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Nursing Fundamentals > Exam 7; Chapters 45,47,48 > Flashcards

Exam 7; Chapters 45,47,48 Flashcards

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1
Q

Nutrition is essential for

A
  • Normal growth/development
  • Tissue maintenance/repair/healing
  • Cellular metabolism
  • Organ function
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2
Q

Assessments to determine nutrition

A

•Daily weights
•Lab tests:
-liver function: AST, ALP, ALT, Albumin, Total protein
-Kidney function: BUN, Crt, eGFR, Glucose

  • Pt diet & health history
  • Conditions that interfere with ability to ingest, digest, or absorb nutrients more thorough assessment ensues
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3
Q

What is Dysphagia.?

A

Difficulty or inability to swallow

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4
Q

Nursing assessments for Dysphagia

A
  • Pt has difficulty swallowing
  • Coughing while eating
  • Change in tone or quality of voice after swallowing
  • abnormal mouth, tongue, or lip movement
  • Slow, weak, imprecise or uncoordinated speech
  • Inability to speak consistently
  • abnormal gag and delayed swallowing
  • Incomplete oral clearance or pocketing
  • Regurgitation
  • Delayed or absent trigger of swallow
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5
Q

What can the nurse do to assess the Pts Dysphagia.?

A

Attempt to have the pt take a small sip of water while sitting upright in bed

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6
Q

If symptoms of Dysphagia are present what are the nurses next steps.?

A

Notify the physician and request a consult from the registered dietician

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7
Q

Complications of Dysphagia are

A
  • Aspiration pneumonia
  • Dehydration
  • Decreased nutritional status
  • Weight loss
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8
Q

Dysphagia leads to…

A
  • Disability/Decreased functional status
  • Increased length of stay
  • Increased healthcare costs
  • Increased likelihood of discharge to institutionalized care
  • Increased mortality
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9
Q

What happens to pts albumin levels when they suffer from Dysphagia.?

A

Albumin levels drop due to malnutrition

Albumin=Protein

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10
Q

Nurses role regarding diet/nutrition

A
  • Review ordered diets
  • Advance diets as pt tolerates
  • Promote appetite
  • Assist w feedings if needed
  • Use of weighted silverware
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11
Q

How can appetite be promoted

A
  • Getting the pt up and moving
  • Practicing oral hygiene
  • Encouraging pt to eat with others
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12
Q

NPO means…

A

Nothing by mouth

If pt is NPO for an extended amount of time, be sure pt is properly hydrated via IV or NG tube

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13
Q

Clear liquid diet

A

Clear liquids or fluids that become clear liquids easily at room temp

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14
Q

Clear liquids include

A
  • Broth
  • Boullion
  • Coffee
  • Tea
  • Carbonated beverages
  • Clear fruit juices
  • Gelatin/Jello
  • Fruit Ices
  • Popsicles
  • Water
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15
Q

Full liquid diet

A

All clear liquids as well as smooth textured dairy products

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16
Q

Full liquids include

A
  • All clear liquids
  • Blended cream soups
  • Custards
  • Refined cooked cereals
  • Vegetable juice
  • Puréed vegetables
  • All fruit juices
  • Sherbets
  • Puddings
  • Frozen yogurt
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17
Q

Thickened liquid diet

A 
All clear and full liquids with the addition of 
•Scrambled eggs
•Puréed meats
•Puréed fruits
•Puréed vegetables 
•Mashed potatoes & gravy
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18
Q

Mechanical soft diet

A

Any food that is mashed up by a machine

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19
Q

Mechanical soft diet includes

A
  • All clear, full, & puréed foods
  • All cream soups
  • Ground or finely diced meats
  • Flaked fish
  • Cottage cheese
  • Rice
  • Potatoes
  • Pancakes
  • Light breads
  • Cooked veggies
  • Cooked or canned fruit
  • Bananas
  • Soups
  • PB
  • Eggs (Not Fried)
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20
Q

Low sodium diet

A

4g, 2g, 1g, or 500mg of salt in the diet with no added salts.
Requires selective food purchases

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21
Q

Low cholesterol diet

A

300mg/day of cholesterol in accordance with the American Heart Association

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22
Q

Diabetic diet

A

Focuses on total energy, nutrient & food distribution. Balanced intake of carbs, fats and proteins.
Caloric allowance depends on individual needs

