Fundamentals of Professional Nursing

Study Guide for Final Exam--Summer 2016

Intro to Nursing and Basic Nursing Process (Chapters 1-4):

 Review the six QSEN competencies

 Know the four aims of nursing.
o Define health promotion, illness prevention, health restoration, and facilitation of coping with disability and
death.
 Review nursing standards of practice and the nurse practice acts and the definition of the nursing process.
 Review the current trends in nursing and health care (p. 19)
 Define the sources of knowledge: Traditional, authoritative, scientific and philosophical.
 Define “Nursing Research”. Know the difference between quantitative and qualitative studies.
 Describe evidence-based practice in nursing, including the rationale for its use.
 Outline the steps in implementing evidence-based practice.
 Review the PICO format for nursing research.
 Describe concepts and models of health, wellness, and illness.
o Wellness: intellectual, physical, environmental, emotional, sociocultural, and spiritual.
o Review acute illness versus chronic illness.
 Review Maslow’s Hierarchy of Needs.
 Nursing Process: Assessment, diagnosis, planning, interventions, and evaluation.
 Review each step and be ready to apply this information to a specific situation. For example, if the nurse had
collected all the data on a patient and was clustering the data to identify a problem, what phase does this
represent? The answer would be diagnosis, which is identifying the problem or potential problem. Be familiar
with each phase of the nursing process in order to identify the phase in an example.

o Nursing diagnoses:
 Actual nursing diagnosis: problem is present, for example, impaired mobility.
 Risk nursing diagnosis: problem is likely to occur.
 Wellness: No problem is present, but client wants to move to a higher level of wellness.
 Health promotion: Motivated by the desire to increase well-being, for example, quitting
smoking to improve lung function and endurance.
 Health protection: Motivated by the desire to avoid illness, for example, quitting smoking to
reduce the risk of COPD.

Activity (Chapter 32):

 Review principles of body mechanics to prevent injury when lifting and moving objects and clients.
 Review the effects of immobility on the body by systems (Table 32-4)
 Review safe patient handling and movement.
 Review patient positioning: Table 32-6
 Review techniques to assist with personal hygiene, dressing, transferring, and moving a patient using a lift.
 Review purpose of and procedure for applying compression stockings
 Review causes and interventions to prevent foot drop
 Review working with assistive devices: crutches, cane, walker
 Passive Range of Motion vs. Active Range of Motion to prevent contractures
 Logrolling a patient (Guidelines, p. 1073)
 Terms: flaccidity, spasticity, contracture, paresis, paralysis, hemiparesis, paraplegia, orthostatic hypotension,
osteoporosis, ankyloses, dangling.
Dangling refers to the position in which the person sits on the edge of the bed with legs and feet over the side of the
bed.

1
 Flaccidity: decrease tone, Spasticity: increased tone, Paresis: impaired muscle strength or weakness, Paralysis:
absence of strength secondary to nervous impairment, paraplegia: paralysis of the legs, Hemiparesis: weakness of
one half of the body. Ankyloses: fixation or immobilization of a joint, Contracture: permanently contracted state of a
muscle

Safety (Chapter 26):

 Assessment for fall risk and risk factors for falling. Review the Morse Safety Scale
 Interventions to prevent falls (Box 26-5)
 Assessment for risk of injury including lifespan consideration (Teaching Tips 26-1)
 Review the nursing process for Maintaining Safety (pp. 691-717)
 Define “sentinel events”
 Restraints (Procedure 23-2)
o Require provider order
o Can be physical or chemical
o Should only be used when all other alternatives have been exhausted
o Strict documentation rules, need frequent monitoring
o Alternatives are 1:1 supervision, monitoring of medications, bed or chair alarms, etc.

Documentation (Chapter 16):

 Review documentation guidelines (Box 16-1)

 Review abbreviation that should not be used (Table 16-2)
 Review measures to protect confidential patient information.
 Review the purpose of the patient record.
 Review the various methods of documentation and the advantages/disadvantages of each: EHR, Source-oriented,
problem-oriented, PIE, focus charting, charting by exception & case management model.
A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses,
and laboratory). Progress notes written by nurses using this method are narrative notes.
The POMR is organized around a client’s problems rather than around sources of information. With POMRs, all health care
professionals record information on the same forms. The advantages of this type of record are that the entire health care team
works together in identifying a master list of client problems and contributes collaboratively to the plan of care.
In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the
intervention carried out.
 Review the documentation of nursing interventions and the different possible formats: should be complete, accurate,
concise, and factual to avoid legal problems.

