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Essentials of Nursing 2024 > Essentials Exam 3 > Flashcards

Essentials Exam 3 Flashcards

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1
Q

Disinfection

A

Removal of pathogenic microorganisms

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2
Q

Sterilization

A

Process used to destroy all microorganisms,
including their spores

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3
Q

7 Principles of Surgical Asepsis

A
  • Sterile can only touch sterile
  • Only sterile objects in sterile field
  • Non-Sterile: Object falling below waist, Unattended objects, Turning back on field, Do NOT cross arm over sterile field!
  • Prolonged exposure to air contaminates field
  • Moisture onto a sterile field causes field to become contaminated.
  • Fluid flow in the direction of gravity
  • 1” border around field contaminated
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4
Q

causes of urinary retention

A

Acute: Sudden onset
-Intervention needed ASAP
Post surgical: Anesthesia /medications
Chronic:
- Progressive blockage
- Prostate
- Stricture
Medications
Neural pathway interruption
Stroke
Multiple sclerosis
Trauma/spinal injury

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5
Q

four types of urinary incontenence

A

overflow stress urge functional

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6
Q

overflow incontinence

A

overdistended bladder/ urinary retention

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7
Q

stress incontinence

A

Small leakage due to incompetent
urethral sphincter.
laughing, coughing, etc

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8
Q

urge incontinence

A

Strong sense of urgency
Frequency, nocturia, unable to
hold urine once the urge begins
STRENGTHEN PELVIC FLOOR

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9
Q

functional incontinence

A

Causes outside the urinary tract
Mobility, cognitive impairment
(dementia), environmental
barriers

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10
Q

Kegel exercises

A
  • Women
  • Urinary Incontinence
  • Pain during intercourse
  • Fecal incontinence
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11
Q

what’s a concerning urinary output?

A

Hourly output of less than 30
mL for more than 2 hours is
cause for concern

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12
Q

characteristics of urine

A

color, odor, clarity

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13
Q

Urinalysis

A
  • Appearance, concentration and content of
    urine
  • Glucose, protein, ketones, nitrites,
    leukocytes, pH
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14
Q

Specific gravity

A
  • Concentration (density) as compared to water
  • 1.005(less concentrated)-1.030(more
    concentrated)
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15
Q

when is a Culture and Sensitivity test used

A
  • Urinary tract infection
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16
Q

another name for the specimen collection cup

A

hat

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17
Q

delegating urine cup

A
  • Clean void/midstream specimens can be delegated
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18
Q

how soon after collection does a urine sample need to be sent to the lab

A

within 2 hours

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19
Q

when to refrigerate urine specimen

A

when completing a culture and sensitivity test for UTI

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20
Q

how to collect a urine specimen

A

clean voided, midstream

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21
Q

non-invasive bladder exams

A

KUB, CT, MRI
* Bladder scan
* Intravenous pyelogram (x-ray)
* Urodynamic testing (Uroflowmetry)

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22
Q

invasive bladder exams

A

Cystoscopy (scope)
Arteriography (xray with dye inserted)

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23
Q

oxybutynin

A
  • Increase bladder contraction, increase
    capacity
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24
Q

Intermittent Catheterization

A

(one time for bladder emptying)
* Relieving discomfort of bladder
distention, providing decompression
* Obtaining sterile urine specimen when
clean-catch specimen is unobtainable
* Assessing residual urine after urination
* Managing patients with spinal cord
injuries, neuromuscular degeneration, or
incompetent bladders long term

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25
Q

Cholinergic drugs

A

increase bladder
contraction and improve emptying

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26
Q

Short-Term Indwelling Catheterization

A

(2 weeks or less)
* Obstruction to urine outflow (e.g., prostate
enlargement)
* Surgical repair of bladder, urethra, and
surrounding structures
* Prevention of urethral obstruction from blood clots
after genitourinary surgery
* Measurement of urinary output in critically ill
patients
* Continuous or intermittent bladder irrigations

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27
Q

Long-Term Indwelling Catheterization

A

(more than a month)
* Severe urinary retention with recurrent
episodes of UTI
* Skin rashes, ulcers, or wounds irritated by
contact with urine
* Terminal illness
* Comfort measures
* When bed linen changes are painful for
patient

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28
Q

indwelling foley catheter

A

balloon, urine flows down

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29
Q

Indwelling Triple Lumen Catheter

A

Third lumen
* Delivers irrigations and instillations
* Clearing the bladder of blood, pus or sediment
* Maintains patency of lumen
* Measurement of urine output
* Deduct input to get accurate output

