may be seen in this stage. Stage 4 The stage 4 pressure injury is also a full-thickness skin and tissue loss, only it involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone Unstageable These pressure injuries also involve full-thickness tissue loss but are impossible to accurately stage due to the wound bed being obscured by eschar or excessive slough Deep Tissue Pressure Injury A DTPI may be intact or nonintact skin. It is deep red, maroon, or purple in color and does not blanch. It may form a blood-filled blister or a thin blister that overlies a dark wound bed.

How do you assess a ostomy?

What was the reason for the ostomy? When was the ostomy performed? What type of ostomy is it? What type of appliance, or ostomy bag, is in use? When was the appliance last emptied or changed? How much of the care is the patient able to perform, if any? Now you will assess the patient and the stoma for objective data, noting the following: Contour and color of the abdomen, scars, and the surgical site; the presence of a dressing, sutures/clamps, and drains Appearance of the stoma, including size and edema, color, and moisture level Appearance of peristomal skin, the skin surrounding the stoma Characteristics of the effluent/fecal drainage Fit of the faceplate and fullness of the appliance bag

define Clostridia

When a wound is infected with bacteria the result is a condition known as gas gangrene. This pathogen grows only in the absence of oxygen and is called an anaerobe. As the bacteria multiply in the wound, poisonous toxins and gases are emitted

First intention healing

When the wound is clean with little tissue loss, such as a surgical incision, the edges are approximated and the wound is sutured closed. This helps prevent pathogens from entering the wound and allows healing to occur quickly.

Second intention healing

When there is greater tissue loss and the wound edges are irregular, the edges cannot be brought together. Examples of this are a pressure injury or a traumatic wound. In these situations, the wound must be left open to gradually heal by filling in with granulation tissue, which will leave a wide scar. pen wounds must be packed with moist gauze to absorb drainage and allow tissue to grow. covered with a another dressing to help protect wound

PROVIDE EMOTIONAL SUPPORT

Whether or not the incontinence can be resolved, it is so important that you not only be professional and kind but that you also try to add an extra dose of compassion when you care for these patients

Obtaining a Stool Specimen

Stool samples may be tested for the presence of parasites, parasitic eggs called ova, blood, and microorganisms. For an alert and oriented patient, you will need to explain the procedure in order to elicit his or her cooperation in the collection. It is important to use terminology that the patient understands when giving instructions about collecting the stool specimen, Include step-by-step instructions on how to collect the specimen, including washing of the hands. If the patient is an infant or is incontinent, collect the stool specimen directly from the diaper or incontinence brief.

what is the Significance of Abnormal Colors and Appearance of Feces?

Stool that appears fluffy, floats on water, and has a foul odor is due to an abnormally high content of undigested fat and is called steatorrhea. It may be due to disorders such as Crohn's disease. Stool that appears yellow and greasy and has a foul odor also may be due to pancreatitis and pancreatic cancer. Ribbon-shaped stool may indicate compression on the colon by a tumor, which may be colon cancer. Stool that contains blood, mucus, and pus generally indicates inflammation or infection of the intestinal mucosa. Stool may contain thread-like worms and granules that are parasite eggs. Stool that is pale or clay colored indicates a lack of bile in the intestines, which may be due to liver or gall bladder disease. Taking antacids or drinking barium for tests can also cause stool to be white. Small amounts of bright red blood in the stool may indicate hemorrhoids. Larger amounts of bright red blood will indicate bleeding or hemorrhage from the colon. Large amounts of maroon-colored blood indicates bleeding from the small intestines. Stool that is black and tarry with a foul odor indicates bleeding from the stomach; the blood has been partially digested, giving it the black, tarry appearance that is known as melena.

When should you stop performing giving a enema?

Stop the enema Remove the tube from the rectum Place the patient in the supine position Assess pulse rate, skin color, and whether or not the patient is diaphoretic Call for immediate assistance, but do not leave the patient If the pulse rate is below 60 bpm, place the patient in the shock position, with the head lower than the feet Assess blood pressure as soon as a cuff is available Supply oxygen if needed

What are the signs of vagus nerve stimulation?

Pallor Clammy skin Pulse rate under 60 bpm

what are the types of enema?

Tap water-Hypotonic; allows fluid to move into interstitial fluid as well as be in the colon; distends colon and increases peristalsis Hypotonic. Safety: Do NOT use for infants, children, or patients with congestive heart failure .Could result in fluid volume overload. Never give more than 3,000 mL total (i.e., three 1,000 mL enemas) normal saline (0.9%)-Isotonic; adds fluid to the colon that does not move elsewhere; distends colon and increases peristalsis Isotonic. Safe for use in children and congestive heart failure patients. Infants: use 50-150 mL Toddlers: use 150-350 mL School-age children: use350-500 mL Soapsuds (use castile soap only)-Works by distending the colon and by irritating the walls of the colon, which further increases peristalsis Safety: Mix castile soap in saline, not tap water, for infants, children, or patients with congestive heart failure. Hypertonic sodium phosphate-Hypertonic; pulls fluid from interstitial spaces into the colon to soften the stool and increase peristalsis Normally used only for adults. Oil retention-Lubricates and softens hard stool mass, making it easier to remove Normally used only for adults. Instill the enema 1 hour before removing an impaction. Medicated enemas-Steroid enemas decrease inflammation in the walls of the rectum and colon; Kayexelate enema pulls potassium from the body tissues and binds with it; excess potassium leaves the body when the enema is expelled Must be retained for a specified period of time. May require a tube with a balloon to be inserted in the rectum to hold the medication in place. Milk and molasses- Hypertonic solution that pulls fluid into the colon and softens hard stool Milk and molasses must be heated together to mix well, and then must be cooled to body temperature before administration; effective but messy. Return flow (also called Harris flush and siphon enema)- Raising and lowering the enema container causes flatus to siphon back into the enema container Prepare tap water or saline enema and administer 100-200 mL of solution and then lower the container below the level of the rectum for flatus to siphon out; repeat until no bubbles come back into the enema container. High enema-Distends the colon and moves up into the descending and transverse colon with position changes Administer about half the fluid of a tap water or saline enema with patient in left Sim's position. Then turn patient to the back, then to the right side, and finish administering the fluid.

what is the main cause for pressure injuries?

Pressure injuries also can develop as a direct result of friction or shearing force

Which of the following signs and symptoms may be an indication of vagal stimulation during the digital removal of an impaction? Complaint of rectal pressure Pulse rate of 42 beats per minute Complaint of difficulty breathing Moist skin Complaint of abdominal cramping Complaint of feeling faint

Pulse rate of 42 beats per minute Complaint of difficulty breathing Moist skin Complaint of feeling faint

What are the symptoms of vagus nerve stimulation?

