NU 301 Exam 3 Flashcards
Define mobility
Freedom and independence in purposeful movement.
What is lordosis?
Increased lumbar curvature
What is kyphosis?
Increase thoracic curvature
What is scoliosis?
Lateral curvature, (can be thoracic, lumbar, or both, rarely cervical)
What effects on endocrine metabolism does immobility have?
Decreased appetite, decreased calorie intake, increased risk of electrolyte imbalance.
What effect does immobility have on calcium reabsorption?
Increases risk of bone fracture
What effect does immobility have on GI system functions?
Constipation risk, and psuedodiarrhea
What effect does immobility have on respiratory changes?
Atelectasis, hypostatic pneumonia
What effect does immobility have on the cardiovascular system?
orthostatic hypertension increased cardiac workload, increased oxygen consumption, risk of thrombus formation
What effect does immobility have on the musculoskeletal system?
joint contractures and disuse osteoporosis.
What effect does immobility have on the urinary system?
Urinary stasis and renal calculi
What effect does immobility have on the integumentary system?
Pressure injuries
What effect does immobility have on the psychosocial aspect?
Depression and sensory alterations.
You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with
A. Atelectasis
B. Hypertension
C. Orthostatic Hypotension
D. Coagulation of blood
A. Atelectasis
What are some metabolic interventions for immobility?
High Protein High calorie diet with vitamin B and C. May need enteral feedings. Assess likes and dislikes. May need to feed patient.
What are some respiratory interventions for immobility?
TCDB, prevention of pneumonia/atelectasis, incentive spirometer, PO hydration
What are some cardiovascular interventions for immobility?
TEDS, SCDS, Dangle legs prior to standing, Ambulate, Heparin, Lovenox, ROM exercises.
What are some musculoskeletal interventions for immobility?
Assess for atrophy, ROM exercises, Appropriate diet.
How long does it take to recover from immobility atrophy?
4 weeks
How do you assess color changes for abnormal reactive hyperemia?
Palpate for induration. Gently press area for blanch. Report to nurse. Document location size and color. Reassess after 1 hour.
What are 2 characteristics of abnormal reactive hyperemia?
- An area does not blanch
- Reddened area that remains red for longer then 1 hour.
What are some psychological interventions for immobility?
Allow for time to talk, assess for behavior responses or changes, Withdraw
What are some tips for crutches and stairs?
Foot first when going up, crutch first when going down
What are some tips for using crutches/walkers?
Gradually shift weight to healthy leg, move crutches in front, then shift weight from healthy leg to arms and swing through. Never support with armpits.
How should you size a walker to a patient?
While patient is standing erect, walker should extend to hip-joint, elbows flexed 15-30 degrees.
How should a cane be sized for a patient?
With patient standing place cane 4 inches (20cm) from side of foot. Top of cane should reach top of hip joint. Arm flexed 30 degrees when holding cane.
A nurse is teaching a client with left leg weakness to walk with a cane, the nurse should include which nursing points about safe cane usage in the teaching? Select all that apply.
1. Place the cane 8”-10” from the base of the little toe.
2. Hold the cane on the uninvolved side of the body.
3. Adjust the cane so the handle is in line with the hip bone.
4. Walk by moving the involved leg, then the cane, then the uninvolved leg.
5. Shorten the stride length on the involved side.
6. Avoid leaning on the cane to get in and out of a chair.
2,3, and 6
What are some knee replacement precautions?
Physical therapy will assist with dangling and extension exercises. CPM machine used. Pillow or rolled towel under ankle to achieve optimal leg extension. Use walker or cane. UP stairs = lead with good knee. Downstairs = lead with operative knee.
What occurs during urinary elimination?
Filtration, reabsorption, and excretion.
How does urine get to the bladder after filtration?
Through the ureters.
A patient with long standing history of diabetes mellitus is voicing their concerns about kidney disease. The patient asks where the urine is formed in the kidneys. The nurse’s response should be.
