Exam 2 Flashcards

Question

what happens during an Alarm Reaction?

Answer 1

- Central nervous system is aroused - Hypothalamus - Posterior Pituitary: - Increased water reabsorption - Decreased urine output - Anterior-Pituitary: - Increased water and sodium reabsorption - Decreased urine output - Increased potassium secretion - Sympathetic nervous system and adrenals: - Increased heart rate - Increased O2 intake - Increased blood glucose - Increased mental acuity - Increased blood flow to muscles - Increased blood pressure - Flight-or-flight response

Answer 2

-Continues the flight or fight response and the body stabilizes and responds in an attempt to compensate for the changes induced by the alarm stage -Hormone levels return to normal -Parasympathetic nervous system activity -Adaptation to stressors . Hormone levels, heart rate blood pressure, and cardiac output return to normal and the body repairs any damage that has occurred, can lead to chronic illness due to wear and tear on the body from fluctuating hormone levels, can cause long term problems such as chronic hypertension, depression, sleep deprivation, chronic fatigue syndrome and autoimmune disorder Body continues to try and compensate at peak capacity as it is trying to adapt to the stressor These compensation efforts consume energy and other body resources

Answer 3

-Increased physiological response -Decreased energy levels -Decreased adaptation -Exhaustion-occurs when the body is no longer able to resist the effects of the stressor and has depleted the energy necessary to maintain adaptation Progressive breakdown of the compensatory mechanisms -Causes the bodies natural defenses to breakdown and the body becomes susceptible to illness, tissue damage, ulcers, high blood pressure and chronic health conditions -Allostatic load: chronic arousal with the presence of powerful hormones causing excessive wear and tear on body organs -Can cause long term problems such as htn, depression, sleep deprivation, chronic fatigue syndrome, autoimmune disorders

Answer 4

-Situational Factors: Personal, job, or family changes. -Maturational Factors: Stressors vary with life stage. Younger-physical appearance, self esteem, peers Mid-focus of changes in life situations Older-loss of loved ones, disease -Sociocultural Factors: Environmental and social stressors often lead to developmental problems.

Answer 5

- First have to establish a trusting nurse patient relationship - Ask questions and observe nonverbal communication - Often have difficulty expressing exactly is most bothersome about the situation - Begin by using open ended questions - Assess patient's perception of the event, available situational supports and how they normally hand a problem they can't solve - Determine if there is suicidal or homicidal intent - Subjective-create a nonthreatening environment for the interaction, assume same height as patient - Objective-observation of physical appearance and nonverbal behavior, grooming, hygiene, gait, characteristics of handshake, quality of speech, eye contact and attitude during the interview

Answer 6

- Flight or fight response - Fatigue and low energy - Emotional reactions such as crying, anger, sadness, frustration, helplessness, tension, irritability - Difficulty making decisions - Difficulty falling asleep, interrupted sleep, insomnia - Jaw pain, tooth pain, and grinding of teeth - Hair loss - Intestinal disturbances - Muscle twitching, aches, muscle and nerve pain - Acne development

Answer 7

- Witness to community violence - Domestic violence - Early childhood trauma - School violence - Physical abuse, sexual abuse, neglect - Medical trauma - Exposure to natural disasters

Answer 8

- Stress causer - Invades your privacy - Tells you what to do - No bend and unable to tear

Answer 9

-Positive: encountering a new experience and it brings few or only minor changes in emotions, hormonal response or heart rate change -Tolerable: more intense experience such as a family death and the adaptation -Toxic: stressor is severe, intense and sustained. Leads to prolonged stress activation Can have profound alterations in brain structure and functioning particularly in the developmental period. Can affect immune system function and reduce learning and memory leading to cognitive defects, can also cause damage to the brain causing problems with memory, learning and cognitive processing

Answer 10

- Infants: Irritable, crying, fearful, GI distress - Toddler: Aggressiveness, regressive behaviors - Preschool: Acting out, fearful of separation/abandonment, nightmares - School age: Poor school performance, aggression, increased acting out behaviors - Adolescents: Poor self esteem, delinquency, high-risk behaviors, problems in relationships

Answer 11

-Anticipation of the stressor influences its effect, More difficult to cope with an unexpected stressor -Primary appraisal: evaluating the event for its personal meaning Secondary appraisal: focuses on possible coping strategies. -Coping: person’s effort to manage psychological stress, effectiveness of strategies depends on the individual’s need, -No single coping strategy will work for every person -Ego-defense mechanisms: regulate emotional distress and give a person protection from anxiety and stress, offer psychological protection from a stressful event

Answer 12

- Begins when a person experiences, witnesses, or is confronted with a traumatic event and responds with intense fear or helplessness - Manifested by nightmares, emotional detachment, flashbacks - Responses can include self destructive behavior such as suicide attempts and substance abuse

Answer 13

- Crisis implies that a person is facing a turning point in life, this means that previous ways of coping are not effective and the person must change - Developmental Crisis: Occur as a person moves through the stages of life. - Situational Crisis: Job change, motor vehicle crash, or severe illness. - Adventitious crisis: Major natural disaster, manmade disaster, or crime of violence. - Vital questions for a person in a crisis - What does this mean to you? - How is it going to affect your life?

Answer 14

- Intervention aimed at returning person to a precrisis level of functioning and promote growth - Nurse helps the patient make the mental connection between the stressful event and their reaction to it - Help the patient explore new coping mechanisms

Answer 15

- Common in healthcare workers - Experience from witnessing other people suffer - Manifested by: - Nightmares and anxiety - Avoid interactions - Difficulty relating to friends or family

Answer 16

- Burnout develops after a clinician experiences chronic and excessive stress without adequate coping mechanisms - Causes can include: - Long shifts - Staffing ratios - Dealing with death on a regular basis - Assisting grieving family members - Symptoms: - Irritability - Frequently calling in sick - Exhaustion

Answer 17

Recovers when the stress is removed or coping strategies are successful -Final stage of adaptation is acknowledgement of the long term implications from the crisis and its consequences

Answer 18

- Anxiety - Caregiver role strain - Ineffective coping - Fear - Risk for PTSD - Insomnia - Situational low self-esteem - Stress overload - Review of data leads the nurse to cluster data that indicate a potential or actual stressor and the patient's response - Focus is generally on coping

Answer 19

- Desirable outcomes include effective coping, family coping, caregiver emotional health, and psychosocial adjustments - Selects interventions for stress and improved coping such as coping enhancement and crisis intervention - At the primary level of prevention you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. - Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. - Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. The nurse and the patient assess the level and source of the existing stress and determine the appropriate points for intervention to reduce it. - Involve the patient and family - Identify community resources accessible to the patient - Safety of the patient and others in their surrounding is always the first priority - Collaboration with healthcare team to help meet needs

Answer 20

- Three modes of interventions for stress - Decrease stress producing situations - Increase resistance to stress - Learn skills that reduce physiological response to stress - Education about health promotion - A regular exercise program improves muscle tone and posture, controls weight, reduces tension, and promotes relaxation. In addition, exercise reduces the risk of cardiovascular disease and improves cardiopulmonary functioning. - Patients who have a history of a chronic illness, are at risk for developing an illness, or are older than 35 years of age should begin a physical exercise program only after discussing the plan with a health care provider. - Patients and family members who are well rested are able to manage stress, problem solve, and maintain as sense of control over the situation.

