EXAM 3 NUR 152
why is diarrhea dangerous?
contents pass too quickly to allow for absorption of nutrients and water
what causes diarrhea?
disorders of digestion, absorption, antibiotic use, enteral feedings, food allergies, pathogens
black wound
goal= debride prescence of eschar, must be removed for healing. surgical debridement best if tolerated, mechanical debridement by nurse.
how can you treat a UTI?
antibiotics, drinking lots of fluids (water/cran juice)
whats constipation?
any difficulty emliminating stool
endurance?
any pain, fatigue or vital sign changes with activity EX: how far they can walk w/o resting
how can we assess for neurovascular complications in THR?
assess CMS( circulation, movement, sensation).
what to assess in a post op orthopedic p.t?
assess CMS, VS every 2 hr
extension
away from body
what is a simple fracture?
closed, no opening in the skin
red wound
goal=protect/keep moist clean,beefy red w/ granulating tissue serous drainage clear
An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?
"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."
why are emollient/ lubricant ( stool softeners) used for post op?
prevent straining
whats the max amount of time a p.t is aloud to be in one position?
2 hrs max
normal protein lab value?
6.4-8.3 g/dL or 64-83 g/L
why is anticoagulant therapy used in post orthopedic p.ts?
prevention of clots due to immobility
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement
ANS:"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."
saddle joint
Bone surfaces are convex on one side and concave on the other; movements include flexion-extension, adduction-abduction, circumduction, and opposition (e.g., joint between the trapezium and metacarpal of the thumb).
An older adult female has a bone density test that reveals severe osteoporosis. What does the nurse understand can be a problem for this client due to the decrease in bone mass and density?
Compression fractures
Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?
Digital removal of stool may cause parasympathetic stimulation.
what must we do as a nurse if we suspect a break?
Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved.
what measures can we take to prevent DVT in THR p.t?
Intermittent compression devices should be applied either intraoperatively or immediately postoperatively; these devices must remain on the legs at all times, even when the patient is out of bed. Patients should be instructed to dorsi- and plantar flex the ankles and the toes 10 to 20 times every half hour while awake. In addition, patients who are post-THA should be mobilized as soon as possible to assist with decreasing venous stasis; even patients with epidural catheters should stand and ambulate when they are physically able
A nurse is working primarily with adult and older adult clients. Which lifespan considerations should the nurse keep in the mind when working with these populations? Select all that apply.
Older men may experience urinary hesitancy and difficulty starting the urinary stream.• Older adults may try to manage incontinence by restricting intake of fluids.• Because of decreased arterial perfusion, kidney function progressively decreases later in life.
how can we manage pain on someone post (THR)?
Patient will require parenteral opioids during the first 24-48 hours and then will progress to oral analgesic agents.
how soon after surgery for THR should the p.t. be walking?
Patients begin ambulation with the assistance of a walker or crutches within a day after surgery.
what are signs of DVT in THR p.t.?
Physical signs of DVT include pain and tenderness at or below the area of the clot, swelling or tightness of the affected leg, possibly with pitting edema, with either warmth or cooling, and skin discoloration; PE symptoms may include acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain
ball-and-socket joint
The rounded head of one bone fits into a cuplike cavity in the other; flexion-extension, abduction-adduction, and rotation can occur (e.g., shoulder/hipjoints).
Which factor is related to developmental changes in bowel habits for older adult clients?
Weakened pelvic muscles lead to constipation.
The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?
Whole wheat spaghetti and broccoli
how to treat/prevent pressure ulcers?
assess risk for pressure ulcers, decerease pressure to wounds/at risk areas. Choose appropriate dressings, monitor labs & nutrition, dietician consult, refer to wound clinic PRN, debridement, flap graft/skin graft.
protein lab what does it measure?
albumin and globulin
what meds are important for immobile p.t.?
analgesics and anti inflammatory meds PRN
Which medication causes constipation?
iron supplements
using different devices to assist in moving p.ts. is an example of what?
body mechanics
What is body mechanics?
efficient coordinated and safe use of the body and its parts ( safe use of body)
risks associated w/ lubricants?
decrease absorption of fat soluble vitamins, may cause aspiration pnuemonia if taken W/ emollients or mineral oil increased risk for fat emboli
what kind of excercises should immobie patients be preforming?
deep breathing and coughing excercises, and leg excercises (and wear TED hose)
mental immobility?
