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Science of Nursing Practice Lecture > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

all pt go through all 3, go under anesthesia, and must obtain informed consent

A

Perioperative Phases

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2
Q
  • Begins when pt and surgeon mutually decide
  • Ends when pt is transferred to OR or operating bed
A

Preoperative

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3
Q
  • Begins when pt is transferred and includes time spent in OR
  • Ends in post-anesthesia care unit (PACU)
A

Intraoperative

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4
Q
  • Begins: Admission to PACU
  • Recovering pt
  • Ends with recovery from surgery and follow-up with provider visit
A

Postoperative

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5
Q
  • elective
  • urgent
  • emergency
  • based on risk
  • based on purpose
A

classification of surgical procedures

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6
Q
  • non-urgent
  • delay has no ill-effects
  • can be schedules in advance based on pt’s choice
  • ex) tonsillectomy, hernia repair, cataract, scare revision, facelift, mammoplasty
A

elective surgery

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7
Q
  • performed within short-time frame (24-48 hours)
  • ex) removal of gallbladder, coronary artery bypass, malignant tumor
A

urgent surgery

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8
Q
  • must be done ASAP to preserve life, limb
  • ex) gunshot wound, perforated ulcer, intestinal obstruction, control of hemorrhage, tracheostomy
A

emergency surgery

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9
Q
  • major risk: may be elective, urgent, or emergency; ex) colostomy, hysterectomy, amputation, trauma repair
  • minor risk: primarily elective; can return to activities sooner, less complications, almost always outpatient; ex) teeth extraction, skin biopsy, cataract
A

based on risk surgery

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10
Q
  • diagnostic: to make or confirm diagnosis (breast biopsy, exploratory)
  • ablative: remove a diseased body part (appendectomy, colon resection, amputation)
  • palliative: relieve or reduce intensity of illness (colostomy, nerve root resection, arthroscopy)
  • reconstructive: restore function to malfunctioning tissue or improve self-concept (scare revision, plastic surgery)
  • transplantation: replace organs or structures that are diseased or malfunctioning (kidney, liver, heart, cornea)
  • constructive: restore function in congenital anomalies (cleft palate)
A

based on purpose surgery

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11
Q
  • general
  • moderate sedation/analgesia
  • regional
  • topical and local
A

types of anesthesia

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12
Q
  • Administered by inhalation or IV or combo
  • Causes LOC, amnesia, analgesia, relaxed skeletal muscles, relaxed reflex
  • Can be used for any age or any surgery
  • Risk: circulatory and respiratory depression, post-op N/V leading to aspirations, bronchospasms can also occur
A

general anesthesia

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13
Q
  • Short-term minimally invasive surgeries
  • Maintains cardiorespiratory function
  • Can respond to verbal commands
  • Airway open and can respond to tactile areas
  • Can be administered by specially trained nurses (endoscopy, radiology)
A

moderate sedation/analgesia

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14
Q
  • injected near nerve or operative sight to lose feeling in that region
  • nerve blocks
  • spinal
  • epidural
A

regional anesthesia

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15
Q
  • Injected in nerve trunk
  • Jaw, face, extremities
A

nerve block (regional)

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16
Q
  • Injected in subarachnoid space through lumbar puncture and causes sensory, motor, and autonomic blockage
  • Surgeries of lower abdomen, perineum, legs
  • Side effects: hypotension, headache, urinary retention
A

spinal anesthesia (regional)

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17
Q
  • Injection of anesthetic through intervertebral space usually in lumbar
  • Chest, abdomen, and legs; most common - child birth
A

epidural anesthesia (regional)

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18
Q
  • Mucus membranes, wounds, burns
  • Intact skin
  • Sprayed, spread, or applied with compress with drug-saturated gauze or cotton-tip
A

topical anesthesia

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19
Q
  • Injected in specific area of body
  • Minor, short-term, or diagnostic procedure
  • Also can be injected in general anesthesia to manage pain
A

local anesthesia

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20
Q
  • Nurse must witness signature on form
  • Doctor should discuss the following in very plain language while taking into account educational level, language, and culturally sensitive:
    ○ Description of procedure including name, site, and side
    ○ Potential alternative therapies and option of non-treatment
    ○ Underlying disease process and natural course
    ○ Name and certification of physician performing procedure
    ○ Emphasize shared decision making
    ○ Explain risk - nature, magnitude
    ○ Benefits
    ○ Explain the pt has the right to refuse treatment and consent can be withdran
    ○ Explain the expected but not guaranteed outcome and recovery course
    ○ Signed, dated, and timed form is a legal document kept in chart
A

informed consent

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21
Q
  • Legal document
  • Protects patient, provider, facility
  • Nurse witnesses signature
A

informed consent

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22
Q
  • Legal document: specify instructions for healthcare if the pt is unable to communicate them
  • Living will: explains instructions
  • Durable power of attorney: appoints an agent the pt trusts to make choices for them in the event of incapacity
A

advanced directives

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23
Q
  • cardiovascular
  • respiratory
  • central nervous system
  • renal
  • gastrointestinal
  • integumentary
A

Age-related changes in perioperative patients

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24
Q
  • decreased cardiac output, stroke volume, and cardiac reserve
  • decreased peripheral circulation
  • increased vascular rigidity
A

age-related cardiovascular changes (perioperative)

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25
Q
  • obtain and record baseline vital signs
  • assess peripheral pulses
  • teach leg exercises, turning, and explain the purpose of early ambulation after surgery
  • document baseline activity levels and tolerance of fatigue
  • monitor fluid administration rate
  • allow sufficient time for effects of medications to occur; administer the lowest dose possible of medications
A

nursing strategies for age-related cardiovascular changes (perioperative)

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26
Q
  • reduced vital capacity
  • diminished cough reflex
  • decreased oxygenation of blood
  • decreased chest expansion and strength of intercostal muscles and diaphragm
A

age-related respiratory changes (perioperative)

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27
Q
  • obtain and record baseline respiratory depth and rate
  • teach coughing and deep-breathing exercises
  • teach use of incentive spirometer
  • assess color of skin
  • explain use of pulse oximeter for monitoring postoperative oxygenation
A

nursing strategies for respiratory age-related changes (perioperative)

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28
Q
  • obtain and record baseline
A
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29
Q
  • decreased reaction time and coordination
  • reduced short-term memory
  • sensory deficits
  • decreased thermoregulation ability
A

CNS age-related changes (perioperative)

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30
Q
  • orient to surroundings
  • institute safety measures, such as keeping environment clear of clutter and using a night-light
  • allow additional time for teaching, teach-back activities, and questions and answers
  • use appropriate measures to conserve body heat
A

nursing strategies for CNS age-related changes (perioperative)

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31
Q
  • decreased renal blood flow
  • reduced bladder capacity
A

renal age-related changes (perioperative)

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32
Q
  • monitor fluid and electrolytes status
  • maintain and record intake and output
  • provide ready access to toileting
A

nursing strategies for renal age-related changes (perioperative)

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33
Q
  • increased gastric pH
  • prolonged gastric-emptying time
  • decreased hepatic blood flow and enzyme function
A

gastrointestinal age-related changes (perioperative)

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34
Q
  • obtain baseline weight
  • monitor nutritional status (weight, laboratory data)
  • observe for prolonged effects of medication
A

nursing strategies for GI age-related changes (perioperative)

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35
Q
  • decreased vascularity
  • decreased skin moisture and elasticity
  • decreased subcutaneous fat
A

integumentary age-related changes (perioperative)

