Powerpoints and Notes Flashcards
(159 cards)
1
Q
Describe Diabetes mellitus.
A
Group of metabolic diseases characterized by hyperglycemia that results from impaired pancreatic secretion of insulin and/or defects in the action of insulin inside cells.
2
Q
Describe type 1 diabetes.
A
Type 1:
Caused by an autoimmune process that destroys the beta cells in the pancreas.
Unable to produce endogenous insulin, so they must inject exogenous insulin to survive.
3
Q
Describe type 2 diabetes.
A
Type 2:
Pancreas may still produce some insulin, but the insulin is not used effectively by the body’s cells.
Can be controlled with medications, diet, and exercise.
4
Q
Describe gestational diabetes.
A
Gestational diabetes:
Presence of diabetes during pregnancy and may be caused by hormonal changes and/or lack of insulin.
Usually disappears after delivery of baby.
5
Q
How is diabetes mellitus managed?
A
Diet (should balance protein, fat, and carbohydrate intake to manage bld glucose levels, cholesterol levels, and body weight.)
Exercise
Medications
*All three important in managing blood glucose levels.
6
Q
The carbohydrates in bread, cereal, pasta, and sweets are responsible for what?
A
These substances are responsible for increasing blood glucose levels.
7
Q
What does insulin do and how is the amount of insulin determined?
A
Insulin is the hormone that allows the body to utilize and store glucose.
The amount of insulin that an individual with diabetes needs depends on:
- The type of diabetes - The presence of other diseases or illnesses - The individual's body weight
Total daily dose of insulin to maintain normal or near-normal blood glucose levels varies greatly from person-person.
8
Q
How is insulin categorized?
A
Categorized according to its action:
- Rapid-acting - Short-acting - Intermediate-acting - Long-acting
9
Q
What concentration do most insulins come in?
A
100 units per mL (U-100)
Only regular (short-acting) insulin comes in two strengths: U-100 and U-500.
10
Q
Describe U-500 insulin.
A
More concentrated, providing 500 units of insulin per mL
Prescribed for individuals who are severely resistant to insulin and require very large doses.
11
Q
How is insulin stored?
A
Stable at room temperature
Store in cool place
Never freeze! Can destroy the integrity…
Good for 30 days (Make sure you date when open & check for expiration.
12
Q
What is the range for hypoglycemia and what are the symptoms?
A
Typically below 70 mg/dL.
Symptoms: Weakness, shakiness, hunger, anxiety, headache, heart palpitations, blurred vision, and sweating, confusion, tachycardia, irritability.
Can lead to loss of consciousness, seizures, and possibly death.
Continue treatment until bld glucose level is greater than 70 mg/dL.
13
Q
How is insulin ordered?
A
- On a routine or fixed schedule
- To be given before a meal (metabolizes glucose that is eaten in meal.
- To be given after a meal (Good for pts that don’t always eat everything. Rapid or short acting)
- As a correction dose
- Using a sliding scale
- Using a combination of methods
14
Q
Describe insulins that are ordered on a routine/fixed schedule?
A
Intermediate and long acting insulin are usually ordered on a routine basis.
Pt will receive insulin injections at specific times during the day.
Provides slow release of insulin over long period, mimicking body’s own natural release of insulin throughout the day.
15
Q
What are examples of routine insulin orders?
A
- Insulin glargine (Lantus) 20 units, subcut, every morning.
- NPH insulin 14 units, subcut, before breakfast
- NPH insulin 25 units, subcut, before evening meal
- NovoLog Mix 70/30, 18 units, subcut, before breakfast and dinner.
16
Q
What insulins are usually given before meals?
A
Usually rapid or shot acting insulins are given just before meals.
Provide burst of insulin that helps metabolize the glucose eaten during the meal.
Amount of insulin depends on quantity of carbohydrates that was planned in the meal.
Pre-meal regimens are usually combined with routine doses of long-acting insulin administered once or twice per day.
17
Q
Describe post-meal insulins.
A
Rapid acting insulin may occasionally be administered after meals.
Giving a routine or standard dose for patients who are very ill and may not be able to eat well can cause hypoglycemia. Therefore insulin can be given after meals, based on the amount of food eaten by the patient.
18
Q
Describe correction doses of insulin.
A
Administered when a patient’s bld glucose level is unexpectedly high.
A situation could occur where routine pre-meal doses of insulin may not be enough to reduce level to normal, therefore correction dose can be used.
Correction dose varies depending on the severity of glucose reading and pt’s total daily insulin requirements.
19
Q
Describe the sliding-scale insulins.
A
Pt is administered a rapid or short acting insulin based upon bld glucose level drawn prior to meals.
Sliding scale reacts to hyperglycemia after it has occurred rather than preventing it from occurring, and it does not account for the carbohydrates that will be consumed in the upcoming meal.
20
Q
Describe subcutaneous insulin.
A
Subcutaneous insulin may be administered periodically or continuously.
Insulin given periodically is administered with single-use syringes or insulin pen devices.
Insulin delivered continuously should be used in an external insulin pump.
21
Q
What unique features differentiate insulin syringes from other syringes?
A
- Caps are usually orange
- Clibration markings include mL and units
- Sizes 0.3 mL (30 units), 0.5 (50 units), and 1 mL (100 units.
- U-100 syringes must be used with U-100 insulin
- Needles are fine and short (27-31 gauge and 3/8 to 5/16 inches in length.)
- All given subQ at 90 degrees
22
Q
Describe injection pens.
A
Convenience & portability, reusable (not needles)
Prefilled cartridges up to 315 unites of insulin, allowing for days or weeks of use.
Helpful for pts with poor eyesight (magnified dials) or ppl who have difficulty manipulating syringes and vials (thicker body).