Answer 21

- Anticipate behaviors - Teaching coping skills - Self-soothing techniques - Meditation, therapeutic play - Ensure child's safety - Listen carefully and encourage child to talk, draw, or engage in play to express fears or concerns - Promote self care - Maintain normal routine

Answer 22

- Meditation - Deep breathing - Progressive muscle relaxation: Diminish physiological tension through a systematic approach to releasing tension in major muscle groups. - Guided imagery - Hypnosis - Biofeedback:learned behavior of monitoring physical characteristics of stress-hr, blood pressure and then relaxing to get back to normal level - Assertiveness training - Yoga - Regular exercise: improves muscle tone, posture, control weight, reduces tension, promotes relaxation - Limit caffeine intake - Music therapy - Journaling - Use of humor - Time management

Answer 23

- Very important for nurses to participate in self-care practices - Recognize the areas over which you have control and can change and those for which you do not have responsibility - Clear separation between work and home life is crucial

Answer 24

- Report feeling better after the stressor is gone - Observe patient behaviors - Ask about sleep patterns, appetite, ability to concentrate - Ask about coping strategies - Refer to appropriate resources for follow up care - If he or she reports continued acute stress, assess for safety by asking about whether or not there have been any recent accidents at home, in the car, or at work. Ask about coping mechanisms used. - An essential part of the evaluation process is collaborating with patients to determine if their own expectations from nursing have been met. Any revision in the plan of care includes steps to address patient expectations.

Answer 25

is a basic component of health and is essential for normal growth and development, tissue repair and maintenance, cellular metabolism, and organ function.

Answer 26

Energy needed at rest to maintain life-sustaining activities for a specific amount of time

Answer 27

Amount of energy needed to consume over 24-hour period for the body to maintain internal working activities while at rest

Answer 28

- Energy necessary for the normal function of numerous body processes. - The Biochemical Units of Nutrition

Answer 29

Provides energy, fiber, and glucose

Answer 30

Contribute to growth, maintenance and repair of body tissues

Answer 31

- Provide energy and vitamins - should have less 35% of calorie intake from fats. - are the most calorie-dense nutrient, providing 9 kcal/g. - Fats are composed of triglycerides and fatty acids.

Answer 32

- Critical for cell function and replaces fluid lost through sweat, elimination and respiration - Water makes up 60% to 70% of total body weight. - Infants have the greatest percentage of total body water due to greater surface area, and older people have the least. When deprived of water, a person usually cannot survive for more than a few days. - We meet our fluid needs by drinking liquids and eating solid foods high in water content such as fresh fruits and vegetables. - Digestion produces fluid during food oxidation. - In a healthy individual, fluid intake from all sources equals fluid output through elimination, respiration, and sweating. An ill person has an increased need for fluid (e.g., with fever or gastrointestinal [GI] losses). By contrast, he or she also has a decreased ability to excrete fluid (e.g., with cardiopulmonary or renal disease), which often leads to the need for fluid restriction.

Answer 33

- Necessary for metabolism(a, d, e, k, c and b) - are organic substances present in small amounts in foods that are essential to normal metabolism. They are chemicals that act as catalysts in biochemical reactions. - Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers think that oxidative damage increases a person’s risk for various cancers. Antioxidant vitamins include beta-carotene and vitamins A, C, and E. - Vitamin synthesis depends on dietary intake. Vitamin content is usually highest in fresh foods that have minimal exposure to heat, air, or water prior to their use. Vitamin classifications include either the labels of fat-soluble or water-soluble. - The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. With the exception of vitamin D, people acquire vitamins through dietary intake. - The water-soluble vitamins are vitamin C and the B complex (which is eight vitamins). Water-soluble vitamins absorb easily from the GI tract. Although they are not stored, toxicity can still occur.

Answer 34

- Complete essential biochemical reactions in the body(calcium, potassium, sodium and iron) - are inorganic elements essential to the body as catalysts in biochemical reactions. - They are classified as macro minerals when the daily requirement is 100 mg or more and micro minerals or trace elements when less than 100 mg is needed daily. - Macro minerals help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid–base balance. Interactions occur among trace minerals.

Answer 35

circulate in the blood and are composed of three fatty acids attached to a glycerol.

Answer 36

are composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other. - Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms - or unsaturated, in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond.

Answer 37

have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds. The various types of fatty acids, referred to in the dietary guidelines have significance for health and the incidence of disease.

Answer 38

- Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. - Linolenic acid and arachidonic acid, another type of unsaturated fatty acids, are important for metabolic processes. - Deficiency occurs when fat intake falls below 10% of daily nutrition. - Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids.

Answer 39

- Mechanical Breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food reduces to its simplest form - begins in the mouth, where chewing mechanically breaks down food. The food mixes with saliva, which contains ptyalin (salivary amylase), an enzyme that acts on cooked starch to begin its conversion to maltose. - Proteins and fats are broken down physically but remain unchanged chemically because enzymes in the mouth do not react with these nutrients.

Answer 40

- Enzymes are the protein like substances that act as catalysts to speed up chemical reactions. They are an essential part of the chemistry of digestion. - Most enzymes have one specific function. Each enzyme works best at a specific pH. - The mechanical, chemical, and hormonal activities of digestion are interdependent. - Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action. - Hormones regulate the flow of digestive secretions needed for enzyme supply. Physical, chemical, and hormonal factors regulate the secretion of digestive juices and the motility of the GI tract. - Nerve stimulation from the parasympathetic nervous system (e.g., the vagus nerve) increases GI tract action.

Answer 41

C=Circulation-you must have adequate perfusion P=Pressure-relieve pressure and friction M=Medication-review to find medications that delay healing D=Devitalized tissue-remove it I=Infection-keep the wound infection free N=Nutrition-MUST have adequate nutrition to heal E=Environment-optimize the wound environment/keep moist but control excess drainage R=Reevaluate dressings and treatment as the wound changes

Answer 42

- Albumin: serum protein that can reflect visceral protein stores: 3.4-5.0mg/dl - stays in body about 21 days (liver function)- if below 2.5 severely protein deficient, if 1.7 then you have enough colloidal pressure to get anasarca (total body edema) - Prealbumin: Also reflects visceral protein stores;18-30mg/dl. A better indicator of acute protein depletion. - aka transthyretin, transports thyroid hormones, stays in body 3-5 days, check once a week - Transferrin: Not used as often, can also reflect visceral protein stores; 250-300mg/dl. - Nitrogen Balance: Malnourished patients are in a state of negative nitrogen balance, thus no nitrogen available for protein synthesis, indicates catabolism and need for more protein. - Total lymphocyte count(TLC): Immunocompetence is compromised in protein-energy malnutrition; <1800-2000 cells/mm3 could suggest malnutrition. - HGB/HCT: Anemia; 13-18/39-54, respectively.

