Skills Exam 7 Flashcards
1
Q
what is a basic component of life?
A
nutrition
2
Q
nutrition is essential for?
A
- normal growth and development
- tissue maintenance and repair
- cellular metabolism
- organ function
3
Q
adequate access to nutrition is ___?
A
imperative
4
Q
assessments for nutrition
A
- daily weights
- lab tests
- health history and diet
5
Q
what are the lab values you need to assess with nutrition?
A
- liver function
- kidney function
- glucose
6
Q
what is dysphagia?
A
difficulty swallowing
7
Q
what are signs of dysphagia?
A
- coughing during eating
- change in voice tone or quality after swallowing
- abnormal movements of the mouth, tongue, or lips
- slow, weak, imprecise, or uncoordinated speech
- inability to speak consistently
- abnormal gag, delayed swallowing
- incomplete oral clearance or pocketing
- regurgitation
- delayed or absent trigger of swallow
8
Q
how do you assess for dysphagia?
A
attempt to have the pt take a small sip of water while sitting upright in bed
9
Q
what are some complications of dysphagia?
A
- aspiration pneumonia
- dehydration
- decreased nutritional status
- weight loss
10
Q
dysphagia often leads to what?
A
malnutrition
11
Q
will dysphagia increase or decrease albumin levels?
A
decrease
12
Q
what can the nurse do to help with dysphagia?
A
- review ordered diet
- gradually advance diets
- promote appetite
- assist with oral feedings if necessary
- use of weighted silverware
13
Q
what is an NPO diet?
A
- nothing by mouth
- if NPO for a long period of time, ensure proper fluids are being administered via IV
14
Q
what is a clear liquid diet?
A
- only clear fluids/solids that easily become liquids at room temp
ex: clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin/jello, fruit ices, popsicles, soda, tea, water
15
Q
what is a full liquid diet?
A
as for clear liquids, with addition of smooth- textured dairy products (ice cream), strained or blended soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, pudding, frozen yogurt
16
Q
what is a dysphagia stage diet?
A
- thickened liquids
- pureed
- same as clear and full liquid + scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy
17
Q
what is a mechanical soft diet?
A
- foods that are mashed up by a machine and made soft
- as for clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)
18
Q
what is a low sodium diet?
A
4-g, 2-g, 1-g, or 500-mg diets; vary from no-added-salt to sever sodium restriction which requires selective food purchases
19
Q
what is a low cholesterol diet?
A
300mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction
20
Q
what is a diabetic diet?
A
nutrition recommendations by the American Diabetes Association; focus on total energy, nutrients, and food distribution
21
Q
what is a gluten free diet?
A
eliminates wheat, oats, rye, barley, and their derivatives
22
Q
what is a regular diet?
A
no restrictions unless specified
23
Q
why would you give nutrition through a NG tube?
A
- if pt is unable to swallow or have dysphagia
- aspiration risk
- not alert enough
24
Q
where does an NG tube enter?
A
nose
25
where does a orogastric tube enter?
mouth
26
what are the purposes of gastric tubes?
- enteral feeding and med administration
- decompression
- lavage
27
what are the NG tube sizes?
12, 14, 16, and 18 french
28
what are the types of nasoenteric tubes?
- nasogastric tube
| - nasojejunal tube
29
what is an orogastric tube?
usually chosen if the pt is intubated or has nasal trauma
30
what are the types of surgical tubes?
- gastrostomy tube
| - jejunostomy tube
31
what tube would you use if a pt is at a high risk for aspiration?
a jejunal feeding tube
32
what is a salem sump?
- dual lumen
- blue tube is an airvent
- preferable, used more commonly
33
what is a levin tube?
single lumen
34
insertion of NG tube
review video on CANVAS
35
documentation of NGT insertion
- size of NGT
- which nare it was placed in
- where it was secured
- placement verification
- gastric content residuals
- pt tolerated? (w or w/ voiced complaints)
- current condition (clampes, suction, meds)
36
management of NGT
- verify tube position hasn't moved
- keep tube secure to nostril or mouth
- ensure tube remains patent
- aspiration/safety precautions
- assess nares frequently for skin breakdown, lubricate nostrils PRN
- assess oral mucosa integrity and moisture, offer oral swabs and chapstick
37
PEG tube
- flexible feeding tube placed through the abdominal wall and into the stomach
- PEG allows nutrition, fluids, and/or meds to be put directly into the stomach, bypassing mouth and esophagus
- used for pt who have difficulty swallowing
38
how do you manage a PEG site?
