elimination

Question 1

SKIN

Answer 1

S- sensory impairment (limited ability to tell you of discomfort) Can they feel it?
K- mobility (kinesthetic) can be at risk for pressure ulcer if not moving and staying in same positions
I- incontinence, dont have control over urinating/moving bowels (moisture irritates skin)
N- nutrition (not good nutrition at risk for pressure ulcers/skin breakdown)

Question 2

position for listening to bowel sounds?

Answer 2

patients should be laying down in the supine position (30 degrees) when listening to bowel sounds

Question 3

GI considerations in infants & children

Answer 3

-infants have deficiency in enzymes (enzymes will not be sufficient to aid in digestion until 4-6 months) why we don’t give babies certain foods because they can’t breakdown the enzymes
lack in enzyme results in frequent abdominal distention and flatulence
at age 2- childs digestive process is generally complete and they can adapt to 3 meals per day
complete set of primary teeth at age 3 to 6 years

Question 4

GI considerations in adults

Answer 4

taste is less acute due to natural atrophy (decrease muscle mass) of the tongue
loss of bone supporting teeth may result some or all permanent teeth loss
saliva production can decrease, may increase swallowing and chewing time
esophagus motility (movement) may decrease and increase risk of aspiration (choking)

*trachea is the windpipe, we don’t want food there

Question 5

motility

Answer 5

(movement)
peristalsis-movement of food through intestines (contracting of muscles
moving food and fluids from mouth—>anus
motility can be affected by inflammation, infection, tumors, obstructions, or changes in structure

Question 6

GI tract issues

Answer 6

nausea: (part of GI assessment) are they able to drink, getting enough food, are they vomiting?
If someone is nauseated: can give ginger ale, crackers (absorbs acid) water can sometimes increase nausea
malaborption/mal-digestion

Question 7

malabsoprtion

Answer 7

when they dont absorb the nutrients from food (some type of inflammation or infection)

Question 8

mal-digestion

Answer 8

food that is incomplete digestion (problem with the enzymes not breaking down the food)

Question 9

intake

Answer 9

oral fluids, IV fluids, tube feedings are documented at intake
solids are documented as percentage consumed (if someone has food tray could document as 50%, 75%, 100% of tray)
want to measure someones intake, the rest is documented as mL
*ICE is half of mL
Example documenting ice: 240 cup of ice, would give 120mL

Question 10

indications: enteral feeding tube

Answer 10

will not or cannot eat
cannot consistently meet their daily needs orally
have a history of unintentional weight loss of greater of greater than 10% of ideal body weight
cancer
neurological and muscular disorders, gastrointestinal disorders
inadequate oral intake
premature babies
respiratory failure

(if someone doesnt get their nutrition may give tube feedings, some type of paralysis may give tube feedings)

Question 11

nasointestinal

Answer 11

nasogastic (clear tube): nose to stomach
gastric decompression if vomiting a lot
insert attach to stomach takes out undigested food (food in short amount of time maye 3 days)
*need a doctors order

NJ tube (nasojejunal feeding tube): nose to the intestines tube feeding in duodenum or jejunum for tube feedings

*yellow tube never attach to suction

Question 12

enteral feeding tube routes

Answer 12

the physician selects the route and formula based on the duration of therapy, condition of the GI tract, and the potential for aspriation

Routes:
Nasogastric- tube enters through the nose
Gastrostomy/ PEG- directly into the stomach (long term can last for years) (surgeons do)
Nasointestinal- nasoduodenal, nasojejunal (for specialists)
jejunostomy- PEJ- directly into jejunum

only one nurses can do is the NG tube

Question 13

PEG tubes (Precutaneous endoscopic gastrostomy tube)

Answer 13

directly into skin into the stomach
patient is still at risk for aspiration
S&S: coughing problems, breathing, etc
used for longer term
"bolus feeding" getting their nutrients

Question 14

assessment prior to NG tube placement

Answer 14

Hx (history) of nasal surgery or deviated septum
auscultate bowel sounds and assess LOC (level of consciousness)
understanding of the procedure
measure distance to insert the NG tube (start at tip of nose go to the earlobe an the to the xiphoid process and mark it with tape)

*dont put them in if patient has history of nose bleeds, sinus surgeries, etc
when we insert document the number

Question 15

nursing responsibilities for feeding tubes

Answer 15

verify tube placement with abdominal x-ray
NEVER begin initial feedings until tube placement is confirmed by a radiologist
radiologist will read it and let you know where its located
(if its acidic you know that its in the stomach)

Question 16

Nursing responsibilities feedings

Answer 16

assess patient’s tolerance of feedings monitor and record:
stool frequency and consistency
abdominal distention/vomiting
urinary output
pulmonary problems
provide frequent mouth care (can be very drying)

Question 17

bowel elimination

Answer 17

ingested food that is not digestible moves through the gastrointestinal system and is eliminated from the bowel as feces or stool
defecation is the expulsion of feces from anus and rectum
frequency is highly individualized, varying from several times per day to two or three times per week

*norm is 2-3 times per week
if someone says 1 time a week isnt normal
(want to ask how their bowel movements are and if they are within their own normal limits)