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23
Q

Cardiac diet

A

Low sodium, Low cholesterol, Low fat, and High fiber

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24
Q

Gluten free diet

A

Illuminates wheat, oats, rye, barley, and their derivatives

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25
Regular diet
No restrictions unless specified
26
Enteral nutrition
``` Provides nutrients directly through the G.I. tract. Provided when pt has an •aspiration risk •are not fully alert •cannot/unable to swallow •Suffer from Dysphagia ```
27
Enteral feeding routes
* Nasogastric * Jejunal * Gastric tubes
28
Gastric tube types
* Nasogastric: nose * Orogastric: mouth * Short term & places in acute care setting * long term/permanent tubes will be placed if needed
29
Purpose of gastric tubes
* Enteral feeding * Med admin * Decompression * Lavage
30
NG tube sizes
<12 French for feeding/ med admin | 12, 14, 16, 18 French for lavage & decompression
31
Nasoenteric tubes
* Nasogastric tube (NGT) | * Nasojejunal tube (NJT)
32
Orogastric tubes are often used…
If the pt is intubated or has nasal trauma
33
Surgical tubes
More permanent solutions | -OSTOMY refers to a surgical creation of an opening in an organ
34
Gastronomy tubes
•Percutaneous Endoscopic Gastronomy (PEG tube)
35
Jejuostomy tube
Percutaneous Endoscopic Jejunostomy (PEJ tube)
36
If pt has an aspiration risk which tube is best.?
Jejunal feeding is preferable because it sits in the jejuom of the small intestine
37
Types of gastric tubes
* Dual lumen: has an air vent that is to be open at all times; most used * Single Lumen
38
What position should the NG tube be in the pt.?
Tip should lie below diaphragm and coiled within the stomach
39
Documentation of NG tube insertion
``` •Tube size •Which nare was utilized •Where it was secured (how many cm) •Placement verification •Gastric contents •How pt tolerated operation •Current condition • ```
40
Where should NG tube be secured.?
To the nostril or mouth; measurements should be checked throughout shift to ensure tube hasn’t moved
41
What should be done before and after NG tube use.?
Flush with 30mL water
42
Aspiration/Safety precautions regarding pt with an NG tube
* Head of bed elevated 30 degrees minimum at all times * Tube should be above stomach level at all times * Assess nares frequently for skin breakdown; Lube PRN * Assess oral mucosa integrity & moisture; offer oral swabs & chapstick PRN
43
Percutaneous Endoscopic Gastronomy (PEG tube)
* Allows nutrition, fluids & meds to be put directly into the stomach * Bypasses mouth & esophagus * Cleaned once a day w soap & water * Keep site dry
44
Complications of the PEG tube
* Pain at PEG site * Leakage of stomach contents around tube site * Dislodgment or malfunction of the tube
45
How long can PEG tubes last.?
Months or years Can become clogged or break down over extended periods of time; can be replaced w in dwelling catheter tubing
46
How is med admin performed w NGT & PEG tubes.?
* Fluid meds preferred * Tablets should be finely crushed unless contraindicated * Capsules should be opened unless contraindicated * Dissolve meds when possible * Meds are flushed w 60mL of water using the enteral tube syringe * Apsirate 30mL stomach contents to confirm placement
47
What is asked before med admin through the PEG/NGT.?
* Ask about N/V | * Ensure bowels are functioning properly before admin of meds
48
If residual stomach contents exceed 500mL what is the nurses next step
If residuals exceed 500mL nurse should hold the feeding/meds for 2 hours and recheck Always verify with the order to know residual content amounts
49
What position should the pt be in after feedings/med admin.? And for how long.!
Pt should be placed in semi or high fowlers position for at least 1 hour after feeding/meds have been given
50
What type of liquid should be used when flushing tube & administering meds.?
Room temperature water
51
Each time the syringe is disconnected the nurse is to…
Clamp the tube.!
52
Continuous feeding
* Small amount delivered over the course of hours * Nurse assesses pt during feedings, checks residuals, and increases feedings per orders & ass tolerated * Feedings can cause discomfort if given too quickly * Serum glucose levels can increase * Always assess for hyperglycemia
53
Bolts feedings
* Given by syringe to the flow of gravity | * Similar to Med admin
54
Reasons for a tube removal
* Permanent solution is being put in * Bowel obstruction resolved * Out of coma * Lavage complete * Dysphagia resolved
55
Gastric tube removal
* Flush w 30mL of air * Educate pt to hold breath during removal * Detach all tape while holding tube securely (never let go of tube) * Swiftly remove tube while pt is holding breath; coil tube in hand