A. Bladder
B. Kidney
C. Nephron
D. Ureter
C. Nephron
What are some common urinary elimination problems?
Urinary retention, UTIs, Urinary incontinence, urinary diversions
Define anuria
less than 100ml in 24 hours
Define oligura
between 100 and 500ml of urine in 24 hours
Define dysuria
Painful urination
Define hematuria
Blood in urine
Define incontinence
Loss of bladder control
Define nocturia
Frequent nighttime urination
Define urgency
Strong, sudden urge to urinate
What is suprapubic pain?
Pain in your lower abdomen where many important organs are e.x. intestines, bladder, genitals.
Define Polyuria
Greater then 2000ml in 24 hours
Define urinary retention
Difficulty urinating and emptying the bladder.
Define residual urine (post-void residual)
Amount of urine in your bladder after using the restroom
How much is a person’s minimum daily fluid intake?
1200-1500ml
How much is a person’s average daily output?
1200-1500ml
How much urine output is considered renal failure?
< 1200ml
What is the average daily fluid intake for a person?
2200-2700ml
What is the desired hourly urinary output for an adult?
A. 30 ml
B. 60 ml
C. 50ml
D. 100ml
A and B
What intervention is most important for a male client who is experiencing urinary retention?
A. Apply a skin protectant.
B. Encourage increased fluid intake.
C. Apply a condom catheter.
D. Assess for bladder distention.
D. Bladder distention
What color is normal urine?
Straw colored
What color is dehydrated urine?
Amber
What color is overhydrated urine?
light straw
What color is urine for someone on medication?
Orange
What color is someone’s urine who is injured, on medications, or has blood in it?
Red
What will the odor of normal urine smell like?
Faint
Describe an abnormal urine odor
Strong;Possible infection or medications
What is the consistency/clarity of normal urine?
Clear
List the abnormal consistencies/clarities of abnormal urine
Cloudy, thick
A healthcare provider may suspect a patient is experiencing urinary retention when the patient has:
A. Large amounts of voided cloudy urine
B. Pain in the suprapubic region.
C. Spasms and difficulty during urination.
D. Small amounts of urine voided two to three times per hour.
D. Small amounts of urine voided two to three times per hour.
What causes functional urinary incontinence?
Factors outside of the urinary tract. i.e. environmental barriers and mobility.
What are some causes of stress incontinence?
Caused by an increase in intra-abdominal pressure. (sneezing, coughing)
How do you treat incontinence?
Fluid management, avoid caffeine and alcohol, bladder retraining, pelvic floor muscle exercises. Normal position, running water, warm water over the perineum, adequate fluid intake.
A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding:
A. In bathrooms that aren’t their own.
B. In a urinal.
C. While lying in bed.
D. In the presence of a person other then one of their parents.
D. In the presence of a person other then one of their parents.
T or F, in a 24 hour urine test you save all urine samples.
False, discard the first voiding and save all urine for the next 24 hours.
What pH range should a urine sample be at?
4.6-8.0; average 6.0
What should the specific gravity of urine be?
1.0053-1.030
What should the number of WBC, RBC, and bacteria in urine be in a microscopic examination?
RBC= scant
WBC= scant
Bacteria= none
What are signs of a positive urinalysis (UTI)?
E-coli, bacteriuria, dysuria, hematuria, fever, positive urinalysis.
The assessment of mobility includes
ROM, gait, and exercise
What are the two types of ROM?
active and passive
What are the pathological influences on mobility?
Postural abnormalities
Muscle abnormalities
Damage to the central nervous system
Direct trauma to the musculoskeletal system
Joint disease
What are some other postural abnormalities?
Torticollis
Congenital hip dysplasia
Knock-knee
Bowlegs
Club foot
Foot drop
How to properly assess for correct body alignment?
Put the patient at ease so that they do not assume an unnatural position. If they have them, remove all pillows and supports and place the patient supine.