depression- decreased PT motivation Anxiety
before using laxatives what must be done?
determine the underlying cause of constipation
how to care for black wound
enzymatic ointments, dressing to promote softening, hydrogel/hydrocolloids wet to dry dressings
what kind of diet for immobile p.t?
high protein and fluids.
what can an abductor pillow be used for in THR?
hip dislocation
whats proteinuria?
protein in the urine
whose at high risk for contracting UTI
sexual active women, women who use diaphrams for contraception, postmenupasual women, patients w/ indewlling catheter, p.ts w/ diabetes & older adults
postural reflexes?
the group of reflexes (automatic movements) that maintain body position and equilibrium, whether at rest or during movement
A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply.
1. provide support 2. prepare to removecast Reason:A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply.
The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?
3 in (7.5 cm)
normal albumin lab values?
3.5-5.0 g/dL or 35-50 g/L
how long is the large bowel?
5-6 ft long cecum, colon (ascending, transverse, descending, sigmoid) and rectum
how many ounces of fluid should you drink a day for UTI?
8-10 ounce
what degree of flexion should we avoid in THR p.t.s and for how long?
90 degrees for the first 4-6 weeks * p.t. may not be able to go past 90 degrees based on the type of hip replacement
Lubricants
=Haileys M-O(mineral oil) coat fecal contents allowing for easier passage, reduce water absorption in colon. prevents straining on defecation.
emollient/lubricant/stool softeners
=colace, docutase sodium lower surface tension of feces so more water and fat can penetrate. ~short term use to prevent straining after surgery, MI or pregnancy.
chemical stimulants/ cathartics
=dulcolax irritate intestinal mucosa to INCREASE mobility, DECREASE absorption in small bowel and colon. ~may cause severe abdominal cramps generally used to prepare bowel for diagnostic procedures
EMEMAS: Saline laxatives(bulk)
=magnesium citrate, MOM, fleet phosphate, fleet enema increasing osmotic pressure in S.I. by inhibiting water absorption & increasing water & electrolyte secretions from bowel wall, promotes peristalsis, lubricates feces.
bulk forming/ stimulant laxatives
=metamucil absorb water and increase bulk in bowel, stretch intestinal walls to stimulate peristalsis, also used to relieve mild diarrhea
The nurse is reviewing prescriptions to irrigate an ostomy. Which clients can have their ostomy irrigated? Select all that apply.
A client with a left-sided end colostomyA client with a sigmoid colostomy
The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action?
ANS:A risk that the peristomal skin will become excoriated REASON:An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed
A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?
ANS:Administer the solution gradually over 5 to 10 minutes REASON:Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.
Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?
ANS:Before removing the tube, discontinue suction and separate the tube from suction REASON:When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath.
A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?
ANS:Collect 15 to 30 mL of the client's liquid stool. REASON:Usually, 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient; this client is more likely to have liquid stool. If portions of the stool include visible blood, mucus, or pus, include these with the specimen. Also be sure that the specimen is free of any barium or enema solution. Because a fresh specimen produces the most accurate results, send the specimen to the laboratory immediately.
The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?
ANS:Left lateral REASON:The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.
The nurse is reviewing a client's laboratory work before administering a large-volume enema. Which laboratory result indicates that a nurse should confer with the health care provider before administering the enema?
ANS:Platelet count of 18,000/mm3 REASON:A platelet count of less than 20,000/mm3 (20.00 × 109/L) may seriously compromise the client's ability to clot blood. Therefore, the nurse should not perform any unnecessary procedures that would place the client at risk for bleeding or infection, such as giving an enema. A serum albumin level of 3.1 g/dL (31 g/L) suggests malnutrition. An arterial pH level of 5.2 indicates acidosis. A WBC count of 15,200/mm3 (15.20 × 109/L) suggests infection. Malnutrition, acidosis, and infection would not contraindicate administering an enema.
The proliferation of Clostridium difficile causes
ANS:antibiotic-associated diarrhea REASON:Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea.
A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan?
Assessing movement and sensation in the fingers of the right hand reason:The nurse should assess a casted arm every 2 hours for finger movement and sensation to make sure the cast isn't restricting circulation. To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered, which allows air to circulate through the cast pores to the skin below. Unlike a plaster cast, a Fiberglass cast dries quickly and can be handled without damage soon after application. The nurse should assess the brachial and radial pulses distal to the cast — not the pedal and posterior tibial pulses, which are found in the legs.
