Exam 3 Study Guide PDF

Exam 3 Study Guide 1. Actions nurses take to promote skin integrity - Perform thorough skin assessments - implement preventative measures (repositioning, moisturizing, pressure relieving devices) - provide wound care (cleaning, monitoring, and dressing wounds)...

Exam 3 Study Guide 1. Actions nurses take to promote skin integrity - Perform thorough skin assessments - implement preventative measures (repositioning, moisturizing, pressure relieving devices) - provide wound care (cleaning, monitoring, and dressing wounds) - ensure proper nutrition and hydrating - educate patients on skin care and preventative measures - collaborate with team members for care planning 2. The purposes of dressings - protection: Dressings protect wounds from further injury, contamination, and infection by providing a barrier - absorption: Dressings absorb wound drainage and exudate to keep the wound bed clean and promote healing. - moisture balance: Certain dressings help maintain an optimal moist wound environment to facilitate healing. - compression: Compression dressings apply pressure to control bleeding and swelling. - medication delivery: Medicated dressings can deliver antimicrobial agents or other therapeutic substances directly to the wound. - debridement: Some dressings aid in removing dead tissue and slough from the wound bed. - immobilization: Dressings help stabilize and immobilize the affected area to prevent further trauma. 3. Dehydration Common signs and symptoms of dehydration include (pg 1279): - Dry mouth and throat - Fatigue and weakness - Dizziness and lightheadedness - Headache - Decreased urine output and dark yellow urine color - Dry skin with poor skin turgor - Sunken eyes - Rapid heart rate - Low blood pressure - Confusion (in severe cases) Assessing for dehydration - mucous membranes appear dry and sticky - skin turgor (poor skin elasticity) - vital signs (tachycardia, hypotension, orthostatic changes) - input/output monitoring 4. function of fats  Exam 3 Study Guide *composed of triglycerides and fatty acids *fat is stored in adipose tissue - provide energy and vitamins - no more than 35% of caloric intake should be from fat - each gram of fat provides 9 kcal - sources: oil, salmon, egg yolks fat also supplies tissue with the basis for - hormone production - protective padding for vital organs - insulation to maintain body temp - covers nerve fibers - aids in absorption of fat-soluble vitamins - structure material for cell walls *a diet high in fat is linked to CVD, hypertension, and diabetes *except for kids under 2yrs old (they need a higher amount of fat to form brain tissue 5. process of digestion. a. Mouth i. Mechanical Digestion: Begins with chewing, which breaks down food into smaller pieces. ii. Chemical Digestion: Saliva, containing enzymes like amylase, starts breaking down carbohydrates into simpler sugars. iii. Swallowing: The food is formed into a bolus and moves through the pharynx to the esophagus via swallowing. b. Esophagus i. Peristalsis: This muscular movement pushes the food down from the esophagus to the stomach. The lower esophageal sphincter prevents backflow of stomach contents. c. Stomach i. Mechanical Digestion: Stomach muscles churn the food, mixing it with gastric juices. ii. Chemical Digestion: Gastric secretions, including hydrochloric acid (HCl) and the enzyme pepsin, break down proteins. iii. Chyme Formation: The food is converted into a semi-liquid form called chyme. iv. Regulation: The pyloric sphincter controls the passage of chyme from the stomach to the small intestine. d. Small Intestine i. Duodenum, Jejunum, Ileum: The chyme moves through these sections of the small intestine. ii. Chemical Digestion: Enzymes from the pancreas (like lipase, amylase, and proteases), along with bile from the liver (stored in the gallbladder), further break down fats, carbohydrates, and proteins.  Exam 3 Study Guide iii. Absorption: The small intestine, especially the jejunum and ileum, is the main site for nutrient absorption. Villi and microvilli increase surface area for nutrient absorption into the bloodstream. e. Large Intestine (Colon) i. Absorption of Water: The large intestine absorbs water and electrolytes from the remaining indigestible food matter. ii. Formation of Stool: As water is absorbed, the waste becomes solid, forming feces. iii. Bacterial Action: Bacteria in the large intestine help digest certain fibers and produce vitamins (e.g., Vitamin K). iv. Defecation: Feces are stored in the rectum and eventually eliminated through the anus when the body initiates the defecation reflex. f. Elimination i. The final step involves the elimination of indigestible substances and waste products from the body through defecation, maintaining homeostasis. 