NUR 101 Test #3 07/24/2016

Select All That Apply

1. Pressure Ulcer- (pressure sore, decubiti ulcer, bed sore) impaired skin
integrity related to pressure, localized injury to skin and underlying tissue
over a bony prominence also skin sheering and friction
a. Pts. at Risk:
i. Older adults, spinal cord injuries, fractured hip, long term
homes/community care, acutely ill
ii. Impaired Sensory- pt who can not feel or sense there is pain or
pressure and is at risk for developing ulcer, impaired mobility,
altered LOC
b. Stages of a Pressure Ulcer:
i. 1. May be painful firm soft warm to cool when color changes
ii. 2. Shiny dry or shallow
iii. 3. Bridge of nose ear occipital ankle
iv. 4. Osteomyelitis- inflammation of bone
2. Wound Complications:
a. Hemorrhage- continuous bleeding resulting from broken skin
dislodgment of clot infection or drainage.
i. Hematoma- blood clot
ii. Internal Hemorrhage- saturated dressing pooling under pt
iii. External Hematoma- swelling hematoma with pain drainage
and shock
b. Infection- microorganisms invade wound tissues; purulent drainage,
S/S of fever tenderness pain red swelling elevated WBCs
i. Purulent- odor and yellow green brown
ii. Dehiscence- partial or total separation of wound layers
Fistula- abnormal passing between organs, organ -> skin caused by
improper wound healing; increased risk for infection and further
skin breakdown
 Dehiscence- partial or total separation of skin layers
o Pts. at risk for poor wound healing- obese pts. location of
wound, strain on abdomen,
o S/S- tearing of skin, increased serous drainage
o Nursing Intervention- splinting
Evisceration- separations of wound layers with organs popping out,
immediate OR, do a sterile saline dressing, NPO, asses for shock
prep for OR
Wound Drainage- inflammatory response, exudate serous
sanguineous, serosanguinous, purulent
3. Promoting Healthy Bowel Habit:
a. Take time for defecation, pt needs to know when the urge of
defecation normally occurs, establish routine time when pooping
occurs, offer bed pan or help pt to bathroom in timely manner (bed
bound pts.)
b. Sitting position on BED PAN- bed raised to high fowlers position
make sure pt is comfortable provide privacy promotion of
urination and bowel movement
4. Potassium:
a. Normal value- 3.5-5.0 mEq/L
b. Maintain resting membrane potential of smooth skeletal and cardiac
muscles, allowing normal function
c. K+ and Na relationship- (enemies) when K+ level is up Na+ level is
down, when Na+ level is up K+ level is down
d. Hypokalemia- low serum potassium concentration
i. Physical Exam- bilateral muscle weakness decreased bowel
sounds, dysrhythmias
ii. Assessment: 1. Vitals 2. Heart Monitor 3. Good IV line
iii. Interventions: heart monitor, use IV pump, monitor IV site,
slow K+ drip, DO NOT push IV, oral supplement can not be
CRUSHED (take with food)
e. Hyperkalemia- high serum K+
i. Physical Exam- muscle weakness and relaxation, cramps,
diahreaha, cardiac arrest (relaxed heart)
ii. Effects kidneys, heart, muscles
iii. S/S- dysrhythmias,
 iv. Nursing Interventions:

5. UTI:
a. infection of urethra, commons causes are poor hygene,
incontienence, catheterization
b. Preventing a UTI- encourage fluids, proper perineal hygene void at
regular intervals, women front to back after pooping, avoid perfume
washes, avoid prolong wetness (incontinence)
c. Nursing Interventions: monitor I&Os, characteristics of urine odor
color consistency, asses for full bladder (distention), changes in
LOC, turn and position patient q2h, hygene, collaboration on lab
results, verbalize pain, increase fluids and hygene education
d. S/S- burn while peeing, fevers, chill, too much sex inflammation
and pain in abdominopelvic