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36
Q
  • assess skin status
  • monitor fluid status
  • pad and protect bony prominences
  • monitor skin for pressure areas
  • use minimal amounts of tape on dressings and IV sites
  • encourage active and passive range of motion, with repositioning as needed
A

nursing strategies for integumentary age-related changes (perioperative)

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37
Q

instruct the pt to:
- list medications and ask provider which ones should be taken or omitted the morning of surgery
- notify surgeon’s office if a cold or infection develops before surgery
- list all allergies, and be sure OR staff is aware
- follow al instructions from surgeon regarding bathing or showering with special soap
- remove nail polish, do not wear makeup, lotion, or deodorant on day of procedure
- leave all jewelry and valuables at home
- wear clothing that buttons in front, loose, easy to put on
- have someone available to transport you home

notify pt where and when to arrive for procedure and how long it will take

A

preoperative information for outpatient/same-day surgery

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38
Q
  • reduces length of hospital stay
  • cut costs
  • reduce stress for pt
  • preop is very important since they are not staying overnight for observation
A

out-patient/same-day surgery

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39
Q
  • Risk factors in physical and psychosocial factors
  • Developmental level
  • Medical and surgical history (ALLERGIES)
  • Medication history (Rx and OTC)
  • Nutritional status
  • Use of alcohol, illicit drugs, or nicotine
  • Activities of daily living, and occupation
  • Coping patterns and support systems
  • Sociocultural needs
A

Preop Health History

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40
Q
  • Anticoagulants: precipitate hemorrhage
  • Diuretics: electrolyte imbalances, respiratory depression from anesthesia
  • Tranquilizers: increase hypotensive effects of anesthetic agents
  • Adrenal steroids: abrupt withdrawal may cause cardiovascular collapse
  • Antibiotics in myocin group: respiratory paralysis when combined with certain muscle relaxants
A

surgical risk of Rx medications

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41
Q
  • Aspirin and Gingko –> bleeding
  • Echinacea and Kava –> liver damage
  • Garlic supplements –> lower BP
  • Ginseng –> raise BP, rapid HR
  • Ephedra –> Raise BP, abnormal heart rhythms
  • St. John’s Wort –> harder to recover from effects of anesthesia
  • Valerian –> harder to wake after anesthesia, abnormal heart rhythm
A

surgical risks of OTC or Herbal Medications

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42
Q
  • general survey: general state of health, body posture, vital signs
  • integumentary: inspect color, characteristics, location/appearance of any lesions; assess skin over boney prominences; determine turgor
  • respiratory: observe excursion and diameter/shape of thorax; auscultate breath sounds; palpate for tenderness/pain
  • cardio: inspect JVD; auscultate apical rate, rhythm character; auscultate heart sounds; inspect for peripheral edema; palpate strength of peripheral pulses bilaterally
  • GI: last intake of food/water; last BM; inspect abdominal contour; auscultate bowel sounds
  • Neuro: orientation, level of consciousness, awareness, and speech; assess reflexes, motor, sensory ability, visual, and hearing ability
  • Musculoskeletal: inspect joint range of motion; palpate muscle strength; assess ambulation
A

focused preop physical assessment

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43
Q
  • risk surgeries do not require AEB
  • readiness Dx do not require R/T statements

Dx impaired comfort
R/T
- insufficient environmental and situational control: impending surgery
- insufficient resources
AEB
- fear
- inability to relax
- irritability, restlessness, sighing
- uneasy in situation: verbalizations of distress, worry, being afraid

Dx risk for infection
R/T
- alteration in peristalsis
- alteration in skin integrity
- obesity
- smoking
- stasis of body fluid

A

preop nursing diagnosis

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44
Q
  • Verbalize physical and emotional readiness for surgery
  • Demonstrates and verbalizes understanding of coughing, turning, deep-breathing, use of incentive spirometry, leg exercises, and early
  • Verbalizes expectations of postoperative pain management
  • Maintains fluid intake and nutritional balance to meet healing needs
A

preop outcome identification and planning

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45
Q
  • check informed consent
  • gather needed equipment and supplies
  • hand hygiene
  • check vital signs and inform provider of pertinent changes
  • verify adherence to food and fluid restriction
  • instruct pt to remove clothing and change into gown
  • give valuable to family members
  • have pt empty bladder
  • attend to special preop orders (IV)
  • complete preop checklist
  • administer preop medications as prescribed
  • help move pt from bed to stretcher
  • tell family where pt will be after surgery and show them the waiting room
  • prepare room for post
A

preop implementation

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46
Q

We know it is effective if pt is physically and emotionally ready for surgery, verbalizes expected events and sensations of perioperative period, and demonstrates postoperative exercises and activities

A

preop evaluation

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47
Q
  • Patient identification/verification process
    ○ Name, DOB, consents, preop checklist information (esp. factors that may increase surgical risk)
  • Final verification just prior to beginning the procedure, time-out
    ○ Team agree on ID of patient, correct surgical site (marked by surgeon), and the procedure to be performed
  • Patient –> anesthetized, positioned, prepped, and draped
  • Nurse continually assesses patient during procedure and monitors supplies used to maintain safety
A

intraoperative assessment

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48
Q
  • dx risk for imbalanced fluid volume R/T potential risk factors: hemorrhage, failure of regulatory mechanisms, administration of fluids in operating room
  • dx risk for perioperative positioning injury R/T immobilization; can be impacted by associated conditions including: disorientation, edema, emacification, muscle weakness, obesity, and sensoriperceptual disturbance from anesthesia
A

intraoperative nursing diagnosis

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49
Q
  • Remain free of neuromuscular injury
  • Remain free from wrong-site, wrong-side, wrong-patient surgical procedure
  • Maintain fluid and electrolyte balance
  • Maintain skin integrity (other than for the incision)
  • Have symmetric breathing patterns
  • Be free of injury from burns, retained surgical items (inaccurate count of sharps, instruments, and soft goods such as surgical sponges used during the procedure), and medication errors
  • Remain free from surgical site infection
    Maintain normothermia
A

intraoperative outcome identification and planning

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50
Q
  • Positioning
  • Draping
  • Documentation: Patient assessment, item counts, vital signs, urine output, blood loss, pulse oximetry, body temp, positioning, medications, dressings and drains, specimens, equipment used, and responses to care
  • Transferring to the PACU: Handoff: patients care, procedure, tourniquet time, drains, medications used, presenting conditions, patient response
A

intraoperative implementation and evaluation

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51
Q
  • Respiratory status
    ○ RR, rhythm, depth, breath sounds, SPO2, CO2 skin color, return of gag reflex, airway patency
  • Cardiovascular status
    ○ ECG/HR and rhythm, skin color, BP, peripheral pulses bilaterally, hypothermia, shivering
  • CNS status
    ○ Level of alertness (unconscious –> responds to touch/sounds –> drowsiness –> awake/not oriented –> awake/oriented), movement
  • Fluid status
    ○ Skin turgor, v/s/, urine output, wound drainage, IV fluid intake, blood products
  • Wound status
    ○ Dressing over incision: amount, consistency, color of drainage, any tube or drains and amount and type of drainage
  • Gastrointestinal status
    ○ Nausea/vomiting
  • Pain assessment
  • General condition
A

immediate postoperative assessment (Q10-15 min)

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52
Q
  • vital signs and oxygen saturation
  • color and temperature of skin
  • level of consciousness
  • intravenous fluids
  • surgical site
  • other tubes
  • comfort
  • position and safety
A

ongoing postoperative assessment

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53
Q

dx acute pain R/T physical injury agent: surgical procedure AEB…
- change in physiologic parameters
- self-report or evidence of pain characteristics using standardized pain instrument
- self-focused
- positioning to ease pain
- guarding behavior

dx risk for delayed surgical recovery R/T
- malnutrition
- obesity
- pain
- postoperative emotional response

