NU1421 Exam 2
NU1421 Exam 2 NU1421
ITT Technical Institute
Popular in Fundamentals of Nursing II
Popular in Nursing and Health Sciences
This 8 page Study Guide was uploaded by Bdavi on Wednesday June 1, 2016. The Study Guide belongs to NU1421 at ITT Technical Institute taught by Catherine Jacob in Summer 2016. Since its upload, it has received 4 views. For similar materials see Fundamentals of Nursing II in Nursing and Health Sciences at ITT Technical Institute.
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Date Created: 06/01/16
NU 1421 Exam 2 Study Guide 1. Physical assessment findings- focus on the abnormal p. 542-545 Inspection Skin- inspect for color, scars, venous patterns, bruising, lesions, and striae Unexpected findings include generalized color changes r/t jaundice or cyanosis; shiny tight skin can indication ascites Umbilicus-Note position, shape, color, and sings of inflammation, discharge, or protruding masses; normal- flat or concave with same color of surrounding skin; everted(pouched-out) indicates distention; upward protrusion indicate hernias Contour and symmetry- inspect for contour, symmetry, and surface motion of the abdomen, noting masses, bulging, or distention. Flat abdomen-forms a horizontal plane; round abdomen protrudes in a convex sphere from horizontal plane. Presence of masses asymmetry possible indicates underlying pathological condition. Intestinal gas, a tumor, or fluid in the cavity causes distention. When gas causes distention, the flanks do not bulge; ask patient if abdomen feels tight. In obesity abd is large, rolls of adipose tissue are often present along flanks and pt does not complain of tightness Enlarged organs or masses- observe the contour while asking the pt to take a deep breath and hold it; this reduces the size of the abd. Enlargements in the upper abd (i.e. liver or spleen) descend below the rib cage to cause a bulge; have pt to raise head causes superficial abd wall masses, hernias, and muscle separations to become more apparent Movement or pulsations- men normally breathe abd and women breathe more costally. Pt with serve pain have diminished respirations and tightens the abd muscle to guard against pain. Peristaltic movement and aortic pulsation are visible in thin pt. Auscultation Bowel motility- listen for bowel sounds in all four quadrants (soft gurgling or clicking sounds) takes 5-20 to hear bowel sounds 5 min to determine if bowel sounds of absent. Best time to auscultate is between meals. Sounds are describes as normal, audible, absent, hyperactive, hypoactive. Absent sounds indicate bowel obstruction; paralytic ileus; or peritonitis. Absent and hypoactive sounds occur after surgery following anesthesia. Hyperactive sounds (loud, growling sounds- borborygmi) indicate increased GI motility due to inflammation, anxiety, diarrhea, bleeding, excessive use of laxatives, and reaction to certain foods Vascular sounds- bruits indicate narrowing of the major blood vessels and disruption of blood flow; presents of bruits indicate aneurysms or stenotic vessels. Normally there are not vascular sounds over the aorta or femoral arteries. Report bruits immediately to provider Kidney tenderness- when pt sitting or standing percuss over the kidneys; if kidneys are inflamed pt feels tenderness Palpation Primarily detects areas of abd tenderness, distention, or masses. Use light palpation over to quadrant to detect tenderness. Use systematic approach of each quadrant to assess for muscular resistance, distention, tenderness, and superficial organs or masses. Observe pt face for signs of discomfort. Guarding or muscle tightness indicates a sensitive area. Routinely check for distended bladder which normal lies below the umbilicus and above the symphysis pubis 2. Urinary/Bowel elimination- focus on anatomy p. 1043 and p. 1088-1089 3. Calculating IV flow rate- refer to dosage calculations book 4. Cancer survivorship care plan p. 97 Box 8-3 5. Types of sleeping pattern in elderly and newborn p. 945 Neonates Birth up to age 3 months averages 16 hours of sleep. Sleep cycle s generally 40 to 50 minutes with wakening occurring after one to two sleep cycles. ~50% of this sleep is REM sleep which stimulates higher brain centers. This is essential for development b/c not up long enough for external stimulation Older Adult More than 50% complain of sleep difficulties. Experience weakened, desynchronized circadian rhythms that alter the sleep-wake cycle. REM sleep is shorten, progressive decrease in stages 3 and 4 NREM sleep; some have almost no stage 4, or deep sleep. They awaken more often and it take more time to fall asleep. Presence of chronic illness results in sleep disturbances. Changes in sleep pattern are often caused by changes in the CNS, sensory impairment reduces an older person’s sensitivity to time cues that maintain circadian rhythms 6. Stages of Sleep p. 941 7. NSAIDs p. 981 Such as aspirin and ibuprofen provide relief for mild-to-moderate acute intermittent pain such as headache or muscle strain. Most NSAIDs act on peripheral nerve receptors to reduce transmission of pain stimuli and inflammation. NSAIDs do not depress the central nervous system nor interfere with bowel and bladder functions. Chronic NSAIDs in older pt are linked to more frequent adverse effects (i.e. gastrointestinal bleeding and renal insufficiency). This pain in older pt is treated with acetaminophen. Pt with asthma or allergic to aspirin are also allergic to NSAIDs. Discuss OTC NSAIDs with the provider Selective COX-2 Taking these NSAIDs over long periods of time experience heart attacks and strokes (i.e. Celebrex). Cannot be taken by pt with sulfa allergy. 