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Ch 17 of Foundation of Nursing


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State the steps utilized for assisting with elimination.
1. Purpose of hygiene and client safety 2. types of urinals and bedpans 3. nursing interventions
What is the purpose of hygiene and client safety in accordance with elimination?
Hygiene includes taking care of the skin, hands, hair, eyes, nose, mouth, back, and perineum area. Client safety includes proper lighting.
What are 2 types of urinals?
Urinals collect urine. Both male and female urinals are used for voiding.
What are the 3 types of bedpans?
1. Standard has a high back. 2. Fracture- flat and smaller
3. Bedside commode is a portable chair that usually has a removable toilet seat.
What are the nursing interventions for assisting with elimination?
Rationale: Purpose is to assist patient who cannot walk.
Procedure: Assist patient w/ bedpan or urinal while they are in bed. Measure output and immediately dump content when done (in toilet).
What are the characteristics of urine?
color, amount, clarity, specific gravity, pH
Identify the NORMAL characteristics of urine?
1. color (pale straw to amber) 2. amount (30 cc/ per 1hr. 3. clarity (transparent) 4. specific gravity (1.002 - 1.028 ) measures particles in urine 5. pH (4.5 - 8) 7 is neutral
Define incontinence?
Etiology: Pressure in the bladder is too great OR sphincters are too weak.
Management: The Health team asseses the cause and extent of incontinence to determine methods of treatment.
Urge incontinence?
Urge Incontinence: is when you know you want to urinate but you cannot hold it long enough to make it to the restroom in time. Urine can leak the instant you feel the urge to pass it. Even the sound of running water can provide the stimulus.
Stress incontinence
Stress Incontinence: is the most common type of incontinence and one a lot of women who have had children will relate to. Urine leaks during coughing, sneezing and laughing, when lifting heavy objects or in any sort of exercise that puts pressure on the bladder.
Overflow incontinence?
Overflow Incontinence: is when the quantity of urine exceeds the capacity of the bladder and leakage of urine then occurs. You may feel as if your bladder is never fully empty and some people with overflow incontinence can spend long periods of time in the bathroom because of this unpleasant feeling. Other people do not feel as though their bladder is full but dribble and pass urine with little control. This type can be due to a physical obstruction, a common example of this is prostate problems in men.
Functional incontinence?
Functional Incontinence: is when you know you want to go to urinate but because of a physical or communication problem you cannot get to the restroom quickly enough.
Reflex incontinence?
Reflex Incontinence: occurs due to spinal or neurological trauma or disease when there is little or no sensation or voluntary control of the bladder
Total incontinence?
Is the continuous total loss of urinary control. The patient is continually wet.
Causes of total incontinence are neurological, post surgical, after childbirth or due to pelvic disease. Damage to the nerves controlling the bladder may occur from spinal deformities such as spina bifida or scoliosis, trauma to the spinal cord, diseases such as multiple sclerosis or Lou Gehrig's disease or pelvic surgery.
List 7 factors that affect intestinal elimination?
1. amount of food consumed 2. type 3. fluid intake 4. cycling 5. drugs 6. nervous tension 7. exercise
Factors that affect intestinal elimination; amount of food consumed?
High in fiber, beans, cabbage, etc.
Factors that affect intestinal elimination; type?
Certain foods determine type of stool.
Factors that affect intestinal elimination; fluid intake?
2000-3000 mL
Factors that affect intestinal elimination; drugs?
DO NOT overdose or depend on laxatives
Factors that affect intestinal elimination; nervous tension?
Embarassment leads to constipation. Remember, patients need privacy.
Factors that affect intestinal elimination; exercise?
Need anything to promote muscle tone and peristalsis.
What are the characteristics of stool? (5)
1. amount 2. color 3. odor 4. consistency 5. components
Characteristics of a normal stool; amount?
moderate amount is per 1-3 days.
Characteristics of a normal stool; color?
Characteristics of a normal stool; odor?
Odor is affected by what you eat.
Characteristics of a normal stool; consistency?
soft and firm
Characteristics of a normal stool; components?
Undigested food, dead bacteria, fatty bile, living cells, intestinal mucosa, and water are components of a normal stool.
Define each step utilized for stool specimen collection; routine urinalysis.
A routine investigation should be performed with each physical examination to provide important information about how your body utilizes food, reacts to stress, and its ability to metabolize medications. It can also be a valuable screening tool for the detection of underlying medical conditions such as diabetes, kidney disease, and many other medical problems.
Define each step utilized for stool specimen collection; urine culture.
Test done on a sample of urine which is smeared on a special culture media in the lab and allowed to grow. It is then examined.
The urine sample is analyzed for signs of infection.
Define each step utilized for stool specimen collection; 24 hr urine collection?