6. Urinary Incontinence
a. Defined as the complaint of any involuntary loss of urine
b. Involuntary leakage associated with urgency
c. Involuntary loss of urine associated with effort or exertion such as
sneezing coughing
d. Mixed UI is when stress and urgency are present
e. Overactive bladder urinary urgency
f. Chronic retention overflow UI is leakage caused by overfull bladder
g. Multifactorial UI risk factors some within urinary tract and others
not (illness, meds, age, environmental
h. Functional UI factors that prohibit patient access to bathroom

Focused Topics
1. Hygiene Male and Female:
a. Female Peri Care- clean gloves, wash labia majora with cloth, wipe
in direction from perineum to rectum farthest side away first then
side closest, rinse and dry
i. Separate labia to expose urethral meatus and vaginal orifice,
wash labia minora same way, wash down from vagina to
rectum down middle, using two separate cloths
ii. Think about how you wash to insert a catheter its the
same technique
b. Male Peri Care- clean gloves, retract foreskin and wash tip of penis
at urethra meatus using circular motion in to out, return foreskin
and wash shaft and scrotum underlying skin folds

2. Indwelling Urinary Catheter:

a. Placement of tube through urethra into bladder to drain urine, MD
order needed, sterile technique, can be intermittent (straight cath),
monitor urine output, used for urinary incontinence to avoid skin
breakdown, used at end of life for comfort,
b. Painful for patient, increased risk for UTI
c. Catheter care: to decrease CAUTI do regular pericare, empty urine
bag when full, check tubing for kinks
d. CAUTI- catheter associated UTI, caused by breaking sterile field
while instering catheter, poor peri care, imporper placement of
catheter (stat-lock)
e. Inserting a Catheter
3. Braden Scale:
a. Assesses patient risk for developing a pressure ulcer
b. Sensory Perception: ability to respond to pressure
i. 1. Completely limited- unresponsive to pain
ii. 2. Very limited- responds only to painful stimuli, no verbal
communication, only moan and restlessness, sensory
impairment
iii. 3. Slightly limited- responds to verbal commands, cant always
communicate discomfort, some sensory impairment
iv. 4. No impairment- responds to verbal commands no sensory
deficit
a. Moisture: degree to which skin is exposed to moisture,
i. 1. Consistently moist skin perspiration or body elimination
damp when is moved to turn
 ii. 2. Moist- often but not always moist change linen once a shift
iii. 3. Occasionally moist
iv. 4. Rarely moist
a. Activity: degree of physical activity
i. 1. Bed rest
ii. 2. Chair bound but cant bear own weight needs assistance
iii. 3. Walks occasionally w assist
iv. 4 walks frequently no assist needed
a. Mobility: ability to change and control body position
i. 1. Completely immobile
ii. 2. Very limited rarely makes slight movements
iii. 3. Slightly limited makes slight frequent movements
iv. 4. No limitations
a. Nutrition: usual food intake pattern
i. 1. Very poor- never eats complete meal no protein poor fluid
intake is NPO on clear liquids IV nutrients
ii. 2. Inadequate- no complete meal eats small protein poor
fluid intake
iii. 3. Adequate- eats over of meals, 4 servings protein
occasionally refuses meal, on tube feed or paternal nutrition
iv. 4. Excellent- eats most of every meal good fluid intake, snacks,
no fluid supplications
a. Friction and Sheer:
i. 1. Problem- moderate- dependent to move lift pt with out
sliding against sheets, slides down in bed, contracted flaccid
comatose
ii. 2. Potential problem- moves freely minimal assistance skin
slides to sheets maintains good position in bed or chair
occasionally slides down
 iii. 3. No apparent problem- self care walky talky

4. Collecting Urinary Specimen:

a. Clean voided/midstream- provide fluids hour prior to collection,
explain reason for mid-stream, free of poop, clean area with towelette
correctly, patient voids first then catches second stream- flushes out
microorganisms or solutes that could give wrong UA or C&S result
b. Indwelling catheter: use syringe or vacutainer and attach to where
catheter inserts to drainage tube (collection port), can only be taken from
that site its considered sterile, cant be taken out of urine collection bag
(not sterile).
c. 24 Hour Urine Collection- time begins when pt first voids then ends at
the 24 hour mark when pt voids. Patient is given special specimen
collection container that has preservatives. Educate patient on making
sure no poop, toilet paper are in the container. Also if any voids are
missed and not put in container the results would be inaccurate

