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Foundations II Midterm I Cumulative Review

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NURS 1503U

Foundations Midterm Review Notes S.1­ 5 Session 1 Bowel elimination GI tract: Mouth, esophagus, stomach, small intestine, large intestine, rectum Mouth – Mechanical and chemical breakdown Esophagus – Passage of bolus from mouth to stomach – peristalsis Stomach – Mechanical and chemical breakdown with Hydrochloric acid, mucus, pepsin and intrinsic factor. Chyme – semi-fluid material from stomach Small intestine – Duodenum, jejunum, ilium - Chyme mixes with digestive enzymes (bile and amylase), moves slowly - Nutrients almost entirely absorbed in the duodenum and jejunum - Ileum absorbs certain vitamins, iron, and bile salts Include various ostomies, j-tubes and procedures Large intestine – Cecum (ileocecal valve), colon (ascending, transverse, descending) - Water, sodium and chloride are absorbed in colon - Valsalvar maneuver contraindicated in some clients with heart problems, stool softeners Rectum – Peristalsis (mass movement) – The coordinated, rhythmic serial contraction of smooth muscle that forces food through the digestive tract, bile through the bile duct, and urine through the ureters - A wave of peristaltic contractions propels the bolus (moist, soft ball) into the stomach  peristaltic contractions relax over the bolus and contract behind the bolus, thus moving contents through the length of the GI tract - Two types of muscle contraction occur in the colon: slow-mixing contractions and mass peristalsis. - Slow mixing contractions – move contents through colon and expose chime to mucosa, where active absorption of sodium and chloride causes water absorption and dries the chime to feces. - Mass peristalsis movements – Push feces toward rectum; ingestion of food is the main stimulus for mass peristalsis (gastrocolic reflex) - These mass movements occur 3-4 times a day in adults Factors affecting Bowel Elimination Age – Control of defecation is at 2-3 years - Peristalsis decreases with age, esophageal emptying slows, older adults may have difficulty controlling bowel evacuation - Some people are less aware of the need to defecate and as a result, develop irregular bowel movements and are at risk of constipation - Many issues associated with aging can significantly affect bowel elimination, including polypharmacy, poo r nutrition, life stressors, and comobidities Infection – can cause diarrhea and inflammatory or ulcerative changes in the small or large intestine. Most infections are spread by the oral-fecal route, through contaminated food or water. - Colitis (C. difficile) is a bacterial infection associated with antibiotic therapy. C. difficile is usually acquired in the hospital setting, where the organism is commonly found  Treatment includes immediate discontinuation of the antibiotic and in cases where symptoms are severe, treatment is aimed at eradication of the infection. Diet – Fiber provides bulk for absorbing fluids, thereby increasing fecal mass - Insoluble fibre is found in whole grains, wheat bran, and vegetables and does not dissolve in water  effective in preventing constipation. - Soluble fibres are found in some beans, certain fruits and vegetables, and wheat bran  forms a gel when mixed with water and is not as effective in preventing constipation. - When a patient’s dietary fibre is low, the stool becomes dry, hard, and difficult to pass. - Lactose intolerance – is the inability to digest lactose, the predominant sugar in milk  People who have lactose intolerance must learn how much lactose their body can tolerate; ie. Some individuals can drink on glass of milk without effect, but not two. Fluid intake – an inadequate fluid intake or disturbances that result in fluid loss (such as vomiting) can affect the character of feces. Fluid liquefies intestinal contents to ease their passage through the colon. - Reduced fluid intake slows the passage of food through the intestine and can result in hardening of the stool  unless a medical issue suggests otherwise, an adult should drink 6 – 8 glasses (1400 - 2000ml) of non-caffeinated fluid daily. - For some patients, artificial sweeteners can be a bowel irritant. - Older adults tend to have an insufficient intake of fluids and are more at risk to develop constipation  sometimes older adults reduce their fluid intake in order to attempt to reduce micturition. - In some people, an increased ingestion of milk or milk products may slow peristalsis and cause constipation. Physical activity – Promotes peristalsis, whereas immobilization depresses peristalsis - Patients who experience these changes in the abdominal and pelvic floor muscles are at increased risk for constipation Psychological factors – Stress increases peristalsis to provide nutrients for defense; depression decreases peristalsis - Stomas can cause serious body image changes - Often perceived as form of mutilation - Client feels different - Nurse needs to be aware of their own response to the ostomy - Personal habits – Gastro-colic reflex highest after meals, embarrassment to deny urge Position – Squatting is the normal position during defecation. Toilets are designed to facilitate this posture – allowing body to lean forward, exert intra-abdominal pressure, and contract the thigh muscles - In supone position it is impossible to contract the muscles used during defecation - If patient’s condition permits, raise the head of the bed; this action assists the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate Pain – Hemorrhoids, rectal fistulas, abdominal surgery (supressing urge to defecate) - Patient may avoid urge to defecate to avoid pain and constipation and impaction may develop - Hemorrhoids are dilated, engorged veins lining the rectum. External hemmroids are clearly visible as protrusions of the skin; internal hemorrhoids have an outer mucous membrane. The presence of hemmorhoids is frequently accompanied by fecal soiling of undergarnments and irritation of distended veins by overly vigourus cleaning of the anus. Pregnancy – as pregnancy advances, the size of the fetus increases and pressure is exerted on the rectum. A temporary obstruction created by the fetus impairs the passage of feces. rd - Slowing of peristalsis during the 3 trimester often leads to constipation. A pregnant woman’s frequent straining during defecation or delivery can result in the formation of permanent hemorrhoids. - Damage to the perineum extending to the anal sphincters during labour can also alter sphincter integrity. Surgery and anesthesia – Temporary cessation of peristalsis with manipulation of the bowel (paralytic ileus) lasts 24-48 hours, early ambulation facilitates return - Surgical interventions on the GI tract affect bowel elimination, as will surgery on other systems, such as the musculoskeletal and cardiovascular systems. - The general anaesthetic agents used during surgery cause temporary cessation of peristalsis. Patient who receives local or regional anaesthesia is less at risk for bowel elimination alterations because bowel activity may be affected minimally or not at all. - Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis  this condition is called paralytic ileus: usually lasts 24 – 48 hrs; if the patient remains inactive or is unable to eat after surgery, return of normal bowel function may be further delayed. - Early ambulation stimulates the evacuation of flatus, stimulates peristalsis, and alleviates abdominal pain. Medications – Narcotics, anti-cholinergic slow peristalsis, antibiotics contribute to diarrhea, NSAIDs irritate GI mucosa, aspirin and gastritis, laxatives and cathartics promote peristalsis Bowel Problems Constipation – The signs of constipation vary among patients, but usually include infrequent bowel movements (fewer than 3 times per week), difficult evacuation of feces, inability to defecate at will, and hard feces. - Constipation is a common concern during acute hospital admissions for older adults. - Constipation can also occur in conjunction with the treatment of urinary conditions, as an adverse effect of the medication but also because individuals with urinary incontinence may reduce their fluid intake to reduce the frequency of their need to urinate. Impaction – Large mass of dry, hard stool that can develop in the rectum due to chronic constipation - Mass may be so hard it cannot come out of body - Watery stool from higher in the bowel may move around the mass and leak out, causing soiling and diarrhea - Incontinence: Inability to control passage of feces - Incontinent x2 = Incontinent of urine and feces - Hemorrhoids dilated, engorged veins in the rectum Diarrhea, fluid & electrolyte imbalance – Diarrhea is an increase in the number of stools (several bowel movements per day) and the passage of liquid, unformed feces  can be acute or chronic. Excess loss of colonic fluid can result in serious fluid, electrolyte, or acid-base imbalances - Older adults are particularly susceptible to complications associated with diarrhea. - Repeated passage of diarrhea stools exposes the skin of the perineum