A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet? a) regulation of osmotic pressure in the blood b) maintenance of normal bowel elimination c) production of hemoglobin to carry oxygen to tissues d) promotion of energy storage in adipose tissue
B
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?a) Potassium b) Vitamin C c) Vitamin K d) Calcium
C
A client was playing softball and dislocated four of his fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as?
Closed reduction reason:In a closed reduction, the bone is restored to its normal position by external manipulation. A bandage, cast, or traction then immobilizes the area. In an open reduction, the bone is surgically exposed in the operating room and realigned. If internal fixation is needed to stabilize a reduced fracture, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pin.
A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing? a) Vitamins b) Fats c) Carbohydrates d) Protein
D
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?
Disconnect the nasogastric tube from suction during the assessment of bowel sounds.
gliding joint
Flat surfaces of the bone slide over one another; flexion-extension and abduction-adduction can occur (e.g., carpal bones of wrist and tarsal bones of feet).
what are ways to maintain skin integrity?
HTT upon admission, turning p.t. every 2 hrs
A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation
Lower the solution container and check the temperature and flow rate.
A client presents at the emergency department with a compound fracture of the right femur. Skeletal traction is applied to align the bones. What type of traction would be used?
Steinmann traction Reason:Skeletal traction is applied directly to a bone by using a wire (Kirschner), pin (Steinmann), or cranial tongs (Crutchfield). General or local anesthesia may be used when inserting these devices.
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
Stop the procedure, monitor heart rate and blood pressure.
What is stress incontinence?
The loss or leaking of 50 ml or less of urine during exercise, sneezing, laughing, coughing, or when lifting something heavy. (activites of increased abdominal pressure)
When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?
The stoma is prolapsed.
whats a way that we can manage pain in THR w/o medication?
The use of pillows to provide adequate support and relief of pressure on bony prominences assists in minimizing pain.
A female client is diagnosed with a urinary tract infection (UTI) and states this is her second one in the last 6 months. In teaching the client about health promotion, the nurse would include which statement?
Try to urinate immediately after sexual intercourse."
what should nurse assess on a patient post THR
VS, respiratory status, s/sx of bleeding & infection
what is a complication in post op orthopedic pt?
VTE is one of the most common and dangerous of all complications occurring in the postoperative orthopedic patient.
what should we do with an open fracture?
With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints are applied for immobilization
pivot joint
a ring-like structure that turns on a pivot; movement limited to rotation; (e.g, joints between the atlas and axis of neck and between proximal ends of the radius and the ulna at the wrist)
hinge joint
a spool-like (rounded) surface of one bone fits into a concave surface of another bone, only flexion and extension can occur; (e.g., elbow, knee, ankle joint)
whats the function of the colon?
absorption, secretion, elimination
isotonic?
active movement
who is at risk for malnurishment?
adverse effect of meds, geriatric p.t., low income, decreased ADL, incognitive impairment, malabsorption, depression/loneliness
ROM goal?
aim to initiate as soon as possible after occurence of immobility
what can help p.t. with pain post op orthopedic?
analgesics for pain, PCA pump ( patient care analgesia, p.t is given pump that administers med when they need it)
what part is attached to a colostomy?
ascending, transverse, and descending
abduction
away from midline
why do we frequently assess immobile P.ts?
being immobile can affect ALL body systems, skin, respiratory, heart, GI, urinary, mental ect.
What's a compression fracture?
bone jammed across itself
What are saline laxatives (bulk) used for?
bowel prep in diagnostic procedure/surgery
what character is the bone in a transverse fracture?
broken and seperate
Which nursing action associated with successful tube feedings follows recommended guidelines? a) Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. b) Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. c) Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. d) Prevent contamination during enteral feedings by using an open system.
c
effects of iron supplements on the GI tract?
causes constipation, nausea, flatulence, ABD pain, diarrhea, and black tarry stools ( iron binds w/ hemoglobin)
A student nurse studying human anatomy knows that a structure of the large intestine is the:
cecum
how to care for a yellow wound?
clean, can use a wound vac
GI immobility
constipation, decreased peristalsis
what could be causing constipation?
diet, activity, meds, physiological probs
whats dysuria?
difficulty or painful urination
what do you need a physicians order for in a bowel impaction?
digitally removing stool
why might someone need an ostomy?