5. IV Dye for Radiological Testing:

a. Intravenous pyleogram- is a special x-ray exam of the
kidneys, bladder, and ureters, clear bowels (enema) and
bladder before procedure
b. Injection of an iodine-based contrast (dye) into a vein in your arm.
A series of x-ray images are taken at different times. This is to see
how the kidneys remove the dye and how it collects in your urine
c. Assess for allergies to IODINE or CT contrast;
d. Pt education on procedure sign consent form prior
e. Cytoscopy- (endoscopy) procedure that provides direct
visualization of bladder and urtehtra, local or general anastesia,
small camera goes up urethra and looks around and repairs if
necessary.
1. obtain consent and complete bowel cleansing if ordered
2. follow pre op procedure
3. after pt return from PACU asses vitals, characterisitics
of urine and output, I&Os, encorurage fluids, observe
for fever dysuria pain in subpubic

6. Urinary Retention:
a. Inability to partially or completely empty bladder, stretches bladder
causing pressure discomfort pain tenderness over pubic symphysis,
b. Patients may have no output for hours, some experience frequency
urgency small volume voiding and incontinence
c. Chronic- slow gradual onset, decrease in voiding volumes and
frequency urgency sensation of incomplete emptying
d. Post void residual- amount of urine left in bladder after voiding
measured by straight cath or bladder scanner
e. Incontinence caused by urinary retention is caused by bladder
overflow pressure on sphincter and causes passage or dribble of
urine

7. Enemas:
a. Instillation of solution into rectum and sigmoid colon promote
defecation by stimulating peristalsis, medication rectal sopistories,
empty bowel before procedure, beginning bowel training, sims
position
b. Cleansing enemas- promote complete evacuation of feces in colon
c. Tap water- hypotonic and exerts osmotic pressure to stimulate
defecation before large amounts of water leave bowel
d. Normal saline- safest solution, volume of infused saline stimulates
peristalsis
e. Hypertonic solutions- infused into the bowel to exert osmotic
pressure that pulls fluids out of interstitial spaces of cells, colon fills
with fluid then distention promotes defecation
f. Soap suds- add soap suds to water or saline to irritate intestines
to stimulate peristalsis
i. High- cleanse colon
ii. Low- cleanse rectum and sigmoid colon
g. Oil retention- lubricate feces in rectum and colon
h. Inserting and giving enema- lubricate tip, tell pt to breathe in
and exhale (relaxes anus) then insert, monitor for bradycardia
because vagus nerve is stimulated, tell pt about any pain cramping,
hold in as directed,
i. Insertion lengths: Adults 3-4 in Children 2-3 inches Infants 1-
1.5 in

8. Changing a Wound Dressing:

a. Check MD order for dressing type, when to change dressing,
frequency solutions and ointments needed, check hospital protocol
for post- op pts.
b. Dry-sterile- gauze and tefla
c. Wet-dry- wet sterile gauze in sterile saline for irrigation, pack in
wound, dry gauze over wet gauze
d. Transparent film- tegaderm
 e. Hydrocolloids- duoderm

9.Wound Dressing Devices:

a. Used when large amount of drainage expected from wound site, can
be open or closed
i. Closed- hemovac Jackson pratt, connect to suction constant
low suction sutured in place
ii. Open- Penrose empties into dressing and absorption
iii. Wound vacuum assisted closure (wound VAC)- uses negative
pressure on wound bed to reduce bacteria and excess fluid
while promoting blood flow, heals from inside out
iv. Jackson Pratt- JP drain grenade
v. Hemovac drain- accordion
vi. Penrose- absorptive material
b. Management of Devices: (Sudden Minimal drainage) check for
any kinks in tubing, make sure dressing and device are in proper
place and function, then notify MD for further assessment