Not designed to be opened and mixed together.
23
Q
Describe external insulin pumps.
A
Push rapid or short acting insulin
Contained in pre-filled syringe, through a very thin tube into the subcutaneous tissue of the abdomen.
Catheter is inserted through the skin using a very small fine needle. Needle is then removed, and the catheter is secured to the skin with tape or a transparent dressing.
Can stay in place for up to three days
Can be disconnected for showering or other activities.
Can deliver basal (continuous small amount of insulin throughout the day and night) or bolus (delivered around mealtimes.)
Some can test blood glucose levels.
24
Q
When is insulin administered intravenously?
A
Used to treat individuals with extremely high blood glucose levels.
Most are regular insulin, however several of the rapid acting insulins may be used.
Rapid and short have relatively fast onset of action.
Nurse frequently checks bld glucose and titrates infusion rate.
High risk for adverse reactions. A second nurse should verify.
25
What drugs increase the hypoglycemic effect?
Ace Inhibitors
Beta Blockers
Alcohol
Calcium
Ginsing
Aspirin
26
What drugs decrease the hypoglycemic effect?
Oral contraceptives
Diuretics
Morphine
Niasin
Nicotine
27
Describe the effect of lipodystrophy.
Atrophy or hypertrophy of subcutaneous site
Rotate the site!!!
Give insulin at room temp to avoid lipodystrophy.
28
What effect does nicotine have on insulin.
Interferes with subcutaneous absorption.
29
What are signs of an allergic reaction?
Swelling ,erythema
Usually goes away after short period of time.
30
What can you give for hypoglycemia?
OJ, Milk
IV if not lethargic
IM glucagon
31
State the steps for mixing insulin.
1. Fill syringe with air equivalent to full dose of insulin
2. Inject air into intermediate acting insulin
3. Inject remaining air into rapid acting or short acting insulin
4. Draw up ordered # of units
5. Withdraw the ordered # of units from intermediate acting insulin
32
Describe NovoLog.
| Rapid acting
Insulin aspart (NovoLog)
Onset: 10-20 minutes
Peak: 1-3 hours
Duration: 3-5 hours
Recommended Timing: 5-10 minutes before meals
33
Describe Humalog.
| Rapid acting
Insulin lispro (Humalog)
Onset: Within 15 minutes
Peak: 1 to 1 1/2 hours
Duration: 3-4 hours
Recommended Timing: 15 minute before meals or immediately after a meal
34
Describe Apidra.
| Rapid acting
Insulin glulisine (Apidra)
Onset: Within 15 minutes
Peak: 1 hour
Duration: 2-4 hours
Recommended Timing: 15 minutes before meals or within 20 minutes after starting a meal.
35
Describe Novolin R, Humulin R.
| Short acting
Regular Insulin
Onset: 30-60 minutes
Peak: 2-4 hours
Duration: 5-7 hours
Recommended Timing: 15-30 minutes before meals.
36
Describe Novolin N, Humulin N
| Intermediate acting
NPH insulin [isophane insulin suspension]
Onset: 1-2 hours
Peak: 4-12 hours
Duration: 18-24 hours
Recommended Timing: 30-60 minutes before meals.
37
Describe Levemir
| Long acting
Insulin detemir
Onset: 3-4 hours
Peak: 3-14 hours
Duration: 24 hours
Recommended Timing: With evening meal or at bedtime.
38
Describe Lantus
| Long acting
Insulin glargine
Onset: 3-4 hours
Peak: No peak
Duration:24 hours
Recommended Timing: At same time each day.
Steady throughout day
39
What three major considerations determine the extent of a neurologic exam?
1) The client's chief complaints
2. ) The client's physical condition (i.e., level of consciousness and ability to ambulate) because many parts of the exam require movement and coordination of the extremities.
3. ) The client's willingness to participate and cooperate.
40
What is the nurse's role for the neuro exam and what is included in the neuro assessment?
Nurse role- To identify clients that need further neuro testing.
Neuro Assessment
1. History of Present Illness
- Determine chief complaint
- Include onset, duration, and current status.
2. Past Medical History
- Major Adult Illnesses
- Allergies
- Pertinent Family History
- Medications
41
Examination of the neurologic system includes assessment of what?
1. Mental status including level of consciousness
2. The cranial nerves
3. Reflexes
4. Motor function
5. Sensory function
42
Assessment of mental status reveals the client's general cerebral function. What functions are included in this?
Intellectual (cognitive)
Emotional (affective)
43
What are major areas of a mental status assessment?
Language
Orientation
Memory
Attention span
Calculation
44
Describe tests for cerebral function (mental status exam)
Describe patients LOC and orientation
- lethargic?
- where are you? date? time?
Describe patient's:
-recent: events within the last several hours
(What did you have for breakfast?)
-intermediate: personal or general events within the last 5 years. (Who is the president?)
-long term: where and when were you born?
Describe patient's thought processes.
- abstract or concrete?
- check educational level before questions
- ask proverb and judgement questions
- attention and concentration
45
What is aphasia and how is it categorized?
___________ describes any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex.
Categorized as sensory or receptive aphasia, and motor or expressive aphasia.
46
Describe sensory or receptive aphasia.
Sensory or receptive aphasia is the loss of the ability to comprehend written or spoken words.
Two types:
- auditory (acoustic): lost the ability to understand the symbolic content associated with sounds.
- visual: lost the ability to understand printed or written figures.
47
Describe motor or expressive aphasia.
Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, or speaking.
Clients may find that even though they can recall words, they have lost the ability to combine speech sounds into words.
48
What does orientation measure?
Orientation determines:
- the client's ability to recognize other persons.
- awareness of when and where they presently are
- who they, themselves are
(person, time/place, self)
49
What is included in a memory assessment?
