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Nursing Fundamentals > Exam 7; Chapters 45,47,48 > Flashcards

Exam 7; Chapters 45,47,48 Flashcards

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1
Q

Nutrition is essential for

A
  • Normal growth/development
  • Tissue maintenance/repair/healing
  • Cellular metabolism
  • Organ function
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2
Q

Assessments to determine nutrition

A

•Daily weights
•Lab tests:
-liver function: AST, ALP, ALT, Albumin, Total protein
-Kidney function: BUN, Crt, eGFR, Glucose

  • Pt diet & health history
  • Conditions that interfere with ability to ingest, digest, or absorb nutrients more thorough assessment ensues
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3
Q

What is Dysphagia.?

A

Difficulty or inability to swallow

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4
Q

Nursing assessments for Dysphagia

A
  • Pt has difficulty swallowing
  • Coughing while eating
  • Change in tone or quality of voice after swallowing
  • abnormal mouth, tongue, or lip movement
  • Slow, weak, imprecise or uncoordinated speech
  • Inability to speak consistently
  • abnormal gag and delayed swallowing
  • Incomplete oral clearance or pocketing
  • Regurgitation
  • Delayed or absent trigger of swallow
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5
Q

What can the nurse do to assess the Pts Dysphagia.?

A

Attempt to have the pt take a small sip of water while sitting upright in bed

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6
Q

If symptoms of Dysphagia are present what are the nurses next steps.?

A

Notify the physician and request a consult from the registered dietician

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7
Q

Complications of Dysphagia are

A
  • Aspiration pneumonia
  • Dehydration
  • Decreased nutritional status
  • Weight loss
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8
Q

Dysphagia leads to…

A
  • Disability/Decreased functional status
  • Increased length of stay
  • Increased healthcare costs
  • Increased likelihood of discharge to institutionalized care
  • Increased mortality
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9
Q

What happens to pts albumin levels when they suffer from Dysphagia.?

A

Albumin levels drop due to malnutrition

Albumin=Protein

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10
Q

Nurses role regarding diet/nutrition

A
  • Review ordered diets
  • Advance diets as pt tolerates
  • Promote appetite
  • Assist w feedings if needed
  • Use of weighted silverware
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11
Q

How can appetite be promoted

A
  • Getting the pt up and moving
  • Practicing oral hygiene
  • Encouraging pt to eat with others
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12
Q

NPO means…

A

Nothing by mouth

If pt is NPO for an extended amount of time, be sure pt is properly hydrated via IV or NG tube

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13
Q

Clear liquid diet

A

Clear liquids or fluids that become clear liquids easily at room temp

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14
Q

Clear liquids include

A
  • Broth
  • Boullion
  • Coffee
  • Tea
  • Carbonated beverages
  • Clear fruit juices
  • Gelatin/Jello
  • Fruit Ices
  • Popsicles
  • Water
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15
Q

Full liquid diet

A

All clear liquids as well as smooth textured dairy products

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16
Q

Full liquids include

A
  • All clear liquids
  • Blended cream soups
  • Custards
  • Refined cooked cereals
  • Vegetable juice
  • Puréed vegetables
  • All fruit juices
  • Sherbets
  • Puddings
  • Frozen yogurt
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17
Q

Thickened liquid diet

A 
All clear and full liquids with the addition of 
•Scrambled eggs
•Puréed meats
•Puréed fruits
•Puréed vegetables 
•Mashed potatoes & gravy
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18
Q

Mechanical soft diet

A

Any food that is mashed up by a machine

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19
Q

Mechanical soft diet includes

A
  • All clear, full, & puréed foods
  • All cream soups
  • Ground or finely diced meats
  • Flaked fish
  • Cottage cheese
  • Rice
  • Potatoes
  • Pancakes
  • Light breads
  • Cooked veggies
  • Cooked or canned fruit
  • Bananas
  • Soups
  • PB
  • Eggs (Not Fried)
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20
Q

Low sodium diet

A

4g, 2g, 1g, or 500mg of salt in the diet with no added salts.
Requires selective food purchases