and the buttocks to irritating intestinal contents; therefore, meticulous skin care and containment of fecal drainage is needed to prevent skin breakdown. Incontinence – Fecal incontinence is the inability to control the passage of feces and gas from the anus  is devastating to patients and has a significant effect on functional, social, and psychological well-being. - Patients without the cognitive awareness of the urge to defecate are at risk for incontinence. - Fecal incontinence can be successfully managed and treated with nursing intervention. Flatulence – Is a common cause of abdominal fullness, pain, and cramping. In most healthy individuals, 100 to 200 mL of gas is present in the GI tract. - For a person eating a normal diet, 50 to 500 mL of gas is passed 10 to 15 times a day. Bowel diversions/ostomies - Location of ostomy determines consistency of stool - An ileostomy is a stoma that has been constructed by bringing the end or loop of small intestine (ileum) out onto the surface of the skin. Intestinal waste passes out of ileostomy and is collected in a pouch stuck to skin. Ileostomies are usually sited above the groin to the right hand side of the abdomen. - A transverse colostomy is an opening into the transverse colon (large bowel) and is usually sited above the waist. It can be on right or left side. Assessment of bowel elimination history Usual pattern – Routines around elimination – Coffee in the morning may trigger b.m. Characteristics of stool – Diet history – Fluid intake – Exercise, mobility and dexterity – Can they perform personal hygiene themselves? Aids present – Elevated toilet seats, medications (stool softeners) Illnesses affecting GI tract – Crohn’s disease, IBS Emotional/social history – Hygiene related to some cultures (ex. right hand eating, left hand only for cleansing) - Loop Colostomy – is usually performed in a medical emergency when closure of the colostomy is anticipated; are usually temporary large stomas constructed in the transverse colon (the surgeon pulls a loop of bowel onto the abdomen). The proximal end drains stool, whereas the distal portion drains mucus. - End Colostomy – consists of one stoma formed from one end of the bowel with the distal portion of the GI tract either removed or sewn closed (aka Hartmann’s pouch) and left in the abdominal cavity  For many patients, end colostomies are a result of surgical treatment for colorectal cancer. - Double-Barrel Colostomy – the bowel is surgically severed and the 2 ends are brought out onto the abdomen. - Location of ostomy determines the consistency of the stool. - An ileostomy is a stoma that has been constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out of the ileostomy and is collected in an external pouching system stuck to the skin. Ileostomies are usually sited above the groin on the right hand side of the abdomen. - A transverse colostomy is an opening into the transverse colon (large bowel) and is usually sited above the waist. It can be on the right or left side. - A transverse colostomy is an opening into the transverse colon. Physical  assessment Inspect abdomen – - Contour, shape, symmetry, skin colour, scars, presence of stomas, lesions, distension Auscultation Palpation Percussion Promoting normal defecation - Squatting position • Elevated toilet seat if needed • Position with bedpan: Call light and toilet paper within reach, privacy, cultural aspects Enemas - Too much potassium in body – kayexulate enema absorbs - Order of “enemas to clear” – caution to administer no more than 3 as fluid and electrolyte imbalance possibility - Cleansing enemas - Tap water - Normal saline - Soapsuds - Oil retention - Medicated (kayexulate) Oxygen Therapy - Physiology of Respirations - Oxygen – To sustain life - Cardiac and respiratory systems function to supply body’s oxygen demands - Major respiratory muscle – - Accessory muscles – COPD patients use many accessory muscles (pumping shoulders up to breathe) - Breathing is the effort required for expanding and contracting the lungs - Breathing is determined by the compliance of the lungs, airway resistance, and use of accessory muscles of respiration - Adequate oxygenation is affected by adequate circulation, ventilation, perfusion, and transport of gases to the tissues - Diaphragm lies (like a stingray) Factors affecting Oxygenation - Low hemoglobin – Hgb binds to ? Respiratory rate must increase to compensate for low hgb, decrease in oxygen carrying capacity – anemia, carbon monoxide - Decreased inspired oxygen concentration - High altitudes have lower oxygen