- clean the site once a day with diluted soap and water or normal saline
- no special dressing covering the site is needed
39
what are some complications of a PEG tube?
- pain at the PEG site
- leakage of stomach contents around the tube site
- dislodgement or malfunction of the tube
40
med administration through NGT & PEG tube
- prep meds
* crush
- inspect, auscultate, palpate
- confirm placement of tube using syringe EVERY TIME
- flush tube with 30 mL of water
- administer meds
- flush tube with 30 mL of water again
- document meds
- keep pt in semi to high folwers position for at least an hour after administration
41
enteral tube feedings
same as medication administration, give foods per diet ordered
42
what are some complications of tube feedings?
- aspiration of contents
| - inappropriate positioning after feeding
43
feedings can be continuous or ___?
bolus
44
continuous feedings may cause ...
an increase in serum glucose levels
45
why would a gastric tube be removed?
- temporary tube being removed because permanent tube is being places
- bowel obstruction resolved
- out of coma
- lavage completed
- dysphagia resolved
46
gastric tube removal
- flush tube with 30 mL of air
- educate pt to hold breath during removal
- detach all tape
- remove
47
regular elimination of bowel waste products is ___ for normal body functioning.
essential
48
what is the flow of digestion through the body?
- mouth
- esophagus
- stomach
- small intestine
- large intestine
- anus
- defecation
49
what is peristalsis?
series of involuntary wave-like muscle contractions which move food along the digestive tract
50
digestion
begins in the mouth and ends in the small and large intestines
51
absorption
intestine is the primary area of absorption
52
elimination
chyme is moved through peristalsis and is changed into feces
53
mouth
digestion begins with mastication
54
esophagus
peristalsis moves food into the stomach
55
stomach
stores food; mixes food, liquid, and digestive juices; moves food into small intestines
56
small intestine
duodenum, jejunum, and ileum
57
large intestine
the primary organ of bowel elimination
58
anus
expels feces and flatus from the rectum
59
what are some factors that influence bowel elimination?
- age
- diet
- fluid intake
- physical activity
- psychological factors
- personal habits
- position during defecation
- pain
- surgery and anesthesia
- medications
60
constipation
infrequent stools and/or hard, dry, small stools that are difficult to eliminate
61
impaction
results from unrelieved constipation; a collection of hardened feces wedged in the rectum
62
diarrhea
an increase in the number of stools
63
incontinence
inability to control passage of feces and gas to the anus
64
flatulence
accumulation of gas in the intestines causing the walls to stretch
65
hemorrhoids
dilated, engorged veins in the lining of the rectum
66
bowel diversions
- temporary or permanent artificial openings in the abdominal wall (stoma)
- surgical opening in the ileum or colon
- location of ostomy determines stool consistency
- ileostomy= thin to thick
- sigmoid= more formed stool
- transverse= thick liquid to soft consistency
67
ostomies
- an effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous
68
nutritional considerations for ostomies
- consume low fiber for the first weeks
- eat slowly and chew food completely
- drink 10-12 glasses of water daily
- pt may choose to avoid gassy foods
69
what are some psychological considerations with ostomies?
- serious body changes/ self image
- intimacy needs
- odor
70
assessment for ostomies
- nursing history
- physical assessment
- lab tests
- fecal specimens
- diagnostic examinations
71
collection of stool sample
- have pt defecate into hat or obtain from brief
- wear gloves
- collect stool
- seal well
- place in bag for transport
- send to the lab
72
what are some ways we can encourage pt to defecate?