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21
Q

Low cholesterol diet

A

300mg/day of cholesterol in accordance with the American Heart Association

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22
Q

Diabetic diet

A

Focuses on total energy, nutrient & food distribution. Balanced intake of carbs, fats and proteins.
Caloric allowance depends on individual needs

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23
Q

Cardiac diet

A

Low sodium, Low cholesterol, Low fat, and High fiber

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24
Q

Gluten free diet

A

Illuminates wheat, oats, rye, barley, and their derivatives

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25
Q

Regular diet

A

No restrictions unless specified

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26
Q

Enteral nutrition

A 
Provides nutrients directly through the G.I. tract.
Provided when pt has an
•aspiration risk
•are not fully alert
•cannot/unable to swallow 
•Suffer from Dysphagia
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27
Q

Enteral feeding routes

A
  • Nasogastric
  • Jejunal
  • Gastric tubes
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28
Q

Gastric tube types

A
  • Nasogastric: nose
  • Orogastric: mouth
  • Short term & places in acute care setting
  • long term/permanent tubes will be placed if needed
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29
Q

Purpose of gastric tubes

A
  • Enteral feeding
  • Med admin
  • Decompression
  • Lavage
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30
Q

NG tube sizes

A

<12 French for feeding/ med admin

12, 14, 16, 18 French for lavage & decompression

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31
Q

Nasoenteric tubes

A
  • Nasogastric tube (NGT)

* Nasojejunal tube (NJT)

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32
Q

Orogastric tubes are often used…

A

If the pt is intubated or has nasal trauma

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33
Q

Surgical tubes

A

More permanent solutions

-OSTOMY refers to a surgical creation of an opening in an organ

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34
Q

Gastronomy tubes

A

•Percutaneous Endoscopic Gastronomy (PEG tube)

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35
Q

Jejuostomy tube

A

Percutaneous Endoscopic Jejunostomy (PEJ tube)

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36
Q

If pt has an aspiration risk which tube is best.?

A

Jejunal feeding is preferable because it sits in the jejuom of the small intestine

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37
Q

Types of gastric tubes

A
  • Dual lumen: has an air vent that is to be open at all times; most used
  • Single Lumen
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38
Q

What position should the NG tube be in the pt.?

A

Tip should lie below diaphragm and coiled within the stomach

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39
Q

Documentation of NG tube insertion

A 
•Tube size
•Which nare was utilized 
•Where it was secured (how many cm)
•Placement verification 
•Gastric contents
•How pt tolerated operation 
•Current condition 
•
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40
Q

Where should NG tube be secured.?

A

To the nostril or mouth; measurements should be checked throughout shift to ensure tube hasn’t moved

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41
Q

What should be done before and after NG tube use.?

A

Flush with 30mL water

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42
Q

Aspiration/Safety precautions regarding pt with an NG tube

A
  • Head of bed elevated 30 degrees minimum at all times
  • Tube should be above stomach level at all times
  • Assess nares frequently for skin breakdown; Lube PRN
  • Assess oral mucosa integrity & moisture; offer oral swabs & chapstick PRN
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43
Q

Percutaneous Endoscopic Gastronomy (PEG tube)

A
  • Allows nutrition, fluids & meds to be put directly into the stomach
  • Bypasses mouth & esophagus
  • Cleaned once a day w soap & water
  • Keep site dry
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44
Q

Complications of the PEG tube

A
  • Pain at PEG site
  • Leakage of stomach contents around tube site
  • Dislodgment or malfunction of the tube
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45
Q

How long can PEG tubes last.?

A

Months or years

Can become clogged or break down over extended periods of time; can be replaced w in dwelling catheter tubing

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46
Q

How is med admin performed w NGT & PEG tubes.?

A
  • Fluid meds preferred
  • Tablets should be finely crushed unless contraindicated
  • Capsules should be opened unless contraindicated
  • Dissolve meds when possible
  • Meds are flushed w 60mL of water using the enteral tube syringe
  • Apsirate 30mL stomach contents to confirm placement
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47
Q

What is asked before med admin through the PEG/NGT.?