rate - Hypovolemia – Shallow breathing, O2 sat decreased, resps decreased, patient needs to be told to take deep breaths - Increased metabolic rate - Increased oxygen demand - Chest wall movement (kyphosis in the elderly), broken ribs Dyspnea management Pharmacological agents - Bronchodilators, steroids, mucolytics, low dose anti-anxiety medications Oxygen (caution with COPD, hypoxic drive) Physical techniques - Breathing techniques - Relaxation techniques - Normal ventilator stimulus is CO2. The ventilator drive of COPD clients varies considerably. - For patients with COPD (severe asthma, emphysema), give no more than 2-3 L/min of oxygen or patients may go into resp. arrest, they have become adapted to low oxygen. Oxygen Therapy - Oxygen therapy requires safe and accurate administration to promote health and reduce risk to client - Requires a doctor’s order for type, amount, and frequency - Check policy re- amount, doctor’s order • The right client (name, birth date, ID#) • The right medication (oxygen) • the right reason (ordered, or needs it ASAP) • The right dose (L/min) • The right frequency • The right route (nasal prongs, mask, etc.) • The right site • The right time Oxygen Safety - Oxygen does not burn but supports combustion - Do not use in presence of open flame or any strong heat source - Do not store near radiators, heat ducts, steam pipes, or other sources of heat - All smoking materials must be removed from the room (lighter, cigarettes) - Smoking within 3 meters of oxygen is prohibited - Do not lubricate oxygen equipment – oil and grease (Vaseline, petroleum jelly) ignites easily (lotion, face creams, hair dressings) - Do not use aerosol sprays near oxygen Nursing responsibilities ASSESS: At start and end of shift and at least q4h in between - equipment – care if portable - Flow rate – is it set as ordered??, is it meeting the patient’s needs? O2 sats good? - humidifier – don’t let it run low, too drying for patient - connections – check frequently, easy to become dislodged especially if using extension tubing or changing from prongs to mask after meals - Tubing – not kinked, pinched off etc. under pt - Client – comfort, RR rate, depth, quality, chest sounds, O2 sats, energy level, able to eat??, able to sleep?? - also check O2 sats on room air if weaning from oxygen – patient needs to be monitored carefully in case they get into trouble - observe for decreased anxiety, improved level of care, fatigue, absence of dizziness, decreased pulse, RR, return to baseline VS, improved color CARE: - all delivery systems can be uncomfortable for patient - Must remove mask, prongs etc.. and clean skin underneath - moisture buildup is a problem - Area behind ears must be checked for signs of breakdown from straps, tubing etc. - remember to change from mask to nasal cannula for meals Pulse oximetry - measures oxygen saturation of arterial blood - Pt. with low Hgb can still have good O2 sats but not enough O2 for tissue needs - Oxygen Saturation - “amount of hemoglobin that is fully saturated with oxygen expressed as percent of total available hemoglobin” - If a pt has a low hgb, all the RBC’s that they have could still be saturated with O2 therefore showing a high O2 saturation - In order to accurately interpret the O2 saturation you need to know what the patient’s Hgb is th - Often called the 5 vital sign - Should be 95 – 100 % - DON’T JUST TRUST THE EQUIPMENT – always “match” the results with the rest of your assessment!! O2 saturation/pulse oximeter procedure - Clean site with alcohol wipe and allow to dry - Remove nail polish/artificial nails if necessary - Apply to skin (use adhesive if required) - Check that equipment is functioning properly - Set alarms if present - Check Hgb status Session 2 Surgical Asepsis - Procedures used to eliminate all microorganisms, pathogens and spores from an object or area - Procedures may include: wearing a mask; protective eyewear; caps and gowns; sterile gloves; “no touch” method; following principles of surgical asepsis for procedures - Objective: to maintain asepsis and not contaminate area or objects - Used in: • The OR, labour and delivery, diagnostics (ex. aniogram) • At the patient’s bedside for care in specific situations (dressing changes, catheter care, IV, suctioning tracheal tubes. - Explain to patient to avoid moving arms and legs under the drapes, to avoid touching and explain where the field is, to avoid coughing, sneezing, and talking over the field Principles of Asepsis 1. Sterile objects remain sterile when touched by only sterile objects - Sterile