Client's recall of information presented seconds previously. (immediate recall)
Events or information from earlier in the day or examination (recent memory)
Knowledge recalled from months or years ago (remote or long term memory)
50
Describe level of consciousness.
Can lie anywhere from a state of alertness to coma.
Fully alert client: responds to questions spontaneously
Comatose client: may not respond to verbal stimuli.
Glasgow Coma Scale can be used to assess LOC.
-Tests eye response, motor response, & verbal response.
15 points= alert and completely oriented
7 or less= comatose client
51
Describe reflexes.
Reflex is an automatic response of the body to a stimulus.
Not voluntarily learned or conscious
Deep tendon reflex is activated when a tendon is stimulated and its associated muscle contracts.
As a person ages, reflex responses may become less intense.
Tested using percussion hammer.
Response is described on scale of 0-4.
Babinski reflex=possible spinal cord injury.
52
What does neurologic assessment of the motor system evaluate?
Evaluates proprioception and cerebellar function.
Structures in proprioception: proprioceptors, posterior columns of the spinal cord, the cerebellum, and the vestibular apparatus (innervated by cranial nerve 8) in the labyrinth of the internal ear.
53
Describe proprioceptors.
Proprioceptors: sensory nerve terminals that occur chiefly in the muscles, tendons, joints, and internal ear.
Give information about movements and the position of the body.
Stimuli from proprioceptors travel through posterior columns of the spinal cord.
Deficits of function of the posterior columns of the spinal cord result in impairment of muscle and position sense.
54
Describe the cerebellum's function.
1. Helps control posture
2. Acts with the cerebral cortex to make body movements smooth and coordinated
3. Controls skeletal muscles to maintain equilibrium
55
What is included in sensory functions?
```
Touch
Pain
Temperature
Position
Tactile discrimination
```
56
What are abnormal responses to touch stimuli?
- Loss of sensation (anesthesia)
- More than normal sensation (hyperesthesia)
- Less than normal sensation (hypoesthesia)
- Abnormal sensation such as burning, pain, or an electric shock (paresthesia)
57
What does a detailed neurologic exam include?
Position sense
Temperature sense
Tactile discrimination
-One and two-point discrimination (ability to sense whether one or two areas of the skin are being stimulated by pressure.
- Stereognosis: the act of recognizing objects by touching and manipulating them
- Extinction: failure to perceive touch on one side of the body when two symmetric areas of the body are touched simultaneously.
57
What does cortical sensory interpretation include and what does it test?
Tests for agnosia: inability to recognize objects through any of the five senses.
Sound recognition (auditory agnosia)
Visual object recognition (visual agnosia): don't know use for fork, cup
Tactile object recognition (stereognosis): penny in hand, close hand, ask what it is, and they can't recall/tell what is in hand.
-also known as astereognosis.
58
What is included in the language portion of the neuro exam and what does it test?
Tests for aphasia: inability to communicate through speech or writing due to damage to the brain. Includes difficulty understanding, speaking, reading, and writing.
Expressive aphasia (Broca's aphasia): a disturbance of the ability to express oneself, either in writing or in speech. Usually frontal lobe damage.
Receptive aphasia: inability to comprehend the spoken word. Patient is able to speak, but may not make sense. Usually temporal lobe damage.
59
How do you test the olfactory nerve 1?
Close one nare and smell.
60
How do you test the optic nerve 2?
Read snellen chart by covering one eye first then the other.
Confrontation test: tests peripheral vision.
61
How do you test the oculomotor nerve 3?
Tests eye movement and pupillary reaction.
Examine pupils for size, check for pupillary constriction, and consensual reaction.
```
4+ = brisk
3+ = less than brisk
2+ = slow
1+ = very slow
0 = absent
```
Check convergence and 6 cardinal fields of gaze.
62
How do you test the trochlear nerve 4?
Tests eye movement
Have patient look at tip of nose.
63
How do you test the trigeminal nerve 5?
Tests motor function and facial sensation.
Motor function: fingertips on temporalis muscle and clench teeth. Test masseter muscles using same technique.
Facial sensation: Test corneal reflexes by dropping sterile saline from eye drops and watching for blink reflex. Test areas of the skin by the 3 divisions for sensitivity of light touch (cotton ball) and pain (paperclip)
64
How do you test the facial nerve 7?
Tests motor function: Smile with teeth, lift eyebrows, frown, and close eyes tightly.
Sensory: Taste. Use salt and sugar.
65
How do you test the acoustic nerve 8?
Tests hearing and balance
Hearing: block one ear canal, someone whispers in ear.
Vibration: strike tuning fork, place on mastoid process to test for bone conduction, then hold fork away to test for air conduction.
Air conduction is greater than bone conduction.
66
How do you test the glossopharyngeal nerve 9?
Tests taste, swallowing, and voice.
67
How do you test the accessory spinal nerve 11?
Controls muscles used in head movement.
One hand on cheek and the other palpates the sternocleidomastoid.
Test strength of subject's shrug while you press down.
68
How do you test the hypoglossal nerve 12?
Controls muscles of tongue.
Assess subject's speech by asking subject to read aloud.
Have subject protrude their tongue in the midline. Check for deviations of the tip of the tongue to the left or the right.
69
Describe tests for cerebellar function.
Rapidly alternating movements (pronate/supinate on leg)
Run heel down opposite shin
Romberg's test (stand w/ arms down, first with eyes open and then closed. Checks for balance.
Tests walking
- observe patients gait
- ataxic (inability to coordinate muscular movement) gait
- Parkinsonian gait
- Scissors gait
- Steppage gait
70
What does the cerebellum control?
Balance
Coordination
71
How do you test muscle tone?
Nurse needs to move each muscle group through ROM and assess the tone while doing this.