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30
Q

Catheter Irrigations

A

Common after bladder surgery
* Continuous or intermittent
* Closed catheter irrigation
* Decreased risk of infection
* Keeps catheter free of clots and
sediment
* Cannot be delegated

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31
Q

complications of catheter irrigation

A

bright red blood
pain
irrigation solution does not return

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32
Q

coude catheter

A

Single lumen, Stiffer tip
* Enlarged prostate
* Less traumatic
* Easier to guide

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33
Q

Infants Fr

A

5-6

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34
Q

Children Fr

A

8-10

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35
Q

Young Girl Fr

A

12

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36
Q

Women Fr

A

14-16

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37
Q

Men Fr

A

16-18

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38
Q

latex catheter

A

up to 3 weeks

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39
Q

plastic catheter

A

intermittent

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40
Q

Silicon/Teflon catheter

A

Long term up to 2-
3 months

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41
Q

What can be Delegated catheter-wise

A
  • Assist with positioning and privacy
  • Report patient discomfort/pain
  • Leaking of urine around catheter
  • Abnormal characteristics of urine: Blood, odor, drainage
  • Emptying drainage bag: Report output
  • Perineal care: Same sex caregiver if possible
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42
Q

catheter specimen collection characteristics

A

cannot be delegated
needle free
port sampling

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42
Q

suprapubic catheter

A

Inserted surgically
* Reinsert immediately if dislodged
* Cover with sterile dressing
* Blockage of outflow: Urethra
* Long term catheterization

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42
Q

abnormal findings from catheter assesment

A
  • More than 500 mL to 1000 mL of urine drains
    at the time of insertion
  • Bladder discomfort
  • Unable to advance the catheter
  • Lack of urine
  • Leakage of urine from around the catheter
  • Pain while inflating the balloon: Is the catheter in the urethra?
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42
Q

when to collect specimen from a catheter

A

Specimen can be collected from drainage
bag ONLY WHEN IMMEDIATELY inserted

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43
Q

delegated care of the suprapubic catheter

A

Delegated care
* Increase fluid intake (2200 mL/24 hours)
* Empty drainage bag
* Report signs and symptoms of infection
* Drainage at insertion site, foul order, redness

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44
Q

Condom Catheter Indications

A
  • Men who have complete and
    spontaneous bladder emptying
  • Incontinence
  • Nocturia
  • can be mobile
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45
Q

condom catheter parts

A

Held in place with adhesive
* Attached to the drainage bag
* Bedside bag
* Large volume
* Leg bag
* Small volume, ambulatory

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46
Q

Orthotopic neobladder

A

Reconstructed bladders/reservoirs made from intestines

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47
Q

Nephrostomy Tubes

A

surgically placed catheter into the renal pelvis
due to an obstructed ureter

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48
Q

Ventilation

A

 Process of moving gases in and out of the lungs

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49
Q

Perfusion

A

Ability of the cardiovascular system to pump oxygenated blood to the tissues and
return deoxygenated blood to the lungs

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50
Q

Diffusion

A

Responsible for moving the respiratory gases from one area to another by
concentration gradients

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51
Q

Postural drainage oxygenation benefits

A

 Drainage, positioning, and turning that improves secretion clearance and
oxygenation

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52
Q

Positive expiratory pressure (PEP)

A

 Air inhaled easily, forces patient to exhale against resistance

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53
Q

Ambulation oxygenation benefits

A

 Maintains and promotes lung expansion
 Immobility leads to atelectasis, ventilator-associated pneumonia, muscle weakness

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54
Q

semi-fowlers position degree and benefits

A

Maintains and promotes lung expansion
 45 degree

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55
Q

Pursed-lip breathing

A

 Deep inspiration and prolonged expiration through pursed lips

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56
Q

Diaphragmatic breathing

A

 Increases tidal volume and decreases respiratory rate

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57
Q

Invasive mechanical ventilation

A

 Aka positive pressure ventilation
 Used with artificial airways (ETT or TT)
 Physiologic indications
-Reduce work of breathing
-Increase lung volume
-Support cardiopulmonary gas exchange
 Clinical indications
- Relieve respiratory distress, reverse hypoxia, prevent/reverse atelectasis and
respiratory muscle fatigue, stabilize chest wall, decrease oxygen consumption, allow
for sedation or neuromuscular block
 Ventilator-associated pneumonia (VAP)

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58
Q

Noninvasive positive pressure ventilation
(NPPV)