A

postoperative nursing diagnosis

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54
Q
  • Carry out leg (including foot and ankle) exercises every 2-4 hours
  • Deep breathe and cough effectively every 2 hours
  • Engage in early ambulation
  • Verbalize decreasing levels of pain
  • Regain and maintain a balanced intake and output
  • Regain normal bowel and bladder elimination
  • Exhibit a healing surgical incision
  • Remain free of infection
  • Verbalize any concerns about appearance of wound
  • Verbalize and demonstrate would self-care
A

postoperative outcome identification and planning

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55
Q
  • Preventing cardiovascular complications
    ○ Hemorrhage, shock, thrombophlebitis/venous thromboembolism
  • Preventing respiratory complications
    ○ Pulmonary embolism, atelectasis, pneumonia
  • Preventing surgical site complications
  • Promote a return to health
    ○ Elimination needs, fluids/nutrition needs, comfort/rest needs
  • Helping patient cope
  • Providing outpatient surgery postoperative care
  • Evaluation
A

postoperative implementation and evaluation

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56
Q

Leading causes of mortality in US

A

Heart disease

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57
Q
  • Vital for exchange of gases
  • Composed of the heart and the blood vessels
  • The heart is a cone shaped, muscular pump, divided into four hollow chambers
  • The upper chambers, the atria (singular, atrium), receive blood from the veins (the superior and inferior vena cava and the left and right pulmonary veins).
  • The lower chambers, the ventricles, force blood out of the heart through the arteries (the left and right pulmonary arteries and the aorta).
A

Cardiovascular system

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58
Q
  • Dysrhythmia or arrhythmia
  • Myocardial ischemia
  • Angina
  • Myocardial infarction
  • Heart failure
A

Alterations in the cardiovascular system

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59
Q
  • Level of health
  • Developmental considerations
  • Medication considerations
  • Lifestyle considerations
  • Environmental considerations
  • Psychological health considerations
A

Factors affecting cardiopulmonary functioning and oxygenation

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60
Q
  • Hypoxia - not enough oxygenated blood
  • Ischemia - inadequate supply of blood
    ○ Ex. Blood clot
  • Cyanosis - discoloration of skin, blue/gray, lack of deoxygenated blood
  • Angina - pain from ischemia
  • Cardiac output: amount of blood ejected from the left ventricle over 1 minute
  • Tachycardia: fast heart rate (>100 bpm)
  • Bradycardia: slow heart rate (<60 bpm)
  • Myocardial infarction: death of heart muscle due to lack of blood flow
A

Perfusion Vocabulary

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61
Q

Cardiovascular
- Apical:
○ Rhythm: regular / irregular / regularly irregular
- monitor (telemetry): NSR / …etc
○ Quality: strong / distant / muffled
○ Murmurs/rubs/gallops: present? Extra heart sounds?
- Pain: discomfort / heaviness / pressure / crushing / radiation to where? arm / shoulder / jaw
- Vascular: Skin color: pink / pallor / ashen / dusky / cyanotic / flushed
○ Skin Temperature: warm / cool / cold to touch
○ Nail beds: capillary refill < 3 secs / 3 secs / > 3 secs
- Pulses (brachial, radial, femoral, popliteal, posterior tibial, pedal) quality: absent / thready / weak / diminished /equal / unequal / palpable / strong / bounding / present only with Doppler
- Edema: periorbital / anasarca / hands / peripheral pitting: 0 / 1+ / 2+ / 3+ / 4+

A

From “Nursing Assessment Phrasing”

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62
Q
  • CLASS: RESPIRATORY FUNCTION
    • Impaired gaseous exchange
  • CLASS: CARDIOVASCULAR/PULMONARY
    • Activity intolerance
    • Risk for activity intolerance
    • Ineffective breathing pattern
    • Decreased cardiac output
    • Risk for decreased cardiac output
    • Risk for ineffective gastrointestinal perfusion
    • Risk for ineffective renal perfusion
    • Impaired spontaneous ventilation
    • Risk for decreased cardiac tissue perfusion
    • Risk for ineffective cerebral tissue perfusion
    • Risk for ineffective peripheral tissue perfusion
    • Ineffective peripheral tissue perfusion
    • Dysfunctional ventilatory weaning response
      • Risk for impaired cardiovascular function
A

“NANDA Nsg Dx” - Domain 4 – ACTIVITY/REST

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63
Q
  • popliteal (behind knee)
  • dorsalis pedis (on top of foot)
  • posterior tibial artery (inside ankle)
  • if you can’t find, use doppler
A

peripheral pulses

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64
Q
  • Cardiac coronary catheterization
  • Cardiac exercise stress testing
  • Echocardiogram
  • Endoscopic studies
  • Holter monitor
  • Lung scan
  • Skin tests
  • Radiography
A

Common diagnostic methods to assess cardiopulmonary function

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65
Q
  • Amount of blood ejected from left ventricle x HR; Stroke rate x HR
  • Measured by invasive hemodynamic monitoring or by echocardiogram
  • Indirect measures of CO
    • 2+ pulses
    • Skin warm & dry
    • Good capillary refill
    • BP WNL
    • Good UO
    • Clear Sensorium
    • HR WNL
    • RR WNL
    • Clear breath sounds
A

Cardiac Output

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66
Q
  • Partial pressure of oxygen (PaO2)
  • Partial pressure of carbon dioxide (PaCO2)
  • pH
  • Bicarbonate (HCO3)
  • If you think your pt has an ABG the first thing you should do is pulse ox. ABG is more accurate and thorough
A

Collecting arterial blood gas (ABG) sample

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67
Q
  • either side of sternum (V1-2)
  • one next to left sternum (V3)
  • midclavicular line (V4)
  • anterior axillary line (V5)
  • midaxillary line (V6)
  • right arm
  • right leg
  • left arm
  • left leg
A

Cardiac rhythm monitoring: 12-lead ECG

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68
Q

“clouds over sky; smoke over fire”
brown in middle

A

telemetry

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69
Q
  • P wave: atrial depolarization
  • QRS complex
  • ventricular contraction
  • T wave: ventricular depolarization
  • ventricular filling phase: cardiac muscles are completely depolarized
A

electrical conduction represented on ECG

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70
Q
  • R wave = ventricular rate
  • P wave = atrial rate
  • Is there a P wave for every R?
  • Is rhythm regular?
    6 seconds x 10 = 60 seconds
A

normal sinus rhythm

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71
Q
  • HR over 140/min or less than 40/min
  • RR over 28/min or less than 8/min
  • Systolic BP > 180 mmHg or < 90 mmHg
  • O2 Sat less than 90% despite O2 supplementation, deep breathing and coughing efforts, etc.
  • Acute change in mental status
  • Urine output < 30 cc in 1 hour
  • Staff, family, or visitor has significant concern about the patient’s condition
A

rapid response

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72
Q
  • Person has stopped breathing
  • Person has no pulse
  • Unable to determine if the person has a pulse or if they are breathing, and is unresponsive
A

call a code

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73
Q

1) assess patient’s description of chest discomfort and effect of coronary ischemia on perfusion to the heart (change in BP/rhythm), brain (change in LOC), kidneys (decrease urine output), skin (color/temp)
2) Dx risk for decreased cardiac tissue perfusion R/T reduced coronary blood flow
3) Planning: pt reports beginning relief of chest discomfort and symptoms; adequate cardiac output AEB stable/improving ECG
4) Implementation: administer oxygen, continuous ECG, administer medication therapy, ensure physical rest
5) Evaluation