10. Mobility and Immobility:

a. Body mechanics- alignment posture balance lifting bending moving
safety to prevent injury
b. Applying body mechanics- good posture proximity slide roll push use
body weight as force to push or roll rock back and forth smooth
movement break up heavy loads
c. Factors influencing mobility- developmental physical health mental
health lifestyle attitude fatigue stress
d. Transferring a patient from bed to wheel chair- high fowlers
position, use gait belt, assist pt in sitting up, moving legs off to side of
bed, ask if dizzy pain, then rock three times pt hands on RN shoulders to
stand up, ask if dizzy pass out pain, then get behind patient and walk
them to chair with your leg in between pt legs incase of fall, touch back of
knees to wheel chair, ask if dizzy pass out pain, then slowly help pt sit
down in a LOCKED wheelchair

11. Elastic Stocking and Compression:

a. Compression- intermittent pneumatic compression stockings made
of fabric and plastic wrapped around leg and secured with Velcro,
inflates and deflates, inflates for 10-15 seconds then deflates 45-60
seconds
b. Elastic stockings- antiembolitic stocking, maintains external
pressure on muscles of lower extremities to promote venous return,
apply properly and remove once per shift, assess for circulation at
toes, ROM exercises
c. Nursing Intervention: prevent DVTs pulmonary emboli, MD order
for heparin vitamin K, bleeding precautions,
d. Patients at Risk for DVT-
e. Prolonged bed rest, such as during a long hospital stay, or
paralysis. When your legs remain still for long periods, your calf
muscles don't contract to help blood circulate, which can increase
the risk of blood clots.
f. Injury or surgery. Injury to your veins or surgery can increase
the risk of blood clots.
g. Pregnancy. Pregnancy increases the pressure in the veins in your
pelvis and legs. Women with an inherited clotting disorder are
especially at risk. The risk of blood clots from pregnancy can
continue for up to six weeks after you have your baby.
h. Birth control pills or hormone replacement therapy. Birth
control pills (oral contraceptives) and hormone replacement therapy
both can increase your blood's ability to clot.
i. Being overweight or obese. Being overweight increases the
pressure in the veins in your pelvis and legs.
j. Smoking. Smoking affects blood clotting and circulation, which can
increase your risk of DVT.
k. Cancer. Some forms of cancer increase the amount of substances
in your blood that cause your blood to clot. Some forms of cancer
treatment also increase the risk of blood clots.
l. Heart failure. People with heart failure have a greater risk of DVT
and pulmonary embolism. Because people with heart failure already
have limited heart and lung function, the symptoms caused by even
a small pulmonary embolism are more noticeable.
m. Inflammatory bowel disease. Bowel diseases, such as Crohn's
disease or ulcerative colitis, increase the risk of DVT.
n. A personal or family history of deep vein thrombosis or
pulmonary embolism (PE). If you or someone in your family has
had DVT or PE before, you're more likely to develop DVT.
o. Age. Being over age 60 increases your risk of DVT, though it can
occur at any age.
Sitting for long periods of time, such as when driving or
flying. When your legs remain still for many hours, your calf
muscles don't contract, which normally helps blood circulate. Blood
clots can form in the calves of your legs if your calf muscles aren't
moving for long periods.

13. Fluid Electrolyte Acid Base Balance

Priority= death
 First= what do you need to initially do

Extra Cellular Fluid Volume Deficit

Isotonic imbalance, decreased intake of water and salt
Increased GI output vomit diarrhea laxatives diuretics
Hemorrhage or burns
Nursing Interventions- encourage fluids, light clothes, daily weight at
same time of day
S/S- sudden weight loss hypotension tachycardia thread pulse dry
mucous membranes poor skin turgor confusion thirst hypovolemic shock

Extracellular Fluid Volume Excess: Na+H2O=friends Na+K=

enemy (inverse relationship)
Sodium and water greater than output, isotonic gain excessive
administration of Na+ or oral intake of salty foods and water
Sudden weight gain, edema, confusion, pulmonary edema
Heart liver kidney failure
Nursing Interventions- raise HOB if im drowning, push oral water if
possible, ICU pts. (at risk= intubation), asses neurological function, restrict
fluids and sodium
S/S: poor skin turgor, BP low, decreased LOC, thirsty feeling

