VINAYAKA NURSING INSTITUTE, BAKROL

2ND INTERNAL EXAMINATION

GNM-1ST YEAR

FUNDAMENTALS OF NURSING

Date: 12/4/2017

Time: 10:00am – 1:00pm

Total marks: 75

Notes:

1. Figure right side indicates marks.

2. Draw diagram whenever necessary.

3. Write legibly.

______

Q-1 (A) Define ANY 5 of the following terms:(10)

  1. Nursing: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people.
  2. Loss :Lossis one of the most common experiences that brings about grieving, and although this is often viewed asnormal, there are times when it is disqualified. Some examples of when grieving over a loss is disenfranchised include: the loss of a grandchild, of an ex-spouse, of a sibling, or of a child through adoption.
  3. First aid: First aidis the assistance given to any person suffering a suddenillnessorinjury,with care provided to preserve life, prevent the condition from worsening, and/or promote recovery.
  4. Hematuria: haematuria, is the presence ofred blood cells(erythrocytes) in theurine. It may beidiopathicand/orbenign, or it can be a sign that there is akidney stoneor atumorin theurinary tract(kidneys,ureters,urinary bladder,prostate, andurethra), ranging from trivial to lethal. Ifwhite blood cellsare found in addition to red blood cells, then it is a signal ofurinary tract infection.
  5. Comfort: astateofeaseandsatisfactionofbodilywants,withfreedomfrompainandanxiety
  6. Algor mortis:the secondstage of death, is the change inbody temperaturepost mortem, until the ambient temperature is matched. This is generally a steady decline, although if the ambient temperature is above the body temperature (such as in a hotdesert), the change in temperature will be positive, as the (relatively) cooler body acclimates to the warmer environment. External factors can have a significant influence. Algor mortis also occurs when the body dies.

(B)Write down the purposes of the following: (10)

  1. Back care:

1. To improve circulation to the back

2. To refresh the mode and feeling

3. To relieve from fatigue, pain and stress

4. To induce sleep

  1. Nasogastric feeding:

1. To provide adequate nutrition

2. To give large amounts of fluids for therapeutic purpose

3. To provide alternative manner to some specific clients who has potential or acquired swallowing difficulties

3. Sponge bath: Bathing creates a feeling of well-being and the physical appearance of cleanliness.

Bathing may also be practised for religiousritualor therapeutic purposes[34]or as a recreational activity.

Therapeutic use of bathing includeshydrotherapy, healing, rehabilitation from injury or addiction, and relaxation.

(C)Health Assessment (10)

A. Palpation

B. Inspection

C. Percussion

D. Auscultation

Assessment Techniques: AUSCULTATION is usually performed following inspection, especially with abdominal assessment. The abdomen should be auscultated before percussion or palpation to prevent production of false bowel sounds. When auscultating, ensure the exam room is quiet and auscultate over bare skin, listening to one sound at a time. Auscultation should never be performed over patient clothing or a gown, as it can produce false sounds or diminish true sounds. The bell or diaphragm of your stethoscope should be placed on your patient’s skin firmly enough to leave a slight ring on the skin when removed. Be aware that your patient’s hair may also interfere with true identification of certain sounds. Remember to clean your stethoscope between patients.

Assessment Techniques: PALPATION, another commonly used physical exam technique, requires you to touch your patient with different parts of your hand using different strength pressures. During light palpation, you press the skin about ½ inch to ¾ inch with the pads of your fingers. When using deep palpation, use your finger pads and compress the skin approximately 1½ inches to 2 inches. Light palpation allows you to assess for texture, tenderness, temperature, moisture, pulsations, and masses. Deep palpation is performed to assess for masses and internal organs

Assessment Techniques: PERCUSSION is used to elicit tenderness or sounds that may provide clues to underlying problems. When percussing directly over suspected areas of tenderness, monitor the patient for signs of discomfort. Percussion requires skill and practice.

Assessment Techniques: PERCUSSION The method of percussion is described as follows: Press the distal part of the middle finger of your nondominant hand firmly on the body part. Keep the rest of your hand off the body surface. Flex the wrist, but not the foreman, of your dominant hand. Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger contacts the patient’s skin, keeping the fingers perpendicular. Listen to the sounds produced (Jarvis, 2012). These sounds may include:

• Tympany

• Resonance

• Hyperressonance

• Dullness

• Flatness

Tympany sounds like a drum and is heard over air pockets. Resonance is a hollow sound heard over areas where there is a solid structure and some air (like the lungs). Hyperressonance is a booming sound heard over air such as in emphysema. Dullness is heard over solid organs or masses. Flatness is heard over dense tissues including muscle and bone

Tympany sounds like a drum and is heard over air pockets. Resonance is a hollow sound heard over areas where there is a solid structure and some air (like the lungs). Hyperressonance is a booming sound heard over air such as in emphysema. Dullness is heard over solid organs or masses. Flatness is heard over dense tissues including muscle and bone