Communication (Chapter 20):

 Review the handout from lab with the various therapeutic communication techniques as well as the blocks to communication.
 Review non-verbal communication
 Review the use of therapeutic communication in the nursing process (p.457-458).
 Review the phases of the helping relationship.
 Review “Communicating with Patients Who Have Special Needs” (Box 20-6).
 Review the ISBARR model of communication.

Vital Signs (Chapter 24):

 Review the physiologic processes involved in homeostatic regulation of temperature, pulse, respirations, and blood
pressure.
 Review the factors that increase or decrease the body temperature, pulse, respirations, and blood pressure.
o Mechanisms of heat transfer: Radiation, convection, evaporation, conduction.
Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing
over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination
of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.
o Ranges of normal for blood pressure, pulse, respirations, temperature, and O2 saturation (Table 24-3)
2
 o Review normal ranges of VS and identify VS outside of normal range to report to HCP
o Pulse rhythm and amplitude (Table 24-5),
o Identify when to take an apical pulse
Amplitude: 0 absent, +1 diminished, +2 normal Brisk, +3 bounding
o Review the one-step and two-step procedure for taking a blood pressure

Hygiene (Chapter 30):

 Functions of the bath

 Terms: pruritus, maceration, excoriation, abrasion, pressure ulcers.
 What duties can the RN delegate to the assistive personnel and what must be done by the professional RN?
 Review procedure for bed bath: head to toe, clean to soiled areas.
 Care of the skin
 Bathing patients with dementia
 Foot care principles
 Oral care principles
 What bath to choose? Bedbath, partial bath, shower, tub, etc.

Physical assessment (Chapter 25):

 Patient positions (p. 634).

 Definitions and order of assessment for of abdomen: inspection, auscultation, palpation and percussion.
 General survey (what is included?)
The general survey is the first component of the physical assessment. It includes observing the client’s overall
appearance and behavior, taking vital signs, and measuring height and weight. Information from the general
survey provides clues to the client’s overall health. Palpating the integument and assessing the head and neck
are part of the physical assessment. Identifying risk factors for altered health occurs in the health history.
 Assessments by system (heart, skin, lungs, abdomen, musculoskeletal, etc.)
Plaque and nodules are palpable, elevated, solid masses that may measure 1 cm.
Macules and patches are circum- scribed, flat, nonpalpable changes in skin color. Macules are less than or equal
to 1 cm and patches are greater than 1 cm.
Bulla and pustules are circumscribed, superficial skin eleva- tions formed by free fluids in a cavity with skin
layers. Bulla are greater than 0.5 cm and pustules are filled with pus.
 See diagram for heart landmarks below
 Adventitious breath sounds: wheezes, rhonchi, crackles, stridor, friction rub (Table 25-6)
Bronchial breath sounds are high pitched, with expiration longer than inspiration. Bronchovesicular sounds are
moderate “blowing” sounds with equal inspiration and expiration. Vesicular sounds are soft and low-pitched,
with longer inspiration than expiration. Adventitious sounds are not normally heard in the lungs.
Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. They are described as
“fine” when air passes through moisture in small air passages, and as “coarse” when air passes through moisture
in the bronchioles, bronchi, and trachea. A wheeze is produced by narrowed air passages. The lungs normally
contain air.
Wheezes are musical or squeaking high-pitched, continu- ous sounds heard as air passes through narrowed
airways.
Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air passes through
secretions.
Crackles are bubbling, cracking or popping, low- to high-pitched, discontinuous sounds that occur when air
passes through fluid in the airways.
Stridor is a harsh, loud, high-pitched sound due to narrowing of the upper airway.
 Review the procedures at the end of the chapter, particularly the assessment skill 25-2

Sensory Functioning (Chapter 43):

o Define sensory perception and sensory deprivation and sensory overload

o Review states of arousal/awareness (Box 43-2)
3
 o Review nursing interventions for sensory deprivation and sensory overload (Box 43-3)
o Examine the concept map on Page 1651 and review the assessment data, outcomes, interventions and
evaluation of the plans for the patient with Impaired sensory function.
o Review the care plan on pages 1652-1654, including the sample documentation at the end of the care plan.

