Exam 3 Study Guide: Quizlet Flashcards
Underweight BMI
< 18.5
Healthy Weight BMI
18.5 - 24.9
Overweight BMI
25 - 29.9
Obesity Class 1 BMI
30 - 34.9
Obesity Class 2 BMI
35 - 39.9
Obesity Class 3 BMI
> or = 40
how do you measure for an NG tube?
measure from nose to ear then to xiphoid process
what two things do you need to do prior to administering a tube feeding?
confirm head of bed is elevated at least 30 degrees
check for gastric residual
what is the proper order of steps to administer a tube feeding?
confirmed placement
patient up in fowlers position (or at least semi fowlers 30 degrees)
administer tube feed
pause feed and evaluate to see how well the patient is tolerating it by checking for residual
what are safety measures when placing an NG tube?
have oxygen and suction ready to go during placement
identify patient
- name
- DOB
- allergies
HOB in high fowlers (above 30 degrees)
properly measure the tube prior to placement
make sure supplies are clean but not sterile
the Mediterranean diet is recommended for which patients? what foods are included?
good for heart patients
rich in olive oil, fish, fruits, vegetables, and nuts
low in dairy foods, processed foods, saturated fats and red meat
includes a glass of wine per day
what are guidelines for the low cholesterol diet?
high fiber foods have been found to lower cholesterol and should be incorporated in the low cholesterol diet (oatmeal)
butter is high in saturated fat and can increase LDL cholesterol
- egg yolks are high in cholesterol and should be limited to 2 - 3 per week (egg whites are okay)
- fried food is high in saturated fat and increases LDL cholesterol
avoiding the harmful fats and eating the healthy ones greatly reduces the risk of stroke
if a patient starts falling, what do you do?
extend your leg between their leg and slide them down it gently
if you find a patient that has already fallen, what is the first thing you should do?
assess them for injury before trying to get them up or move them
what are the concerns with an immobile patient?
decreased gi motility/constipation
embolisms
sores and skin breakdown
what is the trendelenburg position?
supine position and HOB is lower than feet
what is limb circumduction?
movement of the limb, hand, or fingers in a circular pattern, using the sequential combination of flexion, adduction, extension and abduction motions
what is the best lab value to assess overall nutrition status?
albumin
prealbumin
what is a concern with a low blood albumin level?
low protein level with subsequent decreased wound healing
what are some potassium rich foods?
banana
orange
cantaloupe
spinach
broccoli
What are some calcium rich foods?
dairy
broccoli
kale
fortified foods
Vitamin C aids with absorption of what mineral?
iron
What are some signs of malnutrition?
brittle and thin nails
weakness
fatigue
dry and scaly skin
when floating the heels, should you place a pillow under the knees?
no, it should be under the calves
- dont want to compress the artery or vein behind knee
What foods would be included in a pureed diet?
applesauce
mashed potatoes
puree meats
when assessing a patient with malnutrition that was last seen 3 months ago and experienced significant unintentional weight loss.
what should you look at/for?
check mouth for sores, missing teeth, loose teeth
loss of taste, smell, thirst (age-related)
What are the 3 ways to confirm NG tube placement?
chest x-ray
air bolus while auscultating stomach
monitor gastric pH < 5.5
what will be the pH in the stomach versus the lungs?
lungs = 7 or greater
stomaach = 0 - 4
is an NG tube placement a sterile procedure?
not sterile
just a clean procedure
how do you find the appropriate length to insert the NG tube?
measure the NG tube from the top of the ear lobe to the tip of the nose and then down to the xiphoid process
Before inserting NG tube, what must be checked in the nose and mouth?
make sure patient has gag reflex
use penlight to check the nose for polyps or anything unusual or obstruction
which nostril is preferred for NG tube placement?
right nares because it’s slightly bigger than the left
how long is formula good for once it is opened?
formula should be used within 8 - 12 hours unless refrigerated then the formula should be discarded after 24 hours
- the formula that has been opened for greater than 24 hours is at increased risk for bacteria growth and could increase the risk for gastrointestinal infection
why would a patient be on a mechanical soft diet and what are examples of foods used on this diet?
patients who have difficulty chewing
- includes foods that require minimal chewing before swallowing
- i.e. egg salad or tuna salad
what is one reason to limit chair sitting to one hour?
lower extremity edema
what are important interventions for a client sitting in a chair?
limit time to one hour
shift weight every 15 min and use a cushion to decrease pressure
what are some ways to prevent falls?
nonskid socks
proper fitting shoes
bed locked and lowered
hourly rounding to offer toilet
ensure high use items are close by
call light within reach
two head side rails up
bed alarm
close to nursing station
remove clutter
adequate lighting
sensory aids in
assistive devices being used
what side is the cane used on?
the unaffected/strong side
what is the 3-point gait?
requires the client to bear all weight on strong leg/side
- client moves both crutches with the weak leg forward and then moves the strong leg
if you are teaching a client the 3-point gait and they move the strong leg first, is this correct?