Answer 43

``` Acute wounds: - Incisions - Trauma Chronic wounds: - Venous ulcers - Arterial ulcers - Diabetic ulcers ```

Answer 44

- All wounds have some level of bacterial burden, but may not be infected. - Wound infection is when the microorganism invades the tissue. - Do NOT culture pus or other drainage. - Signs: increased pain, drainage, purulence, peri-wound erythema and fever.

Answer 45

- Primary intention-wounds that have been closed using staples, sutures or skin glue. - Secondary intention-left open Occurs with skin ulcers and infected or dehisced incisions

Answer 46

- Dehiscence- cough, move, ripping (7-10 days after surgery), about 1/3 abdominal incisions, pink drainage - Evisceration- call surgeon, elevate head to take some tensions off, sterile dressing with saline and place over, VS, make NPO, establish IV - Retention sutures- sutures that have a little plastic slip around them not to heal into wound (lots of tension around wound)

Answer 47

- Penrose drain- wicking fluid that accumulates around incision, do not replace - Jackson-Pratt or JP drain- check frequently, may pull them out if instructed, premedicate - Hemovac- vacuum that draws fluid, coiled spring, drain every shift

Answer 48

- Do NOT cleanse with substances toxic to fibroblasts: alcohol, hydrogen peroxide, betadine. - DO cleanse with normal saline or approved commercial wound cleanser. - Cleaning lowers the surface temperature of the wound.

Answer 49

- Purpose: Protection from contamination, further injury, abscess formation, Provide compression, Application of medications, Absorption of drainage/Debridement of necrotic tissue, Promote healing of the wound. - Goal: Keep moist tissue moist and dry tissue dry: Keep the open area moist, but the skin around it dry. Choose something that will control drainage, but not dry out the wound. - Biocclusive- seals wound off and can still look, does not absorb drainage but can put overtop something that does - Hydrocolloid- can leave on up to 7 days, acts like a scab (have it at store, called wound healing strips) - Hygrogel- keeps wound moist - Foam- absorbs drainage, can layer this - Alginate- made from seaweed, absorbs huge amounts of drainage - Wet to dry dressings- never want wound to dry out so it should be wet to moist (takes out all tissue when you remove if dry) cools wound bed down, takes a lot of time - Impreganated with silver- helps cut down on infections - XEROFORM™ Petrolatum Gauze. - 3% Bismuth Tribromophenate - Vaseline impregnated in gauze - engineered skin (skin grafts) - wound VAC (Machine with sponge inside wound, Removes drainage, Improves rate of granulation tissue, Decreases infection, Improves circulation) - montogomery straps - Bandage role or Kerlix - Use skin protective barrier before tape - Kelex- white roll - Coban- created by a vet, only thing It sticks to is self

Answer 50

- Surgical or “sharp” (scapel, scissors) - Autolytic- provides a moist environment where the body “dissolves” slough ( self-digestion, refers to the destruction of a cell through the action of its own enzymes) - Enzymatic- applied enzymes dissolve devitalized tissue - Biosurgery- sterile maggots - Mechanical- least effective (letting dressing rip it out)

Answer 51

a flap of skin that closes over the trachea as a person swallows to prevent aspiration

Answer 52

- esophagus, and wavelike muscular contractions (peristalsis) move the food to the base of the esophagus, above the cardiac sphincter - Pressure from a bolus of food at the cardiac sphincter causes it to relax, allowing the food to enter the fundus, or uppermost portion, of the stomach..

Answer 53

pepsinogen

Answer 54

Gastrin: a hormone that triggers parietal cells to secrete hydrochloric acid (HCl)

Answer 55

HCl and intrinsic factor (IF), which is necessary for absorption of vitamin B12 in the ileum. HCl turns pepsinogen into pepsin, a protein-splitting enzyme.

Answer 56

fat and starch digestion, respectively.

Answer 57

lining of the stomach from autodigestion.

Answer 58

Alcohol and aspirin

Answer 59

acts as a reservoir where food remains for approximately 3 hours, with a range of 1 to 7 hours.

Answer 60

atrium, or distal stomach, through the pyloric sphincter and enters the duodenum. Food is now an acidic, liquefied mass called chyme.

Answer 61

- Manufactured in the liver and then concentrated and stored in the gallbladder. - It acts as a detergent because it emulsifies fat to permit enzyme action while suspending fatty acids in solution.

Answer 62

amylase to digest starch; lipase to break down emulsified fats; and trypsin, elastase, chymotrypsin, and carboxypeptidase to break down proteins.

Answer 63

- continues in the small intestine, mixing the secretions with chyme. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions. - Epithelial cells in the small intestinal villi secrete enzymes (e.g., sucrase, lactase, maltase, lipase, and peptidase) to facilitate digestion.

Answer 64

in the small intestine, producing glucose, fructose, and galactose from carbohydrates; amino acids and dipeptides from proteins; and fatty acids, glycerides, and glycerol from lipids. Peristalsis usually takes approximately 5 hours to pass food through the small intestine.

Answer 65

- Body Absorbs nutrients | - Small intestine primary absorption site

Answer 66

-Gather information on current condition, assessment whether it will worsen, or if disease process will worsen condition

Answer 67

- Subjective global assessment | - Mini nutritional assessment

Answer 68

malnutrition or risk of malnutrition using sample tools.

Answer 69

- Include height, weight, weight change, primary diagnosis, presence of other co-morbidities - Subjective statements included too - Identification of risk factors-unintentional weight loss, presence of a modified diet, presence of altered nutritional symptoms(nausea, vomiting, diarrhea, constipation) requires nutritional consultation.

Answer 70

- Measurement system of the size and makeup of the body - An ideal body weight provides an estimate of what a person should weigh. - Body Mass Index: Measures weight corrected for height and serves as an alternative to traditional height-weight relationships

Answer 71

more useful information than a single measurement. The patient needs to be weighed at the same time each day, on the same scale, and with the same clothing or linen.

Answer 72

it usually reflects fluid shifts. One pint or 500 mL of fluid equals 1 lb (0.45 kg).

Answer 73

fluid balance, liver function, kidney function, and the presence of disease.

Answer 74

malnutrition

Answer 75

by dividing the patient’s weight in kilograms by height in meters squared: weight (kg) divided by height2 (m2).

Answer 76

E. Coli, listeria, norovirus, salmonella, shigellosis, staphylococcus

Answer 77

- Clean - Separate - Cook - Chill

Answer 78

not only need to be aware of factors related to food safety but also should provide patient education to reduce risks for foodborne illnesses.

Answer 79

wash hands, food, clean fridge and microwave, clean cutting surfaces, use separate surfaces for food preparation

Answer 80

wash cooking utensils in hot soapy water, wash hands after handling foods, clean vegetables and lettuce thoroughly, wash dishrags regularly

Answer 81

use a food thermometer to verify food cooked, do not eat raw meats or unpasteurized milk

Answer 82

keep food refrigerated and stored at the appropriate temperature

Answer 83

- NPO - Advancing Diets - Gradual progression of dietary intake or therapeutic diet to manage illness - ADAT: Advance Diet as tolerated - Promoting appetite

Answer 84

Disrupt food intake

Answer 85

nothing by mouth (NPO).

Answer 86

- Offer a gradual progression of dietary intake - Promoting appetite-create environment that promotes nutritional intake-keep free of odors, maintain comfort, provide oral hygiene - Usually a social activity so encourage visitors to eat with client

Answer 87

-Provides fluids and electrolytes to prevent dehydration -No solids -For malnourished, bowel prep, post op, fever, vomiting, diarrhea -Easily ingested and absorbed -Usually intended for short term use -Examples: Water, bouillon, gelatin, lemonade, tea, some fruit juices

Answer 88

- Liquid at room temp - Provides nourishment for those having difficulty swallowing or chewing solid foods - Can advance to full liquid diet - Examples: Ice cream, pudding, juices, soups, milk

Answer 89

- Thickened liquids - Level 1: pureed - Level 2: Mechanically altered - Level 3: Advanced - Liquids: thin, nectar, honey, spoon - Includes clear and full liquid options with addition of scrambled eggs, pureed foods, mashed potatoes and gravy - Level 1: smooth pudding consistency, pureed meats, applesauce, scrambled eggs - Level 2: soft texture, semi solid foods that are easily chewed and swallowed-ground meat, well moistened, soft canned or cooked fruit - Level 3: near normal textured foods that are moist

