Basic Care and Comfort Flashcards
diabetic diet
decreasing serum lipid levels
accurate carbs counting
DASH diet
limit sodium to 2300 mg/day
lower DASH diet = 1500 mg/day of sodium
low in saturated fat, cholesterol and total fat
low tyramine
avoid foods high in tyramine:
- aged cheese
- cured, processed or smoked heats
- beer
- pickled or fermented foods
low purine diet
used for clients with gout
restrict - glandular meats - chicken - ducks - fowl foods anchovies - beer and wine
low calcium
limit to 400 mg/day
restrcits:
- dried fruits and vegetables
- shellfish
- cheese
- nuts
enteral nutrition
breast milk can be given to newborns or infants through a feeding tube
types of feeding tubes:
NG tube, oro tube
- used for short term nutirtional supports
- usually less than 4 weeks
enteral nutrition interventiosn
HOB 30-45 degreee
monitor character and frequency bowel movements
pH less than 6
administration of enteral nutrition feedings
may be continuous or intermittent
hang for 8 hours or less
change tubing every 24 hours
administer at room temp
receive “free water” or water boluses
gastric residual monitoring
evaluate gastric residual every 4-6 hours for conitnuous feeding or prior to intermittent feedings
if gastric residual is greater than volume given over 2 hours
- may be necessary to reduce the heart rate of feeding
- or temporarily hold the feeding
DO NOT discard the aspirated residual
- return the entire residual amount to the stomach
flush tube with approc 30 mL at room temp every 4 hours after feeding is complete and before and after meds
hypercalcemia causes and findgins
causes:
- hyperparathyroidism
- metasis of cancer
- prolonged immbolization
- Pagets disease
findings:
- weakness
- paralysis
- decreased deep tendon reflexes
hypocalcemia causes and findings
causes:
- vit D deficiency
- renal failure
- pancreatitis
- hypoparathyroisim
findings:
- mscle tingline
- twitching
- tetany
magnesium is used for
normal muscle and nerve function heart rhythm immune system blood sugar regulation BP
hypermagenesemia causes and findings
causes:
- chronic renal disease
- overused of mangesium-containing antacids like Maalox and Mylants
- Addison’s disease
- uncontrolled diabetes mellitus
signs and symptoms will be the opposite of “hyper” so all the findings will be slow or low
hypomagnesemia causes and findgins
causes:
- malnutrition
- malabsorption
- alcoholism
- diabetic acidosis
signs and symptoms will be the opposite of “hypo” so all the findings will be high or erratic
phosphate is used for
aids in cellular energy absorption
combines with calcium in one
assistsin structure of genetic maternal
normal: 2.8 - 4.5
balanced by parathyroid gland, along with calcium
potassium is used for
regulated by kidneys
hyperkalemia and hypokalemia:
high or low findings can results ina fast or slow and irregular heart rhythm, changes in ECG and muscle function
- like leg cramps
sodium is used for
regulated by slat intake, aldosterone and urianry output
hyponatremia
fluid overload
hypernatremia
dehydration
hypertension
generalized edema or anasarca
pressure ulcers
turn and reposition at least every 2 hours
use heel and elbow protectors
use alternating pressure mattrees or other pressure-reducing bed surface
avoid massaging any reddned areas and potentially damaging any skin tissue
limit sitting in chair for no longer than 2-4 hours
- shift weight at least every 30-60 minutes
mobility for respiratory system
instruct client to cough and deep breathe every hour
perofrm incentive spirometry every hour
turn immobile client every 2 hours
oropharyngeal suctioning if needed
mobility for urinary renal system
ensure that client drinks at least 2000 to 3000 mL (2-3L) of water per day
orthostatic hypotension
put the client at risk for falls
instruct to change positions slowly, progressing from lying down to sitting up and then standing
highest risk of falling is while moving from supine to standing position
increased cardiac workload
avoid bearing down when exhaling and to minimize coughing
allow limited sitting in high fowlers position from 1-2 hours
venous thromboembolism formation
apply thigh or knee-high anti embolic stockings and/or intermittent pneumatic compression
tunr every 2 hours
administer anticoagulation therapy
initate ambulation or assist with dorsiflexion and plantar flexion of the foot
limit client sitting with feet in dependent position to 1-2 hours at one time
full weight bearing
healthy person can carry their own weight without any type of assistive device
upper extremities are also considered full weight bearing when lifting and moving objects without assistance
partial weight bearing
limitation that is greater than non-weight bearing
assistive device such as:
- walker
- cane
- crutches
- CAM walker boot
imagine that there is a raw egg underneath their foot and cannot crak it
toe touch weight bearing
client toes may lightly rest on ground while sitting, stnaidng or transferring to maintain balance
but no actual weight should be place on affected leg
non weight bearing
stricted limitation
no weight whatsoever, not even for a moemtn or 2 whether standing, walking or sitting
for an upper extremity:
- should wear sling or similar device to prevent client from placing weights on affected limb