A

 Treat obstructive sleep apnea (OSA), COPD, neuromuscular disorders,
cardiogenic pulmonary edema
 Used at home and in acute care settings
 Contraindications
 Advantages
 Continuous positive airway pressure (CPAP)
 Steady stream of pressure throughout a patient’s breathing cycle
 Bilevel positive airway pressure (BiPAP)
 Provides inspiratory positive airway pressure and expiratory airway pressure (aka
positive end-expiratory pressure (PEEP)

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59
Q

oxygen therapy goal

A

Goal: Lowest amount of oxygen possible to achieve adequate tissue oxygenation

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60
Q

Low flow devices: Nasal cannula rates

A

 1-6 LPM
 FiO2: 24-44%

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61
Q

nasal cannula pros and cons

A

 Advantages
- Safe and simple, easily tolerated, effective for low concentration, doesn’t impede
speaking or eating, disposable
 Disadvantages
-Unable to use with nasal obstruction, can be drying, can dislodge, may cause skin
irritation, patient breathing pattern affects Fio2

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62
Q

Low flow devices: Oxygen-conserving
cannula (Oxymizer) rates

A

8LPM
 FiO2: 30-50%

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63
Q

Low flow devices: Oxygen-conserving
cannula (Oxymizer) pros and cons

A

 For long term O2 use in the home
 More expensive than standard cannula

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64
Q

Low flow devices: Simple face mask rates

A

6-12 LPM
 FiO2: 35-50%

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65
Q

Low flow devices: Simple face mask pros and cons

A

 Useful for short periods
 Contraindicated in patients who retain CO2

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66
Q

Low flow devices: Partial and
nonrebreather masks

A

 10-15 LPM
 FiO2: 60-90%

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67
Q

partial and nonrebreather masks

A

 Useful for short periods
 Bag should always be partially inflated
 Needs tight seal

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68
Q

High flow devices: Venturi mask rates

A

 FiO2: 24-50%

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69
Q

venturi masks purpose

A

 Provides specific amount of oxygen with humidification
 Low, constant O2

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70
Q

High flow devices: High-flow nasal
cannula

A

 Provides specific amount of oxygen with humidification
 Low, constant O2

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71
Q

high-flow nasal cannula

A

Adjustable FiO2 with modifiable flow
 Provides heated, humidified oxygen

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72
Q

Noninvasive ventilation: CPAP and
BiPAP rates

A

iO2: 21-100%

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73
Q

Noninvasive ventilation: CPAP and
BiPAP purpose

A

 Avoids use of artificial airway in patients with acute respiratory distress,
postextubation respiratory failure, or neuromuscular disorders
 Treats obstructive sleep apnea (OSA)

74
Q

Stomach functions

A
  • Storage
  • Mixing
  • Emptying
75
Q
  • Pyloric Sphincter
A
  • Controls gastric emptying
76
Q
  • Small Intestines
A

Digestion
- Chyme
- Absorption
- Villi and microvilli

77
Q

Duodenum size function

A

(approx. 1 foot)
* Process fluid from stomach
* Pancreatic enzymes and bile

78
Q

Jejunum size function

A

(approx. 8 feet)
* Absorbs carbohydrates,
proteins, nutrients,
electrolytes

79
Q

Ileum size function

A

(approx. 12 feet)
* Absorbs water, fats,
iron, bile salts

80
Q

Large Intestines parts

A

(approx. 6 feet)
* Cecum
* Ileocecal valve
* One way valve preventing backup into
small intestines

81
Q

Rectum parts

A
  • Internal Sphincter
  • External Sphincter
82
Q

ADPIE

A

assesment
diagnosis
planning
implementation
evaluation

83
Q

endoscopy

A

scope top to bottom

84
Q

colonoscopy

A

scope bottom to top

85
Q

Clostridium difficile

A
  • Overgrowth secondary to disruption of normal flora
86
Q

when to not use anti-diarrheal medications?

A

Do not use anti-diarrheal
medication with ‘infectious’
diarrhea

87
Q

purpose of enemas

A
  • Promotes bowel cleansing
  • Empties the bowel for diagnostic testing or
    surgery
  • Aids in the visualization of bowel mucosa
  • Begin a bowel training program
  • Relieves constipation
88
Q

Hypertonic enema

A

Cleansing,
Work by osmotic pressure, drawing fluid out of interstitial spaces into the colon, which then fills with fluids and distends

89
Q

isotonic enema

A

cleansing,

90
Q

Oil retention enema

A

Lubricates the rectum and colon. Feces absorb the oil and
become softer and easier to pass.

