Study Guide #3 (brief)

1. Discuss the education needed to prevent urinary infections.
-focus on client’s specific elimination problem
-learn significance of symptoms for prevention control

2. Discuss the goals/outcomes that will improve mobility.
-obtain appropriate assistive devices, reposition patient throughout the day, physical therapy, teach relaxation breathing, develop therapeutic relationship, and provide a positive, safe environment

3. Discuss factors that affect the nutritional status of the elderly patient.
-income, therapeutic diet, loss of teeth, dentures, risk for drug-nutrient interaction

4. Discuss the nursing care of the patient with enteral feedings.
-assess
-check for placement: aspirate or pump air, check for residual, elevate head to at least 30 degrees
-monitor weight, I&Os, lung sounds, O2, BS and BM
-maintain good oral hygiene

5. Discuss the nursing diagnoses appropriate for patients with oxygenation dysfunction.
-activity intolerance, anxiety, decreased cardiac output, fatigue, impaired gas exchange, impaired spontaneous ventilation, impaired verbal communication, ineffective airway clearance, ineffective breathing pattern, ineffective health maintenance, risk for imbalanced fluid volume, and risk for infections
-related to…patient etiology and as evidenced by…patient’s signs and symptoms

6. Discuss the nutritional education needed for patients who have fluid and electrolyte dysfunction.
-make a patient focused meal plan that includes patient’s preferences, income,

7. Discuss the education needed to prevent dehydration.
-avoid certain types of food, knowing medications which cause increased thirst, knowing daily values of water needed everyday, be aware of early signs and symptoms

8. Discuss the complications of diarrhea.
-serious fluid and electrolyte or acid-base imbalances

9. Discuss the interventions needed for the patient with a fecal impaction.
-laxatives, enemas, and digital removal of stool
-increased fiber diet, increased fluid intake, and bowel training

10. Discuss the assessment needed for the patient with hypoxia.
-defined as inadequate tissue oxygenation at the cellular level
-cyanosis, increased HR, increased RR and depth, increased BP
-apprehension, restlessness, inability to concentrate, declining level of consciousness, dizziness, behavioral changes, unable to lie down, appears fatigued and agitated

11. Discuss the signs and symptoms of urinary retention.
-bladder distention causing pressure, discomfort, tenderness, restlessness, and sweating
-absence of urine output or only small amounts (dribbling) over several hours

12. Discuss the assessment needed for patients with allergies.
-ask about allergen exposures, the type and degree of allergic response, and what improves or worsens the condition

13. Discuss the assessment needed for patients with sodium imbalance.
-weight change, dry and sticky mucosa, personality change, increased RR, decreased BP with postural change, changes in HR, and dry and flushed skin

14. Discuss the assessment needed for patients with altered perfusion.
-SpO2, RR, HR, BP, lung sounds, heart sounds, changes in activity tolerance, shortness of breath, difficulty breathing

15. Discuss the physiological factors that affect oxygenation.
-decreased oxygen-carrying capacity
-decreased inspired oxygen concentration
-hypovolumia: shock or severe dehydration resulting in extracellular fluid loss and reduced circulating blood
-increased metabolic rate and increased oxygen demand

16. Discuss factors that affect immobility.
-loss of muscle, negative nitrogen balance, increased weakness, decreased nutritional intake

17. Discuss the assessment needed for the patient at risk for aspiration.
-coughing during eating, change of voice after swallowing, abnormal mouth, tongue, and lip movements, unusual speech, regurgitation, abnormal gag, pooling of food, and delayed swallowing

18. Describe the nursing interventions for the patient experiencing respiratory distress.
-breathing/coughing techniques: promotes relaxation and effective breathing and more productive coughs
-positioning: positions patient in more comfortably to breath and drain secretions effectively
-suctioning: dislodge and loosen secretions to clear airway

19. Describe the assessment needed for patient in respiratory distress.
-increased RR, difficulty breathing, irregular lung sounds, increased HR, pain, fatigue, lifestyle, health risks, medications and allergies

20. Discuss the education needed for a healthy diet.
-meal plan patient focused with preferences and income integrated with daily values and food guidelines (MyPyramid)
-high fiber, low fat

21. Discuss the nursing interventions needed for the patient with urinary incontinence.
-schedule toileting, bladder training exercises, use absorbent product, limit fluids 2 hours before bedtime

22. Discuss the nursing interventions for the patient in acute respiratory distress.
-breathing/coughing techniques, airway maintenance, suctioning, humidification, nebulization, postural drainage and chest percussion

23. Discuss the signs and symptoms of patients with excess fluid volume.
-decreased LOC, convulsions, and coma

24. Discuss the nursing interventions for the patient receiving oxygen therapy.
-keep patient hydrated, teach coughing techniques, teach breathing exercises, improve muscle strength and endurance for increased activity tolerance with respiratory muscle training

25. Discuss the assessment needed for the patient with a productive cough.
-inspect sputum speciman of color, changes in color, odor, quantity, consistency, and presence of blood

26. Discuss the education needed for the patient with a urinary diversion.
-manage diversion
-enhance coping and adaptation to lifestyle and body-image changes
-ability to maintain normal ADLs

27. Discuss the assessment needed for the patient who just had a central venous catheter placed for TPN.
-check infusion rate of pump (not gravity driven), monitor complications like perforation through vessel and hyperglycemic reactions, monitor daily weights and I&Os, BS, and BM

28. Discuss the assessment needed for patients with fluid and electrolyte dysfunction.
-age, prior medical history, environmental factors, diet, lifestyle, medication, I&Os, laboratory studies

29. Discuss the assessment needed for the patient with GI dysfunction.
-urination pattern, symptoms of urinary alterations, factors affecting urination, skin and mucosal membranes inspection, kidney palpation, bladder palpation, urethral meatus inspection, and assessment of urine (subjective and objective)

30. Discuss the purpose of the various suctioning techniques.
-oropharyngeal and nasopharyngeal: patient effectively coughs, but is unable to clear secretions
-orotracheal and nasotracheal: patients with pulmonary secretions, no artificial airway, and no effective cough
-tracheal: dislodge and loosen secretions in artifical airway