A
  • Ask about N/V

* Ensure bowels are functioning properly before admin of meds

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48
Q

If residual stomach contents exceed 500mL what is the nurses next step

A

If residuals exceed 500mL nurse should hold the feeding/meds for 2 hours and recheck

Always verify with the order to know residual content amounts

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49
Q

What position should the pt be in after feedings/med admin.? And for how long.!

A

Pt should be placed in semi or high fowlers position for at least 1 hour after feeding/meds have been given

50
Q

What type of liquid should be used when flushing tube & administering meds.?

A

Room temperature water

51
Q

Each time the syringe is disconnected the nurse is to…

A

Clamp the tube.!

52
Q

Continuous feeding

A
  • Small amount delivered over the course of hours
  • Nurse assesses pt during feedings, checks residuals, and increases feedings per orders & ass tolerated
  • Feedings can cause discomfort if given too quickly
  • Serum glucose levels can increase
  • Always assess for hyperglycemia
53
Q

Bolts feedings

A
  • Given by syringe to the flow of gravity

* Similar to Med admin

54
Q

Reasons for a tube removal

A
  • Permanent solution is being put in
  • Bowel obstruction resolved
  • Out of coma
  • Lavage complete
  • Dysphagia resolved
55
Q

Gastric tube removal

A
  • Flush w 30mL of air
  • Educate pt to hold breath during removal
  • Detach all tape while holding tube securely (never let go of tube)
  • Swiftly remove tube while pt is holding breath; coil tube in hand
56
Q

Parts of bowel process

A
  • Mouth: digestion starts w mastication
  • Esophagus: Peristalsis moves food to stomach
  • Stomach: Stores food, mixes food, liquid, & digestive juices; moves food to small intestine
  • Small intestine:Duodenum, jejunum, & ileum
  • Large intestine: primary organ of bowel elimination
  • Anus: Expels feces and flatus from rectum
57
Q

Digestion

A

The mechanical breakdown that results from chewing, churning, and mixing w fluid and chemical reactions in which food reduces to its simplest form

Begins in mouth and ends in small and large intestines

58
Q

Absorption

A

Intestine is the primary area of absorption

Small intestine is lined w villi; carbs, protein, minerals, and water soluble vitamins are absorbed in small intestine

Water is absorbed in the large intestine as feces moves toward the rectum

59
Q

Elimination

A

Chyme is moved through peristalsis through the ileocecal valve into the large intestine and is changed into feces

60
Q

Peristalsis

A

A series of involuntary wave-like muscle contractions which move food along the digestive tract

61
Q

Factors that influence bowel elimination

A
  • Age
  • Diet
  • Fluid intake
  • Physical activity
  • Psychological factors
  • Personal habits
  • Position during defecation
  • Pain
  • Surgery & Anesthesia
  • meds
62
Q

Constipation

A

A symptom, not a disease

Infrequent stool, &/or hard, dry, small stools that are difficult to eliminate

63
Q

Fecal impaction

A

Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that are very hard to expel

64
Q

Diarrhea

A

An increase in the number of stools and the passage of liquid, unformed feces

65
Q

Hemorrhoids

A

Dilated, engorged veins in the lining of the rectum

66
Q

Bowel diversions

A
  • Temp/Permanent artificial openings in the abdominal wall (STOMA)
  • Surgical openings in the ileum or colon
  • Location of an ostomy determines stool consistency
67
Q

Types of ostomy

A
  • Ileostomy: ileum/ small intestine
  • Colostomy: colon/large intestine

Effective pouching system that protects skin, contains fecal matter, remains odor free, & is comfortable & inconspicuous

68
Q

Ileostomy forms:

A

Thin to thick liquids expelled

69
Q

Ascending colostomy & transverse colostomy form:

A

Thick liquid to soft consistency

70
Q

Descending colostomy & sigmoid colostomy form:

