Exam 7 Flashcards
What does nutrition do for the body?
Essential for growth and development, tissue maintenance and repair, and organ function.
Assessments for nutrition
Daily weights
Labs: (Liver) AST, ALT, ALP, Albumin, Total protein (Kidney) BUN, Creatinine, eGFR, Glucose
Assess diet and health history
Any conditions affecting food consumption and and absorption
Assessment for dysphagia (G=GI)
Signs: Cough while eating Change in voice after swallowing Abnormal oral movements Uncoordinated, inconsistent, slow speech Abnormal gag and swallowing Pocketing Regurgitation
How to assess for dysphagia?
Have pt sit in high Fowler and take a sip of water. If difficulties persists notify physician and registered dietician.
Complications of dysphagia?
Aspiration pneumonia
Dehydration
Decreased nutrition
Weight loss
Nurses role in nutrition?
Review orders Advance diet as tolerated Promote appetite Assist with eating Use weighted silverware
Types of ordered diets?
NPO, Clear liquid, Full liquid, [Dysphagia stages, Thickened liquids, puréed] Mechanical Soft, Low sodium, Low cholesterol Diabetic Cardiac Gluten free Regular
NPO
Nothing by mouth
Clear liquid
Liquids that are clear at room temperature.
Ex: Clear fat-free broth, bouillon, coffee, tea, soda, clear fruit juice, jello, popsicles, water
Full Liquid
Same for clear with dairy, strained or blended soup, refined cooked cereal, vegetable juice, puréed vegetables, all fruit juice, sherbets, puddings, frozen yogurt
Dysphagia stages
All foods for clear and full in addition to scrambled eggs, puréed meats, vegetables, fruit, mashed potatoes and gravy
Mechanical soft
Foods that are mashed up by a machine
Low sodium
4g, 2g, 500mg restriction. Can vary from no salt added to severe restriction
Low Cholesterol
300 mg a day
Diabetic Diet
A balanced intake of carbs, fats, proteins and varied caloric recommendation based off the American diabetes association
Gluten free diet
Eliminates wheats, oats, rye, barley, and their derivatives from their diet.
Regular diet
No restrictions
How to feed patients with dysphagia or no ability to swallow?
Enteral nutrition via gastric tube (nasogastric, jejunal, or gastric).
Needed if pt is an aspiration risk or not alert.
Gastric tubes (naso/oro) are for permanent use. True or False?
False, if it’s still needed a permanent option will be added.
What are the sizes of NG tubes? What is it used for?
<12,12,14,16, and 18 French.
12 or greater French is for gastric decompression or removal of gastric contents
Use: feeding/med admin, decompression, lavage (stomach pumping)
Types of gastric tubes?
Nasogastric (NGT)
Nasojejunal (NJT)
Orogastric
Surgically placed
Percutaneous Endoscopic Gastrostomy (PEG)
Percutaneous Endoscopic jejunostomy (PEJ)
True or false: Going past the stomach is okay when inserting a gastric tube?
True, it’s okay since the small intestine is most important.
What to document for NGT insertion?
Size Nare it was placed in Where it was secured Gastric content residuals Did pt tolerate Current tube condition
How to manage a nasogastric tube?
Very tube hasn’t moved by checking measurement.
Keep tube secure.
Always flush 30ml water before and after use.
Use aspiration/safety precautions: HOB higher than 30, ensure tube stays about stomach.
Assess nares for skin breakdown, and lube nostrils PRN
Assess oral mucosa integrity and moisture, offer oral swabs and chapstick PRN
Complications of a PEG tube?
Pain at site
Leakage of stomach contents around site
Dislodged or malfunction of tube.
How long can a PEG tube last?
Months or years.
What medications do you need to use for an NGT or PEG.
Liquid is perfected but can also use crushes tables, opened capsules. 60ml enteral tube syringe is used to deliver medications.
What’s important to do before insertion and before use of an NGT?
Assess your abdomen and bowel sounds.
Inspect, auscaltate, palpate
What do you have to do before you can use the NGT or PEG tube? (hint: 60ml)
Confirm placement using enteral tube syringe (60mL). Aspirate 30mL gastric contents and assess color/consistency and then flush 30mL of air and listen for “air swoosh” utilizing stethoscope (this can only be done after xray has confirmed placement).