Test of renal function and urine composition, such as measurements of levels of adrenalcoricol steroids, hormones, protein, and creatine clearance, require a 24 hr collection of urine. (Setting up a time limit to show what can be in a urine sample)
What is midstream, "clean catch" urine specimen?
Midstream urine collections are usually only collected when a UTI (Urinary tract infection) is suspected, and are usually called 'Clean
Catch' urines. By wasting the first part of a urine stream, vaginal
and urethral contamination is eliminated, or lowered to a point that the it is insignificant. Midstream urine collection is more costly. A sterile, often sealed cup, is necessary, along with TWO antiseptic towelettes.
What is sugar and acetone testing?
This refers to a urine specimen which is collected after first emptying the bladder and then waiting until another specimen can be collected. These double-voided urine specimens are more accurate for purposes of glucose testing (urinalysis). If you test a urine specimen that has been held in the bladder for an extended period of time, it will not accurately reflect the glucose content in the bloodstream. A freshly, double voided specimen is preferred.
Standard precautions of collecting urine?
1. Follow universal precautions when collecting or handling all specimens.
2. Clarify with the physician as to the proper preparation of all specimens.
3. Specimens should be properly fixed as soon as possible.
4. Affix a patient label container the following:
A) Patient’s name.
B) Date
C) Site
D) Physician’s name
If smears are made, label with the patient's name and date.
5. Complete the appropriate requisition form.
6. Specimens will be picked up by a courier and transported to Micro Path Laboratories.
7. Any specimen which is improperly identified as to location or patient ID will be rejected until the discrepancy is corrected by the attending physician.
What is the purpose of stool specimen collection?
Stool culture is performed to identify bacteria or other organisms in persons with symptoms of gastrointestinal infection, most commonly diarrhea. Identification of the organism is necessary to determine how to treat the patient's infection.
What are ttpes of stool specimen collection?
Fecal occult blood tests are based on the observation that slow bleeding from colon polyps or cancers can cause chronic blood loss from the colon (sometimes causing iron deficiency anemia). Such bleeding are often not visible (occult) to the naked eye. Therefore, sensitive chemical tests are developed to detect blood traces in stool.
What is "ova" stool specimen collection?
This stool analysis determines the presence of ova and parasites such as protozoa, flatworms, or roundworms.
What is the procedure for a stool specimen collection?
Specimen should be collected in sterile bedpan, not contaminated with urine, residual soap, or disinfectants. Those portions of stool which contain pus, blood, or mucous should be transferred to sterile specimen container.
How do immobile patients develop decubitus ulcers?
Immobility does not allow relief for pressure of blood.
How do malnourished patients develop decubitus ulcers?
Lack of cushion for bones
How do incontinent patients develop decubitus ulcers?
Continues contact of fluids cause irritation which causes imapired skin integrity.
How do low-hemoglobin patients develop decubitus ulcers?
Decreases oxygen and nutrients to cells resulting in skin impairment because cells are not nourished enough.
How do obese patients develop decubitus ulcers?
Fat tissues decrease, Vascularity and resilience, and increase rate cause decubitus ulcers.
How do patients with draining wounds develop decubitus ulcers?
Draining wounds cause pressure on bony prominence which can lead to decubitus ulcers.
How many stages are there in the classification of decubitus ulcers?
4 stages
Stage 1 of a decubitus ulcer?
The skin is red and you can start to see lesions.
Stage 2 of a decubitus ulcer?
There is partial thickness skin loss. The ulcer manifests as a blister, abrasion, or shallow crator.
Stage 3 of a decubitus ulcer?
Full thickness skin loss with extensive damage to muscle, bone, and supporting structures.
Stage 4 of a decubitus ulcer?
Full thickness skin loss. Does not extend further than the underlying fascia. It manifests as a deeper crator.
Identify the characteristics of the skin?
1. Integrity; warm, dry, and smooth 2. temperature; warm, dry, and smooth 3. turgor; elasticity should return to normal when pulled within 3 seconds 4. color; varies with racial background, hereditary, sun exposure- dark brown to light tan w/ pink or yellow overtones.
List the causes of skin breakdown?
Poor circulation, friction, moisture, pressure
What is poor circulation in accordance with skin breakdown?
It is the stretching of blood vessels that interrupt blood flow and causes poor circulation.
What is friction in accordance with skin breakdown?
The rubbing of skin results in layers of tissue becoming removed.
What is pressure in accordance with skin breakdown?
This occurs when there is enough pressure placed on the skin that the blood vessels colapse.
What is moisture in accordance with skin breakdown?
Foot odor, pitted keratolysis, and athlete's foot are all related to overly wet feet, and their prevention depends on drying measures

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