6. water-soluble vitamins (RDA: recommended dietary allowance) (AI: adequate intake) vitamin best source function deficiency thiamine (B1) pork, liver, whole grains, beans, nuts carbohydrate metabolism headache, weight loss, fatigue riboflavin (B2) dairy products, whole grains nutrient oxidation cracked lips, swollen tongue niacin (B3) meat, milk, eggs, nuts, poultry, whole nutrient oxidation skin lesions, grains dementia, pellagra Pantothenic acid (B5) Whole grains, meat, vegetables Nutrient oxidation rare body system failures Pyridoxine (B6) Meat, fish, poultry, beans, grains, Protein metabolism anemia, poor growth, oranges CNS disturbances Biotin (H) Eggs, milk, cereal Nutrient oxidation rash, hair loss, depression, fatigue Folic Acid (B9) Green leafy vegetables Red blood cell formation, prevention of spina bifida Vitamin B12 Animal products Red blood cell formation, anemia, GI findings, nerve cell maintenance poor muscle coordination Vitamin C Citrus fruits Antioxidant, collagen bleeding gum,  Exam 3 Study Guide vitamin best source function deficiency thiamine (B1) pork, liver, whole grains, beans, nuts carbohydrate metabolism headache, weight loss, fatigue formation decreased iron absorption, scurvy 7. Signs of inadequate fiber intake - Constipation/bloating - Hunger after meals - Blood sugar fluctuations - High cholesterol - Fatigue/low energy - Inflammation 8. BMI - Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships. - Calculate BMI by dividing a patient's weight in kilograms by height in meters squared: weight (kg) divided by height? (m?). - For example, a patient who weighs 165 lb (75 kg) and is 1.8 m (5 feet 9 inches) tall has a BMI of 23.15 (75 ÷ 1.82 = 23.15). 9. Dysphagia a. Types of Dysphagia i. Oropharyngeal Dysphagia: Difficulty initiating the swallowing process due to issues with the mouth or throat (e.g., neurological conditions like stroke or Parkinson's disease). ii. Esophageal Dysphagia: Difficulty with the passage of food through the esophagus, often due to structural abnormalities (e.g., strictures, esophageal cancer, or achalasia). b. Causes of Dysphagia i. Neurological Causes: Stroke, Parkinson's disease, multiple sclerosis, ALS (amyotrophic lateral sclerosis), dementia, and traumatic brain injury. ii. Structural Causes: Tumors, strictures, gastroesophageal reflux disease (GERD), and congenital abnormalities like cleft palate. iii. Muscular Causes: Conditions affecting the muscles involved in swallowing (e.g., myasthenia gravis). iv. Aging: Elderly patients may experience dysphagia due to weakening of the muscles involved in swallowing. c. Signs and Symptoms of Dysphagia i. Coughing or choking during or after eating/drinking. ii. Drooling or difficulty managing saliva.  Exam 3 Study Guide iii. Pocketing food in the cheeks or difficulty moving food around in the mouth. iv. Gurgling or wet-sounding voice after eating/drinking. v. Sensation of food "sticking" in the throat or chest. vi. Frequent pneumonia or respiratory infections (sign of aspiration). vii. Unintended weight loss due to difficulty eating. d. Nursing Interventions for Dysphagia i. Positioning: Keep the patient in an upright position (90-degree angle) during meals and for 30–60 minutes after to prevent aspiration. ii. Modify Diet Consistency: Work with dietitians and SLPs to provide the appropriate texture, such as: Pureed foods. iii. Thickened liquids (thin liquids pose a higher risk of aspiration). iv. Encourage Small, Frequent Meals: Small portions can help patients manage food more safely. v. Provide Sufficient Time for Eating: Dysphagia patients need to eat slowly and chew thoroughly. vi. Chin-Tuck Method: Instruct patients to tuck their chin while swallowing to close the airway and reduce the risk of aspiration. vii. Oral Hygiene: Ensure good oral care to prevent bacteria buildup that could be aspirated and cause pneumonia. viii. Monitor for Signs of Aspiration: Look for coughing, wet voice, or respiratory changes during meals. ix. Hydration: Ensure that the patient receives adequate fluids through thickened liquids if necessary, and monitor for dehydration. 10. paralytic ileus a. Causes of Paralytic Ileus i. Surgery (Especially Abdominal Surgery): The most common cause of paralytic ileus is abdominal surgery, where manipulation of the intestines or anesthesia can slow down or stop peristalsis. ii. Medications: Opioids, anticholinergics, and other medications that slow gastrointestinal (GI) motility. iii. Electrolyte Imbalance: Hypokalemia (low potassium) and other electrolyte disturbances can affect muscle contractions in the intestines. iv. Infections or Inflammation: Conditions like peritonitis, pancreatitis, or sepsis can cause paralytic ileus. v. Trauma or Severe Illness: Traumatic injuries, especially involving the abdomen, and severe illnesses can trigger ileus. vi. Neurological Conditions: Diseases that affect the nervous system, like Parkinson's disease, may lead to paralytic ileus. b. Signs and Symptoms of Paralytic Ileus i. Absence of Bowel Sounds: No bowel sounds (or hypoactive sounds) upon auscultation is a classic sign of paralytic ileus. ii. Abdominal Distention: The abdomen becomes visibly swollen due to the accumulation of gas and fluids in the intestines.  