Slight resistance to passive lengthening.
72
Describe abnormal innervation.
____________ ____________ is the arrangement or distribution of nerves to an organ or body part.
73
Describe pronator drift.
__________ ___________ is a sign that something is happening in the brain, usually means immediate attention is needed.
Person stands, closes eyes, hands straight up. Side with problem will drift.
74
Describe tests for sensory system.
Superficial touch: tests the anterior spinothalamic tract.
Superficial pain: tests the lateral spinothalamic tract
Vibration sense: test the posterior columns of the spinal cord. Index fingers and big toes.
Position sense: also tests the posterior columns. Raise finger up & down.
75
Describe components of the glasgow coma scale.
Best Eye Opening
- spontaneous (4)
- to verbal command (3)
- to pain (2)
- no response (1)
```
Best Motor Response
-to verbal command (6)
-to painful stimuli
localizes pain (5)
flexes and withdraws (4)
assumes flexor position (3)
assumes extensor position (2)
no response (1)
```
Best Verbal Response
- oriented and converses (5)
- disoriented and converses (4)
- uses appropriate words (3)
- makes incomprehensible sounds (2)
- no response (1)
76
People in glass houses shouldn't throw stones is testing what?
The client's thought process.
77
A diminished sense of smell is usually cause by cranial nerve 1 (olfactory) drainage. True or false?
False
79
The Romberg test is a test for cerebellar function. True or false?
True.
80
What are the factors included in a nutritional assessment?
1. Anthropometric measurements
- Height, weight, ideal body weight, usual body weight, body mass index.
2. Biochemical Data
- Creatine excretion
- Transferrin
- Serum Albumin (3.5-5g/dL) (slow to change)
- Nitrogen balance
- Total lymphocyte count
- -Hbg
3. Clinical signs of nutritional status
- skin, hair/nails, mucous membranes, activity level
4. Dietary history
- 24 hour food recall, food frequency record
81
What are factors of the patient's dietary history?
Height and weight
Eating patterns and habits (frequent small meals=good)-eat breakfast!
Dietary Problems (health illnesses, lack of sleep, GURD, dysphagia, teeth, etc.)f
Healthy history (how active? medications?)
Food buying and preparation (processed foods may not be healthy)
82
What is the best lab value to determine nutritional status?
Albumin is the best lab value to determine nutritional status.
ex: not enough protein can lead to decrease in albumin.
83
What is included within the nutrition physical assessment?
Dentition
Oral mucous membranes
Swallowing
Nausea
84
Describe two examples of nursing diagnoses/STG's related to nutrition.
Altered Nutrition: Less than body requirements R/T swallowing difficulty AEB weight 15% under ideal for height and frame.
-Pt will gain 2 lbs within 2 weeks
Altered Nutrition: More than body requirements R/T emotional factors AEB weight 25% over ideal for height and frame.
-Pt will lose 2 lbs within 2 weeks.
85
Describe what nursing interventions are associated with nutrition.
Teaching about specific nutritional problems
General nutrition and diet information: Calorie count (% of what they ate), read labels!
Monitor foods and fluids: Intake (IV and anything po that is liquid & room temperature) Output (urine, vomit, diarrhea, incontinent x3 (etc.) Intake should roughly equal output.
Daily calorie count as needed
Monitor lab values
86
Describe Albumin.
Primary function: maintenance of colloidal osmotic pressure.
Normal range= 3.5-5 g/dL
Low albumin=malnourished
Could see edema w/ low Albumin (2.5 or lower), not enough protein to hold fluid, fluid leaks into interstitial cells.
87
What are causes for a decrease in Albumin levels?
Causes for decrease:
- Acute and chronic inflammation and infections
- Cirrhosis, liver disease, alcoholism
- Nephrotic syndrome, renal disease
- Crohn's disease, colitis
- Burns, severe skin disease
- Heart failure
- Starvation, malnutrition, malabsorption, anorexia
- Thyroid disease
88
What are general principles of assisting clients with meals?
Check NCP for feeding needs
HOB at least 30 degrees
Cut food into small pieces
Make sure you have appropriate diet for client
Check for NPO status
Be sensitive to client's feelings over loss of autonomy
If possible, allow client to choose foods
89
Relating to dysphagia, what are the four phases of swallowing?
Oral preparation
Oral
Pharyngeal
Esophageal
90
What are warning signs of dysphagia?
Risk for choking/aspiration!!!!
Collection of food under tongue
Pocketing of food in cheek
Spitting food out of mouth
Poor tongue control
Excessive tongue movement
Delay/absence of elevation of Adam's apple
Coughing or choking
Excessive secretions/drooling from mouth
Gargled voice after eating or drinking
91
What are nursing implications associated with dysphagia?
Check gag and swallow reflex (on admission)
Small ice chips to stimulate reflexes
Do not give liquids if you are not sure of patient's abilities.
Directions for feeding posted at bedside
Encourage patient to swallow 2x before giving another bite
Pinch straw while drinking
Sit upright for at least 15 minutes pc
Check for pocketing of food
Thicket
92
What is performed to determine fat stores? Muscle? Skeleton? Lean body mass?
A skinfold measurement measures fat stores
- Most common site is the triceps skin fold.
- Measures subcutaneous tissue.
Mid arm circumference-measures fat, muscle, and skeleton.
Mid-arm muscle area-formula that incorporates both the TSF and the MAC.
Changes in these measurements are chronic, not acute.
93
Describe prealbumin.
Prealbumin:
Has the shortest half-life and is the most responsive serum protein to rapid changes in nutritional status.
Levels of 15-35 mg/dL =normal
Below 15= client at risk
Below 11= aggressive nutritional intervention needed.
94
Describe urinary creatinine.
