Exam 4 Flashcards
Know the types of therapeutic diets
-clear diet
-full liquid
-pureed
-mechanical/dental soft
-soft/low residue; low fiber
-high fiber
-regular
Clear Liquid Diet
Foods that are clear and liquid at room or body temperature that leave little residue and are easily absorbed; commonly ordered for short-term use (24 to 48 hours) after surgery, before diagnostic tests, and after episodes of diarrhea and vomiting.
Examples: water, apple/cranberry juice, gelatin, popsicles
Full Liquid Diet
Includes foods on clear-liquid diet plus addition of smooth-textured dairy products like milk and ice cream, strained soups, custard, refined cooked cereals, vegetable juice, and pureed vegetables; commonly ordered before or after surgery for patients who are acutely ill from infection or for patients who cannot chew or tolerate solid foods.
Pureed
Includes foods on clear- and full-liquid diet plus easily swallowed foods that do not require chewing (scrambled eggs, pureed meats, vegetables and fruits, mashed potatoes);
ordered for patients with head and neck abnormalities or who have had oral surgery; can be modified for low sodium, fat, or calorie count.
Mechanical/ Dental Soft
Consists of all previous diets plus addition of lightly seasoned ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, peanut butter; AVOID tough meats, nuts, bacon, and fruits with tough skin or membranes
Soft/ low residue; low fiber
Addition of low fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and veggies; includes foods that are easy to chew and simply cooked. Does NOT permit fatty, rich, and fried foods
High Fiber
Addition of fresh uncooked fruits, steamed veggies, bran, oatmeal and dried fruits; includes sufficient amounts of ingestible carbohydrates to relieve constipation, increase GI motility, and increase stool weight
Regular Diet
NO dietary restrictions
Restricted Fluids
required in severe heart failure or kidney failure
Sodium Restriction
-Allows low levels of sodium and may include a 4g (no added salt), 2g (moderate), 1g (strict), or 500mg (very strict)
-ordered for pt’s with heart failure, renal failure, cirrhosis, hypertension
Fat modified
-low total and saturated fat and low cholesterol intake limited to < 300mg daily, and fat intake 30% to 35%
-eliminates/reduces fatty foods for hypercholesterolemia, malabsorption disorders, diarrhea
Diabetic
allows for patients to select amount of food from basic food groups
What are the risk factors for nutritional problems?
-Clear/Full-liquid diets for more than 3 days without or with inappropriate/insufficient nutrient supplementation.
-IV feeding (dextrose or saline) or NPO for more than 3 days without supplementation.
-Low intakes of prescribed diet/tube feedings.
-Weight 20% above or 10% below desirable body weight (accounting for edema).
-Pregnancy weight gain deviating from normal patterns.
-Diagnoses that increase nutritional needs, decrease nutrient intake, or both: Cancer, malabsorption, diarrhea, hyperthyroidism, excessive- inflammation, postoperative status, hemorrhage, infected/draining wounds, burns, infection, major trauma.
-Chronic use of drugs (especially alcohol).
-Alterations in chewing, swallowing, appetite, taste, and smell.
-Body temperature consistently above 37° C (98.6° F) for more than 2 days.
-Hemocrit : <43% in men, <37% in women.
-Hemaglobin: <14 g/dL in men, <12 g/dL in women.
-Absolute decrease in lymphocyte count ( <1500 cells/mm3).
-Elevated (>250 mg/dL)/Decreased ( <130 mg/dL ) total plasma cholesterol.
-Serum albumin <3 g/dL in patients without renal or liver disease, generalized dermatitis, overhydration.
How to assist with feeding patients
- Prepare patient’s room for mealtime.
a. Perform hand hygiene. Clear over-bed table.
b. Help patient to comfortable sitting position in
chair or place bed in high-Fowler’s
position. If patient is unable to sit, turn him or
her on side with head of bed
elevated.
- Prepare patient for meal.
a. Help patient with pain relief and elimination
needs and help him or her perform hand
hygiene before meals.
b. Help patient put in dentures and put on
eyeglasses or insert contact lenses if used.
- Ask in which order patient would like to eat his or her meal. Ask about desired seasonings. Help patient to cut food in bite size pieces if unable to do independently.