Exam 3 Study Guide iii. Pain or Discomfort: The patient may experience vague abdominal discomfort, cramping, or a feeling of fullness. iv. Nausea and Vomiting: In severe cases, the patient may vomit, particularly if ileus causes a buildup of intestinal contents. v. Inability to Pass Gas or Have a Bowel Movement: This is a hallmark sign. The patient may report no flatus or bowel movements over several days. vi. Anorexia (Loss of Appetite): The patient may have no desire to eat due to abdominal discomfort and distention. c. Complications of Paralytic Ileus i. Bowel Perforation: If the bowel becomes severely distended, it can rupture, causing peritonitis. ii. Infection or Sepsis: Ileus can lead to bacterial overgrowth and translocation, which may result in infections. iii. Electrolyte Imbalances and Dehydration: Ongoing vomiting or lack of oral intake can lead to imbalances like hypokalemia, which may further worsen ileus. iv. Aspiration Pneumonia: Vomiting, especially in post-operative or sedated patients, increases the risk of aspiration. d. Nursing Interventions for Paralytic Ileus i. Monitor Bowel Sounds and Abdominal Girth: Perform frequent abdominal assessments and document findings (bowel sounds, distention, and pain). ii. Nasogastric (NG) Tube Insertion (if indicated): A nasogastric tube may be used to decompress the stomach and relieve nausea, vomiting, and distention. Nurses should monitor and manage NG tubes, including ensuring proper placement and monitoring output. iii. NPO (Nothing by Mouth): Patients with paralytic ileus are often placed on NPO status to rest the bowels and prevent further distention. iv. IV Fluids and Electrolytes: Maintain hydration and electrolyte balance through IV fluids. Potassium levels should be monitored and corrected if needed. v. Pain Management (Avoid Opioids if Possible): Since opioids can exacerbate ileus, pain management should aim to minimize opioid use. Non-opioid analgesics or alternative pain relief methods should be considered. vi. Encourage Early Ambulation: If possible, early ambulation helps stimulate peristalsis and bowel function. vii. Assess for Return of Bowel Function: Nurses should observe for the return of bowel sounds, passing gas, or bowel movements, which are signs that the ileus is resolving. viii. Monitor Input and Output: Carefully track fluid intake, output, and the balance between them to prevent dehydration and electrolyte imbalances. 11. supplement to reduce birth defects a. calcium- fetal bones mineralize b. protein  Exam 3 Study Guide c. iron- fetal blood storage d. folic acid (600mg)- DNA synthesis (inadequate intake can lead to fetal neural defects, anencephaly, megaloblastic anemia) 12. nutrition for infants through school-age children a. Infant Nutrition (0-1 year): - Breast milk or formula provides complete nutrition for the first 4-6 months - Iron-fortified cereals are typically introduced as first solid foods around 6 months - New foods should be introduced gradually, one at a time to check for allergies b. Toddler Nutrition (1-3 years): - Require fewer calories but more protein per body weight - Small, frequent meals and nutrient-dense snacks improve intake - Limit milk to 2-3 cups per day to ensure adequate appetite for solid foods - Avoid choking hazards like nuts, hard candy, raw veggies c. Preschooler Nutrition (3-5 years): - Nutritional needs similar to toddlers, around 1800 calories per day - Focus on quality over quantity of food to prevent obesity - Engage children in meal preparation to encourage trying new foods d. School-Age Nutrition (6-12 years): - Steady growth rate with gradual decline in calorie needs per weight - Ensure adequate protein, vitamins A and C despite unsupervised eating - Limit high-fat, sugary, salty snack foods that contribute to childhood obesity 13. lipids and lipoproteins Lipids are a group of organic compounds that are insoluble in water but soluble in nonpolar solvents. They include fats, oils, waxes, and steroids. Lipids play crucial roles in energy storage, cell membrane structure, and hormone production. Lipoproteins are complex particles that transport lipids in the bloodstream. They consist of a nonpolar lipid core containing triglycerides and cholesterol esters, surrounded by an amphipathic coating of phospholipids, cholesterol, and proteins called apolipoproteins. The major lipoproteins are: a. Chylomicrons - Transport dietary triglycerides and cholesterol from the intestines to tissues. b. Very Low-Density Lipoproteins (VLDL) - Synthesized in the liver, transport endogenous triglycerides to tissues. c. Low-Density Lipoproteins (LDL) - Deliver cholesterol to peripheral tissues. High LDL levels are associated with atherosclerosis. d. High-Density Lipoproteins (HDL) - Remove cholesterol from tissues and transport it back to the liver for excretion, reducing cardiovascular disease risk.  Exam 3 Study Guide 14. nasogastric tube Purpose: - Decompressing the stomach by removing gastric contents and air, relieving pressure and distension. - Administering medications, fluids, or liquid nutrition directly into the stomach. - Obtaining gastric samples for analysis. Complications: - Tube dislodgement or misplacement - Can lead to aspiration if the tube migrates out of the stomach/intestine. - Aspiration - Regurgitation of gastric contents can enter the lungs, causing aspiration pneumonia. - Tube clogging - Thick formulas or medications can clog the feeding tube. - Metabolic complications - Refeeding syndrome with electrolyte shifts, diarrhea, hyperglycemia. - Gastrointestinal issues - Nausea, vomiting, constipation, diarrhea, abdominal cramping. - Tube site infection or irritation - Poor hygiene around the tube insertion site. - Dehydration - Inadequate free water flushes with continuous feedings. - Careful monitoring, tube care, and adjusting feeding rates/formulas as needed can help prevent or manage many of these complications. 