Reflects a person's total muscle mass because creatinine is the chief end product of the creatine produced when energy is released during skeletal muscle metabolism.
Removed from bloodstream by the kidneys and excreted in the urine. < the muscle mass, < the excretion of creatinine.
When skeletal muscle atrophies during malnutrition, creatinine excretion decreases.
Influenced by: protein intake, exercise, age, sex, height, renal function, and thyroid function.
95
What happens to the number of lymphocytes if protein is depleted?
The total number of lymphocytes decreases as protein depletion occurs.
96
What are the four possible methods for collecting dietary data?
24 hour food recall (all foods & beverages in 24 hrs)
A food frequency record (how often general food groups/specific foods are eaten)
A food diary (usually 3-7 days of all food and fluids consumed)
A diet history (Characteristics of foods usually eaten, frequency, amount of food consumed, medical, and psychosocial factors.)
97
What are major goals for clients with or at risk for nutritional problems?
Maintain or restore optimal nutritional status
Promote healthy nutritional practices
Prevent complications associated with malnutrition
Decrease weight
Regain specified weight
98
What is included in planning nutrition for a home care resident?
Need help with eating, purchasing food, and preparing meals.
Instructions about nutrition therapy
Incorporates assessment of the client's and family's abilities for self-care, financial resources, and the need for referrals and home health services.
99
What are nursing interventions to promote optimal nutrition?
Create an atmosphere that encourages eating
Provide assistance with eating
Monitor client's appetite and food intake
Administer enteral and parenteral feedings
Consult with primary care provider and dietitian about nutritional problems that arise.
100
What are dietary guidelines for Americans?
Eat a variety of foods
Maintain ideal weight (realistic goal)
Avoid too much fat, saturated fat, and cholesterol
-saturated fat: candy bars, fried foods, animal proteins
Eat foods with adequate starch and fiber
Avoid too much sugar
Avoid too much Na+
Alcohol in moderation (2 drinks for men)
101
Describe a full liquid diet.
Contains only liquids or foods that turn to liquid at body temperature, such as ice cream.
Eaten by clients who have GI disturbances or those who cannot tolerate solid or semisolid foods.
Not recommended for long term-low in iron, protein, and calories. Cholesterol content is high due to amount of milk offered.
Full liquid diet is monotonous and difficult for clients to accept. Plan six or more feedings each day to encourage adequate intake.
Examples:
- All milk products
- All fruit and vegetable juices
- Refined/strained cereals
- Eggs in custard
- Strained cream soups
- Custard, ice crew, pudding, sherbet, honey, syrups.
101
Describe the clear liquid diet.
Limited to water, tea, coffee, clear broths, ginger ale, or other carbonated beverages, strained and clear juices, and plain gelatin, popsicles, hard candy.
Provides client with fluid and carbohydrate, but does not supply adequate protein, fat, vitamins, minerals, or calories.
Used 24-36 hours
Used after certain surgeries, in acute stages of infection (ex-GI)
Advantages:Relieve thirst, prevent dehydration, minimize stimulation of the GI tract, requires minimal digestion.
Avoid red colored fluids (could be confused with blood)
101
Describe the pureed diet.
Modification of the soft diet.
Liquid may be added to the food, then blended to a semisolid consistency.
Designed to provide foods that are soft and smooth and can be swallowed with minimal or no chewing.
Examples:
- Yogurt, pureed cottage cheese
- Pureed cooked vegetables
- Nectars, fruits strained for seeds
- Cook cereals
- Mashed or creamed potatoes, rice or noodles if pureed and thinned.
- Strained or pureed meat, fish, poultry
- Cooked soft eggs
- Butter, margarine, cream, cooking fats and oils, gravies.
102
Describe dysphagia and who is at risk.
Clients may have inadequate solid or fluid intake, be unable to swallow their medications, or aspirate food or fluids into the lungs-causing pneumonia.
Clients at risk:
- Older adults who have experienced a stroke
- Clients with cancer who have had radiation therapy to head and neck.
- Clients with cranial nerve dysfunction.
103
Compare enteral vs parenteral nutrition.
Enteral (through the gastrointestinal system) are administered through nasogastric and small-bore feeding tubes, or through gastrostomy or jejunostomy tubes.
Parenteral (all nutrition via IV access)
- intravenous hyperalimentation
- TPN (total parenteral nutrition)
- Frequent accu checks
**Treat products as medications**
104
Describe nasogastric and nasoenteric tube feedings.
Nasogastric: used for client who have adequate gastric emptying, and who require short-term feedings. Not advised for clients without intact gag and cough reflexes.
Nasoenteric: Used for clients at risk for aspiration. Longer than nasogastric tube.
105
What are nutritional considerations for the elderly that should be noted?
```
Oral alterations
Low income
Depression
Thirst sensation decreases
Interactions from drugs
Many perceptual changes
Effects of aging process
Reduction in appetite
Slowed intestinal peristalsis
```
Acronym "Old Timers"
May be at risk for these but its not a given
106
What are the causes of vitamin B 12 deficiency?
Causes:
- Poor dietary intake: Found in animal products only (liver, meat, fish, poultry, milk, egg, cheese)
- Malabsorption syndrome: s/p total gastrectomy or ileal resection.
- Pernicious anemia: caused by lack of intrinsic factor
107
What are the signs/symptoms of vitamin B 12 deficiency?
Neurological abnormalities: peripheral neuropathy, parasthesia, loss of balance, loss of proprioception, mental status changes, impaired memory, dementia, depression.
Glossitis (red, sore, beefy tongue)
Abnormal Schillingtest results: demonstrates the inability to absorb vitamin B12 unless intrinsic factor is also administered.
People over 50 are at risk
108
Describe treatment options for people with vitamin B 12 deficiency.