8. OPIOIDS p.982-983 Generally prescribed for moderate-to-serve pain. Adverse effects is respiratory depression. If pt experience respiratory depression, administer naloxone (Norcan). Other adverse reactions are nausea, vomiting, constipation, itching, urinary retention, myoclonus, and altered mental processes. Before administering, consider pt situation including current treatments, diseases/conditions, and /or organ (kidney/liver) function 9. UTI p.1046 Most common health care acquired infection; 80% result from indwelling catheter others are poor hygiene in women and introduction of instruments into the urinary tract. Lower UTI have pain or burning during urination (dysuria); fever, chills, nausea, vomiting, and malaise develop as the condition worsens. An irritated bladder (cystitis) causes frequent and urgent sensation to void, this irritation causes blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of white blood cells or bacteria. If infection spreads to the upper urinary tract (kidneys-pyelonephritis) flank pain, tenderness, fever, and chills are common 10. Guaiac Test p.1099 Measures microscopic amounts of blood in feces 11. Urine Retention p. 1046 An accumulation of urine resulting from an inability of the bladder to empty properly. Asses the abdomen for evidence of bladder distention and tenderness. In acute retention signs are bladder distention and absence of urine output over several hours. In severe retention the bladder holds as much as 2000 to 3000 mL of urine. Retention occurs as the result of urethral obstruction, surgical or childbirth trauma, and alterations in motor and sensory innervation of the bladder such as neuropathy secondary to diabetes. Retained or residual urine also known as postvoid residual (PVR) occurs if a pt has urinary retention or cannot empty the bladder completely. You can use a bladder scanner or the technique of straight/intermittent catheterization to assess for PVR. 12. Diagnostic tests for Urinary and Bowel complications p.1055 & 1101 13. Controlling Arthritis p. Nursing need to discourage pt from having multiple health care providers for treating pain and refer them to pain specialists. Pain centers offer a holistic approach to chronic pain using both nonpharmacological and pharmacological strategies for pain management. 14. Paralytic Ileus Nonmechanical obstruction of the bowel caused by physiological, neurogenic, or chemical imbalance associated with decreased peristalsis. Common in initial hours after abdominal surgery caused by the handling of intestines during surgery leads to loss of peristalsis for a few hours to several day 15. Pain management and delegation Nursing approach pain management systematically to understand and treat a pt’s pain. Successful management of pain depends on establishing a relationship of trust among health care providers, pt, and family. Pain management extends beyond pain relief, encompassing the pt’s quality of life and ability to work productively, enjoy recreations, and function normally in the family and society. Stimulation of the skin (i.e. massage, warm bath, ice bag, and transcutaneous electrical nerve stimulation) during pain management can be delegated to other health care personnel or family members. 16. Managing abuse in children/elderly p.497 Observe the behavior of the individual for any signs of frustration, explanations that do not fit his or her physical presentation, or signs of injury. Report signs to social service when abuse or neglect is suspected. If abuse is expected, find a way to interview the patient in private; pt are more likely to reveal any problems when the suspected abuser is absent from the room. It is imperative that you help the pt find safe housing or seek protection from the abuser since the risk for further abuse is high one the victim has reported it or tries to leave the abusive situation. 17. Safety precautions managing IVs and Foley catheters 1. Inspect the condition of the IV or foley and surrounding tissue and ask patient about discomfort 2. Observe for leaking from around IV or catheter, if so catheter may need replacing 3. If IV or catheter becomes dislodged assess for trauma and notify health care provider.
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