Hypernatremia- +145
Loss of more water than salt, body fluids are too concentrated
Diabetes insupidius large amounts of perspiration and water out put
with out replacing water
Tube feedings hypertonic fluids, lack of access to water dysfunction of
osmoreceptor
S/S- decreased LOC confusion lethargy thirst seizures (BRAIN) poor
skin turgor dehydration
At risk- ICU intubated pts. oliguria <400 Anuria <100

Hyponaturemia- -135
 Gain of more water than salt body fluids too dilute
Excessive ADH excessive water intake D5W hypotonic solutions
replacement of fluid with no salt
Asses hydration status; skin turgor mucous membranes
S/S: decreased LOC confusion lethargy coma seizures
Hypovolemic congestion leads to pulmonary edema (drowning) raise
HOB GIVE O2

Clinical Dehydration: EVC Deficit + hypernatremia

Sodium and water intake is less than output, loss of more water than
salt
Decreased intake of oral fluid and salt, increased GI output, burns,
hemorrhage, fever
Assessment: labs and hypernatremia s/s
Nursing interventions: daily weight orthostatic blood pressure
(hypotension)

Potassium K+
Fruits potatoes dark leafy greens
Hypo= need K+ in diet (milk)
Hyper+ avoid K+ no salt substitutes
Maintains resting membrane potential skeletal smooth cardiac muscle,
allowing for normal function

Calcium CA2+
Dairy canned fish broccoli oranges vitamin D
Excites nerve and muscle cells necessary for muscle contraction
 Magnesium Mg2+
Dark leafy greens whole grains laxatives antacids
Influences neuromuscular junctions co factor for enzymes

Phosphate
Milk processed foods aluminum antacids
ATP production cellular metabolism

Hypokalemia K+ under 3.5 mEq

Low K+ concentration, shift into cells= alkalosis, DKA with insulin
Out put via GI vomit diarrhea
Assesment: decreased bowel sounds, constipation dysrhythmias
Intervention: do vitals first second heart monitor third get good IV line
Use IV pump, monitor IV site, K+ drip, NO iv push, dont crush oral
supplements

Hyperkalemia 5mEq +
High K+ concentration, rapid infusion of stored blood, ingestion of salt
substitute
Shift out of cells = acidosis cell damage (chemo) insufficient insulin
(DKA)
Acute or chronic oliguria (decreased urine output)
Assessment: muscle weakness abdominal cramps dysrhythmias
cardiac arrest, dialysis, diet (kidneys filtration renal failure) muscle damage
(burns) loose diarrhea fleet enema auscultate for bowels (obstruction)
 Hypocalcaemia Ca2+ -8.45 Ca+Mg= friends (inverse)
Decreased intake of Ca vitamin D deficiency end stage renal disease
diarrhea
Shift of Ca into bone- alkalosis pancreatitis, increased output by
diarrhea
S/S- tingling fingers + chvostek sign (contraction of facial muscles
when tapped) muscle twitch and cramping hyperactive reflexes tetani
dysrhythmia
Trousseaus- cardio pedal spasm

Hypercalcemia Ca2+ 10.5+ Phos= enemy Phos decrease Ca2+

increase Ca2+ increase Phos decreases
Heart killer alkali syndrome, kidney stones, malignant Hypercalcemia=
stage 4 bone metastisis (cancer) Ca in blood, sedation
S/S- constipation, vomit, fatigue, diminished reflexes decreased LOC
confusion flank pain
Nursing Interventions- cardiac monitor (priority) first= IV line second=
Vitals

Hypomagnesemia- Mg2+ -1.5 mEq

Low Mg in blood, ALCOHOLISM, diarrhea laxative misuse GI losses
sedation diuretics
S/S- + chevostek sign hyperactive deep tendon reflexes muscle
cramps twitching dysphagia tetani tachycardia hypertension dysrhythmias

Hypomagnesemia- Mg2+ +2.5 mEq

Excessive use of MG laxatives parenteral overload of Mg
S/S: oliguria end stage renal disease, renal failure, lethargic
hypoactive deep tendon reflexes bradycardia hypotension