Monthly injections (or nasal spray) of vitamin B12
Patient education: importance of maintaining monthly injections, nature of the illness, food/diet if r/t poor nutrition.
109
Describe Iron deficiency anemia.
Most common form of anemia.
Tx includes underlying causes, and iron supplements.
Side effect is from the iron supplement: black, tarry stool, constipation, anorexia. Increase fiber intake! (veg, fiber supplements, cereals)
Adequate fluid intake good for constipation
Vitamin C helps with anemia.
Can get iron from salad
Take on empty stomach for better absorption, if still nauseous then take with food.
Nursing process
- assess nutritional deficits, risk factors
- diet/nutrition assessment, education
112
Describe treatment facts about pernicious anemia.
Drink through straw: it will stain teeth. Provide mouth care!
2-3 inch needle for IM Iron. Dorsogluteal is the only muscle deep enough for this.
113
What features are included in the upper and lower urinary tract?
Upper: Kidneys, ureters
Lower: Bladder, urethra, and pelvic floor
114
Describe the difference between the internal and external sphincter muscle.
Internal sphincter:
- Situated in proximal urethra and the bladder neck
- composed of skeletal muscle
- under involuntary control
- provides active tension to close the urethral lumen.
External sphincter:
- composed of skeletal muscle
- under voluntary control
- allows individual to choose when urine is eliminated
115
Describe the physiology of urinary elimination.
Urine collects in bladder until pressure stimulates stretch receptors.
Stretch receptors transmit impulses to the spinal cord, specifically to voiding reflex center (2nd to 4th sacral vertebrae) causing the internal sphincter to relax and stimulate the urge to void.
Conscious portion of brain relaxes the external urethral sphincter muscle and urination takes place.
OR micturition reflex will subside until bladder becomes more filled and the reflex is stimulated again
116
What are factors that affect the voiding of urine?
Developmental factors
Psychosocial factors: privacy, normal position, sufficient time, running water.
Fluid and food intake
Medications: diuretics increase urine formation, some alter the color of urine.
Muscle tone and activity: can suffer from retention catheters.
Pathologic conditions: kidney diseases affects urine production, heart and circulatory disorders affect bld flow, interfering with urine production, blockages, hypertrophy of prostate gland
Surgical and diagnostic procedures: urethra may swell after cystoscopy, postop blding, spinal anesthetics affect client's awareness of needing to void, lower abdominal swelling.
117
How can certain fluids and foods affect urine?
Alcohol: increases fluid output by inhibiting production of antidiuretic hormone.
Caffeine: increase fluid output
Food and fluids high in sodium: can cause fluid retention (water is retained to maintain the normal concentration of electrolytes)
Beets: cause urine to turn red
Foods with carotene: urine appears more yellow than usual.
118
Describe polyuria, oliguria, and anuria.
Polyuria (diuresis): several liters more than daily client's intake. Diabetes is a cause, polyuria can cause fluid loss, dehydration, weight loss.
Oliguria: low urine output. less than 500 mL/day or less than 30 mL/hour. Can indicate renal failure
Anuria: lack of urine production
119
What is the normal hourly and 24 hour urine output?
250-500 mL's of urine causes sensation/urge to urinate
After surgery we want at least 30 mL /hour
Analgesia can cause urinary retention
Call Dr if it has been ~8 hours without voiding (possibly have to use catheter.)
120
Describe urinary frequency and what conditions can cause it.
Urinary frequency= 4-6 times/day
Can be caused by increase of fluid intake
Conditions: UTI, stress, and pregnancy can cause frequent voiding of 50-100 mL's of urine.
Total fluid intake and output may be normal
121
Describe nocturia, urgency, dysuria, and urinary hesitancy.
Nocturia: voiding two or more times at night
Urgency: sudden, strong desire to void. May or my not be a great deal of urine in bladder. Accompanied by stress and irritation of trigone and urethra
Dysuria: voiding is either painful or difficult. Injury of urethra, bladder, urinary infections.
Urinary hesitancy: delay and difficulty in initiating voiding.
122
Describe nocturnal enuresis, urinary retention, and a neurogenic bladder.
Nocturnal enuresis: involuntary urination at night.
Urinary retention: Urine accumulates and the bladder becomes overdistended. Causes include prostatic hypertrophy, surgery, medications (anesthesia, narcotics, anticholinergics), physical blockages. Usually see 25-50mL output at frequent intervals. Bladder is firm, distended, and displaced from midline.
Neurogenic bladder: Does not perceive bladder fullness and cannot control the urinary sphincters. Bladder may become flaccid, distended, spastic, with frequent involuntary urination.
-will see in spina bifida and paralyzed patients.
123
Describe urinary incontinence and the difference between acute and chronic UI.
Urinary incontinence: involuntary leakage of urine or loss of bladder control.
Causes include UTI's, urethritis, pregnancy, hypercalcemia, volume overload, delirium, restricted mobility, stool impaction, psychological causes.
Acute: arrives suddenly, lasts 6 months or less, has reversible causes.
Chronic: Six categories=Stress, urge, reflex, retention with overflow, total urinary, and functional incontinence. Treatment can include surgery, medication, pelvic floor exercise, behavioral therapies.
124
What are risk factors/causes of UTI's?
Short female urethra: closer to anal and vaginal areas.
Reflux
Fecal contamination: E. coli accounts for majority of UTI's.
Sexual intercourse
Instrumentation
Stasis of urine
Obstruction to urinary flow
Diabetes (decreased blood flow to area)
125
Describe factors included in obtaining urine samples.
24 hour sample: disregard first urine sample, then collect amount from each urination. Set bucket on ice
Single UA: get wipes to clean perineal area, start the sample midstream. If you just put in foley bag then get sample from there. After initial insertion of foley bag, then get from tubing.