touching sterile = sterile • i.e. sterile gloves to sterile objects in a dressing tray - Sterile touching clean = contaminated • i.e.. when a sterile catheter touches clean gloves - Sterile touching contaminated = contaminated • i.e.. when a sterile gauze touches the over-bed table - Sterile touching/?maybe touched=contaminated • i.e.. a catheter flips and may have touched the table. When in question always assume contaminated 2. Only Sterile objects are placed on a sterile field - Sterile objects are those which have been properly prepared and identified as sterile - They must have certain characteristics • Clean • Identified as sterile • Dry • Packaging is intact – not torn, punctured, wet or open 3. Objects are contaminated if below waist or out of sight - Contamination can accidentally occur from clothing, hair, patient - Nurses never turn their backs on a sterile field - Hands are kept above the waist and together - Anything that falls below the waist or is out of sight is considered contaminated and discarded 4. Prolonged exposure to air causes contamination - Sterile fields can be contaminated by air currents carrying microorganisms and by droplet contamination - When doing sterile procedures avoid creating air currents with linen, curtains or movement in the room - No one should cough, sneeze, or talk over a sterile field - Placing equipment onto a sterile field should be done from as close as possible without contamination by touching - Minimal rearranging of field reduces air contamination 5. Capillary contamination - Microorganisms will travel quickly through water or dampness like a wick (sometimes called wicking) - All wet objects are discarded or re-sterilized - Sterile liquids spilled onto sterile trays which sit on clean or contaminated surfaces contaminates the field i.e. pouring H2O or betadine - Sterile objects placed on wet surfaces (i.e.. gauze are considered contaminated by capillary contamination) 6. Fluids flow to gravity - Contaminated liquids can flow over sterile field/areas by gravity - Important for hand washing principles - Hands held above elbows while washing - Water and contaminants flow from clean-(hands) to dirty-(elbows) - Hands are dried from fingers to elbows - Hands then kept above the waist and together 7. Outer 1” if sterile field is contaminated - Edges include drapes, sterile towels, package containers, needle covers etc.. - Anything touching the edge or 1’’ perimeter of a field is considered contaminated and discarded - When pouring fluids the edge of a container is considered contaminated and rinsed clean by pouring a small amount of the liquid over the rim and then fluids onto you sterile field container Sterile gloving - Most nosocomial infections are the result of the transfer of microorganisms from staff members’ hands. - Sound aseptic technique can reduce a patient’s length of stay, speed healing, and reduce patient discomfort. - Always begin with a through hand washing - Open and remove outer package from gloves - Grasp inner package and place on a clean, dry surface which is above waist level - Carefully open package keeping gloves in the middle of the packaging - Identify right and left gloves - Glove dominant hand first: • With gloved hand slip fingers under the cuff • Keep thumb up and away • Carefully pull glove over nondominant hand • With both gloves on interlock fingers and adjust gloves to a snug fit - Using thumb and 2 fingers of non-dominant hand, carefully, touching only the inner surface of the glove, pull glove onto dominant hand - Do not unroll cuff - Removing contaminated gloves: • Grasp dominant glove by wrist area and remove while turning inside out • Glove may be discarded or held in non-dominant hand • Tuck bare dominant hand into cuff of non-dominant hand and peel off turning inside out • Discard in appropriate receptacle Latex allergies - Observe patients for sensitivity to latex - Itching - Hives - Redness - Runny nose - Changes in V S - Document observations in detail Establishing a sterile field ALL principles of asepsis apply in establishing a sterile field. - Gather all supplies you will need for the dressing - Wash hands - Choose a flat, dry surface – have lots of room - Holding tray firmly, peel off cover of package away from your body, do not reach over tray - Carefully pick up the forceps tucked on top, always keep the forceps tips down - In the following order, open each of the flaps of the wrapper around the tray being careful not to contaminate the forceps or the inner wr
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