A

ADPIE for myocardial infarction

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74
Q
  • Atherosclerosis (plaque deposits on wall of arteries), can fully occlude or clot can break off and cause occlusion (CVA, MI)
  • Thrombus can form in vein and if it enters circulation = embolism (DVT)
A

Clotting

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75
Q

Immobility, pregnancy or hormonal contraception, surgery or trauma, indwelling devices such as catheters, other co-morbidities such as cancer, older age…

A

venous thromboembolism (VTE)

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76
Q

1) decreased blood flow to skin and GI tract: cold, clammy hands; pale, ashen, cyanotic skin; decreased bowel sounds; diarrhea/constipation
2) decreased blood flow to kidneys, liver, lungs: increased RR, BUN, Cr, K, ALT/AST; decreased SpO2, urine output
3) Decreased blood flow to brain and heart: LOC, disorientation; slow pupils; CP, pressure; change in HR; ST elevation

A

clinical assessment of VTE

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77
Q
  • Integrity of the airway system to transport air to and from lungs
  • Properly functioning alveolar system in lungs
    • Oxygenates venous blood
    • Removes carbon dioxide from blood
  • Properly functioning cardiovascular and hematologic systems
    * Carry nutrients and wastes to and from body cells
A

Factors essential to normal functioning of the respiratory system

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78
Q
  • Function: warm, filter, humidify inspired air
  • Components
    • Nose
    • Pharynx
    • Larynx
    • Epiglottis
A

Upper Airway

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79
Q
  • Functions: conduction of air, mucociliary clearance, production of pulmonary surfactant
  • Components
    • Trachea
    • Right and left mainstem bronchi
    • Segmental bronchi
    • Terminal bronchioles
A

Lower Airway/Tracheobronchial Tree

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80
Q
  • Inspiration: the active phase of ventilation
    • Involves movement of muscles and the thorax to bring air into the lungs
  • Expiration: the passive phase of ventilation
    * Movement of air out of the lungs
A

Pulmonary Ventilation

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81
Q

Which respiratory organ is the site of gas exchange?

A

alveoli

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82
Q
  • Level of health
  • Developmental considerations
  • Medication considerations
  • Lifestyle considerations
  • Environmental considerations
  • Psychological health considerations
A

Factors affecting cardiopulmonary functioning and oxygenation

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83
Q
  • Orthopnea: positional breathing problem; laying down; COPD pt
  • CHF: fluid filling lungs
  • Tachypnea: fast breathing >20
  • Apnea: stopping breath; sleep apnea
  • Crackles: popping sounds; fluid in alveoli
  • Wheezing: whistling sound; expiration; narrowed airway; inflammation or edema of bronchi
  • Kussmaui respirations - diabetes
  • Dyspnea - pain or difficulty breathing
A

Respiratory vocabulary

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84
Q
  • Mucous Membranes: pink / pale / cyanotic/ reddened / dry / moist
    • Breath sounds: clear / diminished / absent / wheezing / stridor / crackles / rhonchi / friction rub / bilateral
    • Pattern: unlabored / labored Rhythm: even / uneven / shallow / deep / nasal flaring /
    • Chest expansion: symmetrical / asymmetrical Chest shape: normal / barrel-shaped / symmetrical
    • Accessory muscles: retractions: mild, moderate, severe location?
    • Cough: quality: dry / hacking / loose / moist / harsh / croupy / barking
      • frequency: infrequent / occasional / frequent
      • productive - sputum consistency: thin / thick / tenacious / mucous
      • amount: small / moderate / copious color: clear / yellow / green / blood-tinged / hemoptysis
    • Pulse oximetry: continuous / intermittent
    • Supplemental oxygen: cannula/mask/ET-ventilator settings: O2%, O2 flow rate, humidification, vent settings…
A

Nursing Assessment Phrasing

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85
Q

CLASS: RESPIRATORY FUNCTION
* Impaired gaseous exchange
CLASS: CARDIOVASCULAR/PULMONARY
* Activity intolerance
* Risk for activity intolerance
* Ineffective breathing pattern
* Decreased cardiac output
* Risk for decreased cardiac output
* Risk for ineffective gastrointestinal perfusion
* Risk for ineffective renal perfusion
* Impaired spontaneous ventilation
* Risk for decreased cardiac tissue perfusion
* Risk for ineffective cerebral tissue perfusion
* Risk for ineffective peripheral tissue perfusion
* Ineffective peripheral tissue perfusion
* Dysfunctional ventilatory weaning response
* Risk for impaired cardiovascular function

A

From “NANDA Nsg Dx” - Domain 4 – ACTIVITY/RESP

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86
Q
  • Determine why the patient needs nursing care.
  • Determine what kind of care is needed to maintain a sufficient intake of air.
  • Identify current or potential health deviations.
  • Identify actions performed by the patient for meeting respiratory needs.
  • Make use of aids to improve intake of air and effects on patient’s lifestyle and relationship with others.
A

Guidelines for obtaining a nursing history

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87
Q
  • Why would patients with cardiac or renal problems have subsequent respiratory problems?
  • What about chronic illness overall leading to muscle weakness…how could this affect respiratory function?
  • What class of medication can cause respiratory depression?
  • How big of a concern is cigarette smoking?
  • Encourage cardiopulmonary fitness
  • Don’t dismiss the importance of environmental factors
A

Risk factors

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88
Q
  • Lungs are transformed from fluid-filled structures to air-filled organs.
  • The infant’s chest is small, airways are short, and aspiration is a potential problem.
  • Respiratory rate is rapid and respiratory activity is primarily abdominal.
  • Synthetic surfactant can be given to the infant to reopen alveoli.
  • Crackles heard at the end of deep respiration are normal.
A

Respiratory Activity in the Infant

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89
Q
  • Bony landmarks are more prominent due to loss of subcutaneous fat.
  • Kyphosis contributes to appearance of leaning forward.
  • Barrel chest deformity may result in increased anteroposterior diameter.
  • Tissues and airways become more rigid; diaphragm moves less efficiently.
  • Older adults have an increased risk for disease, especially pneumonia.
A

Respiratory Functioning in the Older Adult

90
Q
  • Supine - back
  • Semi-fowler - 30-45 degrees
  • High-fowler - 60-90 degrees
  • Prone - stomach
A

Patient Positioning

91
Q
  • Vesicular: low-pitched, soft sound during expiration heard over most of the lungs
  • Bronchial: high-pitched and longer, heard primarily over the trachea
  • Bronchovesicular: medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area
A

Breath Sounds

92
Q
  • Crackles: intermittent sounds occurring when air moves through airways that contain fluid
    • Classified as fine, medium, or coarse
  • Wheezes: continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors
    * Classified as sibilant or sonorous
A

Abnormal (Adventitious) Lung Sounds

93
Q

True or False: Wheezes are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors

A

True

94
Q
  • Tidal Volume (TV)
  • Vital Capacity (VC)
  • Forced Vital Capacity (FVC)
  • Forced Expiratory Volume (FEV)
  • Total Lung capacity (TLC)
  • Residual Volume (RV)
  • Peak Expiratory Flow Rate (PEFR)
A

Values measured from pulmonary function tests

95
Q
  • Nasal cannula
  • Nasopharyngeal catheter
  • Transtracheal catheter
  • Simple mask
  • Partial rebreather mask
  • Nonrebreather mask
  • Venturi mask
  • Tent
A

Oxygen Delivery System

96
Q
  • 1L - 24%
  • 2L - 28%
  • 3L - 32%
  • 4L - 36% - extremely drying; without an order can add humidification to prevent dry nasal mucosa
  • 5L - 40%
  • 6L - 44%
  • Normal pulse ox reading: 95-100
  • We breathe in 20-21% in room air
A

