Test 4 Flashcards by Whit Neyy

Q

Difficulty swallowing or the inability to swallow

A

Dysphagia

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Q

The misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract

A

Aspiration

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Q

For aspiration precautions which position should the patient sit in if receiving food orally?

A

Fowlers position

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Q

For aspiration precautions how should the patient be sitting for enteral feeding tube feeding

A

Semi fowler

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Q

for enteral food feeding what is the rationale for lowering the feeding

A

so that the patient does not aspirate

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Q

what do you for enteral or ng feeding first?

A

check residual because of vomiting

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Q

What are the assessments for dysphagia?

A

fever pnemonia coughing crackling in lung fields

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Q

gradual feeding on a timed pump

A

continuous

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Q

is a feeding that is giving all at once

A

bolus

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Q

How many mL of water are you supposed to flush after feeding?

A

30 mL

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Q

feeding that hangs like an IV can be made faster or slower depending of the position of the bag

A

gravity

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Q

feeding tube placed in opening of stomach

A

gastrostomy (peg) tube

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Q

Why is a PEG tube the best option and what clients is it ideal for ?

A

less risk for regurgitation and aspiration ; comatose

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Q

For gastrostomy (PEG) tube is it for short term or long term?

A

long term

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Q

What assessments would you do before a gastronomy (PEG) tube?

A

bowel sounds, vomiting, nausea, diarrhea

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Q

For a gastrostomy peg tube what should you do to ensure nothing is left behind and that it doesn’t get impacted

A

flush tube before and after feedings

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Q

Before inserting an NG tube what should you do?

A

assess for nasal obstructions and tissue irritation around nares

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Q

How do you check the placement of NG tube?

A

flush tube with air then withdrawal gastric fluid (check color consistency then put back in stomach then flush with 30 mL of water)

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Q

Steps for administering medication through enteral tube

A

Check medication order ( 3 checks)
gather materials
Aspirate residual then return it to stomach
flush 20 ml –> admin meds flush 5 mL between meds

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Q

Nursing process in promoting adequate nutrition

Assessment

A

assess for dietary data, bmi

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Q

Nursing process in promoting adequate nutrition

Analyze:

A

Analyze lab results and identify nutritional problem

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Q

Nursing process in promoting adequate nutrition

Planning/Outcome:

A

should be a SMART goal in filling nutritional void or keeping from an excess of nutritents through modified diets

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Q

Nursing process in promoting adequate nutrition

Implement:

A

teaching on nutritional information/rationale and modified diet

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Q

Nursing process in promoting adequate nutrition

Evaluation:

A

monitor nutritional status if goal is being reached

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Requires minimal digestion and leaves minimal residue, includes coffee tea clear fruit juices clear broth gelatin popsicles

clear liquid diet

known as blenderized diet because the diet is made up of liquids and foods blenderized to liquid form all foods are allowed

pureed diet

regular diet with modifications for texture excludes most raw fruits and veggies foods are chopped ground mashed or soft

mechanically altered food

Protein lab range

240-480 mg/dl

Albumin lab range

3.5-5.5 g/dL

prealbumin range

23-43 mg/dL

iron normal range

12-18 g/dl

creatinine noraml range

0.4-1.5 mg/dl

decreased protein leads to?

anemia and protein deficency

decreased orealbumin leads to

malnutrition and protein depletion

increased creatinine means

dehydration

decreased creatinine means

severe malnutrition

measure of density of chemicals and particles in urine

specific gravity

Higher than normal specific gravity can indicate dehydration

concentrated urine

lower than normal specific gravity can indicate overhydration

diluted urine

discomfort when urinating

dysuria

excessive urine output

polyuria

strong desire to void

urgency

involuntary loss of urine

urinary incontinence

abnormally small amounts of urine

oligoria

pus in urine

pyuria

increase incidence of voiding

frequency

for single use taken out immediately after use

straight catheter

empties into bag that can attach to leg bed or wheel chair

indwelling (foley) catheter

bladder does not completely empty with urination

urinary retention

what are the assessments for urinary retention?

difficulty urinating, paid adominal distension, frequency

from coughing sneezing laughing

stress incont

strong need to urinate bu leaking occurs before client get to toilet

urge incont

leakage as a result of nerve damage

reflex

incomplete bladder emptying that results in the bladder overfilling when full leads to leakage

overflow

physical inability to reach toilet in time (wheelchair bound, arthritis)

functional incont

common in children but can occur in adults who have consumed too much alcohol

nocturnal enuresis

ways to promote bowel elimination

high fiber diet laxatives if needed enemas if needed mobility

what are you looking for during an adominal assessment?

tenderness distension bowel sounds in all 4 quads

what re the risk factors of constipation?

age immobility low fiber diet hydration status mediations

what are different types of interventions for constipation

high fiber diet ecercise hydration bowel training stoool sofentig meds

this enema soften stools and is used for constipation

retntion

this enema has castile soap and is water based

cleansing enema

is a type of laxative that encourages peristalsis

stimulant

type of laxative that adds water to fecal matter in the gi tract to reduce compaction (colace)

stool softener

type of laxative that is not fdigested absorbe liquid to form soft bulky stool used to treat diarrhea

bulk forming

0.9% NaCl iv solution

isotonic

lacatated ringer solutionq

isotonic

5% dextrose in lactated ringer (d5lr)

hypertonic

0.33% NaCl normal saline iv soulution

hypotonic

0.45% NaCl

hypotonic

FLuid volume excess

hypervolemia

isotonic loss of water and solute lack of BV less blood prefusses to organs

hypovelemia

s & s includes edema weight gain crackles in lungs tachypnea dysphagia

hypervolemia

s & s includes dry mucous membranes excessive thirst dark urine tachycardia but low BP

hypovolemia

isotnic overload of water and solute bv is excessive fluid overload

hypervolemia

fluid excess in interstitial space

edmea

what is an intervention for edema

eleavte swollen area of body if possible

more water is taken into the body that Na+

overhydration

normal level for Na

136-145 mEq/L

normal level for K

3.5-5 mEq/L

normal level for Ca

9.0-10.5 mEq?L

normal level for Mg

1.3-2.1 mEq/L

Muscle weakness leg cramps fatigue dysrhythmias

Hypokalemia