56
Parts of bowel process
* Mouth: digestion starts w mastication * Esophagus: Peristalsis moves food to stomach * Stomach: Stores food, mixes food, liquid, & digestive juices; moves food to small intestine * Small intestine:Duodenum, jejunum, & ileum * Large intestine: primary organ of bowel elimination * Anus: Expels feces and flatus from rectum
57
Digestion
The mechanical breakdown that results from chewing, churning, and mixing w fluid and chemical reactions in which food reduces to its simplest form Begins in mouth and ends in small and large intestines
58
Absorption
Intestine is the primary area of absorption Small intestine is lined w villi; carbs, protein, minerals, and water soluble vitamins are absorbed in small intestine Water is absorbed in the large intestine as feces moves toward the rectum
59
Elimination
Chyme is moved through peristalsis through the ileocecal valve into the large intestine and is changed into feces
60
Peristalsis
A series of involuntary wave-like muscle contractions which move food along the digestive tract
61
Factors that influence bowel elimination
* Age * Diet * Fluid intake * Physical activity * Psychological factors * Personal habits * Position during defecation * Pain * Surgery & Anesthesia * meds
62
Constipation
A symptom, not a disease | Infrequent stool, &/or hard, dry, small stools that are difficult to eliminate
63
Fecal impaction
Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that are very hard to expel
64
Diarrhea
An increase in the number of stools and the passage of liquid, unformed feces
65
Hemorrhoids
Dilated, engorged veins in the lining of the rectum
66
Bowel diversions
* Temp/Permanent artificial openings in the abdominal wall (STOMA) * Surgical openings in the ileum or colon * Location of an ostomy determines stool consistency
67
Types of ostomy
* Ileostomy: ileum/ small intestine * Colostomy: colon/large intestine Effective pouching system that protects skin, contains fecal matter, remains odor free, & is comfortable & inconspicuous
68
Ileostomy forms:
Thin to thick liquids expelled
69
Ascending colostomy & transverse colostomy form:
Thick liquid to soft consistency
70
Descending colostomy & sigmoid colostomy form:
More formed stool
71
Nutritional considerations for Ostomy’s
* Low fiber for the first few weeks * Eat slowly and chew food completely * Drink 10-12 glasses of water daily * Pt may want to avoid gassy foods
72
Psychological considerations of Ostomy’s
* Body changes/ self image * Intimacy needs * odor
73
Nursing assessment regarding bowel elimination
* Nursing history * Physical assessment of mouth & abdomen: identify normal/abnormal patterns, habits, and pt perception of normal/abnormal w regard to elimination * Lab tests * Fecal specimens: stool tests for parasites, blood etc. •Diagnostic exams •
74
How is a stool sample collected
* Pt defecates in a hat or collect stool from brief * Wear gloves.! * Collect in a dry, clean, leak proof container * Not very much stool needed * Seal specimen * Biohazard bag for transport * Look for blood, parasites, ovum; notice color & consistency * Send to lab
75
How can the nurse promote normal defecation.?
* Allow pt to take normal elimination position * Develop routine for pt * Give pt privacy * Make sure Pt is safe
76
How is the bedpan positioned.?
The widest part of the bedpan covers the upper buttocks and lower back
77
How is a fracture bedpan positioned.?
The widest part is positioned on the lower buttocks
78
Cathartics & laxatives
* Initiate and facilitates stool passage * Empties bowel * Cathartics have a stronger & more rapid effect on the intestines than laxatives * Laxatives can be given PO or as suppositories
79
Antidiarrheal agents
Decrease intestinal muscle tone to slow passage of feces
80
Enemas
* Instillation of a liquid solution into rectum & sigmoid colon * Promote defecation by stimulating peristalsis * Fluid breaks up fecal mass, stretches rectal wall & initiates defecation reflex * Can give meds via enema
81
What position is the pt in when administering an enema.?
Left lateral sims position
82
How far should a suppository be inserted.?
Approx. 1 inch or once you feel the med bypass the sphincter Make sure med is not placed in the stool
83
Common rectal suppositories
Acetaminophen, Dulcolax
84
What position is the Pt in when administering and enema.?
Left side lying position with top leg bent (Sims position)
85
Bowel training
Bowel training is performed when pts have chronic constipation or fecal incontinence secondary to cognitive impairment
86
Reasons/ aspects for/of bowel training
* Keeps pt in routine for bowel movements * Increase fluids to decrease episodes of constipation & impactions * Promoting exercise promotes peristalsis * Pt may avoid eliminating due to hemorrhoid pain * Avoids skin breakdown