91
Q

Medication enema

A

Antibiotic enemas are used to treat local infections (worms,
parasites); a type of retention enema

92
Q

Carminative
Return-flow

A

Provide relief from distention by stimulating peristalsis to
improve the passage of flatus

93
Q

Delegation of enema

A
  • Cannot delegate ‘medication’ enemas
  • Kayexalate-hyperkalemia
  • Neomycin-antibiotic
94
Q

Positioning during enema

A
  • Sim’s: left side lying, right knee flexed
95
Q

enema Unexpected outcomes

A
  • Rigid abdomen
  • Distention
  • Cramping
  • Bleeding
96
Q

Valsalva Maneuver

A
  • Increase in intrathoracic pressure then
    release may cause reflex bradycardia
    and hypotension
  • Loss of consciousness
    *
97
Q

when to Suspect Impaction

A
  • Unable to pass stool for several days
  • Loss of appetite; N/V; abdominal distention
  • Continuous oozing of liquid stool
98
Q

Digital removal of stool

A
  • Use if enemas fail to remove an impaction
  • This is the last resort for constipation
99
Q

is a health provider order necessary for an impaction

A
  • A healthcare provider’s order is necessary to remove an impaction.
  • May stimulate Vagal nerve
  • Bradycardia, hypotension, irregular HR
100
Q

Single Lumen nasogastric tube

A
  • Fine- or small-bore for medication
    administration and enteral feedings
    (Levin)
101
Q

double Lumen nasogastric tube

A
  • Large-bore (12-French and above) for
    gastric decompression or removal of
    gastric secretions
  • Salem sump
  • Blue “pigtail”
102
Q

Salem slump NG tube

A
  • Double lumen
  • Sump: Air vent (blue pigtail)
  • Indications: Gastric decompression, Lavage
  • Advantages: DOES NOT ADHERE TO GASTRIC MUCOSOA
  • Main lumen connected to suction: Air vent: NEVER
    -Clamp off
    -Connect to suction
    -Irrigate
103
Q

levin tube

A

*Single lumen
* No pigtail air vent
* Indications
*Gastric decompression
*Enteral tube feeding
*Medication administration

104
Q

Contraindications to NG insertion by the nurse!

A
  • Head, facial or neck trauma
  • Severe craniofacial trauma: Intracranial
    insertion
  • Damage to cribriform plate
  • Recent nasal surgery
105
Q

Suspicion/history of alcoholism with NG tubes

A
  • Esophageal varices: bumps down tract
  • Sengstaken-Blakemore Tube: tubes for hemorrhages
    -not a nurse job
106
Q

Measurement of NG placement on face

A
  • Tip of nose to earlobe to xiphoid process
107
Q

insertion of NG tube

A
  • Water soluble lubricant
  • Client position
  • High Fowler’s
  • Initially tilt head back
  • Tilt forward
  • Swallow
108
Q

how to verify NG tube placement

A

Chest/KUB x-ray confirmation
* Aspirate syringe to obtain gastric content
-Observe color of gastric secretions
-Measure pH of contents
-Should be pH of 5 or less for gastric
contents

109
Q

how to remove NG tube during resp distress

A

Remove the tube to the posterior nasopharynx until normal breathing resumes!

110
Q

NPO

A

nothing by mouth

111
Q

Irrigating an NG Tube

A
  • Verify physician’s order
  • Medical asepsis/clean technique
  • Standard precautions
  • Confirm NG tube placement
  • reconnect to suction
  • Draw up 30 mL of normal saline into
    catheter tipped syringe
  • Attach irrigation syringe
  • Instill solution without force
112
Q

NG tube discontinuation

A

Verify order
* Assess patient for bowel sounds*
* Disconnect from suction to assess
* Explain procedure
* Medical Asepsis/ Standard precautions
* Apply gown, gloves and goggles
* Turn off suction
* Have client take a deep breath and hold it
* Kink tubing
Smoothly and steadily remove tube
* Dispose of equipment
* Biohazard bag
* Provide mouth care
* Follow up Assessment
* Abdomen for tenderness, rigidity,
distention
* Auscultate bowel sounds
* Assess for presence of
nausea/vomiting after removal
* Status of nares and nostrils

113
Q

bowel diversions

A

Temporary or permanent
artificial opening in the
abdominal wall
* Stoma
* Surgical opening in the
ileum or colon
* Ileum (small intestines)
* Ileostomy