Answer 90

- Foods that have been altered in texture to require minimal chewing - For client's with dental problems, surgery of the head or neck, dysphagia - Degree of texture depends on individual need - Foods to avoid: Nuts, dried fruit, raw fruits and vegetables, fried foods, tough meats, foods with coarse texture - Soft diet: All food and seasonings are permitted but foods with soft consistency are best - Addition of soups, finely diced foods, flaked fish, cottage cheese, peanut butter

Answer 91

- For clients with inflammatory bowel disease, partial obstructions of the intestinal tract, gastroenteritis, diaarhea - Examples: White bread, refined cooked cereals, cooked potatoes (no skin), white rice and refined pasta - Avoid: Raw fruits and vegetables, nuts and seeds, plant fibers and whole grains, dairy limited to two servings a day - Low Fiber diet

Answer 92

- For clients with constipation, IBS with alternating consitpation/diarrhea - Provides 20-35 mg of fiber - Volume and weight are added to stool speeding the movement - Examples: Fruits, vegetables, whole grain products - Limit gas forming foods - High fiber diet - Whole grains, raw and dried fruits

Answer 93

-For clients with HTN, heart failure, renal disease, cardiac disease and liver disease -Common restrictions from 1 g to 4 g daily -Encourage intake of fresh foods Avoid: Canned, frozen, smoked, pickled, boxed foods, lunch meats, soy sauce, salad dressings, fast food, soups, salty, snack foods

Answer 94

- Used for clients with diabetes and obesity | - Groups foods: Carbohydrates, meats, and fats

Answer 95

is a basic component of health and is essential for normal growth and development, tissue repair and maintenance, cellular metabolism, and organ function.

Answer 96

- Promote Health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights - Promote healthful diets and healthy weight encompasses increasing household food security and eliminating hunger

Answer 97

- Consume a variety of nutrient-dense foods within and across the food groups - Limit the intake of saturated and trans fats, cholesterol, added sugars, sodium, and alcohol - Limit caloric intake to meat caloric needs - Avoid unhealthy weight gain

Answer 98

the health benefits of eating a healthful diet and maintaining a healthy body weight. The objectives also emphasize that efforts to change diet and weight should address individual behaviors, as well as the policies and environments that support these behaviors in settings such as schools, worksites, health care organizations, and communities.

Answer 99

Provides average daily consumption guidelines for five food groups

Answer 100

Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and potassium

Answer 101

the Dietary Guidelines for Americans 2010 and provide average daily consumption guidelines for the five food groups: grains, vegetables, fruits, dairy products, and meats.

Answer 102

provides a basic guide for making food choices for a healthy lifestyle. The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars.

Answer 103

The FDA first established two sets of reference values: - The referenced daily intakes (RDIs) are the first set, comprising protein, vitamins, and minerals based on the RDA. - The daily reference values (DRVs) make up the second set and consist of nutrients such as total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium. - Combined, both sets make up the daily values used on food labels. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.

Answer 104

- Religious and cultural practices - Muslim, Christian, Hinduism, Judaism, Mormons, seventh day Adventists - Cultural influences food choices and routines - Always ask questions to better understanding - Financial issues - Environmental factors - Disease and illness - Medications - Developmental/age

Answer 105

religion, cultural background, ethics, health beliefs, and preference.

Answer 106

plant foods - Through careful selection of foods, individuals following a vegetarian diet can meet recommendations for proteins and essential nutrients. - Students need to consult with dietitians to ensure that patients receive the nutrients needed for recovery and rehab.

Answer 107

need to know care givers diet patterns as this will direct impact the pediatric client

Answer 108

- Obesity: Sedentary lifestyle, work schedules, poor meal choices - Lack of food access - High cost of food - Lack of access to play and exercise

Answer 109

-Rapid Growth -High protein, vitamin, mineral, and energy requirements -Birth weight doubles by 4-6 months and triples weight by one year -Intake: Breastfeeding Formula Solid food

Answer 110

Leads to fewer allergies and intolerances, fewer infant infections, easier digestion, fresh, temperature is always correct, and cheaper than formula

Answer 111

contains the approximate nutrient composition of human milk

Answer 112

due to inability of kidneys to manage-too concentrated and is a poor source of iron and vitamins c and e

Answer 113

increased risk for botulism toxin in the first year

Answer 114

- after 4-6 months infants need additional intake. - Use of iron-fortified cereals are typically first and the most important nonmilk/formula source of protein - Introduce 1 food at a time 4-7 days apart to help identify any allergies

Answer 115

-Growth rate slows -Finger foods -Whole milk until age 2 -1 tbsp. for each year of age serving size -Nutritional concerns: Iron deficiency Vitamin D deficiency Choking hazards -Exhibit strong food preferences at this age -Needs: Nutrient dense foods Small frequent meals -Appetite decreases at 18 months -Iron deficiency-most common, need lean red meats and vitamin c to maximize absorption -Vit D is essential for bone development, also need adequate sunlight for the absorption of calcium

Answer 116

-Steady growth and weight gain -Preferences for certain types of food common -Family and Peer influences -Nutritional concerns: Over feeding Poor diet choices Iron deficiency anemia Lead posioning

Answer 117

-Grow at a slow and steady rate -Gradual decline in energy requirements per unit of body weight -Need to monitor diets closely for adequate protein and vitamins -Nutritional concerns: Skipping breakfast Obesity

Answer 118

-Energy needs to increase to meet metabolic demands of growth -Sports and exercise acitivty need dietary modification to meet increased energy needs -Protein, calcium, and iron needs increase -Snacks are approximately 25% of total diet -Nutritional concerns: Fast food, skipping meals, eating disorders Deficient in vitamins and minerals Exceed recommended fats, cholesterol, sodium and sugar Concern about body image and appearance, desire for independence, peer pressure, diets -Carbohydrates are a main source of energy -Adequate hydration also very important -Iron needs increase for muscle development and female menstrual loss

Answer 119

-Reduction in nutrient demands because growth period ends -Need for balanced diet -Energy needs decline and nutrients needed for maintenance and repair -Pregnancy and lactation -Nutritional concerns: Obesity Outside factors affecting diet Pregnancy poor nutrition can cause low birth weight both baby and mother will suffer if not meeting needs folic acid is very important for dna synthesis 400mcg to 600 mcg daily during pregnancy Lactation-needs 500 calories a day above the usual allowance because milk production increases energy requirement

Answer 120

-Decreased need for energy because metallic rate slows with age -Therapeutic diets -Drug interactions -Nutritional concerns Oral health Income Lack of transportation Calcium loss Kidney function Dehydration -Use of therapeutic diets becomes more prevalent in the older adult population due to the increase in different disease processes -A good health history is important to determine client’s diet, home life and any medications that the client is taking

Answer 121

Difficulty Swallowing

Answer 122

-Myogenic: results from issues with the muscle tissue, such as aging, muscular dystrophy, myasthenia gravis -Neurogenic: is caused by the issues within the nervous system such as stroke, cerebral palsy, multiple sclerosis, parkinsons -Obstructive: Obstructive can be cancer, trauma, cervical spondylosis, masses Other: surgical resection and tissue disorders

Answer 123

Helps you initiate referrals for more in-depth assessment by a speech pathologist

Answer 124

an inadequate amount of food intake, which often results in malnutrition.

Answer 125

- Cough during eating - Change in voice tone or quality after swallowing - Abnormal movements of the mouth, tongue, or lips - Slow, weak, imprecise, or uncoordinated speech - Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak

Answer 126