Glucose regulation (Content from notes and PowerPoint slides, and supplemental reading)

 Know normal ranges for blood glucose

 Review the role of glucagon, glycogen, cortisol, ketones, and insulin
 Review the effects of steroid use and infection for the diabetic client
 Know the signs and symptoms of Hypoglycemia and Hyperglycemia
o Review nursing interventions for both
o Review long-term consequences of hyperglycemia
o Review consequences of untreated hypoglycemia
 Review the differences between type 1 and 2 diabetes
 Review common diagnostic tests, particularly Hgb A1C and significance
 Review the process for collecting a blood glucose reading
 Be able to apply the nursing process to clients with glucose regulation issues
o Assessment, diagnosis, planning, interventions, and evaluation

Comfort and Pain Management (Chapter 34):

o Origin of pain
o Causes of pain
o Descriptors of pain: Sharp, dull, throbbing, stabbing, shooting, etc.
o Influencing factors of pain
o Non-pharmacologic treatments for pain: Distraction, humor, imagery, relaxation, cutaneous
stimulation (TENS), acupuncture, hypnosis, healing touch, and animal therapy
o Pharmacologic treatments for pain: Analgesics (opioid and non-opioid) & adjuvant drugs
o Review the differences between addiction, physical dependence, drug tolerance and know the
signs and symptoms of withdrawal
o Pain rating scales: Numeric (Adult and children >9), Wong-Baker FACES (Adult and children >3),
CRIES (Neonates 0-6months), FLACC (Infant and children 2months-7years) & PAINAD (Dementia)
o Different types of pain: nociceptive (Aching or throbbing pain), neuropathic (numbness or tingling),
intractable (hard to treat the pain), phantom (Pain in amputated site), psychogenic

Skin Integrity and Wound Care (Chapter 31):

o Review Skin anatomy

o Factors that affect skin integrity: Age, impaired mobility, nutrition and hydration, diminished
sensation or cognition, impaired circulation, medications. Moisture, fever, contamination or infection
and lifestyle
o Types of wounds: Acute vs. Chronic, Open vs. Closed, Clean vs. Contaminated vs. Infected,
Superficial vs. Partial thickness vs Full thickness.
o Primary, secondary and tertiary healing definitions.
A clean surgical incision is an example of a wound with little loss of tissue that heals with primary
intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness
repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe
partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary
intention is seen when a wound is left open for several days, and then the wound edges are approximated.
Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a

4
 burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes
filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of
infection is greater.

o Complications of wound healing: Hemorrhage, infection, dehiscence, evisceration, fistula.

Patients often report feeling as though something has given way with dehiscence. Dehiscence occurs when
an incision fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical
wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is
seen when vital organs protrude through a wound opening. When there is an increase in serosanguineous
drainage from a wound in the first few days after surgery, be alert for the potential for dehiscence. Infection
is characterized by drainage that is odorous and purulent.
o Identify the four stages of pressure ulcers as well as “unstageable”
Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis and dermis.
The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with
nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be
visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with
exposed bone, tendon, or muscle.
o Types of tissue in the wound bed: p. 1230 table, including slough, eschar, granulation
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates
progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs
to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be
removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved
for the wound to heal.
o Debridement techniques
Debridement is the removal of nonviable necrotic (black) tissue. Removal of necrotic tissue is necessary to
rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base
for healing. A wound will not move through the phases of healing if the wound is infected. Documentation
occurs after completion of skill. When treating a pressure ulcer, it is important to monitor and reassess the
wound at least every 8 hours.
o Braden Scale Assessments
With use of the Braden Scale, the total score is a 20. The patient receives 3 for slight sensory perception
impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for
intake of meals, and 4 for no problem with friction and shear.
o Drains and dressings
o Heat and cold therapy
o Wound vac
o Principles for obtaining a wound culture
o Review Table 31-2: Prevention of Pressure Ulcers