- proper positioning
- privacy
- safety
73
bedpan use
- positioning on bedpan
| - raise hips when on bedpan
74
cathartics and laxatives
- meds that initiate and facilitate stool passage
- empty the bowel
- cathartics are stronger than laxatives
75
antidiarrheal agents
decrease intestinal muscle tone to slow passage of feces
76
enemas
- instillation of a liquid solution into the rectum and sigmoid colon
- promotes defacation by stimulating peristalsis
- fluid breaks up fecal mass, stretches rectal wall and initiates the defecation reflux
- can also give meds via eneman route
77
rectal suppository administration
- does NOT require sterile technique
- explain procedure
- position in left lateral sims position
- hand hygiene and apply gloves
- lubricate finger and medication
- insert approximately one inch, or once you feel med bypass sphincter
- med will melt when it reaches body temp
78
what are common meds to administer via suppository routes?
- acetaminophen
| - dulcolax
79
enema administration
- does NOT require sterile technique
- wear gloves
- explain procedure, positioning, precautions to avoid discomfort, length until removed
- position pt in left side lying position with top leg bent upwards
80
digital removal of stool
- physically remove stool
| - used as a last resort
81
what is the purpose of digital removal?
to break up fecal mass and remove it so pt is able to voluntarily pass stool on their own
82
how do you perform digital removal?
- assess heart rate
- position pt, educate, don gloves
- lubricate fingers, insert slowly
- gently locate fecal mass by massaging around and remove slowly
83
what are some risks or complications of digital removal?
- irritation to mucosa, bleeding
| - possible stimulation of vagus nerve
84
bowel training
- performed when pt have chronic constipation or fecal incontinence secondary to cognitive impairment
- it keeps pt on a schedule with bowel movements
- increase fluids
85
epidermis
top layer of skin
86
dermis
inner layer of skin
87
dermal- epidermal junction
separates dermis and epidermis
88
skin assessment
- assess all areas in a head to toe manner
- critically think when you are able to assess these things
- lift up skin folds
- turn pt and assess backside
89
what is a wound?
an interruption of the integrity of the skin
90
what kinds of wounds are there?
- incisions
- cuts
- skin tears
- ulcers
91
assessing wound characteristics
- location
- color
- size
- drainage
- odor
- pain
- skin around wound
- old dressing? remove it
- drainage on old dressing
92
what are factors that influence the healing process?
- nutrition
- tissue perfusion
- infection
- age
- stress
93
skin tears
- when layers of the skin separate or peel back
94
causes?
- bumping skin on hard objects
- wound dressing change
- aggressive washing
95
care of skin tears
- control bleeding
- apply saline or warm water and clean area gently
- pat dry with clean gauze
- measure size of skin tear
- add steri strips to site
- cover skin with dressing
- use stockinettes instead of dressings
- document skin tear location, size, clean of dressing
96
simple wound cleaning
- if unsure, ask for help!
- leave dressing on unless visibly soiled
- assess old dressing, remove
- assess wound characteristics
- clean wound per order
- apply any topical ointments
- apply top dressing securely
- document
97
adhesives
- be gentle
| - be cautious when removing
98
pressure injuries
- impaired skin integrity related to unrelieved, prolonged pressure
- localized damage to the skin and underlying soft tissue
- injury may present as intact skin, a blister, or an open ulcer
- pt at risk for pressure injuries
99
risk factors for pressure ulcer development
- impaired sensory perception
- alterations in level of consciousness
- impaired mobility
- shear
- friction
- moisture
100
risk factors for pressure ulcer development
- impaired sensory perception
- impaired mobility
- alteration in LOC
- shear
- friction
- moisture
101
what are some ways we can prevent pressure ulcers?
- protect bony prominences
- skin barriers
- positioning
- pillows
- seat cushions
- special mattresses
102
what is the braden scale?
it evaluates the following
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
103
a score of <19 indicates the pt is at risk for skin breakdown
15-18 = mild risk
13-14 = moderate risk
10-12 = high risk
less than 9 = severe risk
104
classification of pressure ulcers
stage 1: intact skin with nonblanchable redness
stage 2: partial thickness, skin loss, involving epidermis, dermis, or both
stage 3: full thickness tissue loss with visible fat
stage 4: full thickness tissue loss with exposed bone, muscle, or tendon
105
what is the nursing role with wound management?
- identify risk factors for pressure ulcer development
- thorough skin assessment
- identify infection if present
- identify any change in skin assessment
- keep wounds clean and dressed per orders
- communicate