Health History The purpose of obtaining a health history is to provide you with a description of your patient’s symptoms and how they developed. A complete history will serve as a guide to help identify potential or underlying illnesses or disease states. In addition to obtaining data about the patient’s physical status, you will obtain information about many other factors that impact your patient’s physical status including spiritual needs, cultural idiosyncrasies, and functional living status. The basic components of the complete health history (other than biographical information) include:

• Chief complaint

• Present health status

• Past health history

• Current lifestyle

• Psychosocial status

• Family history

• Review of systems Communication during the history and physical must be respectful and performed in a culturally-sensitive manner. Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and tone of voice while interviewing the patient

Q-2 Write a short note on the following: (15)

1. Asphyxia: Asphyxiaorasphyxiationis a condition of severely deficient supply ofoxygento thebodythat arises from abnormalbreathing

Cause:Situations that can cause asphyxia include but are not limited to: the constriction or obstruction of airways, such as fromasthma,laryngospasm, or simple blockage from the presence of foreign materials; from being in environments where oxygen is not readily accessible: such as underwater, in a low oxygen atmosphere, or in a vacuum; environments where sufficiently oxygenated air is present, but cannot be adequately breathed because of air contamination such as excessive smoke.

Other causes of oxygen deficiency include but are not limited to:

  • Acute respiratory distress syndrome
  • Carbon monoxide inhalation, such as that from acar exhaustand the smoke's emission from a lightedcigarette: carbon monoxide has a higher affinity than oxygen to thehemoglobinin the blood's red blood corpuscles, bonding with it tenaciously, and, in the process, displacing oxygen and preventing the blood from transporting oxygen around the body
  • Contact with certain chemicals, includingpulmonary agents(such asphosgene) andblood agents(such ashydrogen cyanide)
  • Drowning
  • Drug overdose
  • Exposure to extreme low pressure orvacuumto the pattern (seespace exposure)
  • Hanging, specifically suspension or short drop hanging
  • Self-inducedhypocapniabyhyperventilation, as inshallow waterordeep water blackoutand thechoking game
  • Inert gas asphyxiation
  • Congenital central hypoventilation syndrome, or primary alveolar hypoventilation, a disorder of the autonomic nervous system in which a patient must consciously breathe; although it is often said that persons with this disease will die if they fall asleep, this is not usually the case
  • Respiratory diseases
  • Sleep apnea
  • Aseizurewhich stops breathing activity
  • Strangling
  • Breaking thewind pipe.
  • Prolonged exposure tochlorine gas

Signs and Symptoms of Asphyxia

Any of the following symptoms can lead to asphyxia.

  • Difficulty and/ or noisy breathing, which may ultimately lead to cessation
  • Rapid pulse
  • High blood pressure (hypertension)
  • Cyanosis of the face
  • Swollen veins on the head and neck
  • Convulsions
  • Paralysis
  • Slowly losing consciousness

Complications from Asphyxia

Although there are only a few numbers of possible complications from asphyxia, they are, nonetheless, severe and sometimes, irreversible.

  • Coma
  • Brain death
  • Death

It is necessary to give first aid and if necessary, CPR, to any patient who is at risk of asphyxia. Steps will vary per scenario. Disclaimer: the information and procedure to be given do not substitute for the hands on and practical knowledge taught by first aid training. To increase chances of survival of patients and know how to give appropriate first aid, it is highly encouraged to enroll in first aid courses made available by St Mark James.

Treatment:

-Have someone call for emergency medical services immediately.

-Choking

-Perform Heimlich Maneuver (which will vary in adults, children, and pregnant women) to remove the object

-Drowning

-Safely remove the victim from the water.

-Gas poisoning

-Get the victim into fresh air only if it is safe to go in the place. Evacuate anyone else in the same establishment.

-Suffocation

-Remove anything blocking the airway, such as plastic bags immediately

-Strangulation

-Remove the object used to strangle immediately

-Asthma attack

-Assist the victim to sit upright and assist to medication. For all victims of asphyxiation,

-Loosen any tight clothing, especially around the neck.

-Check for airway, breathing and circulation

-If the victim is unconscious and not breathing with no pulse, perform CPR. To do CPR

-Place own hand on the middle’s chest and entangle the second hand on top of the first. Give 30 -chest compressions, followed by 2 rescue breaths.

-To give a rescue breath, tilt the chin upward and backwards to prevent any obstruction in the -airways. Pinch nostril of casualty and seal the mouth of the victim using own mouth.

-Repeat cycle of 30 chest compressions and 2 rescue breaths until signs of circulation are perceived.

-If the victim has pulse but not breathing, give rescue breaths.

-Do not leave victims ofasphyxiaalone at all times, even if consciousness is regained.