Nasal Cannula

97
Q

oxygen delivery by mass has a ______ flow

A

higher

98
Q
  • Avoid open flames in the patient’s room.
  • Place “no smoking” signs in conspicuous places.
  • Check to see that electrical equipment in the room is in good working order.
  • Avoid wearing and using synthetic fabrics (builds up static electricity).
  • Avoid using oils in the area (oils ignite spontaneously in oxygen).
A

Precautions for Oxygen Administration

99
Q
  • Oropharyngeal and nasopharyngeal airway
  • Endotracheal tube
  • Tracheostomy tube
A

Types of Artificial Airways

100
Q

1) Cuffless
2) Cuffed

A

Two types of tracheostomy

101
Q
  • Claustrophobia
  • Skin
  • Challenges with exhalation
  • Hi-Flow NC
A

CPAP vs. BiPAP

102
Q
  • Suction to get mucus out
  • Hyperoxygenate pt
A

Tracheostomy

103
Q
  • Chest Compressions: Check the pulse. If the victim has no pulse, initiate chest compressions to provide artificial circulation.
  • Airway: Tilt the head and lift the chin; check for breathing. The respiratory tract must be opened so that air can enter.
  • Breathing: If the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1 second each.
  • Defibrillation: Apply the AED as soon as it is available.
A

Administering Cardiopulmonary Resuscitation (CAB)

104
Q

Dx inflective airway clearance related to bronchoconstriction, increased mucus production, and ineffective cough as manifested by frequent weak cough, inability to consistently expectorate sputum, presence of sonorous wheezes (rhonchi)

outcome: by 3/20/23, pt will, cough effectively and expectorate sputum

intervention: assess respiratory status at least every four hours, teach importance of adequate hydration

A

respiratory NANDA example

105
Q
  • Assist with insertion and removal of the chest tube.
  • Monitor the patient’s respiratory status and vital signs.
  • Check the dressing.
  • Maintain the patency and integrity of the drainage system.
A

Managing Chest Tubes

106
Q
  • Teaching about a pollution-free environment
  • Promoting optimal function
  • Promoting comfort
  • Promoting proper breathing
  • Managing chest tubes
  • Promoting and controlling coughing
  • Suctioning the airway
  • Meeting oxygenation needs with medications
A

Nursing interventions promoting adequate respiratory functioning

107
Q
  • Cough suppressants
  • Expectorants
  • Lozenges
A

Types of cough medications

108
Q
  • Bronchodilators: open narrowed airways
  • Nebulizers: disperse fine particles of liquid medication into the deeper passages of the respiratory tract
  • Meter-dose inhalers: deliver a controlled dose of medication with each compression of the canister
  • Dry powder inhalers: breath-activated delivery of medications
A

Administering Inhaled medications

109
Q
  • Positioning
  • Maintaining adequate fluid intake
  • Providing humidified air
  • Performing chest physiotherapy
A

Promoting comfort

110
Q
  • Deep breathing
  • Using incentive spirometry
  • Pursed-lip breathing
  • Diaphragmatic breathing
A

Promoting proper breathing

111
Q
  • Demonstrate improved gas exchange in lungs by absence of cyanosis or chest pain and a pulse oximetry reading >95%.
  • Relate the causative factors and demonstrate adaptive method of coping
  • Preserve pulmonary function by maintaining an optimal level of activity.
  • Demonstrate self-care behaviors that provide relief from symptoms and prevent further problems.
A

Planning: Expected Outcomes

112
Q
  • Primary organ of bowel elimination
  • Extends from the ileocecal valve to the anus
  • Functions
    ○ Absorption of water
    ○ Formation of feces
    ○ Expulsion of feces from the body
A

Large intestine

113
Q
  • under control of the nervous system
  • Contractions occur every 3-12 minutes
  • Mass peristalsis sweeps occur one to four times each 24-hour period
  • 1/3 to 1/2 of food waste is excreted in stool within 24 hours
A

Process of Peristalsis

114
Q

the inability of the anal sphincter to control the discharge of fecal and gaseous material

A

Bowel incontinence

115
Q

an opening into the colon that permits feces to exit through the stoma

A

Colostomy

116
Q

passage of dry, hard fecal material

A

Constipation

117
Q

passage of liquid and unformed stools

A

Diarrhea

118
Q

direct visualization of hollow organs of the body using an endoscope (a flexible, lighted tube)

A

Endoscopy

119
Q

introduction of solution into the lower bowl

A

Enema

120
Q

collection in the rectum of hardened feces that cannot be passed

A

Fecal impaction

121
Q

involuntary or inappropriate passing of stool or flatus

A

fecal incontinence

122
Q

moisture-associated skin breakdown caused by prolonged contact of the skin with urine or feces

A

Incontinence-associated dermatitis

123
Q

blood present in such minute quantities that it cannot be detected with the unassisted eye

A

Occult blood

124
Q

general term referring to an artificial opening; usually used to refer to an opening created for the excretion of body wastes

A

Ostomy

125
Q

paralysis of intestinal peristalsis

A

Paralytic ileus

126
Q

artificial opening for waste excretion located on the body surface

A

Stoma

127
Q

forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure

A

Valsalva maneuver

128
Q
  • Developmental consideration
  • Daily patterns
  • Flood and fluid
  • Activity and muscle tone
  • Lifestyle
  • Psychological variables: Anxiety
  • Pathologic conditions: C.Diff
  • Medications: Any drug that causes GI bleeding can cause the stool to look red or black
    § Blood thinners, anticoagulants, aspirin
    § Pepto Bismal
    ○ Iron - black
  • Diagnostic studies
  • Surgery and Anesthesia: Opioids cause constipation - need Stool softener
A

Factors affecting bowel elimination

129
Q
  • Constipating foods: cheese, lean meat, eggs, pasta
  • Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee
  • Gas-producing foods: onions, cabbage, beans, cauliflower
A

Foods affecting bowel elimination

130
Q
  • Infants: Characteristics of stool and frequency depend on formula or breast feedings.
  • Toddler: Physiologic maturity is the first priority for bowel training.
  • Child, adolescent, adult: Defecation patterns vary in quantity, frequency, and rhythmicity.
  • Older adult: Constipation is often a chronic problem; diarrhea and fecal incontinence may result from physiologic or lifestyle changes.
A

Developmental Considerations

131
Q
  • Never buy food with damaged packaging.
  • Take items requiring refrigeration home immediately.
  • Wash hands and surfaces often.
  • Use separate cutting boards for foods.
  • Thoroughly wash all fruits and vegetables before eating.
  • Do not wash meat, poultry, or eggs to prevent spreading microorganisms to sink and other kitchen surfaces.
  • Never use raw eggs in any form.
  • Do not eat seafood raw or if it has an unpleasant odor.
  • Use a food thermometer to ensure cooking food to safe internal temperature.
  • Keep food hot after cooking; maintain safe temperature of 140°F or above.
  • Give only pasteurized fruit juices to small children.
A

Preventing Food Poisoning

132
Q

IAPP
1) Inspection
2) Auscultation
3) Palpation
4) Percussion

A

Nursing Care Plan for Bowel Elimination

133
Q
  • Distension
  • Swelling
  • Movements
  • Parastolisis
  • Shape and contour of abdomen
A

Inspection

134
Q
  • usual patterns of bowel elimination (frequency/time of day/description/straining/impaction)
  • aids to elimination (natural aids/pharmacologic/enemas)
  • recent changes in bowel elimination (color/blood/appearance)
  • problems with bowel elimination (onset/frequency/causes/severity/interventions attempted)
  • presence of artificial orifices (normal routine, history of problems)
A