At what amount of residuals should you hold feeding and medications for 2 hours?
500mL
Why would a gastric tube be removed?
- Temporary tube being removed because permanent tube is being placed (-Ostomy tube)
- Bowel obstruction resolved/Bowel sounds changed from absent to active
- Out of coma
- Lavage completed
- Dysphagia resolved
List the 4 steps of the digestion process.
- Digestion: Begins in the mouth and ends in the small and large intestines
- Absorption: Intestine is the primary area of absorption
- Metabolism and storage of nutrients
- Elimination: Chyme is moved through peristalsis and is changed into feces
What are the three parts of the small intestine (in order)?
Duodenum, jejunum, and ileum
What is absorbed by the small intestine?
Carbohydrates, protein, minerals, and water-soluble vitamins
What is peristalsis?
A series of involuntary wave like muscle contractions which move food along the digestive tract
Where is an ileostomy located?
Ileum/small intestine
Where is a colostomy located?
Colon/large intestine
What is the stool consistency of an ileostomy?
Thin to thick liquid
What is the stool consistency of a transverse colostomy?
Thick liquid to soft consistency
What is the stool consistency of a sigmoid colostomy?
More formed stool
What are some nutritional considerations for a patient with an ostomy?
- Consume low fiber for the first weeks
- Eat slowly and chew food completely
- Drink 10 to 12 glasses of water daily
- Patient may choose to avoid gassy foods
What position should a patient be in for enema and rectal suppository administration?
Left lateral Sims position
What is the difference between impaction and constipation?
A person is unable to relieve the impaction on their own
What do you need to assess before performing the digital removal of stool?
Heart rate
What do different wound colors indicate?
Beefy Red – indicates tissue and skin healing, appropriate blood supply
Pink – no active s/s of infection, blood supply isn’t ideal
Yellow – slough or infection (Slough is the consistency of snot, indicates body ridding itself of bad tissue)
Black – dead tissue, no blood supply
What causes skin tears?
- Skin bumping into a hard object
- Wound dressing changes & adhesive removal
- Aggressively washing and/or drying the skin
How often should you change wound dressing?
Leave dressing on unless visibly soiled or orders indicate dressing needs changed. You may only need to change outer dressing. Some wounds may be left open to air and will require a cleaning only.
What are the risks of adhesive use on skin?
Adhesives can cause further damage, especially on chronic wounds and thin, fragile skin
Who is at risk for pressure injuries?
Patients with decreased mobility, decreased sensory perception, fecal or urinary incontinence, or poor nutrition
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.)
- Lift the patient’s hips off the bed and slide the bedpan under the patient.
- After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle.
- Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient.
- Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed.
- Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
2, 5
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first?
- Stop the instillation.
- Ask the patient to take deep breaths to decrease the pain.
- Tell the patient to bear down as he would when having a bowel movement.
- Continue the instillation; then administer a pain medication.
1
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.)
- Increase fiber and fluids in the diet. 2. Use a low-volume enema daily.
- Avoid gluten in the diet.
- Take laxatives twice a day.
- Exercise for 30 minutes every day.
- Schedule time to use the toilet at the same time every day.
- Take probiotics 5 times a week.
1, 5, 6
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.)
- How to change the pouch
- How to empty the pouch
- How to open and close the pouch
- How to irrigate the colostomy
- How to determine whether the ostomy is healing appropriately
1, 2, 3, 5
What temperature do tube feeds need to be given at?
Room temperature
What is the primary source of absorption?
The small intestine, lined with villi (increases surface area)
What’s influences bowel elimination?
Age, diet, fluid intake, physical activity, psychological factors, personal habits, position, pain, surgery and anesthesia, medications.
Common bowel elimination problems?
Constipation Diarrhea Flatulence Impaction Incontinence Hemorrhoids
Types of bowel diversions?
Stoma Small intestines: Ileostomy (more liquid) Large intestine: Colostomy (more solid) R side Transverse colostomy (thick liq to soft) Descending colostomy (Left mid abd) Sigmoid colostomy (more formed)
Nutrition and ostomy considerations?