no, move weak leg
what are some symptoms of DVT?
swelling
redness/erythema
pain
edema
warm to touch
increased calf circumference
what are 2 ways to prevent pressure ulcers? (fill in the blank/written)
- turn the patient every two hours, maintain hydration, keep skin dry, float the heels
- alternating a lateral position between the right and left side is best for those at high risk for skin breakdown (HOB less than 30 degrees so it doesnt create additional pressure on the coccyx or other bony prominences)
- diet rich in protein and vitamin c
- passive range of motion exercises
- therapeutic mattress
- do not place client in high fowlers
when using a wheelchair, what do you make sure you do before a patient gets in or out of it?
lock the wheels
What is the movement called when you lift up the arm/shoulder?
circumduction
How do you measure residual volume with an NG tube?
use the syringe
is a BMI of 23.6 underweight, overweight, or healthy?
healthy
what drinks are bad choices for a diabetic patient?
grape juice
orange juice
when assessing nutritional status of older adults, what are some things you expect to find?
require fewer calories
metabolism slows down
taste buds change
sensation for thirst decreases
what are good sources of fiber?
grains
oatmeal
beans
veggies
- not white rice, not waffles, not rice like cereal
what can you do to reduce compression of the leg veins?
should not place pillow under the knees
- you should also not cross legs, sit for long periods, wear restrictive clothing on the lower extremities, or massage legs
- you should instead, teach client techniques to promote venous return
what is involved in active ROM?
completing the full ROM of joints and is performed by the client independently such as foot circles, ankle pumps, and knee flexion
causes skeletal muscle contractions which promote blood return
ROM Exercises
What is involved in passive ROM?
when someone else does the exercises for the client
- nurse assisting would be passive ROM
what are isometric exercise and an example?
tightening and then relaxing muscle is an isometric exercise
arms against resistance are isotonic exercises
describe the four-point gait
client alternates each leg with the opposite crutch so 3 points of support are on the floor at all times (four separate points of contact)
describe the two-point gait
client has partial weight bearing on both feet
- the client moves a crutch while moving the oppostie leg at the same time to mirror movements of normal arm and leg motion during walking
how do you determine what size anti-embolism stocking to use?
use a tape measure
- measure the calf and or thigh circumference and the length of the leg
what are the therapeutic effects cold therapy?
decreasing pain by decreasing the velocity of nerve conduction, inflammation, muscle spasms, swelling and fever
what are the therapeutic effects of hot therapy?
increases tissue metabolism, blood flow, muscle relaxation, joint stiffness and pain
client supine with head of bed elevated 45 - 60 degrees
allows for better ventilation
Fowlers
bed is tilted with the HOB lower than the foot of the bed
facilitates postural drainage and venous return
Trendelenburg
which bed position is best for a client receiving enteral tube feedings due to dyphagia?
semi-fowlers
the elevation of 15 - 45 degrees prevents aspiration and regurgitation
what are foods that would be acceptable on a clear liquid diet?
liquids that leave little residue
- clear fruit juices
gelatin
broth
what are foods that would be acceptable on a full liquid diet?
milk
ice cream
juices with pulp-like orange juice
tomato juice
what does AAT stand for and how do you know when to perform this?
Advance and Tolerated
- assessment is the first step
- done after surgery
- the nurse should assess bowel sounds before advancing the diet from NPO (stomach might not be ready)
- once the client can handle clear liquids, then you can move them to full liquid diet and so on
what type of foods should make up the majority of foods consumed by diabetics?
complex carbohydrates
- such as whole grains, fruits and vegetables
what are benefits of a high fiber diet and examples of high fiber food?
- bulk stools to increase peristalsis and prevent constipation
- hydration is important
- oatmeal and beans are good sources of fibers
what foods are high in iron?
oranges
poultry
fish
meat
grains
legumes
What vitamin aids in iron absorption?
Vitamin C increase the absorption of iron
what level of LDLs place a client at risk for cardiovascular disease?
LDL > 100
- risk for hypertension and heart disease
What is the ideal level of HDL for protection?
HDL > 40
- offer protection
what are major sources of calcium?
dairy
broccoli
kale
fortified grains
which vitamins are fat soluble and what is the risk of overconsumption?
A, D, K, and E
- can buildup in the body
what increases the need for vitamin C?
stress
illness
disease
what are the major functions of vitamin K?
Vitamin K = Blood Clotting
what are major functions of vitamin A?
Vitamin A = Vision
what are the major functions and normal lab values of magnesium?
bone formation
smooth muscle relaxation
1.3 - 2.1 mEq/L
What are the major functions and normal lab values of potassium?
fluid volume inside cells
muscle contraction
3.5 - 5 mEq/L
what are the major functions and normal lab values of calcium?
bones/teeth formation
BP
blood clotting
nerve transmission
9 - 10.5 mg/dL
What are the major functions and normal lab values of sodium?
maintain fluid volume
muscle contraction
nerve impulses
136 - 145 mEq/L