- Use adaptive eating and drinking aids as needed according to your assessment (e.g.,two-handled cup with lid, plate with plate guard, utensils with splints, utensils with
enlarged handles)
- Identify food placement for disoriented, visually impaired, or easily fatigued patients by locating on plate as if plate were a clock.
- Feed patient in manner that facilitates chewing and swallowing.
a. Older adult: Feed small amounts at a time, observing biting, chewing, swallowing, and fatigue between bites; be sure that patient has swallowed food.
7.Watch patient successfully swallow first few bites of food and drink. If the patient is able to do so on there on stop here and return back to the room 15-20 minutes later. If patient is at risk to aspirate then stay at bedside.
What should you do if you are feeding your patient and they begin to aspirate?
STOP FEEDING IMMEDIATELY and suction their airway
Precautions with aspirations
Almost any condition that produces general muscle weakness or any condition associated with neurologic impairment of the swallowing mechanism and altered mental status places patients at risk for dysphagia/aspirations (e.g., brain injury, stroke). Be aware that patients without primary neurologic diagnoses such as myocardial infarction (heart attack), pneumonia, and chronic obstructive pulmonary disease are also at risk for dysphagia/aspirations.
Can the assessment of a patient’s risk to aspirate be delegated to a NAP?
No; However, NAP may feed patients after receiving instruction on aspiration precautions.
Nasogastric/nasointestinal tube used for suctioning
Suctioning:
-Following major surgery.
- Conditions affecting GI tract altering normal
peristalsis.
-Keeps stomach empty until normal peristalsis
returns.
Nasogastric/nasointestinal tube for feeding
Feeding:
-Administration of nutrition into the gastrointestinal (GI) tract when a patient cannot
ingest, chew, or swallow solid food but can digest and absorb nutrients.
-Uses a small-bore, flexible feeding tube
How do you check for placement of feeding tube before starting feedings?
-Initial x-ray verification.
-Re-verify tube position before administering medications or bolus feedings per tube.
- Re-verify tube position every 4-6 hours (according to institution policy) during continual feedings.
How do you insert and check the placement of nasogastric tube?
- Position patient upright in high Fowler’s position unless contraindicated.
a. If patient is comatose, raise head of bed as tolerated in semi-Fowler’s position with head tipped forward, chin to chest.
b. If patient is forced to lie supine, place in reverse Trendelenburg’s position.
- Determine length of tube to be inserted and mark location with tape or indelible ink.
a. Measure distance from tip of nose to earlobe to xyphoid process of sternum.
- Prepare NG for intubation.
a. Inject 10 mL of water from 30- to 60-mL Luer-Lok or catheter-tip syringe into the tube.
b.Dip tube with surface lubricant into glass of room-temperature water or apply water-soluble lubricant.
4.Explain the step and gently insert tube through nostril to back of throat (posterior nasopharynx). This may cause patient to gag. Aim back and down toward ear. Advance tube as patient swallows
- When tip of tube reaches carina (approximately 25-30 cm./10-12 in. in an adult), stop and
listen for air exchange from distal portion of tube.
6.. Check for position of tube in back of throat with penlight and tongue blade.
- Keep tube secure and check placement of tube by aspirating stomach contents to measure gastric pH. (should be 5.0 or less)
- Fasten end of NG tube to patient’s gown using clip or piece of tape. Do not use safety
pins to secure tube to gown.
- Obtain x-ray
- perform oral hygiene
The color and ph of gastric contents
color: dark green, cloudy, dingy yellow and clear, dark brown
ph: < 5.0
The color and ph of intestinal contents
color: clear, clear and dingy yellow, clear brown
ph: >6.0
The color and ph of pulmonary contents
color: cloudy yellow
ph: > 6.0
How do you check residual? What to do with aspirant?
Assess residual (tolerance of feedings) by performing syringe aspiration (q4-6 hr; see if pt is tolerating it); usually stop feedings if gastric residual is more than 500 mL or 250 mL when 2 measurements are taken 1 hour apart.
Can the skill of inserting and maintaining an NG tube be delegated to a NAP?
No
How do you give feedings and medications through a feeding tube?
-Continual: uses enteral pump not IV
-Intermittent: “Bolus feeding”; administration using a syringe letting gravity help
with drip.