Focused Assessment Bowel Elimination

135
Q

1) Separate hard lumps, like nuts (hard to pass) - Constipation
2) Sausage-shaped but lumpy - Diarrhea
3) Like a sausage but with cracks on its surfaces - Normal
4) Like a sausage or snake, smooth and soft - Normal
5) Soft blobs with clear-cut edges (passes easily)
6) Fluffy pieces with ragged edges, a mushy stool
7) Water, no solid pieces (entirely liquid)

A

Bristol stool Chart

136
Q
  • Aspirin, anticoagulants: pink to red to black stool
  • Iron salts: black stool
  • Bismuth subsalicylate used to treat diarrhea can also cause black stools.
  • Antacids: white discoloration or speckling in stool
  • Antibiotics: green-gray color
A

Effect of Medication on Stool

137
Q
  • Patients on bedrest taking constipating medicines
  • Patients with reduced fluids or bulk in their diet
  • Patients who are depressed
  • Patients with central nervous system disease or local lesions that cause pain while defecating
A

Individuals at High Risk for Constipation

138
Q

The sequence for abdominal assessment proceeds from inspection, auscultation, and percussion to palpation.
* Inspection: observe contour, any masses, scars, or distention
* Auscultation: listen for bowel sounds in all quadrants
○ Note frequency and character, audible clicks, and flatus.
○ Describe bowel sounds as hypoactive, hyperactive, absent or infrequent
* Percussion and palpations: performed by advanced practice professionals

A

Physical Assessment of the Abdomen

139
Q

Inspection and palpation
○ Lesions, ulcers, fissures (linear break on the margin of the anus), inflammation, and external hemorrhoids
○ Ask the patient to bear down as though having a bowel movement. Assess for the appearance of internal hemorrhoids or fissures and fecal masses.
○ Inspect perineal area for skin irritation secondary to diarrhea or fecal incontinence.

A

Physical Assessment of the Anus and Rectum

140
Q
  • Medical aseptic technique is imperative.
  • Hand hygiene, before and after glove use, is essential.
  • Wear disposable gloves.
  • Do not contaminate outside of container with stool.
  • Obtain stool and package, label, and transport according to agency policy.
A

Stool Collection

141
Q
  • Void first so that urine is not in stool sample.
  • Defecate into the container rather than toilet bowl.
  • Do not place toilet tissue in the bedpan or specimen container.
  • Avoid contact with soaps, detergents, and disinfectants as these may affect test results.
  • Notify nurse when specimen is available.
A

Patient Guidelines for Stool Collection

142
Q

True or False: When collecting stool using the technique “timed specimen” the nurse should consider the first stool passed by the patient as the start of the collection period

A

True

143
Q
  • Stool Collection
    ○ Stool culture
    ○ Occult blood (e.g., gFOBT, FIT)
  • Direct Visualization Studies
    ○ Endoscopy (e.g., EGD, colonoscopy, sigmoidoscopy)
  • Indirect Visualization Studies
    ○ Radiography (e.g., x-ray, fluoroscopy, MRI, CT, abdominal ultrasound)
A

Diagnostic Studies

144
Q

Which of the following direct visualization tests uses a long, flexible, fiberoptic–lighted scope to visualize the rectum, colon, and distal small bowel?

A

Colonoscopy

145
Q
  • Upper gastrointestinal (UGI)
  • Small bowel series
  • Barium enema
  • Abdominal ultrasound
  • Magnetic resonance imaging (MRI)
  • Abdominal CT scan
A

Indirect Visualization Studies

146
Q

1: fecal occult blood test
2: barium studies (should precede UGI)
3: endoscopic examinations
Noninvasive procedures take precedence over invasive procedures

A

Scheduling Diagnostic Tests

147
Q
  • slowing of gastrointestinal motility with increased stomach-emptying time
  • decreased muscle tone/incontinence
  • weakening of intestinal walls with great incidence of diverticulitis
A

age-related changes affecting bowel elimination

148
Q
  • encourage small, frequent meals
  • discourage heavy activity after eating
  • encourage a high-fiber, low-fat diet
  • encourage adequate fluid intake
  • discourage regular use of laxatives
  • develop a daily routine to move bowels. the optimal time is 2 hours after waking up and after breakfast
  • evaluate medication regimen for possible adverse effects
A

Nursing strategies for slowing of gastrointestinal motility with increased stomach-emptying time

149
Q
  • provide easy access to bathroom
  • use assistive devices when necessary
  • ensure safety when ambulating
  • encourage participation in a bowel-retraining program
A

Nursing strategies for decreased muscle tone/incontinence

150
Q
  • encourage a high-fiber diet and adequate fluid intake
  • teach patients not to ignore the urge to have a bowel movement
  • encourage regular exercise
A

Nursing strategies for weakening of intestinal walls with great incidence of diverticulitis

151
Q

R/T
- adverse effects of pharmaceutical agents
- abuse of laxatives
- emotional stress
- intestinal infection
- colon disease
- radiation

AEB
- at least 3 loose, liquid stools per day, increased frequency
- urgency
- reports of abdominal pain and/or cramping
- hyperactive bowel sounds

A

dx diarrhea

152
Q

R/T
- dietary habits
- general decline in muscle tone
- laxative abuse
- rectal sphincter abnormality
- cognitive impairment

AEB
- involuntary passage of stool
- “I couldn’t get to bathroom or on bed pan fast enough”
- “It came so fast, I couldn’t hold back”
- constant dribbling of soft stool

A

dx bowel incontinence

153
Q

R/T
- insufficient fluid intake
- insufficient fiber intake
- inactivity
- delaying defecation when urge is present
- abuse of laxatives

A

risk for constipation

154
Q
  • Have a soft, formed bowel movement without discomfort
  • Explain the relationship between bowel elimination and dietary fiber, fluid intake, and exercise
  • Relate the importance of seeking medical evaluation if changes in stool color or consistency persist
  • Maintain skin integrity
A

Outcomes Identification and Planning (Bowel elimination)

155
Q
  • Promoting regular bowel habits e.g., timing, positioning, privacy, nutrition, physical activity/exercise
  • Providing comfort measures
  • Preventing and treating constipation/diarrhea
  • Decreasing flatulence
  • Emptying the colon of feces
    ○ e.g., cleansing enemas, retention enemas, rectal suppositories, oral intestinal lavage, digital removal of stool
  • Managing bowel incontinence
    ○ e.g., incontinence-associated dermatitis, indwelling rectal tube
    ○ Provide skin care (e.g., wash frequently, barrier creams/ointments)
  • Bowel retraining programs
  • Maintaining a NG tube
    ○ e.g., Levin tube, salem sump
  • Bowel diversions e.g., colostomy, ileostomy
A

Implementing (Bowel Elimination)

156
Q

1) hand hygiene and PPE
2) identify patient
3) assessment and explain purpose
4) scann patient band
5) gloves
6) assist pt into sims position on left side. drape
7) lubricate suppository and index finger of dominant hand
8) separate butt cheeks with nondom hand and instruct pt to breathe slowly and deep through mouth
9) using index finger, insert suppository 3-4 inc
10) use toilet tissue to clean up, remain on side for 5 minutes
11) clean up
12) document

A

Inserting Rectal Suppository

157
Q

1) explain procedure
2) have second person to assist
3) place pt in sim’s position. drape. place pad underneath
4) use bedpan and have toilet paper ready
5) use nonsterile gloves and lubricate index finger
6) slowly use index finger to break up mass and instruct pt to bear down
7) can use oil-retention enema if necessary
8) clean patient
9) document