114
Q

colonoscopy =

A

large intestines
solid waste

115
Q

ileostomy

A

small intestines
liquid waste

116
Q

effluent

A

fecal material

117
Q

ostomy care

A
  • Maintain skin integrity
  • Assess stoma healing and integrity
  • Prevent odors
  • Promote comfort
  • Maintain or increase self-esteem and dignity
118
Q

can an ostomy pouch be delegated

A

pouch care CAN be
new pouch cannot be

119
Q

ileostomy characteristics

A
  • Odorless/limited odor
  • Consistency of effluent
  • Liquid
120
Q

Colostomy characteristics

A
  • Odorous
  • Due to bacteria in the colon
  • Consistency of stool
  • Semi-liquid to solid depending on
    site of ostomy
121
Q

Nutritional considerations for ostomies

A
  • Consume low fiber for the first few weeks.
  • Eat slowly and chew food completely.
  • Drink 10 to 12 glasses of water daily.
  • Avoid gassy foods.
122
Q

Primary Intention

A
  • Edges are
    approximated
  • Sutures aid in healing
    (sutured shut)
122
Q

4 stages of wound healing

A

hemostasis/coagulation
inflammation
prolif/migration
remodeling

123
Q
  • Secondary Intention
A
  • Edges contract
  • Wound bed fills
  • Epithelialization
    and scar tissue
    (no suture)
124
Q
  • Tertiary Intention
A
  • Closed later
    (sutured shut after some healing on own)
125
Q

Granulating Tissue

A
  • Surface: Pink/red, Moist, ‘Bumpy’
    Edges: Clean Intact
126
Q

internal vs external hemorrhage

A

external: visibility bleeding
internal: appearing like a bruise (hematoma)

127
Q

Dehiscence

A
  • Partial or total
    separation of wound
    layers
128
Q

Evisceration

A
  • Total separation and protrusion of visceral organs
  • Surgical emergency
  • Do NOT push organs back in
  • Moist gauze
  • Continue nasogastric suction
129
Q

Fistula formation

A
  • Abnormal connection or passageway
130
Q

nutrition for wound healing and why

A

vitamins A, C, zinc
increased collagen formation

131
Q

conditions impacting wound healing

A

age, iron deficiency, Diabetes, CAD, HTN, Failure to Thrive

132
Q

characteristics of wound drainage

A

color odor consistency amount

133
Q

Serous

A
  • Clear, watery
134
Q

Purulent

A
  • Thick, yellow, green, tan, brown
135
Q
  • Serosanguineous
A
  • Pale, red, watery
136
Q
  • Sanguineous
A
  • Bright red
137
Q

Debridement

A
  • Removing non-viable tissue
138
Q

order to approach wound first aid

A

airway
breathing
circulation
bleeding
protection/cleaning

139
Q

Vanderbilt wound flowsheet

A

sheet to document wounds

140
Q

Penrose drain

A

a straight, flexible tube that drains fluid from a surgery site.
prevents infection
looks like flower bud

141
Q

Jackson Pratt, Hemovac

A
  • Constant, low-pressure vacuum to
    remove and collect drainage
  • Empty when 50% full or once a shift
  • Document COCA
  • Concern with abrupt decrease/increase in
    drainage
  • Foul smell
142
Q
  • Basic Skin Cleansing
A
  • Clean from the least contaminated to the
    surrounding skin
  • Use gentle friction
143
Q

Negative-pressure wound therapy

A

packing wound
* Draws wound edges together
* Decreases edema and fluid removal
* Supports angiogenesis, granulation

144
Q
  • Wet to dry benefits
A
  • Maintains a moist wound
    surface
  • Wicks out drainage
  • Debridement
145
Q

Diabetic neuropathy

A
  • Decreased sensation in hands and feet
146
Q

Peripheral Vascular Disease signs

A
  • Venous: Wet, weeping, edematous irregular edges. Usually develops above the ankle
  • Arterial Insufficiency: Pulses faint, skin cool to touch, +/- edema. Clear demarkation
147
Q

stage 1 pressure ulcer

A
  • Intact skin with non-blanchable erythema (redness)
148
Q

stage 2 pressure ulcer

A
  • Partial-thickness skin loss involving epidermis, dermis, or both; can be intact or open blister
149
Q

stage 3 pressure ulcer

A
  • Full-thickness tissue loss with visible fat
150
Q

stage 4 pressure ulcer

A
  • Full-thickness tissue loss with exposed bone, muscle, or tendon
151
Q

2 classifications of pressure ulcers

A

Unstageable: Cannot see the wound bed; obscured by slough or eschar

Deep Pressure Injury: Intact or non-intact: non-blanchable deep red or maroon/purple discoloration; deep wound bed or blood-filled blister