diseases prevent normal passage of feces through rectum ex: cancer, chrons, deformities
how can you prevent a UTI?
drinking two glasses of water before sex, peeing immediatley after sex, dry perineal area from front to back (urethra to rectum) and p.t education
body mechanics?
efficient coordinated and safe use of the body and its parts , how our bodies move to do activites and move objects
how many hrs should we turn p.t.s?
every 2 hr
importance of correct alignment?
experiencing no undue strain on joints, muscles, tendons, or ligaments while balance is maintained
what is the role of skin? why important?
first line of defense, maintain its integrity to protect our p.t.s from organisms that could harm them, prevents excess fluid loss, temp regulation, sensory perception, sythesis of vit D , absorption/elimination
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?
first thing in AM
respiratory immobility?
fluid build up in lungs
what should we look out for when using chemical stimulants/ cathartics?
fluid/electrolyte imbalance (not for long term usage)
importance of skin?
for health and maintaining musculoskeletal system. shows signs of pain, redness, edema, swelling
what decribes the degree greenstick fracture?
fracture doesnt go all the way through the bone
sinovial joints
freely moveable/ diathrosis joint cavity containing synovial fluid(gliding, hinge, pivot, condyloid, saddle, ball and socket joints)
how to determine risk of immobility?
frequent assessent of all body systems skin, respir, cardiac, GI, urinary, mental ECT.
stage 4 pressure ulcer?
full thickness exposes bone, tendon, muscle. probable tunneling & undermining.
stage 3 pressure ulcer?
full thickness tissue loss, may see subcutaneous fat. Bone, muscle, tendon NOT visible. slough may be present but doesnt obscure depth. may have undermining or tunneling
Unstagable pressure ulcer?
full thickness, base of wound not visible due to slough or eschar
how to dress a red wound?
gentle cleansing & moist dressing
yellow wound
goal= cleanse prescnse of slough, remove non viable tissue (debribe) absorb exudate.
what's a bowel impaction? what are s/sx?
hardened feces wedged in the rectum. no BM for several days, oozing diarrhea, anorexia, nausea, abdominal distention, cramping, rectal pain
A client is diagnosed with frequent urinary tract infections. Which of the following would be an appropriate question for the nurse to ask the client?
how frequently do you urinate each day?
deeper wound what kind of dressing?
hydrocolloid dressing, vaccum assisted closure of wound
After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?
hyperactive bowel sounds
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
hypertonic saline
weakened muscles and cramps/ decreased ROM are symptoms of what?
immobility
fibrous joints
immovable/synarthrosis no joint cavity, fibrous connective tissue between bones ( sutures between skull bones)
why do we pay attention to health hx?
important to determine factors that will put them at risk for impaired skin integrity.
aerobic
improves cardiovascular status
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?
inadequate intake of liquid
What are the symptoms?
incomplete emptying of bladder, burning when peeing, feeling the need to urinate, decreased sphincter, bladder-outlet obstruction due to estrogen depletion, reduced renal blood flow ( dyruria, urinary frequency/ureency, cloudy urine burning when urinating and foul odor)
cardiac immobility?
increased cardiac output, DVT - circulation issues
whats fecal incontinence?
involuntary passage of gas/feces IS embarrassing to p.t may be related to cognitive impairment or disease process
which joint to support while performing ROM excercise?
joint distal to the one being excercised
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:
liquid consistency.
how are fractures classified?
location, type, direction or pattern of fracture line
what describes the degree avulsion fracture?
loss of connective tissue and bone
what indicates malnurishment?
low albumin
nursing assessment for bowl impaction?
lubricate gloved finger, have p.t bear down, lay finger flat against anus to relax rectum and insert finger towards umbilicus. gently assess for impaction, may need to digitially remove stool if other interventions didnt work ( enema, lax)
whats the nurses role in caring for the skin?
maintain integrity identify factors that could put p.t.s at risk for impaired skin integrity intervening to prevent/reduce p.ts. at risk providing specific wound care
purpose of ROM?
maintain joint mobility, improve/maintain muscle strenghth, prevent muscle atrophy/contracture, prevent complications of immobiity
whats albumin?
makes up 60% and helps maintain osmotic pressure w/in vascular space
what should we do when caring for ostomy?
measure when its changed; should appear beefy red and moist, assess skin around ostomy
what character is the bone in a comminuted fracture?
multiple pieces
isometric?
muscle contract w/o moving joint
isokinetic
muscle contraction/tension against resistance
focal body parts in ROM excercise?