15. assessment of flatulence - Auscultating bowel sounds to assess intestinal motility and gas movement - Inspecting and palpating the abdomen for distension, tympany, or tenderness - Inquiring about the patient's diet, medications, and recent changes that may contribute to flatulence - Observing the volume, odor, and any associated discomfort with passing flatus - Reviewing medical history for conditions like irritable bowel syndrome that can cause excessive gas 16. subcutaneous injections - Common sites are the outer aspect of the upper arm, abdomen, and front of thighs. - A short needle (5/8 to 1 inch) is used and inserted at a 90-degree angle. - Pinch up a skinfold to create a tent for easier injection into the subcutaneous tissue. - Medications given subcutaneously include insulin, certain vaccines, fertility drugs, and some anticoagulants. - Advantages include being easier than IM injections, less painful, and avoiding veins. - Disadvantages are slower absorption than IV and potential for injection site reactions. - Proper technique and site rotation are important to prevent complications like bruising or lipohypertrophy.  Exam 3 Study Guide 17. rapid acting insulin - Rapid-acting insulin is a type of insulin that is designed to control blood sugar spikes after meals. It starts working quickly and has a shorter duration of action compared to other types of insulin. It is often used by people with diabetes, particularly Type 1 diabetes, but also in some cases of Type 2 diabetes, to manage their blood glucose levels. Characteristics of rapid acting insulin - Onset: less than 15 min after injection. - Peak: 60 minutes to 90 min after injection. - Duration: 3-5 hours. Common types - Insulin Lispro (Humalog) - Insulin Aspart (NovoLog) - Insulin Glulisine (Apidra) 18. accu check a. Normal Blood Glucose Levels - Fasting: 70–100 mg/dL. - 2 Hours After Eating (Postprandial): Less than 140 mg/dL. - Random Blood Glucose: Typically less than 200 mg/dL (higher levels may indicate diabetes). b. Interpreting Results - Hypoglycemia (< 70 mg/dL): - Symptoms: Sweating, shakiness, confusion, dizziness, and in severe cases, unconsciousness. - Interventions: Provide fast-acting glucose (e.g., juice, glucose tablets), recheck blood glucose in 15 minutes, and repeat if necessary. - Hyperglycemia (> 180 mg/dL): - Symptoms: Increased thirst, frequent urination, fatigue, blurry vision, and in severe cases, ketoacidosis (especially in Type 1 diabetics). - Interventions: Depending on the cause, administer insulin or other medications as prescribed, encourage hydration, and monitor for signs of diabetic ketoacidosis (DKA). 19. preparation of insulin 1. Wash hands and prepare supplies - insulin vial/pen, syringe, alcohol swabs. 2. Roll the insulin vial gently between palms to re-suspend the insulin if it has been refrigerated. Do not shake. 3. Wipe the rubber stopper of the vial with an alcohol swab. 4. Draw air into the syringe equal to the insulin dose by pulling the plunger down. 5. Insert the needle into the vial and push the air from the syringe into the vial. 6. Invert the vial and draw the correct insulin dose into the syringe. 7. Tap the syringe to allow air bubbles to rise, then expel the air.  Exam 3 Study Guide 8. Double check the dose in the syringe before injecting. 9. Choose and clean the injection site per rotation schedule. 10. Pinch skin and insert needle at 90 degree angle for subcutaneous injection. 20. reduce aspiration - Keep the head of the bed elevated at least 30-45 degrees during and for 30-60 minutes after enteral feedings, unless contraindicated. - Measure gastric residual volumes every 4-6 hours for continuous feedings and before intermittent feedings. - Administer prokinetic medications like metoclopramide to promote gastric emptying when ordered. - Ensure nothing by mouth status for surgical patients per provider orders to reduce aspiration risk during anesthesia. - Assess breathing patterns, breath sounds, and level of consciousness to identify aspiration risk factors. - Use proper feeding tube placement techniques and verify placement before initiating feedings. 21. Anorexia Nervosa vs Bulimia Nervosa Anorexia Nervosa: - Intense fear of gaining weight and persistent behaviors to prevent weight gain - Refusal to maintain a minimally normal body weight - Distorted body image and denial of being underweight - Can lead to excessive weight loss and malnutrition Bulimia Nervosa: - Recurrent episodes of binge eating large amounts of food - Followed by compensatory behaviors like self-induced vomiting, laxative abuse, fasting, or excessive exercise - Occurs within a normal or above normal weight range - Sense of lack of control during binge episodes Key Differences: - Anorexia involves severe food restriction, while bulimia involves binge-purge cycles - Anorexia results in being underweight, while bulimia usually maintains normal weight - Anorexia is more overt, while bulimia is harder to detect due to normal weight 22. UTI a. Causes of UTIs - Bacterial Infection: Most UTIs are caused by bacteria, with Escherichia coli (E. coli) being the most common pathogen. - Catheterization: Indwelling urinary catheters increase the risk of infection due to bacterial entry into the bladder. - Sexual Activity: Increased sexual activity can introduce bacteria into the urinary tract, especially in women.  