87
Epidermis
Top layer of the skin
88
Dermis
Inner layer of the skin; holds collagen
89
Dermal-Epidermal junction
Separates dermis and epidermis
90
Intact skin…
Protects the pt from chemical and mechanical injury
91
What is a wound.?
An interruption of the integrity of skin
92
Surgical wounds
* Incisions | * Surgical cuts made to the skin
93
Nonsurgical wounds
•Cuts/Lacerations •Skin tears •Ulcers -Pressure ulcers, arterial wound, Veinous wound, diabetic wound
94
Factors that influence healing
* Nutrition * Tissue perfusion * Infection * Age * Stress
95
What is a skin tear.?
A separation of the layers of skin
96
What causes a skin tear.?
* Skin bumping into hard surfaces * Wound dressing changes & adhesive removal * Aggressively washing &/or drying the skin
97
How to care for skin tears.?
* Control the bleeding * Apply saline or warm water & clean area while gently attempting to replace the torn skin back into place * Pat dry w gauze * Measure size of skin tear * Add steri strips across site, carefully * Cover skin w nonadhesive dressing * Document skin tear location, size, cleansing & dressing, & how the pain is tolerated (Can document how it happened)
98
Wound dressings usually require
A nurse who specializes in wound care
99
When should a wound dressing be changed.?
When it is visibly soiled or orders indicate dressing change frequency Some wounds are left open to air & only require cleaning
100
When dealing w wounds the nurse should always
* Assess wound characteristics * Assess old dressings * Document wound cleanings & dressing changes * Initial, date, & time when changing dressings
101
Risks of adhesives on the skin
* Adhesives can cause further damage, especially on chronic wounds & thin fragile skin * Be cautious when applying and removing adhesives
102
Pressure injuries
Impaired skin integrity related to unrelieved, prolonged pressure. Causes localized damage to skin and underlying soft tissue (Typically over a bony prominence)
103
Pressure injury can present as:
* Intact skin * Blisters * Open ulcers
104
Pts most at risk for pressure injuries
* Pt w decreased mobility * Pt w decreased sensory perception * Pt w fecal or urinary incontinence * Pt w poor nutrition
105
Pathogenesis of pressure injuries
1. Pressure occludes capillaries 2. Ischemia 3. Tissue death occurs
106
Assessing pressure injured areas
Press a finger to the area, if the skin turns lighter in color it is blanchable If the skin does not blanch it is non-blanchable (Deep tissue damage is probable)
107
Pressure injuries can be caused by
* Low intensity pressure over a prolonged period of time | * High intensity pressure over a short period of time
108
Tissue tolerance
How well can the tissue endure pressure * Depends on skin integrity in the area & supporting structures * shear, friction, & moisture makes the skin more susceptible to damage
109
Risk factors for pressure ulcer development
* Impaired sensory perception * Alterations in level of consciousness * Impaired mobility * Shear * Friction * Moisture
110
Shear action is
Sliding movement of skin while underlying bone & muscle are stationary
111
Prevention of pressure injuries
* Protect bony prominences * Skin barriers for incontinence * No loose sheets under pts skin * Minimum absorbent pads under pts * Reposition pts often * Support surfaces; Pillows, cushions, special mattresses
112
Braden scale for pressure injuries
An evidence based tool that allows health professionals to predict a pts risk for developing a hospital acquired pressure ulcer
113
The Braden scale evaluates
* Sensory perception * Moisture * Activity * Mobility * Nutrition * Friction & shear
114
Braden scale scores
* 19-23: No risk * 15-18: Mild risk * 13-14: Moderate risk * 10-12: High risk
115
Stage 1 pressure ulcer
Intact skin w non blanchable redness
116
Stage 2 pressure ulcer
Partial thickness skin loss involving epidermis, dermis, or both
117
Stage 3 pressure ulcer
Full thickness tissue loss with visible fat
118
Stage 4 pressure
Full thickness tissue loss w exposed bone, muscle, or tendon
119
Can pressure ulcers go through each stage.?
No. A healing pressure ulcer will be regarded as a healing stage “XYZ” pressure ulcer
120
What injuries cannot be staged.?
Wounds with necrotic tissue cannot be staged
121
Who determines the stage of a pressure injury.?
A specialized & experienced wound care nurse
122
Nursing role of wound management
* Identify risk factors for pressure ulcer development * Thorough skin assessment * identify infection if present * Keep wounds clean & dressed per orders * Communicate

Nursing Fundamentals (5 decks)

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