Aspiration pneumonia, dehydration, weight loss

Answer 127

- Position the client upright (45-90 degrees) - Report any coughing, gagging, drooling or pocketing of food - Assess mental status and ability to follow commands - Assess for swallowing reflex prior to feeding - Use penlight and tongue blade to inspect oral cavity - Have client assume a chin tuck position and have client attempt to take sips of water - If client tolerates, increase fluid amount and attempt other consistencies of food - Add thickener as ordered - Have client sit upright for 30-60 minutes after meal

Answer 128

- Assess patient's nutritional history - Ask patient about food preferences, values regarding nutrition, and expectations from nutritional therapy. - Patient-centered clinical decisions are required for safe nursing care. - Studies demonstrate a link between malnutrition in adult hospitalized patients and readmission rates, higher mortality rates and increased cost. - Close contact with patients and their families enables you to observe physical status, food intake, food preferences, weight changes, and response to therapy.

Answer 129

- Health Status - Age - Cultural background - Religious food patterns - Socioeconomic status - Personal food preferences - Psychological factors - Use of alcohol or illegal drugs - Use of vitamin, mineral, or herbal supplements - Prescription or over-the-counter drugs - General nutrition knowledge - The diet history focuses on a patient’s habitual intake of foods and liquids and includes information about preferences, allergies, and other relevant topics such as the patient’s ability to obtain food. Gather information about the patient’s illness/activity level to determine energy needs and compare food intake.

Answer 130

The physical examination is one of the most important aspects of a nutritional assessment. Because improper nutrition affects all body systems, observe for malnutrition during physical assessment. Complete the general physical assessment of body systems and recheck relevant areas to evaluate a patient’s nutritional status. The clinical signs of nutritional status serve as guidelines for observation during physical assessment.

Answer 131

- Risk for aspiration - Diarrhea - Deficient knowledge - Nursing diagnoses may be related to actual nutrition problems (e.g., inadequate intake) or to problems that place the patient at risk for nutritional deficiencies such as oral trauma, severe burns, and infections. - Be sure to select the appropriate related factor for a nursing diagnosis. Related factors need to be accurate so you select the appropriate interventions. In addition, there are also clinical situations in which patients have multiple related problems.

Answer 132

- Goals and outcomes: Reflect a patient's physiological, therapeutic, and individualized needs - Setting priorities: Commitment of not just client - Teamwork and collaboration: Discharge planning - Nutrition education and counseling are important to prevent disease and promote health - When planning care, be aware of all factors that influence a patient’s food intake. - Individualized planning is essential. Explore patients’ feelings about their weight and diet and help them set realistic and achievable goals. Mutually planned goals negotiated among the patient, Registered Dietician, and nurse ensure success. - The patient and family must collaborate with the nurse in planning care and setting priorities. This is important because food preferences, food purchases, and preparation involve the entire family. The plan of care cannot succeed without their commitment to, involvement in, and understanding of the nutritional priorities.

Answer 133

-Health Promotion Education Early identification of potential or actual problems Meal planning Weight loss plans -The focus of health promotion is to educate patients and family caregivers about balanced nutrition and to assist them in obtaining resources to eat high-quality meals. -Meal planning takes into account the family’s budget and different preferences of family members. -Help patients develop a successful weight loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of the energy content of food. -Planning menus a week in advance helps ensure good nutrition or compliance with a specific diet and helps a family stay within their allotted budget. -Support individuals who are interested in losing weight. patients develop a successful weight-loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of energy content of food. Refer to dietician when appropriate

Answer 134

- Use of assistive devices - Environment - Socialization - Health care providers order a gradual progression of dietary intake or therapeutic diet to manage patients’ illness. - Providing an environment that promotes nutritional intake includes keeping a patient’s environment free of odors, providing oral hygiene as needed to remove unpleasant tastes, and maintaining patient comfort. - Offering smaller, more frequent meals often helps. In addition, certain medications affect dietary intake and nutrient use. - Mealtime is usually a social activity. If appropriate, encourage visitors to eat with the patient.

Answer 135

- Assess aspiration risk - Patient positioning - Speed of feed - Allow client to direct meal - Visual deficits - When a patient needs help with eating, it is important to protect his or her safety, independence, and dignity. - Clear the table or over-bed tray of clutter. - Assess his or her risk of aspiration and need for assistance with feeding and swallowing. - Provide opportunities for patients to direct the order in which they want to eat the food items and how fast they wish to eat. - Use of Clock to describe location of items on client tray

Answer 136

- Use of bottle feedings - Enteral feedings - Breast feeding - Breast feeding education and encouragement or consultation of a lactation specialist

Answer 137

- Recording of all fluid intake and output for a 24 period - Measured in mL - Record all I and O - Weigh clients each day at the same time after voiding in the same clothes - Know your Conversions

Answer 138

- Require documentation of actual intake for a specific period of time - Record everything the patient has to eat and drink, including the portion size, over a set period of time - Document percentage of meals consumed

Answer 139

- Through the patient's eyes - Patients expect nurses to recognize when the outcomes are unsuccessful and modify the plan - Patient outcomes - Compare actual to expected - Use multidisciplinary collaboration - Expectations and health care values held by nurses frequently differ from those held by patients. - Successful interventions and outcomes require nurses to know what patients expect in addition to nursing knowledge and skill. - Work closely with patients to define their expectations, and talk with them about their concerns if their expectations are not realistic. Consider the limits of their conditions and treatment, their dietary preferences, and their cultural beliefs when evaluating outcomes. - You need to evaluate the patient’s current weight in comparison with their baseline weight, serum albumin or prealbumin, and protein and kilocalorie intake routinely. If you do not observe gradual weight gain or if weight loss continues, evaluate the dietary EN prescription and determine if the patient is experiencing any adverse effects from medications that are affecting his or her nutritional status. - Changes in condition also indicate a need to change the nutritional plan of care. - Consult multidisciplinary members of the health care team in an effort to better individualize this plan. The patient is an active participant whenever possible. In the end, a patient’s ability to incorporate dietary changes into his or her lifestyle with the least amount of stress or disruption facilitates attainment of outcome measures. - Failing to meet expected outcomes requires revising the nursing interventions or expected outcomes based on the patient’s needs or preferences. When not meeting outcomes, ask questions such as “How has your appetite been?” “Have you noticed a change in your weight?” “How much would you like to weigh?” or “Have you changed your exercise pattern?”

Answer 140

- Injections are used to instill medications into the body tissue - Injected drugs act faster than oral medications - Utilized when clients are unable to take medications by other methods and when rapid action is desired. - Because an injection is invasive, it poses a greater risk for infection and adverse effects.

Answer 141

- Subcutaneous (Sub-Q) injection: injection into tissues just below the dermis of the skin - Intramuscular (IM) injection: injection into the body of a muscle - Intradermal (ID) injection: injection into the dermis just under the epidermis - Intravenous (IV) injection: injection into a vein