Exam 3 Study Guide - Urinary Retention: Incomplete emptying of the bladder, often seen in older adults or those with neurological conditions, increases UTI risk. - Anatomical Factors: Women are more prone to UTIs due to their shorter urethra, which allows bacteria easier access to the bladder. b. Risk Factors for UTIs - Female Gender: Women are more susceptible due to the shorter urethra and its proximity to the anus. - Urinary Catheter Use: Patients with catheters are at high risk of developing catheter-associated UTIs (CAUTIs). - Sexual Activity: Sexual intercourse increases the risk of bacterial introduction into the urinary tract. - Post-Menopausal Women: Reduced estrogen levels after menopause can lead to changes in the urinary tract, making infections more likely. - Pregnancy: Hormonal changes and the pressure of the growing uterus can increase the risk of UTIs. - Diabetes: Increased blood sugar can promote bacterial growth and impair the immune system's ability to fight infections. c. Signs and Symptoms of UTIs i. Lower UTI (Cystitis - Bladder Infection): - Dysuria: Pain or burning during urination. - Increased Urinary Frequency: Needing to urinate more often than usual. - Urgency: A strong, sudden urge to urinate, even when the bladder is not full. - Cloudy, Foul-Smelling Urine: Presence of bacteria or white blood cells in the urine can lead to a cloudy appearance or foul smell. - Hematuria: Blood in the urine, which may be visible (gross hematuria) or detectable only by a urine test (microscopic hematuria). - Lower Abdominal or Pelvic Pain: Discomfort or pressure in the bladder area. ii. Upper UTI (Pyelonephritis - Kidney Infection): - Flank Pain or Back Pain: Pain around the sides or lower back. - Fever and Chills: Pyelonephritis often presents with systemic signs of infection. - Nausea and Vomiting: These symptoms may accompany a kidney infection. - Malaise or Fatigue: Patients may feel unusually tired or weak. d. Complications of Untreated UTIs - Pyelonephritis: If a UTI ascends to the kidneys, it can cause a severe infection that may lead to kidney damage. - Sepsis: In rare cases, a UTI can spread to the bloodstream, leading to sepsis, a life-threatening condition. - Recurrent Infections: Frequent UTIs can cause long-term bladder or kidney problems if not adequately managed.  Exam 3 Study Guide 23. CAUTI a. Causes of CAUTI - Bacterial Contamination: Bacteria can enter the urinary tract through the catheter itself or the drainage system. Common pathogens include Escherichia coli (E. coli), Enterococcus, and Pseudomonas aeruginosa. - Prolonged Catheterization: The longer a catheter remains in place, the higher the risk of infection due to bacterial biofilm formation on the catheter surface. - Breaks in Sterile Technique: Inserting a catheter without proper aseptic technique can introduce bacteria into the urinary tract. - Contaminated Equipment or Hands: Contamination during catheter care or manipulation of the catheter drainage system can lead to infection. b. Risk Factors for CAUTI - Prolonged Catheter Use: The risk of CAUTI increases with the duration the catheter is in place. - Female Gender: Women are at higher risk due to their shorter urethra, which allows easier bacterial access to the bladder. - Immunocompromised Patients: Those with weakened immune systems are more susceptible to infections, including CAUTIs. - Elderly Patients: Older adults are more likely to have urinary retention, catheter use, and underlying conditions that increase infection risk. - Critical Illness: Patients in intensive care units (ICUs) are often catheterized for longer periods, increasing the risk of infection. c. Signs and Symptoms of CAUTI - Fever: A fever may be the first sign of infection, especially in patients who are unable to verbalize urinary symptoms. - Dysuria: Pain or burning during urination may be present after catheter removal. - Suprapubic Pain: Discomfort or tenderness over the bladder area. - Cloudy, Foul-Smelling Urine: Urine may appear cloudy or have a strong odor due to the presence of bacteria, white blood cells, and pus. - Hematuria: Blood in the urine, which can range from microscopic to visible levels. - Systemic Symptoms (in severe cases): If the infection spreads, it can cause chills, rigors, sepsis, or even shock, especially in immunocompromised or critically ill patients. d. Treatment of CAUTI - Antibiotics: The mainstay of treatment for CAUTI is antibiotics. The specific type depends on the organism identified in the urine culture and the patient's clinical condition. - Catheter Removal or Replacement: If a catheter is suspected of being the source of infection, it should be removed or replaced with a new one using sterile technique.  