Medical-Surgical Nursing CONCEPTS FOR INTERPROFESSIONAL COLLABORATIVE CARE 9th EDITION chapter 2

Medical-Surgical Nursing CONCEPTS FOR INTERPROFESSIONAL COLLABORATIVE CARE 9th EDITION chapter 2 Comfort Ans- A state of physical well-being, pleasure, and absence of pain or stress Interventions for patients with decreased comfort Ans- Anticipate pain and emotional stress, collaborate with members of the inter professional team as needed, and implement pain management measures Elimation Ans- The excretion of waste from the body by the gastrointestinal (GI) tract (as feces) and by the urinary system (as urine) Bowel elimination Ans- Occurs as a result of food and fluid intake and ends with passage of feces (stool) or solid waste products from food into the rectum of the colon Urinary Elimination Ans- Occurs as a result of multiple kidney processes and ends with the passage of urine through the urinary tract Continence Ans- Voluntary control of both bowel and urinary elimination Incontinence Ans- Lack of bowel or bladder control Retention Ans- inability to expel stool or excrete urine Obstipation Ans- Inability to pass stool Oliguria Ans- Scant urine Anuria Ans- absence of urine Aging (when pelvic muscles weaken), neurologic disorders, excessive laxative use, other medication use, GI infections, and lack of exercise Ans- Risk factors for incontinence include: Adequate nutrition and hydration, diet high in fiber, stay well hydrated, health teaching, and collaboration with inter professional team Ans- Interventions to prevent changes in elimination include: Foods high in potassium Ans- Oranges and potatoes Fluid and electrolyte balance Ans- The regulation of body fluid, fluid osmolality, and electrolytes by processes such as filtration, diffusion, and osmosis. Where is extracellular fluid found? Ans- The vascular space (plasma) and interstitial space (fluid between cells, often referred to as third space fluid) Electrolytes Ans- Chemicals in the body needed for normal body functioning, especially the heart and brain Acute illnesses (e.g., vomiting and diarrhea), severe burns, serious injury or trauma, chronic kidney disease, surgery, poor nutritional intake, and older adults Ans- Risk factors that can alter a person's fluid and electrolyte balance include: What is the minimum hourly urinary output? Ans- Atleast 30mL per hour Increase in blood pressure due to increased blood volume, peripheral pulses are often strong and bounding and peripheral edema occurs. Ans- What are the signs and symptoms of someone experiencing fluid excess (overload)? Hypotension, tachycardia and weak/thready pulses. Ans- What are the signs and symptoms of someone experiencing a fluid volume deficit? Changes in weight Ans- What is the best indicator of fluid volume changes in the body? Serum electrolyte concentration, blood urea nitrogen (BUN), and serum osmolality Ans- Tests used to measure fluid and electrolyte imbalances include: Oranges, bananas, and potatoes Ans- Foods that are good sources of potassium include: Fluid replacement, either orally or parenterally Ans- What is the primary collaborative intervention for patients with a fluid deficit? Fluid restriction and diuretic therapy Ans- Interventions for patients experiencing fluid overload include: Glucose Regulation Ans- The process of maintaining optimal blood glucose levels Gas Exchange Ans- The process of oxygen transport to the cells and carbon dioxide transport away from the cells through ventilation and diffusion. Alveoli Ans- As adults age, what loses elasticity causing a decrease in gas exchange? Normal functioning central (brain and spinal cord) neurons, normal diaphragm function, adequate skeletal muscle contractility (especially the intercostal muscles between the ribs), and an intact chest thorax Ans- What does adequate ventilation require? Acute or chronic problems affecting central neurons, diaphragm function, or skeletal muscle contractility, aging (loss of pulmonary alveoli elasticity), lung diseases, smoking, environmental pollutant exposure, and prolonged immobility Ans- Risk factors for decreased gas exchange include: inadequate transportation of oxygen to body cells and organs and/or retention of carbon dioxide AnsWhat does decreased gas exchange result in? Arterial blood gasses (ABGs) and complete blood count (CBC); when necessary a chest x-ray, chest computerized tomography (CT), or V/Q scan may be performed Ans- Laboratory tests used to assess gas exchange include: Immunity Ans- Protection from illness or disease that is maintained by the body's physiologic defense mechanisms Natural active immunity Ans- Occurs when an antigen enters the body and the body creates antibodies to fight off