Chest pain Chest heaviness or pressure Shortness of breath or inability to breathe Dizziness Feeling like he or she is going to faint Nausea

what categories do wounds fall into ?

Clean: A wound that is not infected. Clean-contaminated: A wound that was surgically made and is not infected, but it has direct contact with the normal flora in either the respiratory tract, urinary tract, or gastrointestinal tract. It has more potential to become infected. Contaminated: This can be a surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis. Infected: An infected wound is one in which the infectious process is already established, as evidenced by high numbers of microorganisms and either purulent (containing pus) drainage or necrotic (dead) tissue. The classic signs of infection include erythema (redness), increased warmth, edema (swelling), pain, odor, and drainage. Colonized: A colonized wound differs from an infected wound in that it has a high number of microorganisms present but is without signs of infection.

what are the different types of wounds ?

Contusions Abrasions Puncture Wounds Penetrating Wounds Lacerations Pressure Injuries

A patient returns from surgery with a left shoulder dressing. A 3-inch diameter spot of red drainage is visible on the anterior portion of the dressing. The health-care provider does not want the dressing disturbed for 24 hours. What will you do? Call the health-care provider to report the drainage and request a change in orders. Reinforce the dressing by adding several gauze 4×4s over the area. Draw a line on the dressing outlining the drainage, with the date, time, and your initials. Document the drainage in the chart and observe for further drainage over the next several hours.

Draw a line on the dressing outlining the drainage, with the date, time, and your initials.

Patients who are prone to development of pressure injuries include patients who are:

Elderly: The skin of elderly individuals is thinner and less elastic, making the skin more susceptible to friction and shearing force. Emaciated or malnourished: Emaciation is the state of being very lean or having very little muscle. Incontinent of bowel or bladder: With incontinence of bowel or bladder, the skin of the perineal area tends to be wet much of the time, leading it to become macerated, or softened. Immobile: This includes patients who are paralyzed or who have casts or splints, as well as those restricted to a bed or chair. Impaired circulation or chronic metabolic conditions: Chronic metabolic conditions such as diabetes result in impairment of circulation, which can increase the risk of ischemic tissue.

Which one of the following assessment findings makes it impossible to stage a pressure injury? Purulent drainage Eschar Sloughing tissue Erythema Drainage Signs of infection Undermining

Eschar

What are things you must consider before actually removing the impaction?

First, review the facility's policy and procedures to determine which personnel are permitted to perform the procedure and whether or not a health-care provider's order is required, Next, review the patient's medical record for all of the patient's diagnoses. The same conditions that may contraindicate an enema may also contraindicate digital removal of impaction by the nurse. Once you have determined it is safe, you may proceed, Remember to monitor for signs of vagal nerve stimulation, just as you do with enema administration.

The nurse answers a client's emergency call light, which is activated from the client's bathroom. The nurse discovers pinkish-gray organs protruding from the bottom of an abdominal dressing. Which action does the nurse take first? 1. Get the client to bed and place in a semi-Fowler position with knees bent. 2. Call the physician and report the client has an incisional evisceration. 3. Cover the eviscerated organs with sterile dressings soaked in sterile saline. 4. Make the client NPO in anticipation of surgery to close the open suture line.

Get the client to bed and place in a semi-Fowler position with knees bent. This is correct. Because the client is in the bathroom and at risk for internal organs eviscerating beyond the parameters of the dressing, the nurse should first get the client back to bed. Placing the client in semi-Fowler position with the knees bent will alleviate some of the stress on the already compromised suture line.

A female patient is recovering from abdominal surgery 2 days ago. Her abdomen is distended and firm, and she complains of moderate to severe cramping and abdominal discomfort. As of yet, she has been unable to pass much flatus rectally. Which type of enema would be most helpful to this patient? Fleet Phospho-Soda enema Oil retention enema Harris flush enema Small-volume enema

Harris flush enema

what is the possible cause of wound hemorrhage?

Hemorrhage may be due to a slipped suture, displaced blood clot, or trauma to the incision.

Stool Consistency Based on Location of the Colostomy

If a colostomy is created in the ascending colon, effluent will be liquid to mushy with a foul odor. A right transverse stoma will expel mushy to semiformed effluent, while feces from a left transverse stoma will be semiformed to soft in consistency. A stoma created in the descending or sigmoid colon will produce soft to hard formed stools. This is because more water is absorbed from the feces as it has more contact with the colon.

The nurse assesses a client's wound. Which documentation will the nurse make to indicate a possible infection? 1. Dressing intact, with a small amount of serosanguineous drainage 2. Incision line well approximated, moderate amount of drainage noted 3. Incision intact, suture line is well approximated, and no drainage 4. Incision intact, moderate amount of purulent drainage, foul odor

Incision intact, moderate amount of purulent drainage, foul odor This is correct. Purulent drainage with a foul odor indicates that the incision is infected.

what are the nursing interventions for consipation?

Increase activity Improve fluid and fiber intake Provide privacy Assist with positioning Administer medications Administer enemas

The nurse is providing care for a client with a stage III pressure injury on the right trochanter area. The physician has ordered the use of hydrocolloid dressings. Which action will the nurse perform in the maintenance of the prescribed dressing? 1. Change the dressing daily to prevent infection from collected drainage. 2. Use warm compresses to keep the dressing flat and adhered to the skin. 3. Inspect the dressing for escaping drainage, wrinkling, and excessive exudate. 4. Document the application process and a description of the wound.

Inspect the dressing for escaping drainage, wrinkling, and excessive exudate. This is correct. The hydrocolloid dressing should be inspected daily for escaping

how do you cleanse a wound?

Irrigation is the more gentle method of wound cleansing and is ordered when fragile granulation tissue is present. Wounds also can be cleaned with soft gauze moistened with sterile saline, using a light patting movement. Use care to prevent damaging healthy tissue.

What are the nursing interventions when caring for a patient with an ostomy?

Measuring the stoma Selecting an ostomy appliance Emptying the appliance Providing skin care Providing emotional support

what should you do if you think a bowel sound is absent?

be certain to listen for at least 3 to 5 minutes in each of the four quadrants before declaring this

what is the temperature for enemas?

between 105°F and 110°F to avoid burning the intestinal mucosa

how do you Improve Fluid and Fiber Intake

find out what the patient likes to drink and then provide an adequate supply of those fluids, Water intake should be encouraged, but other fluids such as coffee, tea, carbonated drinks, juice, sports drinks, flavored drink mixes, milk, flavored bottled water, and broth are acceptable replacements

define Flatus

gas produce in the bowel

Define eschar

hard dry dead tissue that has a leathery appearance

How might fecal impaction occur?

may occur in the rectum, the sigmoid flexure, or any part of the large colon. It is more common in elders, patients on bedrest, and severely dehydrated patients, Any cause of constipation may lead also to impaction. One common cause, especially in elderly patients, is the abuse of laxatives.