A

Digital Removal of Fecal Impaction

158
Q
  • Encourage recommended diet and exercise.
  • Use medications only as needed.
  • Apply ointments or astringent (witch hazel).
  • Use suppositories that contain anesthetics.
A

Comfort Measures

159
Q
  • Manipulate factors within the patient’s control.
  • Food and fluid intake, exercise, and time for defecation
  • Eliminate a soft, formed stool at regular intervals without laxatives
  • When achieved, continue to offer assistance with toileting at the successful time.
A

Bowel-Training Programs

160
Q
  • Answer call bells immediately.
  • Remove the cause of diarrhea whenever possible (e.g., medication).
  • If there is impaction, obtain physician order for rectal examination.
  • Give special care to the region around the anus.
A

Nursing Measures for the Pt with Diarrhea

161
Q
  • Inserted to decompress or drain the stomach of fluid or unwanted stomach contents
  • Used to allow the gastrointestinal tract to rest before or after abdominal surgery to promote healing
  • Inserted to monitor gastrointestinal bleeding
A

Nasogastric Tubes

162
Q
  • Sigmoid colostomy (near pubic bone)
  • Descending colostomy (LLQ)
  • Transverse colostomy (Top middle)
  • Ascending colostomy (Right middle)
  • Ileostomy (Deep above sigmoid)
A

Types of Ostomies

163
Q
  • Keep the patient as free of odors as possible; empty the appliance frequently.
  • Inspect the patient’s stoma regularly.
    ○ Note the size, which should stabilize within 6 to 8 weeks.
    ○ Keep the skin around the stoma site clean and dry
  • Measure the patient’s fluid intake and output
  • Explain each aspect of care to the patient and self-care role.
  • Encourage patient to care for and look at ostomy.
A

Colostomy Care

164
Q
  • Explain the reason for bowel diversion and the rationale for treatment.
  • Demonstrate self-care behaviors that effectively manage the ostomy.
  • Describe follow-up care and existing support resources.
  • Report where supplies may be obtained in the community.
  • Verbalize related fears and concerns.
  • Demonstrate a positive body image.
  • Educate pt on dietary considerations for patients with an ileostomy or colostomy
A

Patient Teaching for Colostomies

165
Q
  • Verbalize the relationships among bowel elimination and nutrition, fluid intake, exercise, and stress management.
  • Develop a plan to modify any factors that contribute to current bowel problems or that might adversely affect bowel functioning in the future.
  • Promote bowel functioning as appropriate for the person.
  • Provide care for bowel diversion and know when to notify the primary care provider.
A

Evaluation (Bowel Elimination)

166
Q
  • Enemas
  • Rectal suppositories
  • Oral intestinal lavage
  • Digital removal of stool
A

Methods of Emptying the Colon of Feces

167
Q
  • Cleansing
  • Retention
    ○ Oil
    ○ Carminative
    ○ Medicated
    ○ Anthelmintic
  • Large volume
  • Small volume
A

Types of Enemas

168
Q
  • Oil-retention: lubricate the stool and intestinal mucosa, easing defecation
  • Carminative: help expel flatus from the rectum
  • Medicated: provide medications absorbed through the rectal mucosa
  • Anthelmintic: destroy intestinal parasites
A

Retention of Enemas

169
Q

lack or loss of appetite for food.

A

Anorexia

170
Q

measurements of the body and body parts

A

Anthropometric

171
Q

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

A

Aspiration

172
Q

ratio of height to weight

A

Body Mass Index (BMI)

173
Q

amount of energy required to carry out involuntary activities of the body at rest

A

Basal Metabolism

174
Q

difficulty in swallowing or inability to swallow

A

Dysphagia

175
Q

alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula

A

Enteral Nutrition

176
Q

feeding remaining in the stomach

A

Gastric Residual

177
Q

opening created into the stomach

A

Gastrostomy

178
Q

tube inserted through the nose and into the stomach

A

Nasogastric (NG) Tube

179
Q

tube inserted through the nose and into the upper portion of the small intestine

A

Nasointestinal (NI) Tube

180
Q

nothing by mouth (Latin: nil per os)

A

NPO

181
Q

Parenteral Nutrition (PN)

A

nourishment provided via IV therapy

182
Q

surgically (open or laparoscopically) placed gastrostomy tube

A

Percutaneous Endoscopic Gastrostomy (PEG)

183
Q

prescribed for patients who require nutrient supplementation through a peripheral vein because they have an inadequate intake of oral feedings

A

Peripheral Parenteral Nutrition (PPN):

184
Q

a numerical measurement of the waist, used to assess an individual’s abdominal fat and establish ideal body weight

A

Waist circumference

185
Q
  • Carbohydrates
  • Protein
  • Lipids
A

Nutrients that supply energy

186
Q
  • age
  • biological sex
  • states of health
  • alcohol use
  • medication
  • nutritional supplements
A

factors affecting nutrition

187
Q
  • Physiologic and physical factors: stage of development, state of health, medications
  • Physical, sociocultural, and psychosocial factors influencing food choices
  • Economics, culture, religion, tradition, education, politics, social status, food ideology
A

Factors Affecting Food Habits

188
Q
  • history taking: dietary, medical, SES
  • physical assessment: clinical and anthropometric data
  • laboratory data: protein status, body vitamin, mineral, and trace element status
A

nutritional assessment

189
Q
  • hemoglobin
  • hematocrit
  • serum albumin
  • prealbumin
  • transferin
  • blood urea nitrogen
  • creatinine
A

laboratory data

190
Q
  • Growth: infancy, adolescence, pregnancy, and lactation increase nutritional needs
  • Activity increases nutritional needs.
  • Age-related changes in metabolism and body composition
  • Nutritional needs level off in adulthood.
  • Fewer calories required in adulthood because of decrease in BMR.
A

Nutritional Developmental Considerations

191
Q
  • Developmental factors
  • Gender
  • State of health
  • Alcohol abuse
  • Medications
  • Megadoses of nutrient supplements
A

Risk Factors for Poor Nutritional Status

192
Q
  • 24-hour recall method
  • Food diaries/calorie counts
  • Food frequency record
  • Diet history
A

Dietary Data

193
Q
  • general appearance: alert, responsive
  • general vitality: endurance, energetic, sleeps well, vigorous
  • weight: normal for height, age, body build
  • hair: shiny, lustrous, firm, not easily plucked, healthy scalp
  • face: uniform skin color, healthy appearance, not swollen
  • eyes: bright, clear, moist, no sores, membranes moist, pink color
  • lips: pink color, smooth, moist, not chapped or swollen
  • tongue: deep red, surface papillae present
  • teeth: straight, no crowding, no cavities, no pain, bright, no discoloration, well-shaped jaw
  • gums: firm, pink, no swelling, no bleeding
  • glands: no enlargement of thyroid, face not swollen
  • skin: smooth, good color, slighlty moist, no signs of rashes, swelling or color irregularities
  • nails: firm, pink
  • skeleton: good posture, no malformations
  • muscles: well developed, firm, good tone, some fat
  • extremities: no tenderness
  • abdomen: flat
  • nervous system: normal reflexes, psychological stability
  • cardio: normal HR and rhythm, no murmurs, normal BP for age
  • GI: no palpable organs or masses
A