the antigen Artificial active immunity Ans- Occurs via a vaccination or immunization Natural passive immunity Ans- Occurs when antibodies are passed from mother to fetus through the placenta or using colostrum or the breast milk Artificial passive immunity Ans- Occurs via a specific transfusion such as immunoglobulins Antibody-mediate immunity (humoral immunity) Ans- includes the antigens and antibodies interacting in an attempt to slow down or destroy the foreign body B-cells, macrophages, T-lymphocytes (T-cells), and spleen Ans- Which cells play a role in antibodymediated immunity (humoral immunity)? Cell-mediated immunity Ans- Involves the functions of numerous cells to fight off the antigen, including white blood cells (WBCs), T-cells, natural killer (NK) cells, and multiple cytokines. The thymus and lymph nodes also play a role in this immune process. Older adults (diminished immunity due to normal aging changes), low socioeconomic groups (inability to obtain proper immunizations), non immunized adults, adults with chronic illnesses that weaken the immune system, adults on chronic drug therapy such as corticosteroids and chemotherapeutic agents, adults experiencing substance use disorder, and adults who have a genetic risk for decreased or excessive immunity Ans- Adult populations at risk for impaired immunity include but are not limited to: Enzyme-linked immunosorbent assay (ELISA) and Western blot tests Ans- Which test(s) are used to identify the presence of human immune deficiency virus (HIV)? A complete immune panel, including antinuclear antibody (ANA) and rheumatoid factor (RF) Ans- Which test(s) helps detect autoimmune disease? Mobility Ans- The ability of an individual to perform purposeful physical movement of the body Functional Mobility Ans- When a person is able to perform activities of daily living (ADLs) such as eating, dressing, and walking. Pressure injuries, disuse osteoporosis, constipation, weight loss or gain, muscle atrophy, atelectasis/hypostatic pneumonia, venous thromboembolism, and/or urinary system calculi AnsPhysiologic complications of decreased mobility Depression, changes in sleepwalk cycle, and/or sensory deprivation Ans- Psychosocial complications of decreased mobility 0 to 5 Ans- Assessment of muscle strength and joint range of motion (ROM) can be measured using a scale of what? Nutrition Ans- The process of ingesting and using food and fluids to grow, repair, and maintain optimal body functions Malnutrition Ans- Occurs in adult who are underweight or overweight/obese Familial predisposition or genetic risk, high stress level, depression and social isolation, especially among older adults, consuming fad diets that do not provide adequate nutrients, obesity, substance use, lack of money to purchase food, impaired food intake caused by dysphagia, poor appetite, or poor oral health, thyroid disorders, chronic diseases such as chronic obstructive pulmonary disease (COPD) and cancer, gastrointestinal (GI) distress such as excessive diarrhea or vomiting, anorexia and/or bulimia nervosa Ans- Risk factors for decreased nutrition include: Pre-albumin and albumin measurement Ans- What is the most common assessment for generalized malnutrition? 19-24.9 Ans- What is the normal range for BMI? Peripheral perfusion Ans- Adequate arterial blood flow through the peripheral tissues Central Perfusion Ans- Blood that is pumped by the heart to oxygenate major body organs Ischemia Ans- Impaired perfusion Infarction Ans- Complete tissue death Modifiable risk factors for decreased perfusion Ans- Can be changed; examples include: smoking, lack of physical activity, and obesity Non modifiable risk factors for decreased perfusion Ans- Cannot be changed; examples include age, gender, and family history Sensory perception Ans- the ability to perceive and interpret sensory input into one or more meaningful responses Presbyopia Ans- Far-sightedness Presbycusis Ans- Sensorineural hearing loss Snellen Chart Ans- Test normally used to assess visual acuity Sexuality Ans- A complex integration of physiologic, emotional, and social aspects of well-being related to intimacy; involves sex, sexual acts, and sexual orientation Tissue Integrity Ans- The intactness of the structure and function of the integument and mucous membranes Protection from infection, fluid preservation, and temperature control Ans- What are the functions of the skin? Skin Ans- Which is the largest organ of the body? Partial-thickness wound Ans- Wound that extends through the epidermis and dermis Full-thickness wound Ans- Wound that extended into the subcutaneous tissue and can expose muscle or bone Pressure injuries Ans- What is the most common tissue impairment