Answer 142

- Drugs response too slow or too rapid - Nerve injury and pain - Localized bleeding, bruising, hematoma - Tissue necrosis depending on if it presses on certain areas and cuts of blood supply Sterile absess

Answer 143

- Perform hand hygiene for a minimum of 15 seconds before touching any equipment - Add the time, date, and your initials to the vial you have opened - Swab the top of the opened or unopened vial with alcohol before piercing - Avoid letting the needle touch contaminated surfaces Swab the injection site with alcohol to clean the site

Answer 144

- The type of medication to be given - The volume of solution to inject - The route of the injection - The client's body size

Answer 145

- During blood collection - Recapping needles - Surgery - Discarding sharps - Segregation of waste - Mishandling sharps

Answer 146

Type of injection: diameter, length, angle intradermal: 25- to 27-gauge, 1/2- to 5/8-inch, 5 to 15 degrees subcutaneous: 25- to 27-gauge, 3/8- to 5/8-inch, 45 (thin) to 90 (fat, pinch skin) degrees subcutaneous insulin: 25- to 31-gauge, 5/16- to 1/2-inch, 45 to 90 degrees intramuscular: 18- to 25-gauge, 5/8- to 1 1/2-inch, 90 degrees

Answer 147

- placing a medication into the loose connective tissue under the dermis - Injection sites should be free of infection, skin lesions, bony prominences, and large underlying muscles or nerves - Stay at least 2 inches away from the umbilicus. Injection sites should be rotated - The amount of adipose tissue on a client's body influences the choice of needle length and angle of needle insertion

Answer 148

- Syringe (1-3ml) - Needle – size selected for type and area you are injecting - Small sterile gauze pad or band aide - Alcohol swab - Vial or ampule of medication - Disposable gloves - Medication administration record-record site

Answer 149

- An IM injection involves placing medication into deep muscle tissue - IM route provides faster medication absorption - There is less danger of tissue damage from an IM injection - IM route poses a risk of medication being inadvertently injected directly into a blood vessel - A longer needle must be used to be able to penetrate deep muscle tissue - IM injections can deliver larger volumes (up to 3 mL in adults) of medication - When selecting a site for an IM injection, it is important to choose the correct injection site to prevent nerve damage. - There should be at least 5 mm depth of muscle penetration.

Answer 150

- CDC: 82% of US adults take at least one medication and 29% take 5 or more - The senior population (those aged 65 years and older) comprises 13.7% of the US population but uses 40% of all prescription drugs. People aged 65-69 years fill an average of 14 prescriptions per year and adults aged 80-84 years average 18 prescriptions per year. Jul 2, 2015 - Patient assessment, knowledge of patients history, time management, knowledge of the medication, and how to evaluate if the med is doing what we want it to

Answer 151

- Routine Order: done everyday - Standing Orders/Protocols: predone on computer or preprinted, checklist for usual combo of orders that the provider may want to order ---ex. heparin protocols, potassium protocols Gives guides of what to do without having to call for changes in the order - Single Order/One Time Order: seen written as give this now (as soon as available) or give flu vaccine before they leave - STAT Orders: give immediately - Now – As soon as drug is available - On Call – When representative calls and requests drug be given “now” (OR, diagnostic exam, etc.) or when they tell you to - PRN Orders: as often as order as needed - Verbal Orders/Phone Orders- require a readback, not done a lot (Students at Research Not Allowed)

Answer 152

- Patient’s full name - Date that the order is written - Drug name - Dosage - Route of administration - Time and frequency of administration - Signature of MD, NP or PA - Do not leave them laying out on counters, especially if it has the providers dea number

Answer 153

- BID- twice a day - TID- three times a day, not always every 8 hours - QID- four times a day - Pt. requests now- it may not be able to be given that often so it may be prn meaning they cant have it until after so many hours - Ac - (ante cibum) before meals - Pc- (post cibum)- after meals - Must look at medication schedule - When things ordered daily- normally all given at 9 am - Can contact pharmacy and say you want them spread out - HTN- nondippers, BP does not drop during sleep so these meds may need to be given at nighttime

Answer 154

- Routine drug: Time scheduled is provided – time changes color in computers when scanned or the nurse signs below time indicated - PRN drug: Time scheduled is not provided Parameters are provided (ie: q 4 hours, PRN) - Computer puts in time medication is scanned or the nurse writes it in and signs below - Chart exact time - System will tell you: Time to give: black Late: red to remind you - Sometimes scanning cream with other meds is ok to be given after bath - Look up med history and make sure they are taking the dose they normally do (if ordered as 1-2 tablets)

Answer 155

1. Right Patient 2. Right Drug 3. Right Dose 4. Right Route and form 5. Right Time 6. Right Documentation 7. Right Reason/Indication 8. Right Response 9. Right to Understand and Refuse

Answer 156

- Lack of Knowledge and Skill - Compliance with policy of hospital and administration policy - Failure in Communication - Safety and System Issues

Answer 157

- Monitoring patients' responses to medications – relief, labs, side effects. - Providing education to the patient and/or family about the medication regimen - Informing the physician when medications are effective, ineffective, or unnecessary

Answer 158

- To be informed of the medication's name, purpose, action, and potential undesired effects - To refuse a medication regardless of the consequences - To have qualified nurses or physicians assess a medication history, including allergies - To be properly advised of the experimental nature of medication therapy and to give written consent for its use - To receive labeled medications safely without discomfort in accordance with the ten rights of medication administration - To receive appropriate supportive therapy in relation to medication therapy - To not receive unnecessary medication.

Answer 159

- Check the Medication three times prior to administration - Evaluate the drug being given - Administer the drug appropriately - Assess the patient for therapeutic & adverse effects - Assess Lab results associated with the drug - Provide health teaching and counseling related to the benefit/risk of the drug

Answer 160

- ”Nurses completed an average of 72.3 tasks per hour, with a mean task length of 55 seconds. - Interruptions arose at an average rate of two per hour, but medication tasks incurred 27% of all interruptions. - In 25% of medication tasks nurses multi-tasked.”

Answer 161

- Medication availability - Equipment malfunctions/availability - Patient availability - Patient’s ability to take medications - Meal availability - Availability of other nurses when two are required

Answer 162

- Anorexia - Nausea - Vomiting - Dizziness - Drowsiness - Dry mouth - Abdominal gas - Constipation - Diarrhea

Answer 163

- Patients taking a medication for the first time - Very young and/or elderly clients - Women-especially when pregnant - Patients taking more than four to five medications (polypharmacy) - Patients who are extremely underweight or overweight - Patients with renal and/or hepatic disease - Patients with altered blood flow conditions - Patients with a past history of an adverse medication reaction - Patients with depression and/or anxiety - Patients with sensory deprivation and/or overload - Patients who abuse alcohol, nicotine, or street medications - Patients who self-medicate with over-the-counter medications

Answer 164

- drug-receptor interaction: brain become more sensitive, making psychoactive drugs more potent - metabolism: liver mass shrinks, hepatic blood flow and enzyme activity decline. metabolism drops to 1/2 - 2/3 the rate of young adults. enzymes lose ability to process some drugs, thus prolonging drug half-life - absorption: gastric emptying rate and gastrointestinal motility slow. absorption capacity of cells and active transport mechanism decline - circulation: vascular nerve control is less stable. ex. antihypertensives may overshoot, dropping blood pressure too low. ex. digoxin may slow the heart rate too much - excretion: in kidneys, renal blood flow, glomerular filtration rate, renal tubular secretion and reabsorption, and number of functional nephrons decline. blood flow and waste removal slow. age-related changes lengthen half-life for renally excreted drugs. antidiabetic drugs, among others, stay in the body longer

Answer 165

