what is the waste product excreted by the kidneys?
urine
what factors affect urination? (5)
-developmental considerations
-food and fluid intake
-psychological variables
-activity and muscle tone
-pathologic conditions
What is the correct order to rotate your pt?
Right side, supine, left side, prone.
what are some constipating foods? (7)
processed cheese
lean meats
eggs
pasta
rice
white bread
iron and calcium suppliments
a nurse caring for a patient in an extended care facility performs regular assessments of the patient's urinary functioning. which patients would the nurse screen for urinary retention? (select all that apply)
a. a 78-year-old male patient diagnosed with an enlarged prostate.
b. an 83-year-old female patient who is on bedrest.
c.a 75-year-old female patient who is diagnosed with vaginal prolapse.
d. an 89-year-old male patient who has dementia.
e. a 73-year-old female patient who is taking an antihistamine to treat allergies
f. a 90-year-old male patient who has difficulty walking to the bathroom
a
c
e
the process of emptying the bladder is?
(name all 3)
voiding
micturition
urination
what is stress incontinence and what is something you can teach your patient to do that has this?
stress incontinence: involuntary loss of urine related to an increase in intra-abdominal pressure
teach your patients to do kegels to help strengthen muscles under the bladder.
How often should you check a Montgomery strap for skin integrity?
Q8H
what is the normal range for bowel movements in a 24-hour period?
1-4 BM
a nurse is preparing a brochure to teach patients how to prevent UTI which teaching points would the nurse include? (select all that apply)
a. wear underwear with a synthetic crotch
b. take baths rather than showers
c. drink 8-10 8oz of water per day
d. drink a glass of water before and after intercourse and void right after intercourse
e. dry the perineal area after urination or disinfect from front to back
f. Observe the urine for color, amount, odor, and frequency.
c
e
f
People whose bladders are no longer controlled by the brain because of injury or disease also void by reflex. this is called what?
autonomic bladder
who are at greater risk for UTIs? (6)
- sexually active people
-postmenopausal women
-people with indwelling catheter
- people with diabetes mellitus
-older adults
When should a skin assessment be performed with...
Acute care?
Longterm care?
Home health care?
Acute: on admission, and then every shift.
Long-term: on admission, then weekly for 4 weeks, then quarterly, and whenever there is a change in skin/wound condition.
Home Health: on admission then upon every visit.
a nurse is working in a GI unit caring for a group of patients in patients with which health problems or issues could the assessment possibly reveal decreased or absent bowel sounds after listening for 2 minutes (select all that apply)
a. peritonitis
b. prolonged bed rest
c. gastroenteritis
d. early bowel obstruction
e. postoperative paralytic illius
f. diahrea
a. peritonitis
b. prolonged bed rest
e.postoperative paralytic illius
a nurse is planning a bowel- training program for a patient with frequent constipation. what is the recommended intervention?
a. using a diet that is low in bulk
b. decreasing fluid intake to 1,000 mL
c. administering an enema once a day to stimulate peristalsis
d. monitor bowel movement
d.
what are some factors associated with urinary retention?
-medications
-enlarged prostate
-vaginal prolapse
what are some treatments for UTIs? (6)
-drink 8-10 8oz of water daily
-observe the urine color, amount, odor, and frequency
-dry the perinatal area after urination or disinfect using front to back technique
-drink two glasses of water before and after sexual intercourse and void right after intercourse
-take showers rather than baths
-use cotton undergarments and avoid tight clothing
With drainage pertaining to a wound, what kind of drainage is there and explain each?
serous: clear and watery
sanguineous: a large number of RBC and resembles the look of blood.
serosanguineous: mix of serum and RBC.purulent: (pus) WBC and thick and often has a musty or foul odor.
what are two things you want to include in the aftercare of a barium enema?
1. encourage fluids to prevent dehydration
2. inform the patient that the barium may lighten the color of the stools
a nurse prepares to assist a patient with a newly created ileostomy. which recommended patient teaching points would the nurse stress? (select all that apply)
a. "when you inspect the stoma, it should be dark purple-blue."
b." the size of the stoma will stabilize within 2 weeks."
c."keep the skin around the stoma site clean and moist."
d. "the stool from an ileostomy is normally liquid."
e.you should eat dark-green vegetables to control the odor of the stool."
f. "you may have a tendency to develop food blockages."
d
e
f
what are some medications that can interfere with urination?
-diuretics can increase the amount of urine and dilute it)
-cholinergic medications (stimulate the contraction of the detrusor muscle and produce urination)
-analgesics and tranquilizers (suppress the central nervous system, interfering with urination)
what is post-void residual?
the amount of urine in the bladder immediately after voiding
What is a scale/ most common scale used for pressure ulcers and explain the number and how it resembles the risk factor?
Braden Scale
19-23= no risk
15-18= mild risk
13-14= moderate risk
10-12= high risk
9 or lower= very high risk
what are the types of enema solutions?
-tap water (hypotonic)
-normal saline (isotonic)
-soap
-phosphate (hypertonic)
-oil (mineral, olive, cottonseed oil)
a nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. what response indicates that the patient understands the explanation?
a. "I can expect to have more discomfort in the area where the cold is applied
b. "I should expect more drainage from the incision after the cold is applied"
c. "I should see less swelling and redness with the cold treatment."
d. "my incision may bleed more when the ice is first applied
c.