stress incontinence
sudden increase in intra-abdominal pressure like sneezing or coughing or anything that puts pressure on the bladder
causes urine to leak from bladder
overflow incontinence
bladder empties incompletely so urine dribbles constantly
often due to an obstruction
exmaple: enlarge prostate in men
urge incontinence
overactive bladder
uncontrolled contraction of bladder results in urine leakage beofre one reaches the bathroom
functional incontinence
incontinence that is not due to organic reasons
impaired mobility may prevent client from reaching the bathroom in time
treatment in incontinence
structed peeing schedule
kegel exercises
protect skin integrity
surgery
ileostomy
opening created ti bring the small intestine to surface of abdomen, specifically the ileum
always have liquid stool
poses the highest risk of skin breakdown
after surgery, stool will be dark green, then turns yellow when pt starts to eat
NO enteric coating medications because they dont dissolve
colostomy
opening created to rbing large intestine to surface of abdomen
descending
ascending
transverse
sigmoid
descending and sigmoid: similar to normal consistency of regular stool
ascending: liquid stool
transverse: loose to partly formed stool
after surgery:
may pass mucous stool at first
- will be liquid at first then progress to what it should look like depending on the location
colostomy and ileostomy diet teaching
start out slow for first 6 weeks
low fiber
small meals throughout the day
monitor hydration and electrolyte status
eat slowly and chew thoroughly, then advance as tolerated
with ileostomy, need to stay hydrated and consume fluid and electrolyte solutions like Gatorade
use caution and eat small amount of completely avoid foods that are not completely digestible:
- conr
- celery
- peas
- coleslaw
- popcorn
- nuts and seeds
- raisins
- skin of fruits
- raw mushroom
- pineapple
colostomy and ileostomy pouch care
colostomy: put petroleum gauze over stoma to keep it moist
- then a sterile dressing until pouching system is in place
empty pouch when 1/3 to 1/2 full
change pouch when gut less active
- morning before breakfast
keep stoma and skin around stoma clean
watch for burning around skin or leaking
be familiar with various pouching system
when applying, be sure to measure the stoma and cut the opening of the skin barrier to be 1/8” larger than stoma
stoma irrigation may be ordered by the doctor
colostomy and ileostomy pre-operation
educate what to expect, what it will look like, where it will be on abdomen
start teaching pouching system
MD may prescribe oral antibiotics
2-3 days before surgery soft or semi-liquid diet
cleansing solution and laxative may be ordered
NPO on day of surgery
colostomy and ileostomy post operation
monitor signs of electrolytes and dehydration
after surgery, stoma will be swollen and large for 48-72 hours, but after couple months it’ll shrink down
should always look pink or red and be moist/shiny
if client has a blockage or notices a significant decrease of stool in pouch, the client should call their HCP immediately
loop stoma
usually temporary
proximal end of loop stoma is functioning end while distal end drains mucus
double barrel
forms 2 stomas similar to a loop stoma, but the bowel is surgically severed
sleep and SIDs
infants should be place on their back for sleep
cribs should be clear of pillows, toys and blankets
risk factors of SIDs
co-sleeping history of SIDs low birth weights male age under a year prematurity exposure to second hand smoke twin births poverty
infant play
tend to play alone or with caregivers
toys:
- music boxes
- teething toys
- mobiles or large blocks
toddlers play
alongside other childrenwithout interacting together
toys: push-pull oys - blocks - thick crayons - finger paints - puzzles - dolls - trucks and dress up
play should be active and screen time should be limited to 1 hour a day
preschool play
enjoy group play without rigid rules
toys:
- tricycles
- wagons
- paints
- crayons
- puzzles
- books
- balls
play may be imaginative and dramatic
media time should be limited to 2 hours a day
school age play
cooperative play
toys:
- board games
- jump ropes
- books
- bicycles
- crafts or sports
adolescent play
participating with peers during play
toys:
- music, sports
- career
- training programs
- books
- movies
blood administration
never use dextrose or LR to prime blood and administer blood products
- avoid giving any medications through same IV line used for transfusions
do not discard blood product and blood tubing
- send tubing and product to blood bank
O negative = universal red cell donor
AB blood = universal plasma donor
if transfusion cannot be started within 30 minutes from when product was released from blood bank, then nurse must return to blood bank
should never be stored on nursing unit, even if its refrigerated
blood administration reaction
if reaction occurs:
disconnect blood product and blood tubing
- do not discard
maintain patent IV line with saline
obtain vital and monitor closely
notify blood bank and HCP imediately
send saved blood product and tubing to blookd bank
monitor urine output
pediatrics: giving med orally