Exam 3 Study Guide - Symptomatic Management: Treat fever and discomfort with antipyretics and analgesics as needed. e. Complications of CAUTI - Sepsis: If untreated, a CAUTI can lead to sepsis, a potentially life-threatening condition. - Kidney Infection (Pyelonephritis): The infection can ascend to the kidneys, leading to more serious complications. - Increased Hospital Stay: Patients with CAUTI often require longer hospitalizations and may need more intensive care. 24. Enema Types of Enemas a. Cleansing Enemas: - Purpose: To remove feces from the colon, typically before surgery, diagnostic tests (e.g., colonoscopy), or to relieve constipation. Examples: - Tap Water Enema: Hypotonic solution; stimulates peristalsis by distending the colon. Should be used cautiously to avoid water intoxication. - Normal Saline Enema: Isotonic solution, considered safer for infants and children because it does not alter electrolyte balance. - Soap Suds Enema: A mild soap (often Castile soap) is added to tap water or saline. It irritates the mucosa and stimulates peristalsis. Use with caution to avoid mucosal damage. - Hypertonic (Fleet) Enema: A small volume of hypertonic solution draws water into the colon by osmosis, stimulating defecation. It’s useful for patients who cannot tolerate large amounts of fluid. b. Retention Enemas: - Purpose: To deliver medications or soften stool for easier passage. Examples: - Oil Retention Enema: Contains oil-based solutions (e.g., mineral oil) that lubricate and soften the stool. It is typically retained for a longer period (30-60 minutes) to help ease bowel movement. - Medicated Enema: Used to administer drugs (e.g., antibiotics or corticosteroids) directly to the rectum or sigmoid colon for local effects, such as in inflammatory bowel disease. c. Other Enemas: - Carminative Enema: Helps expel gas from the intestines and relieve bloating. - Return-Flow (Harris Flush) Enema: Used to relieve gas and stimulate peristalsis by repeatedly introducing a small amount of fluid and then allowing it to flow back out. - Barium Enema: Used in radiographic examinations of the colon and rectum to visualize the large intestine. Indications for Enema Use  Exam 3 Study Guide - Constipation: When patients are unable to pass stool for an extended period or experience discomfort. - Bowel Preparation for Diagnostic Tests or Surgery: To clear the bowel of fecal material before procedures such as colonoscopies. - Medication Delivery: When oral or intravenous administration is not suitable or to provide localized treatment (e.g., for ulcerative colitis). - Relief of Fecal Impaction: A large, hardened mass of stool in the rectum may require an enema to soften and remove it. Contraindications for Enema Use - Bowel Obstruction: Enemas are contraindicated in patients with suspected bowel obstruction, as it may worsen the condition. - Rectal Bleeding or Inflammation: Patients with active rectal bleeding, inflammatory conditions such as Crohn’s disease, or severe hemorrhoids should not receive enemas. - Recent Surgery: Avoid enemas in patients who have had recent colorectal surgery or other pelvic procedures unless specifically ordered by the healthcare provider. - Heart Conditions: Hypertonic solutions can cause fluid and electrolyte shifts, which may exacerbate heart failure or other cardiovascular conditions. 25. Diets of vegetarian a. Vegetarian diet includes: Fruits, vegetables, and plant oils, dried beans and peas, nuts, cereals and grains, milk and eggs - Potential nutritional deficiencies: Protein, iron, & zinc b. Deficient Food Intake - Outcome: The patient will incorporate missing nutrients into his or her regular diet. c. Interventions and Evaluation for Vegetarian/Vegan Diets - Individuals who follow a vegetarian or vegan diet may be missing nutrients. Signs and symptoms like lethargy, diarrhea, or wounds that will not heal may indicate anemia or protein deficiency. - Recommend increased consumption of: Beans, legumes, and seeds for protein, Legumes, grains, and vegetables for iron, Green leafy vegetables and tofu for calcium, Whole grains, tofu, and legumes for zinc, Vitamin B12 supplementation 26. Occult blood a. Exposes a small feces sample to a chemical indicator that changes color if it comes in contact with blood. - Detects microscopic (not visible) amounts of blood in the feces; three tests 1 day apart. - Routine screening for colorectal cancer. - Suspicion of GI tract bleeding.  Exam 3 Study Guide - Stool should not be contaminated with toilet water or urine. - Follow special diet 48 to 72 hours before test: some of the foods to avoid include red meat, beets, cantaloupe, horseradish, and vitamin C–rich foods and fluids - Indicates blood in stool; if blood present in stool, chemical indicator will turn blue; additional diagnostic testing may be necessary 27. Nutritional therapy It is necessary for - metabolizing certain nutrients - correcting nutritional deficiencies - eliminating foods that worsen disease states Gastrointestinal disease a. peptic ulcers - avoid caffeine - avoid spicy foods - avoid aspirin & NSAIDS - consume small, frequent meals b. inflammatory bowel disease - Crohn’s disease - elemental diets - parenteral nutrition - vitamins and iron supplements - limit fiber - fat reduction - large meal avoidance - lactose and sorbitol avoidance 28. Diet for zinc - Zinc is an essential mineral that plays a key role in immune system support, protein synthesis, wound healing, DNA synthesis, and cell division. - Animal-based sources: Oysters (highest concentration of zinc), Red meat, particularly beef and lamb, Poultry, especially chicken and turkey, Pork, Fish like crab and lobster, Dairy products such as milk and cheese, Eggs - Plant-based sources: Legumes (chickpeas, lentils, and beans), Nuts (cashews, almonds, and peanuts), Seeds (pumpkin seeds, hemp seeds, and sesame seeds), Whole grains (wheat, quinoa, oats, and brown rice), Fortified breakfast cereals, Vegetables like spinach, mushrooms, and kale - A deficiency in zinc can lead to symptoms like weakened immunity, delayed wound healing, hair loss, and impaired growth. - excessive zinc intake (usually through supplements) can lead to nausea, vomiting, and Interference with copper absorption. 