Consume low fiber for first weeks
Eat slowly and chew food completely
Drink 10-12 glasses of water
Patient may choose to avoid gassy foods
How to assess bowel elimination?
History Physical assessment: mouth and abdomen. Identify normal patterns Lab tests Fecal specimens Diagnostic exams
Medications to help with bowel elimination?
Cathartics and laxatives
Antidiarrheal agents
Enemas
How to administer a rectal suppository?
Sterile technique not required Explain procedure Position patient in lateral sims Hand hygiene and don gloves Lube fingers and meds Insert apx 1” or when past sphincter *place on wall not in stool Med will melt when at body temperature Common meds: acetaminophen and dulcolax
How to digitally remove stool.
Assess HR
Reposition pt and perform hand hygiene and don gloves
Lube fingers and insert into rectum
Gently loosen fecal mass and assess as stool is removed
Layers of the skin?
Epidermis
Dermal (epidermal junction)
Dermis
Types of wounds?
Surgical wounds: incisions
Cut/laceration
Skin tears
Ulcers (pressure ulcers, arterial, venous, diabetic wounds)
How to assess a wound?
What kind and how it occurred? Location, Color, Size, Drainage, Odor , Pain, Assess skin around wound, Assess old dressing when removed, Drainage/exudate amount of old dressing
Factors influencing healing process?
Nutrition Tissue perfusion Infection Age Strese
How to care for a skin tear?
Control bleeding
Apply saline or warm water and gently clean skin. Put ripped skin back into place
Pat dry with clean gauze
Measure size of tear
Add steri strips carefully
Cover skin with no adhesive bandage
Use stockinette instead of tape/adhesive
Document skin tear size, location, cleansing and dressing, how pt tolerated
How to clean a simple wound?
Review orders
Leave dressing unless visibly soiled or indicated by orders.
Assess old dressing if removed. Document amount, color, and odor.
Assess wound characteristics
Clean per orders
Apply topical ointments or special medicated dressing
Apply top dressing securely
Document
DO NOT CHANGE INITIAL SURGICAL WOUND DRESSING
What causes pressure injuries?
Unrelieved prolonged pressure
Localized damage to the skin and underlying soft tissue
Can be intact, a blister, or open ulcer.
Patients at risk for pressure injuries?
Decreased mobility
Decreased sensory perception (quad/paraplegic)
Incontinence
Poor nutrition
Pathogenesis of pressure injury?
Pressure applied over period of time causes a capillary to occlude and causes tissue ischemia
If blood flow returns area is erythematic in color due to vasodilation.
How to assess a pressure injury?
Press a finger to the area:
If it turns lighter in color and erythema returns this is blanchable
If it doesn’t change color this is called non-blanchable. If this occurs deep pressure injury is probable
What decreases tissue tolerance?
Poor nutrition, aging, hydration status, and low BP can decrease tolerance of tissue to pressure.
Risk factors for pressure ulcer development
Impaired sensory perception Shear Alterations on LOC ( coma, disoriented) Impaired mobility Shear (sliding movement) Friction (two surfaces moving across another) Moisture
How to predict pressure ulcers?
Braden scale
Factor risk assessment
How to prevent ulcers?
Protect bony prominences Skin barriers when incontinent Keep sheets tight under pt Keep Chux to a minimum Change position often Support surfaces (pillows, seat cushions, special mattress.)
What is the Braden scale?
Tool that is evidenced base and allows health care professionals to predict pt risk for hospital acquired pressure ulcer
Scored for Braden scale?
19-23 no risk 15-18 mild risk 13-14 moderate risk 10-12 high risk <9 severe risk
Stages of pressure ulcers?
Stage 1: intact skin with non-blanchable redness
Stage 2: partial thickness skin loss involving epidermis, dermis, or both
Stage 3: full thickness tissue loss with visible fat
Stage 4: full thickness tissue loss with exposed bone, muscle, or tendon
Nurse role in wound management?
Identify risk factors for ulcer development
Through skin assessment
Identify if infection is present
Identify any change in skin
Keep wounds clean and dressed per orders
Communicate