Single barreled colostomy

or end stoma A colostomy stoma will have a single opening

Fecal Incontinence Continence,

or rectal compliance, is the ability to voluntarily maintain the stool in the rectum until a convenient time for a bowel movement, as opposed to bowel where the voluntary control is lost

define pallor

paleness of the skin related to impaired circulation, which is a major risk factor for skin breakdown

How would you tape a dressing to a patient's elbow area?

place the tape at the top and bottom edges, catching both dressing and skin, and then add one or two pieces of tape across the middle. Use enough tape to overlap the dressing by 1 ½ to 2 inches on either side. Avoid allowing the edges of the dressing to curl down over the tape at the top or bottom because that can contaminate the wound.

How should you position your patient for a enema?

position the patient in the left Sims' or left lateral side-lying position allows gravity to help pull the solution into the intestine.

How do you determine which size of colostomy bag opening would best meet the patient's needs?

determine the correct size flange and opening on the ostomy bag to use, the stoma must be measured. The stoma size is determined using a stoma measuring device made of card stock.

define bruising

discolored areas; make notations of any such areas that are found so that it will be easy to determine if new breakdown occurs

Explain the importance of normal flora in the GI tract

purpose is to prevent infection and maintain health.

The phase of healing during which granulation tissue forms in a wound is the: inflammatory phase. reconstruction phase. maturation phase. remodeling phase.

reconstruction phase.

Define erythema

redness of the skin

Define sanguineous

resembling blood

You observe pink drainage from a patient's wound. You would describe this as: sanguineous. serous. purulent. seropurulent. serosanguineous

serosanguineous

When using a bedside commode what do you do?

shut the room door, pull the privacy curtain, place the bedpan or assist the patient to the BSC, provide toilet tissue, and wait outside the curtain if at all possible.

Double barreled colostomy

stoma Both ends of the dissected colon are brought to the surface and two stomas are formed, a proximal and a distal stoma.

what are the characteristics of feces?

stool include color, shape, consistency, odor, and frequency, A normal stool will vary depending on diet, amount of fiber and fluids, exercise, medications, and other habits When a disease process is occurring in the GI tract, the changes in the characteristics of stool may provide clues as to the medical diagnosis, which is one of the reasons that assessment of bowel function is important

what are four ways wounds are closed?

sutures, staples, surgical adhesive, and sterile adhesive strips, sometimes referred to by the brand name Steri-Strips

what is one of the first thing you should note about an old dressing?

the amount of drainage and the color of the drainage

define necrotic

the death of cell tissue

who must order meds for constipation for hospitalized patients?

the health-care provider

How do you administer medications for enemas ?

the instillation of a solution into the colon via the rectum, to relieve the problem,

Define debridement.

the surgical removal of the dead tissue

Third intention healing

the wound is left open for a time to allow granulation tissue to form, and then it is sutured closed. An example of this is a draining wound, which is left open until the drainage ceases and then is sutured closed.

true or false Complications of wound healing include infection, dehiscence, evisceration, and hemorrhage. Each of these requires immediate nursing responses.

true

true or false Wound treatments include irrigation to remove necrotic tissue. After irrigation, a wound culture may be obtained to determine which microorganisms are causing infection and which antibiotics will kill them.

true

true or false Wounds may be closed with sutures, staples, or glue. They may have drains in place after surgery. Wounds must be assessed and measured carefully.

true

true or false Avoid pulling or dragging a patient across the bed rather than lifting him or her because the shearing force to the patient's skin can result in destruction of the epidermis and dermis.

true

true or false A variety of nursing interventions are needed to prevent pressure injuries. These include turning, positioning, pressure relief devices, assessment of bony prominences, and keeping skin clean.

true

true or false Accurate documentation of wound care is important so that nurses will know what supplies they need, how many gauze 4×4s are in the wound to be removed, and for purposes of reimbursement.

true

true or false An absence of bowel sounds indicates a problem and should always be reported to the health-care provider

true

true or false Be sure to help your patient splint his or her incision with a pillow before he or she coughs or sneezes to help prevent extra stress on wound edges

true

true or false Determine if skin turgor is elastic or nonelastic. This helps you determine whether the patient's hydration is adequate, another important factor for healthy skin.

true

true or false Do not go back over an area that has already been cleansed. If you do so, you can contaminate the cleansed area with pathogens from an unclean area

true

true or false Many types of dressings may be used to help heal wounds. They are secured in a way to prevent damage to the skin and still keep the dressing in place. Dressing changes are often done using sterile technique.

true

true or false Never attempt insertion of the tip of the tubing into the patient's rectum while the patient is in a sitting position, as on the toilet. The angle of the natural curve of the rectum and sigmoid colon changes when sitting. This can cause the tip of the tubing to scrape the intestinal wall, possibly damaging the mucosal lining, and increases risk of perforating the intestinal wall.

true

true or false Other wounds that occur in hospitalized patients include stasis ulcers, sinus tracts, and surgical incisions.

true

true or false Pressure injuries are identified by stages, based on tissues involved and intact or nonintact skin. They are identified by one of the following: stages 1 to 4, unstageable, and DTPI. In addition, they may be determined to be medical device related (which can be staged) or a mucosal membrane pressure injury (which cannot be staged).

true

true or false Types of wounds include contusions, abrasions, lacerations, puncture wounds, penetrating wounds, and pressure injuries.

true

what is the most comfortable and natural position for bowel elimination?

upright sitting position

what should you do for a patient who is restricted to the bed?

use a bedpan and place the patient in high or semi-Fowler's position

what are the types of bowel sounds and their significance?

Normal-Soft gurgles, irregular clicks Between 5 and 30 per minute Indicates normal bowel function Hypoactive-Fewer than 5 per minute May indicate constipation Hyperactive-More than 30 per minute or continuous May be heard when the patient has diarrhea Borborygmi-Excessively loud gurgling. May be high-pitched and tinkling in one quadrant and absent or decreased in the lower left quadrant. May indicate hunger or, if not hungry, can indicate bowel obstruction

How should you perforate the colon?

Always be gentle when inserting an enema tube; never force it or insert it farther than 4 to 6 inches. You should direct the tip of the tubing toward the umbilicus to follow the natural direction of the sigmoid colon. If you are not careful, it is possible to perforate, or go through, the intestinal wall. This can result in introduction of bacteria into the sterile peritoneal cavity, bleeding, and even hemorrhage. Again, never force the enema tubing if you meet resistance.