29. Hot vs warm compress  Exam 3 Study Guide - Used to minimize pain, increase circulation, and decrease swelling. - The health care provider determines the application time for heat. However, for cold, the maximum time is 20 to 30 minutes. There are several types of heat and cold therapy. a. Moist compress - Can be hot or cold therapy - Cover the towel or waterproof pad to maintain warmth or cold for prescribe time - Placed over the wound/injury b. Moist soak - Can be hot or cold - Place extremity completely in solution - Cover solution to maintain temperature, change solution every ten mins as need to maintain temperature - dry extremity completely. c. Sitz Bath - PRIMARILY for HEAT therapy - Soak perineum/pelvic area for 20 minutes. (The patient must be able to sit up to use this form of therapy. - Adjust temperature, following facility protocol - Use a chair, tub, or toilet attachment (usually has a hose attached that sprays water on the pelvic area and drains into the basin; see image). - Monitor the sensitive perineal area for any complications. d. Aquathermia - Used for hot and cold - Obtain pad and control unit, which regulates temperature and water flow (can only use distilled water) through the pad channels. - Place pad around extremity (some facilities may require a towel wrapped around the extremity before applying pad) - Turn control unit on e. Hot/ Cold Packs - Used for hot and cold - May be commercially prepared or non commercially prepared - For noncommercial ice bags, fill with water or only two-thirds full, if using crushed ice. - Remove air before closing. - Do not place heat or cold pack directly on skin; place a small washcloth between the skin and pack. f. Heat therapy - Vasodilation (draws oxygen, nutrients, and leukocytes to area) When to avoid - Bleeding (exacerbates the bleeding) - Cardiovascular conditions/disease (interrupts blood flow) - Local abscess (could cause rupture)  Exam 3 Study Guide - Unknown pain in abdomen, especially if suspected appendicitis (could cause rupture) g. Cold Therapy - Vasoconstriction (decreases oxygen demands of the tissue and reduces blood flow) When to avoid - Impaired circulation (cool extremities, weak pulse, cyanosis); notify health care provider before applying - Presence of edema/swelling - Circulatory conditions/disease - Shivering 30. Purpose of dressings for wound care - Protects a wound from microorganism contamination - Aids in hemostasis - Promotes healing by maintaining wound moisture - Promotes healing by absorbing drainage and debriding a wound - Supports or splints a wound site - Promotes thermal insulation of a wound surface types of wound care - Gauze dressings - Absorb light drainage and protect the wound. Can be impregnated with petroleum, iodine, or other substances. - Transparent films - Semi-permeable, allow visualization of the wound bed. Used for shallow wounds with minimal drainage. - Hydrocolloid dressings - Absorb drainage and create a moist healing environment. Used for partial and full-thickness wounds. - Alginate dressings - Highly absorbent, made from seaweed. Effective for moderately to heavily draining wounds. - Foam dressings - Absorb moderate to heavy drainage while maintaining a moist environment. Used for chronic or acute wounds. - Hydrogel dressings - Provide moisture for dry wounds and facilitate autolytic debridement of necrotic tissue. - Antimicrobial dressings - Contain silver or other agents to help control infection in contaminated wounds. - Negative pressure wound therapy - Uses a vacuum dressing to promote healing in complex wounds. 31. Evaluating wound Improving: - Decreasing wound dimensions (length, width, depth) - Healthy granulation tissue forming in the wound bed - Decreasing amount or changing color of drainage towards lighter shades - Softening and flattening of wound edges - Reduction in surrounding skin redness, edema, warmth  Exam 3 Study Guide Declining: - Increasing wound size - Presence of necrotic tissue or eschar in the wound bed - Increasing drainage amount or purulent, foul-smelling drainage - Rolled, undermined or thickened wound edges - Increasing surrounding skin redness, edema, warmth Unchanged: - Wound dimensions remaining static over time - Minimal change in wound bed appearance - Persistent moderate drainage without improvement - Wound edges remaining the same - No significant changes in periwound skin condition 32. Abdominal assessment a. Inspection - Visual Examination: The nurse observes