Arterial Blood Gas Measurements

 pH- 7.35-7.45, below 7.35 is acidic, above 7.45 is basic, small
changes could effect H+ concentration
PaCO2- 35-45 mm Hg, partial pressure of CO2 how well the lungs are
excreting CO2 produced by cells, a increase in CO2 accumulation in blood =
hypoventilation, decreased PaCO2= excessive CO2 excretion less carbonic
acid through hyperventilation, high value is acidic and low value is alkaline
HC03- 22-26 mEq, concentration of bicarbonate in blood, how well
kidneys are excreting metabolic acids, increased blood has too few metabolic
acids, decreased is too many metabolic acids, high value is alkalosis low
value is acidosis

IV Fluids
Dextrose in Water Solutions: dextrose 5% in water (D5W), isotonic,
same as blood, diluted in water is isotonic, hypernatremia
Dextrose 10% in water: hypertonic adding to blood diluted ECF
Saline Solutions
NS hypotonic and rehydrates cell
.45% NS NaCl- hypotonic rehydrates cells
.9% NaCl NS- isotonic expands ECV does not enter cells
3-5% NaCl- hypertonic, draws water from cells into ECF by osmosis
Dextrose in Saline Solutions:
Dextrose 5% in .45%, hypertonic, dextrose enters cells rapidly leaving
.45% NaCl hypernatremia
Dextrose 5% in .9% NaCl, hypertonic dextrose enters cells rapidly
then leaving .9% NaCl Hyponaturemia
Balanced Electrolyte Solutions
Lactated Ringers- has Na+ K+ CA2+ Cl- liver metabolizes to HCO-3
does not enter cells isotonic solution
Dextrose 5% in lactated ringers- hypertonic dextrose enters cells
rapidly leaving lactated ringers D5LR

Complications of IV Therapy
Infiltration- blanched cool to touch edematous may be painful
 Priority is contact MD
First place compress elevate
Stop infusion, discontinue infusion, elevate, apply compress, remove
IV and change site
Phlebitis- damage to veins, meds too strong, redness tender pain
warmth
Stop infusion and discontinue IV site apply moist warm compress

Infiltration Scale
0- no symptoms
1- skin blanched edema, 2.54 cm, cool to touch with or without pain
2- skin blanched edema cool to touch with or without pain
3- skin blanched translucent gross edema in any direction cool to
touch mild-moderate pain numbness
4- skin blanched skin tight and leaking discolored bruised and swollen
gross edema in any direction deep pitting tissue circulatory impairment
moderate to severe pain visible infiltration
Phlebitis Scale
0 no symptoms
1 erythema at access site with or without pain
2 pain at site erythema and edema
3 pain at site streak formation palpable venous cord
4 pain at access site with erythema and edema palpable venous cord
purulent drainage

Food and Vitamins that make poop change color:

normal adult= brown normal infant=yellow
 black or tary- iron ingestion or upper GI bleed
pale with fat- malabsorption of fat
Potential causes of black colored stools include:
acidified blood (blood from higher in the digestive
tract)
iron supplements or foods high in iron
Pepto-Bismol or other medicines containing bismuth
black licorice
large amounts of spinach or other greens
blueberries
other foods dark in color
Potential causes of red colored stools include:
blood (such as from hemorrhoids, anal fissures, or
diverticualr disease)
red gelatin, popsicles, or food containing artificial
red coloring
tomato juice or soup
large amounts beets
Pale Or Clay-Colored Stool
Potential causes of pale or clay colored stools include:
liver disease (such as hepatitis or obstruction of bile
ducts)
antacids containing aluminum hydroxide
barium from a recent barium enema test
Green Stool
 Green or dark green stools could be caused by:
large amounts of green, leafy vegetables
green or purple artificial coloring (popsicles, Kool-
Aid, gelatin)
iron supplements
infectious gastroenteritis
rapid bowel transit or decreased colonic transit time

Orange Stool
Potential causes of orange colored stools include:
some medications (such as beta-carotene and
Rifampen)
foods high in beta-carotene: carrots, sweet potatoes,
apricots, winter squash, pumpkin, cantaloupe, and mangoes

Diet for C-Diff Patient-

Diet for Constipated Patient-