neck, shoulder, arms, wrists, hands,hips, knees, ankles and feet
what must we do while assessing for constipation?
need to determine what NORMAL is for specific p.t ( norm is different for everyone) ask how much difficulty when trying to pass stool
how do wound vacs work?
negative pressure, device decreases pressure on wounds, gently pulls fluid from wound over time reducing swelling and may clean wound, pulls edges of wounds together , may stimulate growth of new tissue
Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?
oil
whats a compound fracture?
open, bone breaks through the skin
what is a post orthopedic p.t. at risk for (infefction)?
osteomylitis
rotation
out in a lateral way
what are the s/sx of fracture?
pain, bruising, swelling, deformity, impaired ROM, bruising, crepitus (grating sound/feel w/movement) impaired sensation (numbness, tingling) loss of distal pulse ( fingers/toes might be cold dark in color or blue)
stage 2 pressure ulcer?
partial thickness, shallow open ulcer
whats diarrhea?
passage of liquid unformed feces
active ROM?
patient can do independently
When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:
physiologic or lifestyle changes in the client.
what are some supportive devices for immobile p.t?
pillows, supportive mattress, suspension or heel guard boot, foot board to prevent foot drop, hand roll made out of wash cloth, abduction pillow after hip surgery. trochanter roll
skin immobility?
pressure ulcers
whats a pressure ulcer?
pressures of tissue between any bony prominence and skin for a long time, decreased circulation to area, tissue hypoxia, tissue necrosis/death
what should we do with the adhesive on an ostomy?
push skin don't pull
how to preform excercise for immobile p.t.?
range of motion excercises in bed, isometric excercises
urinary immobility?
renal calculi formation, urinary retention, UTI, urinary incontinence
who should avoid use of saline laxatives?
renal patients/ those on fluid restrictions
whats a stress/fatigue fracture?
repetitive use of body part
passive ROM?
requires nursing assistance
whats the braden scale used for?
risk assessment for pressure ulcers by numbered scale. higher score = less risk. less than 11 higher risk for skin probs.
what should be assessed before prescribing laxs?
s/sx of bowel obstruction pain/distention/bowel sounds nausea/gas pain/nutrition
What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?
sigmoid colostomy
how do you document ulcers?
size (length (head to toe), width, depth) prescence of tunneling/unermining appearance (intact, closed, staples or suture) drainage color, odor, consitency drains- type of drain interventions preformed
The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?
skin turgor response 5 seconds
cartilaginous joints
slightly moveable/amphiarthrosis no joint cavity, cartilage between bones (pubic symphysis, joints between vertebre)
A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?
small intestine
what part is attached for an illeostomy?
small intestine
what character is the bone in impacted fracture?
smushed
whats a pathological fracture?
spontaneous, break with slight pressure or minimal trauma EX:standing and leg snaps (usually an indication of cancer) or arthritis, prior unhealed injury, steriods
stage 1 pressure ulcer?
superficial skin intact, w/ non blanchable redness (doesnt turn white when pressed on and when released pressure back to red). in darker skin tone observe for changes in their skin color
whats on ostomy?
temporary or permanent diversion through the abdominal wall is created. an appliance/ pouch is attached to p.ts skin and collects stool
coordinated body movement?
the ability of muscles to work together for purposeful movement.
importance of body alignment/posture/symmetry?
the alignment of body parts that permits optimal musculoskeletal balance and operation and promotes healthy phisiologic functioning
condyloid joints
the oval head of one bone fits into a shallow depression in another. flexion extension and abduction-adduction can occur ( e.g., wrist joints/ joints connecting fingers to palm)
what should we teach/monitor the use on laxatives?
they are often misused and result in dependence/ or bowel damage
The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?
they place client in fowlers position
adduction
toward center of body
superficial wound what kind of dressing?
transparent dressing
what are laxatives used for?
treatment of constipation
flexion
up towards body
what kind of intervention can we take for p.t.s who are immobile?
use pressure reducing mattress or pads
A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?
wash with mild cleanser and water
A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.
weak abdominal muscles severe dehydration unrelieved constipation
what causes stress incontinence?
weak pelvic muscles
what is abuse of laxatives?
when they are used too often, or used to induce a BM ( someone who denies the urge to deficate)
eastern culture excercise
yoga, ti chi (improve strength balance , tx illness, improve immunity)