A

More formed stool

71
Q

Nutritional considerations for Ostomy’s

A
  • Low fiber for the first few weeks
  • Eat slowly and chew food completely
  • Drink 10-12 glasses of water daily
  • Pt may want to avoid gassy foods
72
Q

Psychological considerations of Ostomy’s

A
  • Body changes/ self image
  • Intimacy needs
  • odor
73
Q

Nursing assessment regarding bowel elimination

A
  • Nursing history
  • Physical assessment of mouth & abdomen: identify normal/abnormal patterns, habits, and pt perception of normal/abnormal w regard to elimination
  • Lab tests
  • Fecal specimens: stool tests for parasites, blood etc.

•Diagnostic exams
•

74
Q

How is a stool sample collected

A
  • Pt defecates in a hat or collect stool from brief
  • Wear gloves.!
  • Collect in a dry, clean, leak proof container
  • Not very much stool needed
  • Seal specimen
  • Biohazard bag for transport
  • Look for blood, parasites, ovum; notice color & consistency
  • Send to lab
75
Q

How can the nurse promote normal defecation.?

A
  • Allow pt to take normal elimination position
  • Develop routine for pt
  • Give pt privacy
  • Make sure Pt is safe
76
Q

How is the bedpan positioned.?

A

The widest part of the bedpan covers the upper buttocks and lower back

77
Q

How is a fracture bedpan positioned.?

A

The widest part is positioned on the lower buttocks

78
Q

Cathartics & laxatives

A
  • Initiate and facilitates stool passage
  • Empties bowel
  • Cathartics have a stronger & more rapid effect on the intestines than laxatives
  • Laxatives can be given PO or as suppositories
79
Q

Antidiarrheal agents

A

Decrease intestinal muscle tone to slow passage of feces

80
Q

Enemas

A
  • Instillation of a liquid solution into rectum & sigmoid colon
  • Promote defecation by stimulating peristalsis
  • Fluid breaks up fecal mass, stretches rectal wall & initiates defecation reflex
  • Can give meds via enema
81
Q

What position is the pt in when administering an enema.?

A

Left lateral sims position

82
Q

How far should a suppository be inserted.?

A

Approx. 1 inch or once you feel the med bypass the sphincter
Make sure med is not placed in the stool

83
Q

Common rectal suppositories

A

Acetaminophen, Dulcolax

84
Q

What position is the Pt in when administering and enema.?

A

Left side lying position with top leg bent (Sims position)

85
Q

Bowel training

A

Bowel training is performed when pts have chronic constipation or fecal incontinence secondary to cognitive impairment

86
Q

Reasons/ aspects for/of bowel training

A
  • Keeps pt in routine for bowel movements
  • Increase fluids to decrease episodes of constipation & impactions
  • Promoting exercise promotes peristalsis
  • Pt may avoid eliminating due to hemorrhoid pain
  • Avoids skin breakdown
87
Q

Epidermis

A

Top layer of the skin

88
Q

Dermis

A

Inner layer of the skin; holds collagen

89
Q

Dermal-Epidermal junction

A

Separates dermis and epidermis

90
Q

Intact skin…

A

Protects the pt from chemical and mechanical injury

91
Q

What is a wound.?

A

An interruption of the integrity of skin

92
Q

Surgical wounds

A
  • Incisions

* Surgical cuts made to the skin

93
Q

Nonsurgical wounds

A

•Cuts/Lacerations
•Skin tears
•Ulcers
-Pressure ulcers, arterial wound, Veinous wound, diabetic wound

94
Q

Factors that influence healing

A
  • Nutrition
  • Tissue perfusion
  • Infection
  • Age
  • Stress
95
Q

What is a skin tear.?

A

A separation of the layers of skin

96
Q

What causes a skin tear.?

A
  • Skin bumping into hard surfaces
  • Wound dressing changes & adhesive removal
  • Aggressively washing &/or drying the skin
97
Q

How to care for skin tears.?