the abdomen for abnormalities. - Contour: Flat, rounded, or scaphoid (concave). - Symmetry: Abnormal bulges or asymmetry may indicate masses or organ enlargement. - Skin: Look for scars, lesions, rashes, or striae (stretch marks). - Movement: Note any visible peristalsis (bowel movement through intestines) or pulsations, especially in thin individuals (e.g., abdominal aortic aneurysm). - Umbilicus: Check for hernias, discoloration, or inflammation around the belly button. - Distention: A distended abdomen may indicate gas, fluid accumulation (ascites), or organ enlargement. b. Auscultation - Bowel Sounds: Use the diaphragm of the stethoscope to listen for bowel sounds in all four quadrants. - Normal Bowel Sounds: High-pitched, gurgling sounds (5-30 times per minute) that indicate active peristalsis. - Hypoactive Bowel Sounds: Fewer than 5 sounds per minute, possibly indicating a slowing of peristalsis (e.g., after surgery, ileus, or constipation). - Hyperactive Bowel Sounds: Frequent, loud, rushing sounds that may indicate diarrhea, gastroenteritis, or early bowel obstruction. - Absent Bowel Sounds: No bowel sounds heard for 5 minutes may indicate an emergency like bowel obstruction or paralytic ileus. - Vascular Sounds: Use the bell of the stethoscope to listen for bruits (abnormal swooshing sounds) over the aorta, renal arteries, and iliac arteries, which can indicate turbulent blood flow (e.g., in cases of aneurysm or arterial stenosis). c. Percussion  Exam 3 Study Guide - General Percussion: Gently tap on the abdomen to identify the underlying structures and detect fluid, gas, or masses. - Tympany: A hollow, drum-like sound heard over areas filled with gas (normal in most of the abdomen). - Dullness: A muffled sound that indicates solid organs (liver, spleen) or fluid (ascites). Dullness over unusual areas could indicate a mass or enlarged organ. - Liver Span: Percuss the liver in the right upper quadrant to assess for liver enlargement. - Bladder: Dullness in the lower abdomen may indicate a full bladder. - Shifting Dullness: If ascites (fluid in the abdomen) is suspected, percuss with the patient in different positions to detect fluid shifts. d. Palpation - Light Palpation: Begin with gentle, superficial palpation (about 1 cm deep) to assess for tenderness, rigidity, or superficial masses. - Normal Findings: The abdomen should be soft and non-tender. - Abnormal Findings: Guarding (tensing of the abdominal muscles), rigidity, or tenderness may indicate peritonitis, appendicitis, or other conditions. - Deep Palpation: Press deeper (about 5-8 cm) to assess for masses, organ enlargement, or deeper tenderness. - Liver and Spleen: Normally, these organs are not palpable unless they are enlarged. - Rebound Tenderness (Blumberg's Sign): Press down slowly and release quickly; pain upon release can indicate peritoneal irritation, often seen in appendicitis. - Costovertebral Angle (CVA) Tenderness: To check for kidney inflammation, gently tap over the lower back (CVA area). Tenderness may indicate a kidney infection (pyelonephritis) 33. Bowel sound assessment Types of Bowel Sounds a. Normal Bowel Sounds - Frequency: Occur about 5-30 times per minute. - Description: Gurgling, high-pitched sounds that indicate normal peristalsis and bowel activity. - Clinical Meaning: These sounds suggest that the gastrointestinal system is functioning normally. b. Hyperactive Bowel Sounds - Frequency: More frequent than normal (loud, rushing sounds). - Description: Often described as high-pitched, rushing, or tinkling sounds. - Clinical Meaning: Hyperactive bowel sounds may indicate conditions like: Diarrhea, Gastroenteritis, Early stages of bowel obstruction, Laxative use, Irritable bowel syndrome (IBS) c. Hypoactive Bowel Sounds - Frequency: Infrequent, less than 5 sounds per minute. - Description: Quiet or barely audible sounds.  Exam 3 Study Guide - Clinical Meaning: Hypoactive bowel sounds may indicate: Constipation, Postoperative ileus (especially after abdominal surgery), Peritonitis, Late stages of bowel obstruction, Injury or trauma d. Absent Bowel Sounds - Frequency: No bowel sounds heard after 5 minutes of auscultation. - Clinical Meaning: Absence of bowel sounds is a serious finding and may indicate: Paralytic ileus (lack of peristalsis), Bowel obstruction, Perforation (hole in the gastrointestinal tract), Severe infection (e.g., peritonitis), Emergency conditions requiring immediate intervention. e. Borborygmi - Description: Loud, prolonged gurgles often heard without a stethoscope. - Clinical Meaning: Normal in some cases (hunger), but frequent or prolonged borborygmi may be related to conditions like irritable bowel syndrome or hyperactive GI motility. Conditions Associated with Abnormal Bowel Sounds - Paralytic Ileus: Absent or hypoactive bowel sounds following surgery or injury. - Small Bowel Obstruction: High-pitched, hyperactive sounds followed by absent sounds as the obstruction worsens. - Diarrhea: Hyperactive, rushing bowel sounds due to increased GI motility. - Constipation: Hypoactive or absent bowel sounds, suggesting decreased bowel motility. - Gastroenteritis: Hyperactive sounds due to inflammation of the stomach and intestines, often accompanied by diarrhea and cramping.