The nurse is providing care for multiple clients in an extended care facility. Which client does the nurse identify for being at the most risk for the development of pressure injuries? 1. An elderly client with daily urinary incontinence 2. A client who is immobile and underweight for age and height 3. An elderly client with diabetes mellitus who is immobile 4. A client who has limited mobility due to poor circulation

An elderly client with diabetes mellitus who is immobile This is correct. The elderly client with diabetes mellitus who is immobile is at greatest risk for the development of pressure injuries. The client has three contributing factors: age, a chronic metabolic condition, and immobility.

Which of the following would be the most accurate statement about digestion and elimination? All individuals have at least one bowel movement daily. An infant may have up to six bowel movements daily. GI peristalsis increases with age, making incontinence a normal finding. A stool is only considered normal if the color is a shade of brown.

An infant may have up to six bowel movements daily.

Define colostomy

An opening in the bowel in the area of the large intestine used as an alternate form of bowel elimination.

Medication side effects

Antibiotics administered to treat infection can also kill some of the good bacteria that the body needs to stay healthy, specifically the normal flora found in the bowel.

Factors Contributing to Diarrhea Lactose intolerance, Medication side effects,

Anxiety and stress, Inflammatory processes, Diverticulosis, Food allergies

What is vagal response ?

Any time you insert an enema tube into a patient's rectum, there is the possibility of stimulating the vagus nerve, which innervates not only the GI tract, but also the heart and bronchioles

Specific food, medications, and supplements to avoid include the following:

Anything containing red dye or food coloring Alcohol Antacids Antidiarrheals Gastric irritants such as nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids Red Jell-O Red meats Red popsicles Vegetables and fruits high in peroxidase, an enzyme found in apples, bananas, grapes, and broccoli Vitamin C and iron supplements

which foods are high in fiber content?

Apples, unpeeled Artichokes Beans Blueberries Broccoli Cabbage Carrots Cauliflower Cherries Corn Dried fruits Flaxseed Legumes Nuts Oatmeal Oranges Pears, unpeeled Plums Popcorn Prunes Raisins Raspberries Strawberries Sunflower seeds Whole-grain breads Whole-grain cereals Whole-grain flour

Your patient has a large abdominal wound with copious drainage and many layers of gauze 4×4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient? Change to surgical adhesive instead of tape to hold dressings in place. Call the doctor and ask for an order to decrease dressing change frequency. Ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape .Wrap gauze around the patient's trunk to hold the dressings in place.

Ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape

how do you document wound care?

Amount and color of drainage on the old dressing Length, width or diameter Depth of the wound Interior of the wound, including sinus tracts and their length Color of the wound and appearance of the surrounding skin Type of dressing applied

Several medications have GI side effects and may lead to diarrhea or constipation. Indicate which of the following medications would be most likely to cause constipation in the patient. Amphojel Maalox Magnesium citrate Meperidine Amoxicillin Ferrous sulfate (iron) Imodium AD Milk of magnesia

Amphojel Meperidine Amoxicillin Imodium AD

Define Abraison

An abrasion is a superficial open wound. Abrasions include scrapes, scratches, or rub-type wounds where the skin is broken, such as a carpet burn or a skinned knee

Which of the following describes borborygmi bowel sounds? A. Soft gurgles, irregular clicks B. Fewer than five sounds per minute C. Continuous sounds D. Excessively loud gurgling

C. BorborygmiGurgling sounds may be high-pitched and tinkling in one quadrant and absent or decreased in the lower left quadrant. May indicate hunger OR if not hungry, can indicate bowel obstruction.

The nurse is caring for a client who is five days postoperative. The physician orders that every other staple be removed from the incision. The nurse notices that the staples appear to be far apart and after the first staple is removed, the incision begins to gap open. Which action will the nurse take? 1. Finish removing the staples as ordered. 2. Call the physician and report wound dehiscence. 3. Apply a sterile dressing and document the event. 4. Use adhesive strips to re-approximate the gaping edges.

Call the physician and report wound dehiscence. This is correct. The nurse is aware that the client's wound is a risk for serious dehiscence. The physician should be contacted immediately for new orders.

what would you teach a patient before discharge about signs and symptoms of wound infection?

Redness or increased warmth of the wound Swelling Wound drainage Wound has an unpleasant smell Pain around the wound Fever above 100°F Explain that the health-care provider should be notified if any of these signs or symptoms occurs. If antibiotics are prescribed, instruct the patient regarding the importance of taking antibiotics until they are gone.

Which of the following assessment data might indicate the patient is having difficulty accepting his or her new colostomy? Asks questions about how to take care of the colostomy Observes as you irrigate the colostomy Looks at stoma and makes good eye contact with you during ostomy care Refuses to attempt care, and tells you to "just do it"

Refuses to attempt care, and tells you to "just do it"

PROMOTE SKIN INTEGRITY

Patients with fecal incontinence or uncontrolled diarrhea stools are at risk for skin breakdown. Topical barrier creams help to prevent excoriation, but if it is not possible to keep the patient clean and dry most of the time, a fecal incontinence pouch may be the best choice to protect skin integrity

Lactose intolerance

Some people are unable to digest lactose, a sugar found in milk and other dairy products. If they do ingest lactose-containing foods, it will usually cause them to have diarrhea. Some alternative dairy products are available with the lactose removed

define pressure injuries

A pressure injury is a wound resulting from pressure and friction. The skin may be intact and erythemic (reddened), or the skin may be nonintact with open areas.

Define puncture wound

A puncture wound is an open wound that results when a sharp item, such as a needle, nail, or piece of wire, pierces the skin. The resulting wound is a round hole in the skin that extends down into the deeper tissues, according to the diameter and length of the offending sharp item

A female client has been admitted with ulcerative colitis. Which appearance of the client's stools will the nurse expect with the exacerbation of this condition? 1. Be black, tarry, and odiferous 2. Float, and be odorless and bloody 3. Contain pus, mucus, and blood 4. Be soft, but ribbon shaped

ANS-Contain pus, mucus, and blood This is correct. Stools of individuals with ulcerative colitis typically contain pus, mucus, and blood.

After an initial assessment, a nurse documents that a client, admitted for abdominal pain, has hyperactive bowel sounds. Which type of bowel movement will the nurse expect this client to have? 1. Hard and shaped in small balls 2. Fluffy, with a tendency to float in the toilet 3. Ribbon-shaped and soft 4. Liquid or semi-liquid

ANS-Liquid or semi-liquid This is correct. Increased peristalsis causes food to pass through the intestines much faster than normal, so less water is reabsorbed, causing stools to be liquid or semi-liquid.

During an admission physical assessment, a nurse questions a client about bowel elimination habits. Which client care goal is the nurse attempting to identify? 1. Assessment about the need for a laxative. 2. Maintain the client's normal elimination habit. 3. Complete collection of all pertinent client data. 4. Determine if further gastrointestinal testing is necessary.