- Non-injectables; usually goes in “orifice” or on skin. - Mouth – oral, sublingual, buccal, inhaled - Eye - Ophthalmic (drops, ointments, irrigation) - Nose - Nasal (drops or sprays) - Ear - Otic (drops) - Vaginal (douche) - Rectal - Skin - Topical

Answer 166

- Open bubble/blister pack in room immediately before administration (can replace if refused and are not charged) Always ask a patient how they would like to receive medications: all together or one at a time - If difficulty swallowing, crush pill or open capsule – place in applesauce or thickened liquid. Don’t crush or open time release pills, capsules or enteric coated medications.

Answer 167

- Inability to swallow - Nausea/vomiting - Bowel inflammation/pancreatitis - Reduced peristalsis (bowel sounds) - Gastrointestinal surgery - Gastric suction

Answer 168

- Most children have problems with taking pills. - Pills must be crushable and “hid” in foods or liquids - Some medications available as chewable - Do not put in a child’s favorite food- may ruin it for them - Liquid medications should come with a measuring device - Do NOT use home spoons or measures

Answer 169

- Instruct patient where to place medication prior to giving it - Ensure correct placement – ie: nitroglycerin is given sublingual for quicker absorption

Answer 170

- Clean skin first with soap and water Cream, lotion, ointment, barrier creams, powders - Transdermal patches-to be absorbed systemically - WEAR GLOVES WHEN APPLYING- you do not want to be dosed! - Always ask the patient where their last patch is and remove it before applying a new one.

Answer 171

- Nasal-sprays and drops- let the patient administer if they want to - Ophthalmic-Drops vs. ointment - Clean eyes if necessary, from inner to outer canthus. Place in conjunctival sac. - Otic (ear) medications- - Kids/ down and back and Adults/up and back to straighten the ear canal - Turn head to the side

Answer 172

- Usually use sterile water, saline, antiseptic/antimicrobial - Ophthalmic-can use IV tubing - Bladder – Usually post surgery, TURP (transurethral resection of the prostate), saline is used. - Vaginal irrigation-douche - Wound-as with a Wound Vac

Answer 173

Vaginal: -Cream or suppository. - Lubricate applicator with KY. - Patient may self administer. - ex. Troche- placed on applicator and put in vagina (fungal or yeast infection)- sometimes can be put in mouth Rectal: - Lubricate anus, insert past sphincter against rectal wall. Do not place in feces – may need enema first

Answer 174

- Metered dose (MDI) –Spacer often added. Shake, hold in 3 point position, spray-inhale, hold breath 10 seconds. Repeat after 20-30 seconds if indicated. Wait between 2-5 minutes between inhalations with different medication. - Dry powdered (DPI) - DPI does not contain propellants or any other ingredients. It contains only the medication. - Administered by respiratory therapist most of the time

Answer 175

- Disciplinary action by hospital/state board - Loss of license - Job dismissal - Mental anguish-life long regret - Possible civil or criminal charges- imprisonment

Answer 176

- for intramuscular injections - Helps lock it into tissues - Aspirate to make sure there is no blood coming back - Dart motion - Check after 30 minutes to see if its working

Answer 177

- the upper outer area of the arm. - the front and outer sides of the thighs. - the abdomen, except for a 2 inch area around the navel. - the upper outer area of the buttocks. - the upper hip.

Answer 178

- into dermis, below epidermis

Answer 179

- Deltoid muscle of the arm. The deltoid muscle is the site most typically used for vaccines - Vastus lateralis muscle of the thigh (preferred in kids) - Ventrogluteal muscle of the hip - Dorsogluteal muscles of the buttocks

Answer 180

- “Reception, perception, and reaction are the three components of any sensory experience.” pg. 1242 - Perception includes integration and interpretation of stimuli. - The brain sorts out what is most meaningful and what to ignore. - “Be careful not to automatically assume that a patient’s sensory problem is related to advancing age.” pg. 1246 Always ask if this is a new problem. - Can have changes to this system People often unaware until they become really profound - Do not want to admit that they have a problem - Medications and different diagnosis can interfere

Answer 181

- Developmental stage - Culture (also think of immigrants and culture shock) - Stress and perceived threats - Medications and illness - Lifestyle and personality - Environment

Answer 182

- Presbyopia- the eye’s lens doesn’t change shape as easily making it harder to focus on near objects - Presbycusis-progressive bilateral symmetrical age-related sensorineural hearing loss - Alteration in taste-decreased ability to distinguish taste of sweet, salty, sour and bitter. Prefer more foods that are more sweet and salty - Change is ability to smell- affects appetite and safety - Increased risk of dry mouth (xerostomia) – Many times this is due to medications - Decrease in balance- increased risk for falls-exercise and stretching helps

Answer 183

- Sensory Deficit- a deficit in the normal function or sensory reception and perception. - Sensory Deprivation-In the hospital we put patients in a room without natural light away from family and friends and all that is familiar. Nursing actions: - Encourage use of sensory aids - Promote use of other senses - Communicate effectively - Ensure patient safety - Hellen keller was deaf, dumb, and blind (wait why did she call her dumb???) - Deficit in normal function - sensory deprivation happens a lot in isolation

Answer 184

- Excessive or multiple sensory stimulation that prevents the brain from responding appropriately to or ignoring certain stimuli. - Leads to : Restlessness, Anxiety, Decreased attention, Stress - Tolerance to stimuli depends on the person, their level of stress, fear, pain, culture and past experience. Nursing actions: - Be aware of the situation - Assess the patient’s response - Minimize noise and stimulation in the environment - Frequently reorientation

Answer 185

- Anosmia=loss of the ability to smell - Loss of sense of smell decreases appetite - Certain odors can cause nausea - Remove unpleasant odors from the room as soon as possible. - Avoid strong perfumes and aftershave. - Ageusia=loss of ability to taste - Dysgusia=the presence of a metallic, rancid, or foul taste in the mouth - Good oral care is vital for good health. - Dry mouth affects the ability to taste. - Medications can cause problems to taste (antibiotics, chemotherapies)

Answer 186

- The most common visual impairments are refractive errors such as nearsightedness (myopia) or farsightedness (hyperopia). - Many diseases and medications can alter vision. - This can be temporary or permanent. - Fear of going blind is universal Some problems: -digitalis toxicity (makes world look green or yellow) - effects cataracts can have on driving (halo around lights) - blurred vision (vision loss or medications)

Answer 187

- Always ask your patient if they normally wear glasses or contact lenses. - If you see glasses setting near the patient ask if they would like to put them on. - Always look through them and clean them if needed. - May need to provide things with larger print or have someone bring in their glasses

Answer 188

- Legal blindness is a level of visual impairment that has been defined by law to determine eligibility for benefits. It refers to central visual acuity of 20/200 or less in the better eye with the best possible correction, as measured on a Snellen vision chart, or a visual field of 20 degrees or less. - They cant see at 20 feet what other people could see at 200 - May be able still tell light from dark or motion - Promote independent living and include that in the hospital, tour of the room - Do not speak louder for them to hear you… duh

Answer 189

- Always introduce yourself as you enter the room and inform the patient what you plan to do. Let them know before you touch them. - Turn on the lights. Some people can’t see well in low light situations. - Keep the room clear of clutter, especially between them and the bathroom. - Be consistent with where things are placed in the room. - Ask where they want items placed and communicate this to others. - Describe where you have placed items or food like the face of a clock. - Always tell the patient when you are leaving the room and if others will remain in the room. - Be sure they know where the call light is and they can reach it. - Do not avoid words like look and see

Answer 190