Oxygenation and Perfusion (Chapter 38):

o Review concept of gas exchange, oxygen therapy, airway management

o Review: Sputum, productive vs non-productive cough, expectorant vs cough suppressant.
A cough that is dry is termed a non- productive cough. A cough that produces respiratory secretions is
termed a productive cough. The respiratory secretion expelled by coughing or clearing the throat is called
sputum.
Expectorants are drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of
the secretions.
Suppressants are drugs that depress a body function—in this case, the cough reflex.
o Review adventitious breath sounds: wheezing, crackles, rhonchi, stridor and friction rub (found in
detail in Chapter 25, Table 25-6, Adventitious Breath Sounds, p. 652)
5
 o Dyspnea, tachypnea, bradypnea, apnea
o Review orthopneic position
patients who must remain in the orthopneic position to aid breathing should be well supported in a manner
that relieves muscle strain. Orthopnea: type of dyspnea in which breathing is easier when the patient sits or
stands
o Diagnostic testing: pulse oximetry, tuberculin skin testing, spirometry, ABGs, ECG, thoracentesis,
Holter monitor, echocardiogram, angiography
o Factors affecting cardiovascular function: age, environment, lifestyle, and medications
o Decreased cardiac output R/T Fluid Overload AEB increased edema, bibasilar rales in lungs, SOB
o Ineffective airway clearance R/T excessive mucus production AEB productive cough, thick, tenacious
secretions
o Impaired gas exchange R/T low hemoglobin AEB SOB, fatigue
o Normal range for Hemoglobin, effects of low Hgb (normal <6%)
o Pursed-lip breathing
Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-
lip breathing. Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing
and prolonging expiration. Prolonged expiration is thought to result in decreased airway narrowing during
expiration and prevent the collapse of small airways. This results in improved air exchange and decreased
dyspnea.

Infection and Inflammation (Chapter 23)

o Review the chain of infection

o Infection versus inflammation: what are the differences
o Stages of infection: Incubation, prodromal, illness, convalescence
Incubation: organisms are growing and multiplying
Prodromal: early signs and symptoms of disease are present but nonspecific (Infection spread)
Full stage of Illness: specific signs and symptoms indicates
Convalescent: recovery period from infection
o Inflammatory response versus immune response
Inflammatory response (Injury)
Immune response (Infection)
o Drug-resistant organisms: VRE, MRSA, C-diff, etc.
o PPE: contact, airborne, droplet, protective (Table 23.4)
o Signs and symptoms of infection: redness, swelling, purulent drainage, increased WBC, heat,
fever
o Systemic vs. localized infections
A localized infection can result in redness, swelling, warmth in the involved area, pain or tenderness,
and loss of function of the affected part. Manifestations of a systemic infection include fever, often
accompanied by an increase in pulse and respiratory rate, lethargy, anorexia, and tender- ness and
enlargement of lymph nodes that drain the area when an infection is present.
o Health care-associated infections (formerly nosocomial infections)
An infection is referred to as exogenous when the causative organism is acquired from other people.
An endogenous infection occurs when the causative organism comes from micro- bial life harbored in
the person.
o Medical asepsis versus surgical asepsis, disinfection versus sterilization
Mdical asepsis: clean technique, performing hand hygiene and wearing gloves
Surgical asepsis: sterile technique, inserting an indwelling urinary catheter and IV catheter
Disinfectoin: destorys all pathogenic organisms except spores
Sterilization: desotrys all microorganisms including spores
o Personal protective equipment (PPE), standard precautions and transmission-based precautions

6
 Standard: blood, body fluids, secretions, and excretions except sweat, non-intact skin and mucous
membrane
Transmission-based: pathogen transmitted by airborne, droplet, or contact routes.
o WBC values: normal vs. infection
Normal value 5000 to 10000/mm3, if infected, value increased
o Primary, secondary and tertiary defenses against infection

Elimination (Chap 36)