How do you care for a gastrotomy or jejunostomy tube?
1.Exit site may have a dressing or be open to air (confirm order).
2.Assess site for excoriation, drainage, signs of infection, or bleeding (q 4-6 hours
depending on institution).
- Cleanse around site with warm water and mild soap (or according to institution
policy) using clean gloves (frequency varies with institution).
- Replace dressing if indicated (date, time, and initial).
5.Document appearance of site, drainage noted, and application of dressing.
What is the difference between a straight and indwelling catheter?
Indwelling catheter: remains in the bladder after urination
Straight catheter: removed from the bladder after urination (one time use)
Know how to obtain urine specimen from a closed system
- Explain that you will use syringe without need to remove urine through catheter
port and that pt will not experience any discomfort.
- Explain that you will need to clamp catheter for 10-15 min before obtaining urine
specimen and that urine cannot be obtained from drainage bag.
- Clamp drainage tubing with clamp or rubber band for as long as 15 min below site
chosen for withdrawal.
- After 15 min, position pt so catheter sampling port is easily accessible.
- Clean port for 15 sec with disinfectant swab and allow it to dry.
- Attach needleless Luer-Lok syringe to built-in catheter sampling port.
- Withdraw 3 mL for culture or 20 mL for routine urinalysis.
- Transfer urine from syringe into clean urine container for routine urinalysis or into sterile urine container for culture.
- Place lid tightly on container and unclamp catheter to allow urine to flow into drainage bag; ensure that urine flows freely.
- Open specimen container, maintaining sterility of inside specimen container, and place
cap with sterile inside up. Do not touch inside of cap or container.
- Replace cap securely on specimen container, touching ONLY the outside.
- Clean urine from exterior surface of the container.
- Securely attach label to container, not lid.
- In patient’s presence, confirm label identifiers
> If patient is female, indicate if she is menstruating.
- Send specimen and completed requisition to lab within 20 min; refrigerate specimen if
delay cannot be avoided
Describe how to obtain a mid-stream catch urine specimen
-have pt independently clean perineum area and collect specimen. Help bedridden patients onto bed pan to facilitate access to perineum
**Males: **
- Hold penis with one hand; using circular motion and antiseptic towelette, clean meatus, moving from center to outside 3 times with different towelettes.
- Have uncircumcised male pt retract foreskin for effective cleaning of urinary meatus and keep retracted during voiding.
- Return foreskin when done.
- Rinse area with sterile water and dry with cotton balls or gauze pad.
- After pt initiates urine stream into toilet or bedpan, have him pass urine specimen
container into stream and collect 90-120 mL of urine
Females:
- Either nurse or pt spreads labia minora with fingers of nondominant hand.
- With dominant hand clean urethral area with antiseptic swab. Move from front
(above urethral orifice) to back (toward anus).
> Use fresh swab each time; clean 3 times;
begin with labial fold farthest from you, then
labial fold closest, and then down center.
- Rinse area with sterile water and dry with cotton ball.
- While continuing to hold labia apart, pt initiates urine stream into toilet or bedpan;
after stream is achieved, pass specimen container into stream and collect 90-120 mL
of urine.
- Remove specimen container before flow of urine stops and before releasing labia or
penis; allow pt to finish voiding into bedpan or toilet. Offer to help with personal
hygiene as appropriate.
What is a bladder scan machine and how is it used for determining residual urine?
A bladder scanner is a noninvasive device that creates an ultrasound image of the bladder for measuring the volume of urine in the bladder. The device makes calculations to report accurate urine volumes (especially lower volumes). Use a bladder scanner to assess bladder volume whenever inadequate bladder emptying is suspected such as after the removal of indwelling urinary catheters, in the evaluation of new-onset incontinence, and after urologic surgery. The most common use for the bladder scan is to measure postvoid residual (PVR), the volume of urine in the bladder after a normal voiding. To obtain the most reliable reading, measure PVR within 10 minutes of voiding. A volume <50 mL is considered normal. Two or more PVR measurements >100 mL require further investigation.
What is a Suprapubic Catheter?
A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon (similar to an indwelling catheter). Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urologic surgery) and in situations when a long-term urethral catheter causes irritation or discomfort or interferes with sexual functioning.