A
  • Control the bleeding
  • Apply saline or warm water & clean area while gently attempting to replace the torn skin back into place
  • Pat dry w gauze
  • Measure size of skin tear
  • Add steri strips across site, carefully
  • Cover skin w nonadhesive dressing
  • Document skin tear location, size, cleansing & dressing, & how the pain is tolerated (Can document how it happened)
98
Q

Wound dressings usually require

A

A nurse who specializes in wound care

99
Q

When should a wound dressing be changed.?

A

When it is visibly soiled or orders indicate dressing change frequency

Some wounds are left open to air & only require cleaning

100
Q

When dealing w wounds the nurse should always

A
  • Assess wound characteristics
  • Assess old dressings
  • Document wound cleanings & dressing changes
  • Initial, date, & time when changing dressings
101
Q

Risks of adhesives on the skin

A
  • Adhesives can cause further damage, especially on chronic wounds & thin fragile skin
  • Be cautious when applying and removing adhesives
102
Q

Pressure injuries

A

Impaired skin integrity related to unrelieved, prolonged pressure.
Causes localized damage to skin and underlying soft tissue (Typically over a bony prominence)

103
Q

Pressure injury can present as:

A
  • Intact skin
  • Blisters
  • Open ulcers
104
Q

Pts most at risk for pressure injuries

A
  • Pt w decreased mobility
  • Pt w decreased sensory perception
  • Pt w fecal or urinary incontinence
  • Pt w poor nutrition
105
Q

Pathogenesis of pressure injuries

A
  1. Pressure occludes capillaries
  2. Ischemia
  3. Tissue death occurs
106
Q

Assessing pressure injured areas

A

Press a finger to the area, if the skin turns lighter in color it is blanchable
If the skin does not blanch it is non-blanchable (Deep tissue damage is probable)

107
Q

Pressure injuries can be caused by

A
  • Low intensity pressure over a prolonged period of time

* High intensity pressure over a short period of time

108
Q

Tissue tolerance

A

How well can the tissue endure pressure

  • Depends on skin integrity in the area & supporting structures
  • shear, friction, & moisture makes the skin more susceptible to damage
109
Q

Risk factors for pressure ulcer development

A
  • Impaired sensory perception
  • Alterations in level of consciousness
  • Impaired mobility
  • Shear
  • Friction
  • Moisture
110
Q

Shear action is

A

Sliding movement of skin while underlying bone & muscle are stationary

111
Q

Prevention of pressure injuries

A
  • Protect bony prominences
  • Skin barriers for incontinence
  • No loose sheets under pts skin
  • Minimum absorbent pads under pts
  • Reposition pts often
  • Support surfaces; Pillows, cushions, special mattresses
112
Q

Braden scale for pressure injuries

A

An evidence based tool that allows health professionals to predict a pts risk for developing a hospital acquired pressure ulcer

113
Q

The Braden scale evaluates

A
  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction & shear
114
Q

Braden scale scores

A
  • 19-23: No risk
  • 15-18: Mild risk
  • 13-14: Moderate risk
  • 10-12: High risk
115
Q

Stage 1 pressure ulcer

A

Intact skin w non blanchable redness

116
Q

Stage 2 pressure ulcer

A

Partial thickness skin loss involving epidermis, dermis, or both

117
Q

Stage 3 pressure ulcer

A

Full thickness tissue loss with visible fat

118
Q

Stage 4 pressure

A

Full thickness tissue loss w exposed bone, muscle, or tendon

119
Q

Can pressure ulcers go through each stage.?

A

No. A healing pressure ulcer will be regarded as a healing stage “XYZ” pressure ulcer

120
Q

What injuries cannot be staged.?

A

Wounds with necrotic tissue cannot be staged

121
Q

Who determines the stage of a pressure injury.?

A

A specialized & experienced wound care nurse

122
Q

Nursing role of wound management

A
  • Identify risk factors for pressure ulcer development
  • Thorough skin assessment
  • identify infection if present
  • Keep wounds clean & dressed per orders
  • Communicate

Nursing Fundamentals (5 decks)

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