126
What is included within a nursing assessment for the urinary system?
History: how much, how often, when
Physical assessment
Urine assessment
I & O records
Collecting urine specimens
- microscopic u/a, C & S
- clean catch
- timed
- indwelling catheter
- 24 hour urine
127
Describe microscopic Urinalysis Results (which are available quickly.)
- Color: amber or yellow
- Clarity: clear
- pH: 4.6-8 (avg=6)
- Specific gravity: 1.010-1.025
- Protein: 0-8 mg/dl
- glucose: 0
- Ketones:0
- RBC's: 0-4
- WBC's:0-5
- Bacteria: 0
- Casts: 0
Presence of only glucose=type 2 diabetes
Presence of glucose AND ketones=type 1 diabetes
Concentrated urine has a higher specific gravity; diluted urine has a lower specific gravity.
128
How do we find out if urine is sterile or not?
Urine is sterile within the bladder, infection then causes nonsterility, therefore have it tested.
129
Describe urine culture & sensitivity.
Can be a clean catch, straight cath (single use), or indwelling.
>100,000 colonies=UTI
Takes at least 24-48 hours for results.
Antibiotics may be started if clinical presentation indicates probable UTI.
Sensitivity: which antibiotics kill the infecting organism.
UA can be done in 30-60 minutes
130
What is included in the planning stage for the urinary system?
Maintain or restore normal voiding pattern or effective alternatives
Prevent associated risks such as infection, skin breakdown, F&E imbalance, lowered self esteem, independent adl's
Home teaching: assessment of client's and family's resources and abilities for self-care, available financial resources, and need for referrals and home health services.
131
What is included in the implementation stage for the urinary system?
Maintain normal urinary elimination
Prevent or treat UTI's
Managing urinary incontinence
Managing urinary retention
Urinary catheterization
- Foley
- Intermittent
- Texas cath=condom catheter
- Suprapubic: opening through bladder and gets hooked up to bag. Good for neurogenic bladder pts.
132
Describe indwelling catheterization, intermittant catheterization, and Foley Catheter Management.
Indwelling: unable to void, monitor output
Foley Cath Management: prevent infection (cath care) and minimize trauma.
Intermittant catheterization: periodic drainage of urine, measure residual urine, aseptic technique in hospital, and clean technique at home.
133
List the drugs used to treat urinary stressors.
Antibiotics:
- sulfa drugs, Septra or Bactim (trimeth/sulfa)
- Macrodantin (nitrofurantoin)
- fluoroquinolones: Cipro (ciprofloxacin) and Levaquin (levofloxacin)
Antispasmodics/anticholinergics: tx for urge incontinence: Detrol & Ditropan
For acute, painful bladder spasms: B & O suppository (Belladonna & Opium)
Analgesic: Pyridium (orange urine color normal)
134
What drugs are used to treat urinary retention in men with enlarged prostates?
Proscar (blocks testosterone)
Doxazosin: Adrenergic blocker (relaxes smooth muscle, also decreases BP)
Cholinergics (to promote emptying)
-urecholine
135
Describe the large intestine.
Adults 125-150 cm (50-60 inches)
Has 7 parts: Cecum, ascending, transverse, descending, sigmoid, rectum, and anus.
Main function:Absorption of water and nutrients, mucoid protection of intestinal wall, and fecal elimination.
Normal contents of bowel: substances from past 3-4 days.
Medications affect rate
136
What are factors that affect defecation?
Age: elderly have atherosclerosis (decreases bld flow to messentaric arteries, which supply intestinal region. Peristalsis decreases, control of anal sphincter decreases in sensation, and nerve impulses are slower.
Diet: who grains, vegetables
Fluid intake:6-8 glasses/day
Activity: immobility affects bowel patterns
Psychological factors: stress (causes diarrhea or constipation)
Medications: narcotics slow digestive system (cause constipation). Laxitive overuse can cause problems.
Diagnostic procedures: having to drink barium will cause light colored stool. Will need to drink many fluids to flush it out.
Anesthesia/surgery: Need to pass gas and hear bowel sounds before feeding. Usually start on clear liquid diet. Paralytic Ileus=no peristalsis
Pain: Can be from rectal or hemorrhoid surgeries
137
Describe the 7 types of stool.
Type 1: Separate hard lumps, like nuts (hard to pass) can cause rectal bleeding
Type 2: Sausage shaped by lumpy
Type 3: Like a sausage but with cracks on its surface
Type 4: Like a sausage or snake, smooth and soft
Type 5: Soft blobs with clear-cut edges (passed easily)
Type 6: Fluffy pieces with ragged edges, a mushy stool.
Type 7: Watery, no solid pieces, entirely liquid
Stool type 4 is most desirable
Stool type 6 and 7 are c diff. Vancomycin or flagul antibiotics
138
List causes and symptoms of common fecal elimination problems.
Constipation: Less than 3 bowel movements per week
Classic signs: hard, dry, difficult to pass stools, nausea & vomiting
Causes:
- Medications (narcs, anticholinergics, anesthetics)
- Decreased activity
- Poor muscle tone or damage
- Poor toileting habits
- Decreased fluid intake and fiber intake
- Decreased food intake
- Change in daily routine
- Chronic laxative or enema use
- Irritable bowel syndrom (periods of diarrhea then constipation)
- Lack of privacy
- Neurologic conditions (affect bowel patterns. Paralyzed pts will have slowed down system.)
139
Describe causes and symptoms of fecal impaction and how drugs affect it.
Fecal impaction: No resolution of constipation. Classic sign is leakage of liquid stool from rectum.
Can have up to 3 days of waste sitting in your system.
Abdomen can become distended
Can use laxative, fleet enema
Opium, morphine, and heroin slow peristalsis.