- Enucleation of the eye is the term for removal of the eye due to tumors, trauma, disease, infection or uncontrollable pain in a blind eye. - The type of prosthetic depends on how much tissue was removed. - A “conformer” or placeholder is put in the socket until it heals. - The socket must be healed-3 to 6 weeks-before the artificial eye is fitted. - An ocularist is a professional who specializes in custom-crafting artificial eyes. - Pupil size will not change and most do not move with the other eye. - Not a ball, just a curve piece - Glass or plastic - Tell other providers - Some are easily removed and others are left in for months or longer. - As the book says, “An eye prosthesis usually lasts about six years depending on the quality of fit, comfort and cosmetic appearance.” - As your patient how you can help them. Most people will know how to insert, remove and care for their prosthetic better than you will and they prefer to do it themselves. - Children will need new ones as they grow

Answer 191

- Only remove the eye when absolutely necessary. - Most patient’s prefer to care for their own eyes. - If removed store in a labeled container and cover with water or soft contact lens solution. (This keep deposits from drying on the eye.) - Never soak the eye in alcohol or other cleansers. Nurses: - perform hand hygiene and apply gloves - Slide a finger or cotton swab under the bottom edge of the prosthesis. - Remove eye and place in container. It may be cleansed with sterile saline. - If needed, gently rinse eye socket with room temperature saline. - Have patient close the eye and pat dry. - Replace eye by putting the top edge in first. - Remove gloves, perform hand hygiene and document. - Clean with soap and water - Return to ocularist once a year

Answer 192

- Chemical splash/burns, blood or body fluid exposure, foreign object - In a controlled setting: Gather supplies and perform hand hygiene. Supplies: - Gloves - Eye irrigator: syringe, bulb, IV tubing - Irrigation solution: normal saline, lactated Ringers, or clean water - Towels - Catch basin - Local anesthetic eye drops if ordered and available - Rinse the eyes for 15-30 minutes - Can save eyesight - Must have eyes checked after

Answer 193

- Instill local anesthetic eye drops. - With the patient lying down, protect the neck and shoulders with a towel or sheet. - Place the bowl or kidney dish against the cheek, on the affected side, with the head tilted sideways towards it. - Fill the feeding cup or syringe with the irrigating fluid and test the temperature on your hand. - Ask the patient to fix his/her gaze ahead. - Open the eyelids gently with thumb and fingers. Avoid applying pressure to the eyeball. - Pour or syringe the fluid slowly and steadily, from no more than 5 centimeters away ( 1 to 1 ½ inches), onto the front surface of the eye, inside the lower eyelid and under the upper eyelid. - If possible, evert the upper eyelid to access all of the upper conjunctival fornix. - Ask the patient to move the eye in all directions while the irrigation is maintained. - Check and record the visual acuity when the procedure is finished. - In alkali and acid burns, refer the patient to an ophthalmologist for assessment. - Remove contacts or glasses - Do not irrigate if there is an object - Do not touch patient with irrigator can use: - Morgan lens irrigation - IV and oxygen tube

Answer 194

- Brain interprets hearing - Hearing never sleeps, always on guard - Coordination and proper working of every part of a complex system - Will not complain unless severe or other people complaining they cannot hear - Sensory neural hearing loss- neurology of anatomy and diseases - Conduction hearing loss- bones and conduction

Answer 195

- About 2 to 3 out of every 1,000 children in the United States are born with a detectable level of hearing loss in one or both ears. - More than 90 percent of deaf children are born to hearing parents. - Approximately 15% of American adults aged 18 and over report some trouble hearing - All hospitals must comply with the Americans with Disabilities Act and provide patients with auxiliary aids and qualified interpreters without additional cost. - Exposure to smoke can cause hearing loss (be careful with children and infants)

Answer 196

- Impaction occurs when earwax becomes wedged in and block the canal. - Common in the elderly-reduces hearing and decreases mental status. - Children frequently put small objects in their ears. - Anyone can get an insect or object in the ear. - Helps remove dust - If dries it becomes impacted and plugs hearing - Do not poke if there is an insect in ear, put in oil or numbing gel - Otalgia- pain in ear

Answer 197

- DO NOT IRRIGATE if there is perforation of the ear drum or otitis media! - Do not occlude ear. Allow space for the irrigant to escape. - Use body temperature water ONLY. Too hot or too cold can cause a “caloric” response. - No matter how you remove the excess cerumen it is an uncomfortable procedure. - Nystagmus and nausea- caloric response - Soften cerumen with mineral oil drops prior to irrigation - After 70mL give them a break - Do not use water picks Irrigation, suctions, and sometimes cleaning it out (specialist)

Answer 198

- Make sure the assistive device is accessible and functioning. - Federal regulations require medical hearing testing or sign a waver for people buying a hearing aid. We want to make sure there isn’t a correctable problem before using a hearing aid. - Speak in different ranges - Don’t cure hearing loss, just help them hear better - Tell other departments about problems so they are prepared - 1/8 people in US over 12 have hearing loss in 1 or both ears - Bring extra batteries or charge them - Some are Bluetooth or audio connected to phone - Whistle- check for a small hole - Does not improve ability to discriminate words. - Requires ear exam and audiometry. - Requires education for best use and longevity. - Cost $1,000 to $4,000 per ear. - Insurance coverage varies. - Last 5 to 8 years with normal use.

Answer 199

- Keep extra batteries on hand and remove them when not in use. Be sure they are put in correctly. - A dead battery is the most common reason for a “dead aid”. - “Whistling” is usually an ear mold problem. Remove the aid and put a finger over the ear mold hole. If the whistling stops, the ear mold was not properly inserted in the ear or is not a good fit. - Avoid shock, temperature extremes and moisture (newer digital ones can be sealed against sweat and water). - Keep ear molds clean of cerumen, do NOT soak them.

Answer 200

- An implanted electrical device that is usually only placed in one ear and directly stimulates the auditory nerve. - A 2 to 3 hour procedure under general anesthesia. - You must be at least one year old to receive one. - Requires an extensive workup with a CT scan, audiometry, ear exam and psychological counseling. - ONLY USED FOR SENSORINEURAL HEARING LOSS. NOT FOR CONDUCTIVE HEARING LOSS. - Only if hearing aids aren't working - Does not restore normal hearing - People have to go to classes to understand what they are hearing - Patient must be free of infection before surgery - can cost over $100,000 - done under general anesthesia - enhances patients life

Answer 201

- Communicating with a hearing-impaired patient makes the use of some combination of the following necessary: speech, hearing, speechreading (lip-reading), writing, visual aids, visual language systems and the assistance of an interpreter. - Get the person’s attention before speaking. Don’t startle them! - Stand in good lighting where they can see you. Don’t stand with the light behind you. - Don’t eat, chew or smoke while speaking. Reduce background noise as much as possible.

Answer 202

- Anesthesia or “Numbness” and loss of protective sensation: - Ischemia (eg, brain infarction (stroke), spinal cord infarction, vasculitis) - Demyelinating disorders (eg, multiple sclerosis, Guillain-Barré syndrome) - Mechanical nerve compression (eg, by tumors or a herniated disk, in carpal tunnel syndrome) - Infections (eg, HIV, leprosy) - Toxins or drugs (eg,purposeful anesthesia, heavy metals, certain chemotherapy drugs) - Metabolic disorders (eg, diabetes, chronic kidney disease, thiamin deficiency, vitamin B12 deficiency) - Immune-mediated disorders (eg, postinfectious inflammation, such as transverse myelitis) - Degenerative disorders (eg, hereditary neuropathies)

Answer 203

- Paresthesia- A sensation of burning, prickling, tingling or skin crawling. - Temporary is due to prolonged or excessive pressure on a nerve. - Chronic is due to an underlying neurological disease or nerve damage. - Hyperesthesia- An increased sensitivity to a stimuli. It often describes a sensation of pain in response to a normally non-noxious stimuli. (what normally wouldn't feel painful does)

Answer 204

in the regression of behavior to a lower developmental stage and a change in behavior that is recognizable

Answer 205

distress-a condition in which one feels the effect of stress beyond emotional reactions and the body begins to respond to the stressful stimuli

Answer 206

Increased Heart Rate