 Review the key terms on page 1265
Micturition: process of emptying the bladder
Enuresis: continued incontinence of urine past the age of toilet training
Nocturia: Urination during the night
Nephrotoxic: capable of causing kidney damage
Hematuria: blood in the urine
Stress incontinence: involuntary loss of urine related to an increase in intra-abdominal pressure
Kegel exercises: targets the inner muscles that lie under and support the bladder.
 Urinary elimination problems: urinary tract infection, urinary retention, and urinary incontinence.
 What is the difference between routine urinalysis, clean catch or mid-stream and sterile urine collection
procedures?
Routine Urinalysis: not require sterile urine specimen, collect urine from clean bedpan, urinal, or receptacle.
Not to place toilet issue into the urine, do not leave urine standing at room temp for long time.
Clean-Catch or midstream specimen (Considered a sterile specimen): discards small amount of urine first and
then collect the urine.
Sterile Specimen: Obtained by catheterizing the bladder or by an indwelling catheter.
 Principles of 24 hour urine collection: Discard first urine and then collect all urine voided for the next 24
hours. At the end of the 24 hours, ask the patient to void. Add this urine to the previously collected urine, and
then send the entire specimen to the laboratory
 How to promote normal urination
Maintaining normal voiding habits (schedule, urge to void, privacy, position, hygiene), promoting fluid intake,
strengthening muscle tone, assisting with toileting
 Additional terms to know: anuria, dysuria, frequency, glycosuria, nocturia, oliguria, polyuria,
proteinuria, pyuria, suppression, urgency, and urinary incontinence.
Dysuria (Pain), which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the
urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria
indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary
volume, and may accompany minor dietary variations.
 Normal characteristics of urine: color, odor turbidity, pH, specific gravity, and constituents (p. 1273)
 Urinary elimination nursing diagnoses: Impaired Urinary Elimination, Functional Urinary Incontinence,
Stress Urinary Incontinence, Urinary Retention
 Types of urinary incontinence: stress, urge, mixed, overflow, functional, reflex, and total incontinence
Transient incontinence: appears suddenly and lasts for 6 months or less caused by confusion secondary to acute
illness, infection, diuretics or IV administration.
Mixed incontinence: indicates that there is urine loss with features of two or more types of incontinence.
Overflow incontinence, or chronic retention of urine: is the involuntary loss of urine associated with
overdistention and overflow of the bladder.
Functional incontinence: is urine loss caused by the inability to reach the toilet because of environmental
barriers, physical limitations, loss of memory, or disorientation.
Reflex incontinence: experience emptying of the bladder without the sensation of the need to void (Spinal cord
injury).
Total incontinence: a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical
malformation.
 What is the post-void residual urine? How is it measured? Significance?

7
 The post-void residual (PVR) urine (the amount of urine remaining in the bladder immediately after voiding)
can be measured by the use of a portable ultrasound device that scans the bladder. A PVR of less than 50 mL
indicates adequate bladder emptying. A PVR of greater than 150 mL is often recommended as the guideline for
catheterization because residual urine volumes of greater than 100 mL have been associated with the
development of UTIs
 Review types of catherization: external condom cath, intermittent, indwelling, suprapubic
Indwelling catheters are also called retention or Foley catheters. The indwelling urethral catheter is designed so
that it does not slip out of the bladder.
Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. Intermittent
catheterization should be considered as an alternative to short-term or long-term indwelling urethral
catheterization to reduce catheter-associated UTIs.
A suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically
through a small incision above the pubic area.
Continuous drainage can be achieved with either an indwelling urinary catheter or a suprapubic catheter.
However, if the continuous drainage is long term, a suprapubic catheter would be best.
 Factors that increase the risk of UTI: sexually active women, diaphragms for contraception, postmenopausal,
indwelling urinary catheter, diabetes mellitus, older adults
 Review types of urinary diversions
Ileal conduit: involves a surgical resection of the small intestine, with transplantation of the ureters to the
isolated segment of small bowel.
Cutaneous ureterostomy: the ureters are directed through the abdominal wall and attached to an opening in the
skin.
Continent urinary reservoir: ureters are diverted into a segment of ileum and cecum in an Indiana pouch.
 Dialysis: hemodialysis versus peritoneal dialysis
Hemodialysis involves a machine that does the work healthy kidneys normally perform by filtering harmful
wastes, electrolytes, and fluid from the blood that would normally be eliminated in the patient’s urine.
Peritoneal dialysis involves using blood vessels in the abdominal lining (peritoneum) to fill in for the kidneys,
with the help of a fluid (dialysate) washed in and out of the peritoneal space.

Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention
include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty
walking to the bathroom may place patients at risk for urinary incontinence.
A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. A normal stoma should be moist and dark
pink to red in color.

Elimination (Chap 37)

 Know how the following factors affect bowel elimination: developmental stage/age, personal and
sociocultural, nutrition, hydration, activity level, medications, surgery, pregnancy, pathological
conditions
Aspirin, anticoagulants: pink to red stool
Iron salts: black
Antacid: white discoloration or speckling in stool
Antibiotic: green-gray color, cause diarrhea
 Describe normal bowel elimination: soft, formed bowle movement every 1 to 3 days without discomfort,
 Describe normal stool characteristics: Volume, color, odor, consistency, shape and constituents
 Review common diagnostic studies for the GI system (Box 37-2)
Fecal occult blood tests (Perform First) to detect gastrointestinal bleeding; barium studies to visualize
gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions; and
endoscopic examinations to visualize an abnormality, locate a source of bleeding, and if necessary, provide
biopsy tissue samples.

