basic care & comfort fundamentals

Question 1

what does cachexia mean?

Answer 1

muscle wasting

Question 2

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?

Answer 2

use a large-barrel syringe to flush and aspirate warm water in a back and forth motion

Question 3

why do we use enteral feedings?

Answer 3

to provide nutrition to clients who cant eat or drink

Question 4

what is a gastrotomy tube?

Answer 4

a tube that travels directly into the stomach for food. its not like a nasgastric tube that goes from the nose into the stomach

Question 5

what are the three types of feeding tubes?

Answer 5

bolus
continuous
cyclical

Question 6

What is a bolus feeding tube ? how often is it administered and over how long a period of time?

Answer 6

it resembles normal feeding patterns

administered over 30 - 60 minutes 3 -6 hours , but the amount and frequency varies on the clients contindion

Question 7

how long does a continuous feeding run over?

Answer 7

24 hours

Question 8

what is a cyclical feeding?

Answer 8

administered continuously over 8 - 16 hours (provides breaks inbetween feeds)

Question 9

what the HIGHEST risk with feeding tubes

Answer 9

aspiration

Question 10

when should you verify placement of an enteral feeding tube?

Answer 10

before initiating

Question 11

how do you verify placement of a feeding tube? (include intially and later)

3 steps

Answer 11

1. intially verify via xray
2. mark where the tube should be at the nose
3. LATER - see the marking on the tube OR measure ph of the aspirated contents

Question 12

should feeds be warm or cold when giving to a patient and why?

Answer 12

warm, to prevent abdominal cramping

Question 13

at what degree should you raise the head of he bed for continuous feeds? bolus feeds?

Answer 13

continuous - semi- fowlers (30 - 45 degrees)

bolus - fowler (90 degrees) for 30 - 60 minutes after feeds

Question 14

how do you assess for gastrointestinal intolerance with nasogastric feeds?

Answer 14

bowel sounds before and after
abd distention and pain
gastric residue (amount aspirated from the stomach following administration of enteral feed)

Question 15

what is the protocol for flushing feeding tubes to maintain tube patency?

Answer 15

flush before and after medications and bolus feeds

flush every 4 hrs on continous feeds

CRUSH MEDS (not extended release ones)

assess for skin breakdwn

Question 16

what is a common side effect of enteral feedings? how can you mitigate it?

Answer 16

Diarrhea

you can mitigate it by slowing down feeds
tubing is warm
make sure its not cdiff/ infection
add fiber

Question 17

what is refeeding syndrome? what two things can it cause/ disturb

Answer 17

a metabolic complication that occurs when someone who is malnourished is reintroduced to fcalorie dense food

the food brings in glucose –? hyperglycemia (Too much glucose in the blood spills into the urine, and it pulls water with it, making you pee a lot — that’s osmotic diuresis)

this messes up you electrolytes

Question 18

what should you do if a patient is vomiting on a nasogastric tube?

Answer 18

check gastric residuals (amount aspirated from the stomach following administration of enteral feed)

if there was more than 500ml left in the stomach, stop the feed and reasses

Question 19

what are the indications for semi fowlers position? (30 - 45 degrees in bed)

Answer 19

it allows better breathing
also relieves pressure off of organs

cirrhosis of the liver (where scar tissue replaces healthy liver tissue, preventing the liver from functioning properly)

asites

aspiration risk for restraints

POST OP PATIENTS (unless its like a demoral artery ccath or spinal surgery)

Question 20

what degrees are semi fowlers positions, fowlers positon and high fowlers position?

Answer 20

semi fowlers - 30 - 45 degrees
fowlers - 45 to 60 degrees
high fowlers - 60 to 90 degrees

Question 21

how often should you turn a patient with a pressure injury?

Answer 21

every 2 hours

Question 21

why can positions like trandelburg be a bad idea for some people? whats happening in the body when a patient is at an angle like that?

Answer 21

blood is rushing to the head
this is contraindication in neural conditions and ascites

Question 21

why is it good to elevate placed of swelling?

Answer 21

it helps promote draininge and prevent venous and lympathic pooling

Question 21

why would some positions like reverse transdelenburg be contraindicated?

Answer 21

it sends blood down to the legs so if you have something like venostasis, the blood will just pool down there, bad idea.

Question 21

why is protein good for patients with pressure injuries?

Answer 21

it helps rebuild damaged tissue

Question 21

why is massing bony prominences not acceptable for pressure injury prevention?