2. Nursing management incase of bowel elimination:

using Interventions and Rationales

  • In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, and aggravating and alleviating factors. Unless questioned directly, patients are unlikely to report the presence of fecal incontinence. The nursing history determines the patterns of stool elimination to characterize involuntary stool loss and the likely etiology of the incontinence .
  • Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual acuity). A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of functional status on stool elimination patterns and incontinence.
  • Complete an assessment of cognitive function. Dementia, acute confusion, and mental retardation are risk factors for fecal incontinence.
  • Document patterns of stool elimination and incontinent episodes via a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. This document is used to confirm the verbal history and to assist in determining the likely etiology of stool incontinence. It also serves as a baseline to evaluate treatment efficacy.
  • Identify the probable causes of fecal incontinence. Fecal incontinence is frequently multifactorial; therefore identification of the probable etiology of fecal incontinence is necessary to select a treatment plan likely to control or eliminate the condition.
  • Improve access to toileting:

o Identify usual toileting patterns among persons in the acute care or long term care facility and plan opportunities for toileting accordingly.
o Provide assistance with toileting for patients with limited access or impaired functional status.
o Institute a prompted toileting program for persons with impaired cognitive status.
o Provide adequate privacy for toileting.
o Respond promptly to requests for assistance with toileting.
• For the client with intermittent episodes of fecal incontinence related to acute changes in stool consistency, begin a bowel reeducation program consisting of:
o Cleansing the bowel of impacted stool if indicated.
o Normalizing stool consistency by adequate intake of fluids and dietary or supplemental fiber.
o Establishing a regular routine of fecal elimination based on established patterns of bowel elimination

  • Begin a prompted defecation program for the adult with dementia, mental retardation, or related learning disabilities. Prompted urine and fecal elimination programs have been shown to reduce or eliminate incontinence in the long term care facility and communitysettings.
  • Begin a scheduled stimulation defecation program, including the following steps, for persons with neurological conditions causing fecal incontinence:

o Before beginning the program, cleanse the bowel of impacted fecal material.
o Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
o Whenever feasible, determine a regular schedule for bowel elimination based on previous patterns of bowel elimination.
o Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may be used.
The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material.

  • Begin a pelvic floor reeducation or muscle exercise program for persons with sphincter incompetence or pseudodyssynergia of the pelvic muscles, or refer persons with fecal incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, includingbiofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with fecal incontinence related to sphincter or pelvic floor muscle dysfunction.
  • Begin a pelvic musclebiofeedbackprogram among patients with urgency to defecate and fecal incontinence related to recurrent diarrhea. Pelvic muscle reeducation, includingbiofeedback, can reduce uncontrolled loss of stool among persons who experience urgency and diarrhea as provacative factors for fecal incontinence. Reducing the incidence of diarrhea can help to reduce bowel incontinence.
  • Cleanse the perineal and perianal skin following each episode of fecal incontinence. When incontinence is frequent, use an incontinence cleansing product specifically designed for this purpose. Frequent cleaning with soap and water may compromise perianal skin integrity and enhance the irritation produced by fecal leakage.
  • Apply mineral oil or a petroleum based ointment to the perianal skin when frequent episodes of fecal incontinence occur. These products form a moisture and chemical barrier to the perianal skin that may prevent or reduce the severity of compromised skin integrity with severe fecal incontinence.
  • Assist the patient to select and apply a containment device for occasional episodes of fecal incontinence. A fecal containment device will prevent soiling of clothing and reduce odors in the patient with uncontrolled stool loss.
  • Teach the caregivers of the patient with frequent episodes of fecal incontinence and limited mobility to regularly monitor the sacrum and perineal area for pressure ulcerations. Limited mobility, particularly when combined with fecal incontinence, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary incontinence reduces this risk.
  • Consult the physician concerning the use of an anal continence plug for the patient with frequent stool loss. The anal continence plug is a device that can reduce or eliminate persistent liquid or solid stool incontinence in selected patients.
  • Apply a fecal pouch to the patient with frequent stool loss, particularly when fecal incontinence produces altered perianal skin integrity. Fecal pouches contain stool loss, reduce odor, and protect the perianal skin from chemical irritation resulting from contact with stool.
  • Consult the physician concerning the use of a rectal tube for the patient with severe fecal incontinence. A large-sized French indwelling catheter has been used for fecal containment when incontinence is severe and perianal skin integrity significantly compromised. The safety of this technique remains unknown.

3. Fracture:

A fracture is the medical term for a broken bone.

A closed fracture is when the bone breaks but there is no puncture or open wound in theskin. An open fracture is one in which the bone breaks through theskin; it may then recede back into the wound and not be visible through the skin. This is an important difference from a closed fracture because with an open fracture there is a risk of a deep bone infection.

Some fracture types are:

  • A Greenstick fracture is an incomplete fracture in which the bone is bent. This type occurs most often in children.
  • A transverse fracture is when the broken piece of bone is at a right angle to the bone's axis.
  • An oblique fracture is when the break has a curved or sloped pattern.
  • A comminuted fracture is when the bone breaks into several pieces.
  • A buckled fracture, also known as an impacted fracture, is one whose ends are driven into each other. This is commonly seen in arm fractures in children.
  • A pathologic fracture is caused by a disease that weakens the bones.
  • A stress fracture is a hairline crack

The severity of a fracture depends upon its location and the damage done to the bone and tissue near it. Serious fractures can have dangerous complications if not treated promptly; possible complications include damage tobloodvessels or nerves and infection of the bone (osteomyelitis) or surrounding tissue. Recuperation time varies depending on the age and health of the patient and the type of fracture. A minor fracture in a child may heal within a few weeks; a serious fracture in an older person may take months to heal.