152
Q

slough

A

the yellow/white material in the wound bed

153
Q

eschar

A

Dead tissue in wound (usually dark/black appearance)

154
Q

Deep Tissue Pressure Injury

A

pressure ulcer
* Persistent non-blanchable deep
red/purple discoloration
* Intact or non intact
* Dark wound bed
* Blood-filled blister

155
Q

Braden scale

A

lower the score= greater risk
fall scale/pressure ulcer risk

156
Q

Baseline (for wound care)

A
  • Admission skin assessment
  • Ongoing
157
Q

can baseline be delegated?

A

NO

158
Q

dressings used for pressure ulcer

A

hydrocolloid dressing

159
Q

Hydrogel

A
  • Keeps wound moist; absorbs exudate
160
Q

Effects of cold application

A

Vasoconstriction
* Swelling and pain

161
Q
  • Effects of heat application
A

Vasodilation

162
Q
  • Factors influencing heat and cold tolerance
A
  • Exposure time
  • Exposed skin
    Perception of sensory stimuli
163
Q

Basal metabolic rate (BMR)

A

– Energy needed at rest to maintain life-sustaining
activities for a specific amount of time

164
Q
  • Resting energy expenditure (REE)
A

– Amount of energy needed to consume over 24-
hour period for the body to maintain internal
working activities while at rest

165
Q

Anabolism

A

– Building of more complex biochemical
substances by synthesis of nutrients

166
Q

Catabolism

A

– Breakdown of biochemical substances
into simpler substances; occurs during
physiological states of negative nitrogen
balance

167
Q

– Ovolactovegetarian

A

(avoids meat, fish, and poultry, but eats eggs and milk)

168
Q

– Lactovegetarian

A

(drinks milk but avoids eggs)

169
Q

– Zen macrobiotic

A

Buddhist religious diet

170
Q

– Fruitarian

A

(consumes fruit, nuts, honey, and
olive oil)

171
Q

An ideal body weight (IBW)

A

provides an
estimate of what a person should weigh

172
Q
  • Body mass index (BMI)
A

measures weight
corrected for height and serves as an
alternative to traditional height–weight
relationships

173
Q

Abdominal fat (waist circumference) vs BMI risks

A

Abdominal fat (waist circumference) has higher risk correlation than BMI

174
Q

Hyperalimentation

A

artificial nutrition (example IV)

175
Q

dysphagia

A

Difficulty in swallowing

176
Q

assisting eating with dysphagia

A

small bites
sit upright
avoid distractions
chin tuck to chest

177
Q

Enteral Access Tubes why one route over another?

A

gastric reflux

178
Q

Nasogastric (NG) and NasoJejunal (NJ)
tubes time of use and delegation

A

–Provide a short-term feeding method
for nutritional intake and hydration.
–Insertion of an NG or NJ tube may
not be delegated to UAP.

179
Q

Enteral Tube Feeding- Intermittent/Bolus

A

– Initiation
* Full strength; Bolus over 20-30 minutes
* 2.5-5mL/kg 5-8 times per day
* 60-120 mL per feeding 8-12 hours
– Tube placement
* X-ray confirmation
* pH 4 gastric secretions; pH 6 intestinal secretions
– Residual: flush with air then aspirate
* 250mL or less return contents and feed
* 500mL hold feed
– Flush with 30mL water Before and after feeding
– Position
* Elevated HOB: 30 degrees, preferably 45 degrees
* Right side lying

180
Q

irrigation for enteral feeding tubes

A
  • Intermittent
    – Irrigate with 15-30 mL water before and after feeding
  • Continuous
    – Irrigate with 30 mL water every 4 h
181
Q

Feeding Intolerance

A
  • Signs of intolerance may warrant holding
    feeding
    – Abdominal distention
    – Vomiting
    – Pain
    – GRV 250mL-500mL
182
Q

patient position during feedings

A

semi-fowlers
at least 30-45 degrees

183
Q

how to administer meds during tube feeding

A

always liquid or powder mixed into sterile water
flush with 20-30 ml water before and after

184
Q

extended or sustained release
medications

A

NEVER CRUSH

185
Q
A

Essentials of Nursing 2024 (3 decks)

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