for meds with unpleasant taste, nurse may mix small amount of meds with
- syrup
- applesauce
- sherbet
with younger children, use a small syringe or nipple giving time for swallowing
- place liquid medication at side of of mouth rather than to the back of the throat to avoid aspiration
pediatrics: IM med
vastus lateralist: preferred location for infants and toddlers
- with infants give 0.5mL/leg
- older children may have up to 2 mL
ventrogluteal: route may less reactions or pain than vastus lateralist
- administer 0.5 mL for infants
- up to 2mL for older children
deltoid: faster absorption than other routes
- should not use this site for infants and small children
- administer 0.5 - 1mL/arm
infiltration sxs
edema
pain
coolness around insertion site
infusion pump alarm
infiltration nursing care
discontinue IV apply warm compress apply sterile dressing elevate arm monitor for compartment syndrome evaluate neruovascular status
phlebitis sxs
reddened, warm are a around insertion site or path of vein
tenderness
swelling
phlebitis nursing care
discontiue IV
apply warm, moist compress
thrombphlebitis sxs
pain swelling redness and warmth around insertion site or path of vein fever leukocytosis
thrombophlebitis nursing care
discontinue IV
apply warm compress
elevate extremity
hematoma sxs
ecchymosis
immediate swelling at site
leakage of blood at site
hematoma nursing care
discontinue IV
apply pressure with sterile dressing
aply cool compress intermittently for 24 hours to site, followed by warm compress
clotting sxs
decrease IV flow rate or infusion pump alarming
back flow of blood into tubing
clotting nursing care
disconitnue IV
do not attempty to flush or irrigate the IV
do not aspirate clot from cannula
circulatory overload sxs
crackles dyspnea increased BP, HR restlessness anxiety confusion seizures
circulatory overload nursing care
reduce IV rate to keep vein open
monitor vitals
notify HCP immediately
central venous access device nursing care
strict hand hygiene
aseptic technique
close monitoring for sxs of complications
changing of administration sets, dressings and add-on devices at recommended intervals
CHG bathing
consulting with HCP for removal
monitor for resp distress, diminishe or absent breath sounds
monitor for chest pain or tracheal deviation from midline
- should not be accessed or used until correct placement has been confirmed via chest x-ray
complications of CVA device
catheter occlusion local catheter infection systemic catheter infection embolism catheter migration
catheter occlusion sxs
inability to infused and/or aspirate from lumen
catheter occlusion treatment
reposition client
“gently” flush client with 10mL NS
instill thrombolytic agent
local catheter infections sxs
redness tenderness warmth edema purulent drainage
local catheter infection treatment
change dressing chlorhexidine biopatch aspetic technique "closed" system wit IV tubing remove catheter if necessary
systemic catheter infection treatment
remove catheter
culture tip of catheter
obtain blood cultures
start antibiotic therapy
embolism sxs
sudden onset of resp distress
hypotension
tachycardia
chest pain
embolism treatment
immediately place on their left side with head lower than heart
administer oxygen
notify HCP
catheter migration sxs
"gurgling" sound in ear edema of chest or neck inability to infused and/or aspirate blood from catheter dysrhythmias change in catheter length
catheter migration treatment
stop any infusions
perform fluoroscopy or chest x-ray
remove catheter if needed
interventions when caring for a client with CVAD
hand hygeiene bathe chlorhexidine on daily basis scrub access port or hub with friction sterile device replace dressings that are wet, soiled, or dislodged perform routine dressing changes - with clean or sterile gloves
daily audits to see if CVAD is still needed
parenteral nutrition or TPN preparation
prepared by or under the supervision of a pharmacist
aseptic technique under a laminar airflow hood
nothign should be added after it has been prepared
good for 24 hours
- mut be refrigerated until 30 minutes before use
parenteral nutrition or TPN administration
- 22 micron filter with TPN without lipids
- 2 micron filter with TPN with lipids
always use infusion pump
use dedicated line for TPN
- do not infused other solutions with TPN or administer intermittent IV meds
- including IV push meds through the same line with TPN
before starting TPN infusion, nurse must verify that the ingredients in the solution match what the HCP ordered
parenteral nutrition or TPN complications
hypoglycemia
- can occur when TPN runs out before a new bag is available
- should hang dextrose-containing IV solutions like (D5, D10, or D20%) until new TPn bag is available
hyperglycemia
- blood sugar should be checked
fluid/circulatory overload
parenteral nutrition or TPN interventions
daily weights
accurate intake and output
blood sugar
regular lab tests
teratogenic drug categories
category A:
no risk to fetus; controlled studies in humans
B: animals studies show no risk to fetus
C: no controlled studies in animals or humans
D: evidence of human risks to the fetus
X: fetal abnormalities in both animals and humans
high alert medications
potassium insuline narcotics chemotherapy heparin