ANS-Maintain the client's normal elimination habit. This is correct. The goal of the nurse's assessment related to elimination is to maintain the client's normal elimination pattern while hospitalized.

A ____________________ flush removes flatus, but not stool as with other types of enemas.

ANS: Harris Feedback: A return flow enema, also known as a Harris flush, is administered for the purpose of removing flatus, or gas, and not specifically for the removal of stool as with other types of enemas.

The nurse is providing care for a client after the surgical removal of the colon. The nurse is aware that the client has a procedure in which the ____________________ does not drain into an external appliance.

ANS: effluent Feedback: Fecal material that empties into an ostomy appliance is termed effluent.

define Ileostomy

An opening in the bowel in the area of the small intestine used as an alternate form of bowel elimination.

A need for a bowel diversion may be due to:

Cancerous tumor Infarcted area in which the bowel walls have become ischemic and died Disease process such as Crohn's disease Ruptured diverticulum Ulcerative colitis Traumatic abdominal injury Bowel perforation

While assessing a client's surgical incision, the nurse notes that it is dry, clean, and intact, with edges approximated. The nurse is aware that which type of healing is taking place? 1. First intention 2. Second intention 3. Third intention 4. Tertiary intention

First intention This is correct. Clean wounds with little tissue loss, such as a surgical incision, heal by first intention.

• Anxiety and stress

High levels of stress or anxiety, as well as other emotional problems, can cause increased peristalsis and intestinal mucus production, which may result in diarrhea.

When using a bedside commode and the patient can be left unattended?

If the patient can be left unattended, leave the room and tell the patient you will return in a few minutes. Make certain the patient can reach the call light before you leave.

The nurse is caring for a client immediately after surgery. During assessment the nurse notes sanguineous drainage on the client's dressing. Which action by the nurse is most correct? 1. Notify the physician about the possibility of hemorrhage. 2. Mark and initial the edges of the drainage, including the date and time. 3. Reinforce the dressing and monitor for additional bleed through. 4. Monitor vital signs for changes indicating excessive bleeding.

Mark and initial the edges of the drainage, including the date and time. This is correct. When the nurse finds drainage on a dressing, especially a fresh surgical dressing, the edges of the drainage area should be marked and initialed by the nurse. Adding the time and date will provide information about the rate of bleeding/drainage.

what color is newborn stool?

Normally newborns have black, shiny, sticky stools called meconium

Assist With Positioning

The most comfortable and natural position for bowel elimination is the upright sitting position. If the patient is allowed to ambulate or have BRP, assist the patient to the bathroom

True or false Constipation is the term for less frequent, hard, formed stools that are difficult to expel. Lack of fiber-rich foods and adequate fluids are often contributing factors, as well as a decrease in activity level, certain medicines and over-the-counter drugs, surgery, pregnancy, depression, aging, and nerve impairments.

True

When you observe possible signs of infection in a wound, notify the health-care provider of your findings immediately. Before calling, what is the appropriate information to have at hand:

Vital sign readingsLaboratory resultsAmount and type of drainageDescription of the wound, including observed signs of infectionPatient's rating of incisional pain

How can you prevent constipation?

at the very least, you must make certain the patient has a bowel movement at least every 3 days

what are the abnormal characteristics of stool

consistency-Liquid or semiliquid, watery, unformed, very hard and dry shape-Balls, clumps, or broken-off chunks; flat or ribbon-like; pencil-like color-Bright red blood, black, coffee grounds appearance, pale, white, gray, or clay color Presence of infection-Presence of pus, excessive mucus, foamy, or floating on water Presence of parasites-presence of worms or eggs odor-Foul odor, strongly odiferous, bloody or old-blood smell, metallic smell

Define purulent

consisting of, containing, or discharging pus

what is the most common seen alteration in bowel elimination?

constipation, fecal impaction, diarrhea, and fecal incontinence.

define surgical incisions

intentionally made with sharp instruments, are linear with more sharply defined edges than most wounds

what are the nursing responsibilities for cleaning wounds?

irrigation the purpose is to remove surface debris without injuring granulation tissue the most commonly used irrigant is sterile normal saline

how do opioid analgesics affect bowel elimination?

it reduces the motility of the GI tract

how are wounds categorized?

open or closed

Define hemorrhage.

profuse flow of blood

true or false When medication does not relieve the problem of constipation, the health-care provider may order an enema, the instillation of a solution into the colon via the rectum, to relieve the problem

true

true or false Wound healing involves the inflammatory phase, reconstruction phase, and maturation phase. Wounds may be closed by one of three methods to promote healing. Wounds may not heal well due to a variety of factors.

true

true or false Wounds fall into one of these contamination categories: clean, clean-contaminated, contaminated, infected, and colonized.

true

true or false hyperbaric chamber delivers oxygen under high pressure to help kill anaerobic bacteria and promote wound healing

true

Why is moisture necessary for wounds to heal?

when a wound is covered moisture is maintained within it, the epidermal cells can move freely through the mositure to promote healing .

Food allergies

In response to food antigens, the body responds with an allergic reaction that can cause edema and inflammation of the intestinal walls with increased mucus production. The inflammation increases peristalsis, which decreases transit time, inhibits absorption, and results in diarrhea.

how much bowl movement will infants usually have a day ?

Infants will normally have between three and six bowel movements daily.

Stat nursing response to wound infection

Inspect and assess surgical incisions and other wounds at least every 8 hours. When you assess an infected wound, you will see pronounced erythema around the staples or sutures and on the edges of the incision. Drainage may increase in amount with each successive day rather than decrease. The drainage may be purulent and malodorous (bad smelling).

define penetrating wound

A penetrating wound is similar to a puncture wound; the difference is that the offending object remains embedded in the tissue. The degree of damage depends on the size of the object and the tissues or organs affected by the penetration

The nurse is obtaining a health history from an older adult client. The client tells the nurse that a bowel movement occurs about every 2 to 3 days. Which question should the nurse ask to determine if this is normal functioning for the client? 1. What is the consistency of your stool? 2. Do you take laxatives to go more often? 3. What is a normal daily diet for you? 4. How do you feel if you don't go every day?

ANS-What is the consistency of your stool? This is correct. The nurse should ask about the consistency of the client's stool in order to determine if the client has constipation. If the stool is soft and easy to pass, the nurse can determine that the client's pattern of elimination is normal.

what are nursing responsibilities for applying dressings?

Gloves should always be worn, and a gown, goggles, and mask are worn when there is danger of splashing. You must keep a good "sterile conscience"; that is, you must admit to any breaks in technique and start over to protect your patient from possible infection. You are also responsible for assessing the wound during a dressing change.