Answer 21

it can lead to deep tissue damage. its not smart to do if you notice inflammation, damaged blood vessels or fragile skin

Question 21

what types of foods should patients with neutropenia avoid?

Answer 21

anything raw, unwashed or undercooked

Question 21

what are the 3 common peripheral venous assess device complications?

Answer 21

phlebitis infiltration extravastation

Question 21

should a person with neutropenia be cleaning litter boxes?

Answer 21

no

Question 21

what are some right sided stroke effects?

Answer 21

right sided - more aggressive, impulsive behaviors

Question 21

what is receptive aphasia? how should you interact with someone who suffered a stroke and had it

Answer 21

issues with verbal and written language comprehension use visual aids and hand gestures to communication

Question 21

what type of food do orthodox jews not eat?

Answer 21

anything containing gelatin

Question 21

signs of phlebitis (vein wall inflammation) which 3 drugs are known for causing this? what are nursing interventions.

Answer 21

pain, warmth and swelling red streaks drug the cause phlebitis: potasium chloride, promethazine (antihistamine and antiemetic, used to treat allergies and motion skinness/vomiting) vancomycin interventions: REMOVE PVAD Apply a warm or cold compress (heat would be avoided with k+, because it is a vesicant) elevate effected extremity

Question 21

what is extravasation? how should you intervene

Answer 21

medication that infiltrates and damages surrounding tissues burning pain, redness, swelling STOP INFUSION, BUT LEAVE CATHETER (aspirate med or give antidote) elevate extremity NO PRESSURE

Question 22

what is infiltration? four manifestation? causes? interventions?

Answer 22

fluid leaking into surrounding tissues manifestation: swelling , pain, blanching (reduced blood flow to area because of pressure from fluids), cool skin causes: incorrect catheter size, dislodged or improperly placed PVAD interventions: - REMOVE elevatate limb

Question 23

why is using a small barrel syringe to flush a feeding tube wrong?

Answer 23

it creates too much pressure, all the air is concentrated in that small container so the force is more direct

Question 24

what does a left sided stroke usually cause

Answer 24

aphasia, communication issues

Question 25

what is important to note with people who have strokes on one side of the brain?

Answer 25

it affects the other side of the body (contralateral)

Question 26

if someone has visual issues, is it important to say goodbye when leaving?

Answer 26

yes, it helps not scare them cause they may see when you leave and enter well

Question 27

what are the clinical manifestations of pneumonia?

Answer 27

fever, tachypnea, hypoxemia, crackles, productive cough with purulent sputum (sputum with pus like bacteria and cell debris in it)

Question 28

if a patient has visual impairments, how should you walk with them?

Answer 28

offer an elbow to hold and walk a half-step ahead to guide them

Question 29

which gait is considered proper gait for someone using crutches?

Answer 29

a 3 point gait (non-weight bearing status)

Question 30

what are three things to note about how to use crutches?

Answer 30

3 - 4 finger width between axilla and pad 30 degree elbow flexion 3 point gait (move the crutch and the affected leg simultaneously then bring the affected leg)

Question 31

what are 5 risk factors for pressure injuries?

Answer 31

immboility impaired sensation (PAD, paralysis) inc skin moisture fever infection nutritional deficit

Question 32

what is palliative care?

Answer 32

a mode of treatment that involves managing symptoms, and providing support and care to assist with relieving suffering and improving quality of life for those with TERMINAL ILLNESSES. you can still recieve curative treatment while getting it.

Question 33

should a patient read before bed if trying to efficiently sleep?

Answer 33

no

Question 34

should terminally ill patients recieve artificial hydration?

Answer 34

no, it can cause symptoms like resp distress, vomiting, diarrhea and the need for a urinary cath

Question 35

what is paresthesia?

Answer 35

the feeling of "pins and needles" on the skin. numbness, tingling

Question 36

what is pruritis?

Answer 36

itching

Question 37

what is delirium?

Answer 37

acute and fluctuating change in mental status

Question 38

what are 6 clinical features of delirium?

Answer 38

- acute (rapid onset) - altered level of conciousness - fluctuating level of conciousness (can be tired to combative overnight) - disturbance in attention - disorganized thinking - sleep-wake changes (worse symptoms at night)

Question 39

what is a nursing intervention for delirium?

Answer 39

reduce overstimulation (noise, lighting) treat the unlying cause if pain? relieve it glasses freq reorientation using friends or familiar objects MAINTAIN NORMAL SLEEP-WAKE CYCLE - open blinds for sunlight - inc physical activity - turn off lights