Heroin addicts often suffer from chronic constipation and may go for several weeks without having a bowel movement.
140
Describe causes and symptoms of diarrhea.
Diarrhea: Passage of liquid feces and increase frequency of defecation.
Symptoms: excessive and frequent evacuatio of watery feces.
Causes: Medications (antibiotics, oral antidiabetics, Aricept (donepezil), and many more. Infection, stress, disease, excessive pancreatic enzyme production.
Monitor potassium & sodium
High risk for dehydration & electrolyte imbalance
141
Describe bowel incontinence.
Bowel incontinence: loss of voluntary control of anal sphincter. (loss of muscle tone, which helps to keep it closed)
2 types of bowel incontinence:
- Partial: gas or a little bit of leakage
- Major: inability to control feces of normal consistency
Causes: Diarrhea, decreased sensation, decreased LOC, decreased muscle control
Incontinence may be infrequent or with every BM.
142
Describe flatulence.
Flatulence: 3 primary sources
- swallowing air
- bacterial action on chyme (waste product in intestines.)
- gas that diffuses between blood stream and intestine.
Can see gas in X-rays
Results in gastric distention & discomfort
143
Describe what is included within the assessment for fecal examination.
- Privacy is needed for the assessment
- Defecation pattern (how much, how often, what time of day)
- Description of feces/assessment of feces
- Problems/difficulties
- Factors that influence fecal elimination
- Physical assessment: look, listen x2, feel x2
- Diagnostic studies (endoscopy, colonoscopy)
- Home care assessment (where the bathroom is, BM's during the night?)
144
List nursing diagnoses about fecal elimination.
```
Bowel incontinence
Constipation
Risk for Constipation
Perceived Constipation
Diarrhea
Risk for FVD
Risk for impaired skin integrity
Low self-esteem
Kowledge deficit (bowel training, ostomy management)
Anxiety
```
145
Describe hemorrhoids.
____________ are dilated, engorged veins in the rectum area.
146
What is included during the planning stage of fecal elimination?
Maintain or restore regular bowel function
Maintain or restore normal stool consistency
Prevent risks associated with the problem (FVD, impaction, skin integrity impairment)
147
What are nursing interventions included for fecal elimination?
```
Provide privacy
Timing (answer the call bell promptly)
Adequate diet and fluids
Exercise promotes peristalsis
Positioning (left lateral position for enemas)
Administer medications properly (senna, colace, etc)
Diarrhea causes skin irritation
Patient education.
```
148
Describe what is included for patient education with fecal elimination?
Wellness teaching
- Regular exercise
- High fiber foods-vegetables, fruits, whole grains
- 2000-3000mL fluids qd
- Do not ignore the urge to defecate (gastrocolic reflex)
- Allow time to defecate, preferably at same time qd
- Minimize OTC tx of constipation or diarrhea
- Medication information: educate them on side effects
149
Describe the difference between the parasympathetic characteristics and the sympathetic characteristics.
Parasympathetic: cholinergic=vagal stimulation
-promotes urination, digestion, defecation, bradycardia
Sympathetic: adrenergic=anticholinergic=fight or flight
-blocks urination, digestion, defecation, causes tachycardia
150
Describe laxatives used for fecal elimination.
Stimulants: Dulcolax suppositories or pills (bisacodyl), senna, cascara
Hyperosmotic laxatives: MOM, GoLYTELY, lactulose, sorbital, Miralax (polyethylene glycol powder)
Bulk forming laxatives: Metamucil (psyllium powder), dietary fiber
Lubricant laxatives: Mineral oil
Fecal wetting agents (stool softeners): Colace, Miralax
Enemas: tap water, soap suds, fleets
151
Describe antidiarrheals.
Absorbents: Kaopectate (bismuth subsalicylate)
Opioid and Opioid Derivatives: Lomotil, Immodium. If client is also in pain, narcotic analgesics will also slow diarrhea.
Anti-gas: Simethicone
152
Define what an ostomy is and describe the different types.
Ostomy: opening for gastro/urinary/respiratory tract onto the skin.
Gastrostomy: abdominal wall into the stomach
Jejunostomy: abdominal wall into the jejunum
Ileostomy: opens into the ileum (small bowel)
Colostomy: opens into colon (large bowel)
Stoma: opening created in the abdominal wall
153
Describe what happens at different ostomy locations.
Ileostomy: produce liquid fecal drainage
Ascending colostomy: similar to ileostomy, produce liquid stool
Transverse colostomy: malodorous, mushy drainage
Descending colostomy: solid stool
154
What does a healthy stoma look like?
Should be moist and beefy red
155
What are common stoma complications?
Include retracted stoma, peristomal hernia, prolapsed and cut stoma
Don't want fecal matter to touch the skin (cause breakdown)
156
Describe a retracted stoma.
Retracted stoma: functions at or below skin level.
- supporting structures at the fascia layer may shrink causing the stoma to be pulled inward.
- May also be due to a surgical problem in which not enough bowel is available to create a protruding stoma.
157
Describe what a peristomal hernia is.
Peristomal hernia:
- characterized by a bulging of the area around the stoma
- It can result in a blockage or obstruction
158
What is a prolapsed stoma?
Prolapsed stoma:
- Increase in size of the stoma, usually in the length of the stoma.
- Possible causes of a prolapse include obesity
- Too large an abdominal opening for the bowel
- Increased intra-abdominal pressure
- Multiple previous incisions
- Stoma sited outside the rectus muscle.
159
What is a cut stoma?
Signs of a cut stoma: noticeable break in the integument of the stoma
Stoma can be traumatized due to: the movement of a flange which is not properly fixed to the peristomal skin
A sharp blow, or an inadvertent cut by scissors or nails