Nursing Interventions for Fecal Incontinence

PROVIDE BOWEL TRAINING, PROMOTE SKIN INTEGRITY, PROVIDE EMOTIONAL SUPPORT,

define Steatorrhea

Stool that contains an abnormally high amount of undigested fat: appears fluffy, floats on water, and has a foul odor.

define stoma

The mouth of an opening in the bowel that is used as an alternate form of bowel elimination

Inflammatory processes

These conditions occur in response to autoimmune diseases such as Crohn's disease or by infectious microorganisms such as bacteria and viruses. The common name for bacterial or viral infections of the GI tract is gastroenteritis

Diverticulosis

This condition occurs when the muscular wall of the colon weakens and separates, allowing small pouches or pockets of the inner wall to protrude outward

True or false If part of the colon is used to create a stoma, it is called a colostomy. If the last portion of the small intestine is used, it is called an ileostomy. A continent ileostomy is called a Kock pouch.

True

True or false Normal bowel elimination changes through the life span. Some adults may have one to two bowel movements daily, while others may go several days between movements. The urge to defecate commonly occurs 30 minutes to an hour after eating

True

what are the steps to dressing a wound ?

Wet-to-damp Securing• Tapes• Montgomery straps• Abdominal binders Taping

what position should the patient be put in for enema insertion?

Positioning the patient in the left Sims' or left lateral side-lying position allows gravity to help pull the solution into the intestine

define jaundice

also known as yellowing of the skin; is a sign of an abnormally high serum level of bilirubin, which can make skin itch and be more susceptible to loss of integrity

How much is adequate fiber intake?

generally 25 to 35 g per day

true or false Pressure injuries are the result of pressure and/or shear and are preventable with good nursing care. Many risk factors predispose patients to developing pressure injuries.

true

true or false The longer a patient lies in one position, the more necrosis can occur in the area of pressure.

true

What are the contraindications to enema?

• Rectal surgery • Severe bleeding hemorrhoids • Ulcerative colitis or Crohn's disease • Rectal fissure • Rectal cancer • Excessive bleeding potential due to disease or medication • Certain heart conditions, such as myocardial infarction or unstable angina

define inflammatory phase

-begins immediately after injury -lasts 3-6 days -major processes: (1.) hemostasis (cessation of bleeding) (2.) phagocytosis (engulfing of microorganisms and cellular debris)

Define evisceration

Protrusion of abdominal contents through an open abdominal wound

what is the normal length of the enema tubing?

3-4 inches

define sinus tract

A channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin.

Define Methicillin-Resistant Staphylococcus aureus (MRSA).

A resistant strain of Staphylococcus aureus that can live on the skin of healthy individuals without causing illness but which can cause serious illness when a wound is infected with it.

The nurse is caring for multiple clients with a variety of bowel conditions. Which client does the nurse consider at greatest risk for surgery to place a colostomy? 1. A client with traumatic injury to the abdomen 2. A client with a portion of bowel without circulation 3. A client with a cancerous tumor in the transverse colon 4. A client who has experienced a ruptured diverticulum

ANS- A client with a portion of bowel without circulation This is correct. When a portion of the bowel is without circulation, ischemia occurs which will progress to tissue death. This is the client that is most likely to need surgery for the placement of a colostomy.

The nurse is administering a cleansing enema to a client in preparation for a diagnostic test. After inserting the rectal tube, the client becomes quiet and does not respond to verbal stimulus. The nurse stops the enema and discovers a pulse rate of 30 beats/minute. The nurse recognizes that the client is exhibiting a ________ response.

ANS: Vagal Feedback: Stimulation of the vagus nerve, known as vagal stimulation, results in bradycardia, which requires that the nurse immediately stop the administration of the enema and place the client in the supine position.

Provide Privacy

As a nurse, you will become comfortable with and view elimination as a natural function and see no reason for embarrassment, that probably does not reflect how your patient will feel about it. It will be helpful for you to consider how you would feel if you had to expel a bowel movement in the presence of a stranger.

timing of elimination

Because peristalsis begins with the introduction of food into the GI tract, the urge to defecate commonly occurs 30 minutes to 1 hour after eating If the patient ignores the reflex and puts off going to the bathroom for a bowel movement until a later time, the stool remains in the intestines longer than necessary and can become dry and hard, contributing to the development of constipation

Define occult blood

Blood in the stool that is hidden or not visible.

Define tenesmus

Bowel cramping that is identified by increased rectal pressure and a feeling of the need to defecate.

normal bowel elimination

Bowel elimination occurs after nutrients are moved through the gastrointestinal (GI) tract, also known as the alimentary canal. This process begins in the os, or mouth, and ends as the waste products are eliminated as feces, or stool, via the anus

what are the contaminations of wounds?

Clean clean-contaminated contaminated infected colonized

what should you include in the assessment of bowel elimination?

Color Amount Consistency Unusual shape Unusual odor

Explain two purposes for colostomy irrigation.

Colostomies may be irrigated to evacuate stool due to constipation, or irrigation may be used postoperatively for stomas located in the descending or sigmoid colon

Define bilious

Comes from the word "bile," which is made by the body to help break down fats for digestion. It is a dark greenish color and is often present in wound drainage after gallbladder surgery.

what are the normal characteristics of stool

Consistency-Soft, formed consistency Shape-Longer curved shape, cylindrical Color-Yellow in infantsLight brown to dark brown in others Presence of infection-Absence of pus, mucous, fat Presence of parasites-Absence of parasites Odor-Slight odor

A surgical wound that bleeds profusely is called a(n): A. Dehiscence B. Evisceration C. Infection D. Hemorrhage

D. Hemorrhage Rarely, a surgical wound may Hemorrhage, or bleed profusely. This is also a medical emergency. When you check for bleeding postoperatively, always look and feel beneath the patient for blood that might have pooled there rather than being absorbed into the dressing.

what factors contribute to constipation?

Decreased activity level, Changes in food intake, Decreased fluid intake, Medication side effects, Surgery, Pregnancy, Depression, Aging, Laxative overuse or abuse, Nerve damage or impairment

how do you obtain a wound culture?

Do not culture drainage Scrape wound bed with Q-tip Insert back into curette Squeeze bottom of tube to activate chemicals

When should wound drains be emptied?

Empty drains every 8 hours or when they become one-half to two-thirds full

How often should an appliance bag be emptied?

Empty the ostomy appliance bag when it is one-third to one-half full to prevent leaking and odor

what are the types of wound closures for healing called?

First, second, and third intention

What tests are commonly performed to help identify the cause of diarrhea and other problems?