8
  Constipation R/T narcotic use AEB no BM x 3 days
 Diarrhea R/T Side effects of antibiotics AEB loose water frequent large stools
 Bowel Incontinence R/T cognitive impairment AEB unaware of BM passage
 Interventions to assist with constipation and diarrhea
 Nursing process for bowel elimination (p. 1352-1375)
 Review routine screening and warning signs for colon cancer, including colonoscopy procedure
Change in the bowel elimination pattern • Blood in the stools • Rectal or abdominal pain • Change in the
character of the stool• Sensation of incomplete emptying after bowel movement
 Review ostomy care: free of odors, empty the appliance frequently, inspect stoma regularly, note the size
(stabilize within 6 to 8 weeks), keep the skin clean and dry, measure fluid intake and output

Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark green vegetables because they
contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to
develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size
usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

Defecation: active process of passing stool

Cathartic: Stimulate bowl movement (Coffee)
Enema: treatment
Flatulence: gas
Fecal impaction: prolonged retention o ran accumulation of fecal material that forms hardened mass in the rectum
Hemorrhoids: blood vessel around anus abnormally distended
Paralytic ileus: postoperative ileus that inhibit peristalsis by abdominal incisions and direct manipulation of the bowel

Chapter 34 Pain
Acute pain is generally rapid in onset and varies in intensity from mild to severe. Causes of acute pain include a pricked finger, sore throat, or
surgery.
Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. The most recent definition of
chronic pain no longer mentions the previous guideline of 3 to 6 months duration for pain to be considered chronic. Commonly, people with chronic
pain experience periods of remission (when the disease is present but the person does not experience symptoms) or exacerbation (the symptoms
reappear).
Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage
to tissue that occurs with a sprain causes deep somatic pain.
Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen. This pain occurs as organs stretch abnormally
and become distended, ischemic, or inflamed. “Guarding” is often noted and is a reflex contraction of the abdominal wall—an automatic tensing—
that a person automatically does (reflex) to protect the area.
Referred pain that originates in one part of the body, but is perceived in another. Example: Myocardial infarction (heart attack). Pain originates in the
heart muscle but is felt in the jaw or left arm
Nociceptive pain Refers to the normal process that results in noxious stimuli being perceived as painful. Example: a cut or abrasion.
Neuropathic pain caused by damage to a nerve or nerve root. Can be difficult to treat. Often described as burning, electric, tingling or stabbing.
Intractable Pain that is resistant to therapy and persists despite a variety of interventions. Difficult to treat as well.
Phantom Pain that is felt in an extremity that has been amputated. Usually improves with time.
Psychogenic pain that cannot be identified. Pain can result from a mental event that is just as intense as pain from a physical event.

Physiologic responses are involuntary body responses; behavioral responses reflect body movements; affective responses reflect mood and emotions.
Typical Sympathetic Responses When Pain Is Moderate and Superficial
Increased blood pressure, Increased pulse and respiratory rates, Pupil dilation, Muscle tension and rigidity, Pallor (peripheral vasoconstriction),
Increased adrenalin output, Increased blood glucose
Typical Parasympathetic Responses When Pain Is Severe and Deep
Nausea and vomiting, Fainting or unconsciousness, Decreased blood pressure, Decreased pulse rate, Prostration, Rapid and irregular breathing

Basic methods of assessing pain: Patient self-report, Report of family member, other person close to the patient or caregiver familiar with the person,
Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, protecting the painful area, Physiologic measures: increased blood pressure and
pulse

Pain assessment tools:

9
CRIES pain scale (Neonates 0-6months)
FLACC scale (Infants and children 2months-7years)
Wong-Baker FACES (Adults and children >3)
COMFORT scale (Used for infants, children and adults unable to use the FACES tool. Critically ill pediatric patients)
PAINAD scale (Pain Assessment in Advanced Dementia)

Nursing intervention: Establishing trusting nurse–patient relationship, Manipulating factors affecting pain experience, Initiating nonpharmacologic
pain relief measures, Managing pharmacologic interventions, Reviewing additional pain control measures, including complementary and alternative
relief measures, Considering ethical and legal responsibility to relieve pain, Teaching patient about pain

10