clinical observations of good nutritional status

194
Q
  • general appearance: listless, apathetic, cachetic
  • general vitality: easily fatigued, no energy, falls asleep easily, looks tired, depressed mood
  • weight: over or underweight
  • hair: dull, dry, brittle, loss of color, easily plucked, thin, and sparse
  • face: dark skin over cheeks and under eyes, flaky skin, facial edema, pale skin color
  • eyes: pale membranes, dry eyes, Bitot’s spots, increased vascularity, small yellowish lumps around eyes
  • lips: swollen and puffy, lesion at corners
  • tongue: smooth, beefy red or magenta, swollen, hypertrophy or atrophy
  • teeth: cavities, mottled appearance, missing teeth
  • gums: spongy, bleed easily, marginal redness, recessed
  • glands: enlarged thyroid, enlarged parotid
  • skin: rough, dry, flaky, swollen, pale, bruises
  • nails: spoon shaped, brittle, pale, ridged
  • skeleton: poor posture, beading of ribs, bowed legs
  • muscles: flaccid, poor tone, difficulty walking
  • extremities: weak, tender, edema of lower extremities
  • abdomen: swollen
  • nervous system: decrease in or loss of ankle/knee reflexes, motor reflexes, mental confusion
  • cardio: cardiac enlargement, tachycardia, abnormal BP
  • GI: enlarged liver or spleen
A

clinical observations of poor nutritional status

195
Q
  • underweight: <18.5
  • normal: 18.5-24.9
  • overweight: 25-29.9 (increased waist circumference)
  • obesity, class I: 30.34.9 (high waist circumference)
  • obesity, class II: 35-39.9 (very high waist circumference)
  • extreme obesity: 40+ (extremely high waist circumference)
A

BMI

196
Q

R/T insufficient dietary intake

AEB
- “foods just don’t taste good anymore”
- reports losing 15 lb within 3 weeks
- several ulcers present on buccal mucosa
- reports “frequent loose stools” every day for past 2 weeks
- patient appears fatigued and undernourished, muscle wasting is evident (laboratory data revel low serum albumin level)

A

Dx imbalanced nutrition: less than body requirements

197
Q

R/T neuromuscular impairment

AEB
- “food seems to get stuck”
- “sometimes I can’t finish eating because I cough too much”
- swallowing evaluation study reports abnormality in oral and pharyngeal phases. Pt observed to have difficulty chewing; delayed swallow; gags and coughs during meals; gurgly voice quality noted after meal

A

Dx impaired swallowing

198
Q

R/T
- excessive food intake in relation to physical activity
- sedentary behavior occurring for => 2 hours/day
- BMI 24; waist circumference 39 in

A

Dx risk for overweight

199
Q

The patient will:
- Attain and maintain ideal body weight
- Eat a diet adequate but not excessive in all nutrients
- Eat a variety of food in each of three or more meals
- Follow the appropriate modified diet

A

Nutrition Outcome identification and planning

200
Q
  • Teaching nutritional information
  • Monitoring nutritional status
  • Stimulating appetite
  • Assisting with eating
  • Providing oral nutrition
  • Providing short- and long-term nutritional support
A

Nutrition Nursing Interventions

201
Q
  • composed of only clear fluids or foods that become fluid at body temperature. Requires minimal digestion and leaves minimal residue
  • clear broth, coffee, tea, clear fruit juice, gelatin, popsicles, commercially prepared clear liquid supplements
  • used for bowel prep surgery and lower endoscopy, acute gastrointestinal disorders, initial postop diet
A

clear liquid diet (modified consistency diet)

202
Q
  • also known as blenderized liquid diet because the diet is made up of liquids and foods blenderized to liquid form
  • all foods are allowed
  • after oral or facial surgery; chewing or swallowing difficulties
A

pureed diet (modified consistency diet)

203
Q
  • regular diet with modification for texture. Excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits.
  • foods are chopped, ground, mashed, or soft
  • chewing and swallowing difficulties; after surgery to the head, neck, or mouth
A

mechanically altered diet (modified consistency diet)

204
Q
  • total daily carbohydrate content is consistent; emphasizes general nutritional balance
  • calories based on attaining and maintaining health weight
  • high-fiber and heart-healthy fats encouraged
  • sodium and saturated fats are limited
  • used for type I and II DM, gestational DM, impaired glucose imbalance
A

consistent-carbohydrate diet

205
Q
  • low-fat diets are intended to lower the patient’s total intake of fat
  • chronic cholecystitis (gallbladder), decrease gallbladder stimulation, cardiovascular disease, to help prevent atherosclerosis
A

fat-restricted diet

206
Q
  • emphasis on increased intake of foods high in fiber
  • prevent or treat constipation; IBS, diverticulitis
A

high-fiber diet

207
Q
  • fiber limited to <10 g/day
  • before surgery, ulcerative colitis, diverticulitis, Crohn’s disease
A

low-fiber diet

208
Q
  • sodium limit may be set at 500-3,000 mg/day
  • hypertension, CHF, acute and chronic renal disease, liver disease
A

sodium-restricted diet

209
Q
  • reduce workload on kidneys to delay or prevent further damage
  • control accumulation of uremic toxins
  • protein restriction 0.6-1 g/kg/day
  • sodium restriction 1,000-3,000 mg/day
  • potassium and fluid restrictions dependent on pt
A

renal diet

210
Q

Using the nasogastric or nasointestinal route

A

Short-Term Nutritional Support: Enteral Nutrition

211
Q
  • Radiographic examination
  • Measurement of tube length and tube marking
  • Measurement of aspirate pH and visual assessment of aspirate
  • Carbon dioxide monitoring
  • Confirming nasointestinal tube placement (Radiographic examination &
    Measurement of aspirate pH and visual assessment of aspirate)
A

Confirming NG feeding tube placement

212
Q
  • An enterostomal tube: stomach (gastrostomy), jejunum (jejunostomy).
  • A gastrostomy is the preferred route to deliver enteral nutrition in the patient who is comatose.
  • Percutaneous endoscopic gastrostomy (PEG) or a surgically (open or laparoscopically) placed gastrostomy tube.
A

Long-Term Nutritional Support: Enteral Nutrition

213
Q
  • aspiration
  • clogged tube
  • nasal erosion with NG or nasointestinal tubes
  • diarrhea
  • other GI symptoms (N/V/D)
  • unplanned extubation
  • stoma infection
A

complications of enteral feeding

214
Q
  • Complete nutrition
  • Hypertonic solution
  • Indicated > 7-14 days
  • Central venous access
  • Monitor blood glucose
A

Total Parenteral Nutrition (TPN)

215
Q
  • Partial nutrition
  • Isotonic solution
  • Indicated < 14 days
  • Peripheral venous access
A

Peripheral Parenteral Nutrition (PPN)

216
Q
  • Insertion problems
  • Infection and sepsis
  • Metabolic alterations
  • Fluid, electrolyte, and acid–base imbalances
  • Phlebitis
  • Hyperlipidemia
A

Complications of Parenteral Nutrition

217
Q
  • Evaluates the patient’s progress toward meeting nutritional outcomes
  • Evaluates the patient’s tolerance and adherence to the prescribed diet
  • Assesses the patient’s level of understanding of the diet and/or dietary-related interventions and the need for further instruction or reinforcement
  • Communicates findings to other members of the health care team
    Revises the plan of care, as needed, or terminates nursing care
A

Nutritional Evaluation

218
Q

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observe the contour of the abdomen, noting any masses, scars, or areas of distension. What action would the nurse perform next

A

Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants

219
Q

A nurse is performing digital removal of stool on a patient with fecal impaction. During the procedure th epatient tells the nurse that she is feeling dizzy and nauseated, and then vomits. What should be the nurse’s next action?

A

Stop the procedure, assess vital signs, and notify PCP

220
Q

A nurse is assessing a pt who has been NPO prior to abdominal surgery. The pt is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced?

A

The patient reports fullness and diarrhea after breakfast

Science of Nursing Practice Lecture (3 decks)

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