Guaiac test, Culture and sensitivity, Ova and parasite test (O&P)

The nurse is admitting a bed-ridden older adult client to an extended care facility. During the initial assessment, the nurse notices the client's bone to be visible in a sacral pressure injury. Which staging will the nurse document in the client's record? 1. I 2. II 3. III 4. IV

IV This is correct. Stage IV involves muscle necrosis and sometimes bone

You are caring for a 67-year-old male who had a cerebrovascular accident 3 weeks ago. In addition, he has developed a pressure injury on his right hip. Which of the following data that you collected will be useful in developing a care plan that will address his pressure ulcer? Last week he weighed 165.5 pounds, and today he weighs 161.8 pounds. The pressure injury is a stage .He has 250 mL of clear yellow urine in his Foley catheter. He is not able to sit up in a chair for longer than 15 minutes at a time. He dislikes cheese, beans, chicken, and fish, but loves steak, eggs, all kinds of nuts, and peanut butter. His affect is flat .He has been on an eggcrate mattress while in the hospital.

Last week he weighed 165.5 pounds, and today he weighs 161.8 pounds. The pressure injury is a stage He is not able to sit up in a chair for longer than 15 minutes at a time. He dislikes cheese, beans, chicken, and fish, but loves steak, eggs, all kinds of nuts, and peanut butter. He has been on an eggcrate mattress while in the hospital.

Define diarrhea

Loose or watery stools occurring three or more times a day.

Which of the following factors is most likely to result in diarrhea? Loss of intestinal normal flora Drinking excessive fluids Administration of opioid narcotics Manipulation of intestines during colon surgery Eating 10 to 15 g of fiber per day

Loss of intestinal normal flora

Nursing Interventions for Diarrhea

MODIFY FOOD INTAKE AND INCREASE FLUIDS, ADMINISTER MEDICATIONS, PROVIDE PERINEAL CARE

Which microorganism is the most resistant to antibiotics?

MRSA

Administer medications

Medications for constipation may work by directly stimulating peristalsis softening the stool or adding bulk to the stool stool softeners and those that add bulk are safer than the laxities that stimulate peristalsis

How do you administer medications for constipations ?

Medications for constipation may work by directly stimulating peristalsis, softening the stool, or adding bulk to the stool, Stool softeners and those that add bulk are safer than the laxatives that stimulate peristalsis.

Define serosanguineous

Pale, red, watery, or pink appearance

Define ischemia

Reduced blood flow to an area

What is the purpose of a wound drain?

Remove secretions from the area so healing occurs.

what is the stat nursing response to wound dehiscence and eviscerations?

Should dehiscence occur, reassure your patient and assist him or her to a supine position. Stay with your patient and notify the health-care provider immediately. Request that sterile supplies be brought to the room, including a basin, normal saline, abdominal dressings, a 60-mL syringe, masks, gowns, gloves, and drapes. A suture removal kit may be necessary. Sterile adhesive strips also should be on hand.

how do static ulcers develop ?

Stasis ulcers develop when venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins

The home care nurse visits a client to assess an abdominal surgery site. The client is elderly, lives alone, and takes multiple medications for chronic illnesses. The nurse notes that the client's wound shows signs of delayed healing. Which factor does the nurse recognize as being least likely to be a contributing factor for the delayed healing? 1. The client has an agency deliver two cold meals and one hot meal daily. 2. The client admits to having difficulty managing dressing changes. 3. The client takes medication for heart and respiratory problems. 4. The client does not shower due to fear of falling while alone.

The client has an agency deliver two cold meals and one hot meal daily. This is correct. The nurse knows that good nutrition is important for wound healing. Because the client has three agency meals delivered every day, the nurse feels that adequate nutrition is the least contributing factor to the client's delayed wound healing.

Administer enema

The instillation of a solution into the colon via the rectum to relieve the problem

what are the normal characteristics of feces?

The typical stool is soft, formed, light yellowish-brown to dark brown, slightly odiferous, and falls into a slightly curved shape.

what temperature should the water be for enemas?

The water temperature of enemas should be between 105°F and 110°F to avoid burning the intestinal mucosa.

True or false Stool specimens may be ordered to test for infection, parasites and their eggs, and hidden blood. Patients bringing in a stool specimen to be tested for blood must avoid certain substances for 48 hours prior to the testing.

True

The patient is to receive a cleansing enema for relief of constipation. Which of the following factors must be assessed prior to administration of the enema? Type of solution to administer Date of last bowel movement Type of diet the patient has been receiving Assessment of bowel sounds The patient's temperature

Type of solution to administer Date of last bowel movement Assessment of bowel sounds

How do you check water temperature for enemas and do you check it?

Use a bath thermometer to check water temperature, if one is not available, pour a small amount of the solution on the inner side of your bare wrist. It should feel warm but never hot. Water that is too cold will cause abdominal cramping and may restrict the patient's ability to retain the water.

what are the factors affecting wound healing?

age-Wounds contract more slowly. Strength of scarred area is decreased. Skin is less elastic as people age. Collagen replacement is impaired. chronic illness-Illnesses affecting major body systems, such as heart, lung, and kidney disease, as well as neurological deficits affect optimal functioning of those systems. In turn, healing of wounds is negatively affected by impairment of other body systems. Diabetes mellitus-Causes decreased circulation due to narrowed peripheral blood vessels. Increased blood glucose interferes with the healing process. Hypoxemia-Decreased oxygen delivered to the wound by the bloodstream causes impaired healing; oxygen is necessary for wounds to heal properly. Lifestyle choices-Smoking decreases the oxygen content of the blood and constricts blood vessels, impeding circulation to wounds. Excessive alcohol intake can lead to poor nutrition, which affects wound healing. Obesity puts patients at risk for wound complications such as infection and dehiscence. Lymphedema-When the area around a wound is edematous, circulation to and from the wound is impaired. Lack of efficient circulation decreases wound healing. Medications-Certain prescription medications delay the healing process and can mask symptoms of inflammation and infection. Multiple wounds-Each wound competes for the available protein and substrates needed for tissue repair, resulting in delayed wound healing for all the wounds. Nutrition and hydration-Lack of calories and adequate protein impairs tissue growth. Deficiency in intake of vitamins A and C and zinc in the diet interferes with wound repair. Inadequate fluid intake causes the wound to be dry, restricting granulation of tissue. Radiation exposure-Cancer treatments involving radiation can cause breakdown of underlying connective tissue, affecting repair capabilities. Wound tension-Extra tension placed on the wound edges can lead to ischemia (lack of blood supply to the area) and necrosis (death of tissue due to lack of blood supply). Tension on wound edges may be due to activities such as coughing, sneezing, lifting, and vomiting.

Define dehiscense

an uncommon but extremely serious complication of wound healing in which there is a partial or complete separation of the outer layers of a wound

where are the most common sites for development of pressure injuries ?

are over bony prominences, such as the sacrum, buttocks, greater trochanters, elbows, heels, ankles, occiput

How much fluid intake should be maintained?

between 1,500 and 2,500 mL per day in most adults

Debilitated, elderly, or confused patients may not be able to drink more than a few sips at a time, how often should they be provided with a drink?

every 15 to 20 minutes in an attempt to provide adequate intake

How often do you change your fecal incontinent bag?

every 2 to 3 days unless a leak requires the pouch to be changed earlier.

A patient's J-P drain should be emptied: every 2 hours. every 8 hours. when one-half to two-thirds full. only when it needs to be reactivated. when the container is full.

every 8 hours. when one-half to two-thirds full.

what blood is visible to the naked eye?

frank blood

define serous

having a somewhat clear or slightly yellow color

define anerobe

his pathogen grows only in the absence of oxygen

what is the most common complication of wound healing?

infections

how a patient with an impaction can exhibit signs of diarrhea?

liquid stool from higher in the rectum or colon may seep around the solid impaction. When this happens, the patient may think he or she has diarrhea or may notice smears of liquid stool in the underwear or incontinence brie

Define granulation tissue

new fragile tissue that grows and fills a wound

what is the frequency of bowel elimination in elderly

one bowel movement daily, while others may go several days between movements, and yet others may have several bowel movements each day

what are other wounds found in hospitalized patients ?

stasis ulcers sinus tract surgical incisions

What is the longest length of time a patient should be allowed to go without having a bowel movement?

the patient has a bowel movement at least every 3 days to prevent constipation.

define Defecation

the process of bowl elimination

true or false Act immediately if you suspect a patient may be hemorrhaging internally or externally.

true

what is the Frequency of bowel elimination in children

usually decreases to one or two bowel movements per day

Loop Stoma

usually the transverse colon, is brought to the surface of the abdomen. A plastic rod known as a bridge or stay is positioned under the loop of colon to keep it outside the body, and it is stitched to the abdominal wall

What are the complications of enema?

vagal response and perforation of the intestinal wall, which can result in hemorrhage and infection.

Explain the defecation reflex

■ Initiated when *Mass peristalsis pushes fecal material into rectum* causing *distension* ■ Distention causes sensory impulses to travel to *sacral spinal cord* ■ *Motor impulses* from cord *travel w/ parasympathetic nerves* back to colon, rectum, & anus ■ Causes *contraction* of *longitudinal muscles* which shortens rectum, increasing pressure ■ Pressure, voluntary contractions and parasympathetic stimulation acts to *open internal anal sphincter*

The nurse is caring for a client who was involved in a motor vehicle accident. The client was thrown from the vehicle and has several areas where skin appears to have been scraped away. The nurse identifies the wounds as abrasions. Which statement is true about this type of wounds? 1. They are much like burns and take an extended period of time to heal. 2. They involve deep tissue and can cause muscle and bone infection. 3. They are generally superficial and will heal quickly if kept clean. 4. They will require systemic antibiotics for treatment of infection.

They are generally superficial and will heal quickly if kept clean This is correct. Abrasions are superficial and will heal quickly and without infection if the wounds are kept clean.

When would you consider using Montgomery straps?

They are used when frequent dressing changes are necessary so that tape does not have to be removed frequently from the skin.

Explain what a Kock pouch is.

A Kock pouch is created for an ileostomy to help control the effluent. It is a diversion that uses the terminal portion of the ileum to form an internal pouch, or reservoir, to collect and store the effluent prior to evacuation from the body

A nurse gathers the necessary equipment and supplies in preparation for the removal of a client's sutures. Place the following steps for suture removal in the correct order (1-7). (Enter the number of each step in the proper sequence. Do not use commas). 1. Pull the suture smoothly and firmly with the nondominant hand. 2. Remove the remaining sutures, unless otherwise ordered. 3. Cut the suture next to the skin, adjacent to the knot. 4. Use the forceps, grasp the knot of the suture with the non-dominant hand and lift the suture away from the skin. 5. Remove every other suture and observe the wound edges for any signs of separation. 6. Open the peel pack containing the suture removal set. 7. Use the notched scissors from the removal kit in the dominant hand, slide the notched blade under the suture.

ANS: 6473152 Feedback: The nurse will first open the peel pack containing the suture removal set or staple remover. Then, using the forceps from the removal kit, he or she will grasp the knot of the suture with the nondominant hand and lift the suture away from the skin. Using the notched scissors from the removal kit in the dominant hand, the nurse will slide the notched blade under the suture and cut the suture next to the skin, adjacent to the knot. As soon as the suture is clipped, the nurse will pull smoothly and firmly with the nondominant hand. The suture will slide out, and the contaminated portion of the suture will not be pulled through the skin. The nurse will remove every other suture and observe the wound edges for any signs of separation. This helps prevent the possibility of dehiscence when all sutures are removed. The nurse will then remove the remaining sutures, unless otherwise ordered

The nurse provides care for a client with a pressure injury covering the entire back of the heel. During assessment the nurse finds a dry, leathery, tan layer of dead tissue. The nurse identifies this thin layer as ____________________.

ANS: eschar Feedback: Eschar is hard, dry, dead tissue that has a leathery appearance. It can be black, brown, or tan. When the eschar is stable and covers an area such as a heel, it should be left alone to cover and protect the damaged tissue. If the eschar comes away, it will reveal either a stage III or IV pressure injury.

Which one of the following interventions would you rate as the most important for care of his pressure injury? Change the wet-to-damp dressing on his right hip wound qid using sterile technique. Tell dietary service about his food likes and dislikes. Reposition the patient every 2 hours around the clock, avoiding the right lateral position. Assess the condition of the pressure injury once daily. Provide Foley care every shift. Work to increase the length of time the patient can tolerate sitting in a chair.

Change the wet-to-damp dressing on his right hip wound qid using sterile technique.

What questions should you ask when doing data collection for bowel funciton?

How often do your bowels normally move? Do you have any current problems, such as diarrhea or constipation, and how long has it been occurring? What is the normal number of stools you pass per day? What is the normal color of your stools? What is the normal consistency of your stools? Is your stool formed or unformed? Does abdominal cramping occur with or before a bowel movement? Do you experience any anal burning or itching? Is there pain with defecation? Do you feel urgency or pressure in the rectum (tenesmus)? Do you have any allergies? Do you take routine medications, and what medications have you taken for the elimination problem, both prescription and over the counter? Have you experienced recent changes in appetite? How much fiber do you eat? Do you have regular mealtimes? How much fluid do you drink in a day? What are your usual beverages? Are you experiencing nausea or vomiting? Do you have any food intolerances? Do you have any hemorrhoids?

What of the following would be the best enema to administer to a patient before digital removal of an impaction? Siphon enema Oil retention enema Soapsuds enema Harris flush enema

Oil retention enema