To properly assess body alignment, you must assess the patient standing, sitting, and lying
How do you assess someone who is standing?
- The head is erect and midline.
- When observed posteriorly, the shoulders and hips are straight and parallel.
- When observed posteriorly, the vertebral column is straight.
- When observed laterally, the head is erect, and the spinal curves are aligned in a reversed S pattern. The cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, and the lum-bar vertebrae are anteriorly convex.
- When observed laterally, the abdomen is comfortably tucked in, and the knees and ankles are slightly flexed. The person appears comfortable and does not seem conscious of the flexion of knees or ankles.
- The arms hang comfortably at the sides.
- The feet are slightly apart to achieve a base of support, and the toes are pointed forward.
- When viewing the patient from behind, the center of gravity is in the midline, and the line of gravity is from the middle of the fore-head to a midpoint between the feet. Laterally the line of gravity runs vertically from the middle of the skull to the posterior third of the foot
How do you assess someone who is sitting?
- The head is erect, and the neck and vertebral column are in straight alignment.
- The body weight is distributed evenly on the buttocks and thighs.
- The thighs are parallel and in a horizontal plane.
- Both feet are supported on the floor and the ankles are flexed comfortably. With patients of short stature, use a footstool to ensure that ankles are flexed comfortably.
- A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. This space ensures that there is no pressure on the popliteal artery or nerve to decrease circulation or impair nerve function.
- The patient’s forearms are supported on the armrest, in the lap, or on a table in front of the chair.”
How do you assess someone who is lying down?
- Put the patient in a lateral position
- Remove all supports from the bed except for the pillow under the head and support the body with an adequate mattress
- Make sure the vertebrae are aligned and the patient is not in discomfort
How do you assess a patient’s mobility?
Begin with the patient in the most supported position, and move to higher levels according to the tolerance of the patient. Generally it starts with the patient lying, and proceeds to sitting positions, transfers to chair, and finally walking.
What factors affect urination?
Growth and Development
Sociocultural Factors
Psychological Factors
Personal Habits
Fluid Intake
Pathologic Conditions
Surgical Procedures
Medications
Diagnostic Examinations
Describe a sterile urine analysis?
Drawn from foley port
Label all specimens
Preserve according to lab protocol
May need refrigeration
Infection control: gloves, biohazard lab bag
Diagnostic examinations are the _____ responsiblitiy
nurse’s
Describe a 24 hour urine sample
Have the patient void and record time
Discard the first void, but save all urine for next 24 hr
Keep on ICE
Inform patient and all staff about collection
Post signs in prominent locations to remind staff of ongoing test and not to discard urine
What do you look for in a routine urine analysis?
pH of 4.6-8.0 (average 6)
protein
glucose
ketones
blood
specific gravity of 1.0053-1.030
Microscopic exams should show RBC (scant), WBC (scant), Bacteria (none)
What are the different types of urinary devices?
Intermittent (straight or curved Cath)
Indwelling retention (foley)
Suprapubic cath
Condom Cath
External female Cath (Wick)
What are methods to prevent CAUTI?
hand hygiene
maintenance of a closed system
prevent pooling of urine in drainage system
avoid kinks in tubing
keep drainage bag below level of bladder
secure the catheter
routine perineal hygiene
What factors influence bowel elimination?
Age
Diet
Fluid Intake
Physical Activity
Psychological Factors
Personal Habits
Positioning during defecation
Pain
Pregnancy
Surgery and Anesthesia
Meds
Diagnostic Tests
What are some common bowel and elimination problems?
Constipation
Diarrhea
Incontinence
Flatulence
Hemorrhoids
What are the main types of stools tests/sampling?
Occult blood test
Fecal fat test
Ova and parasites test
What is an example of a bowel diversion?
Ostomies (develops an artificial opening in the abdominal wall)
What is an ileoanal pouch anastomosis?
Pouch is a reservoir for wastes which are eliminated from the anus
Describe acute care for bowel elimination
Proper environment
Cathartics and laxatives
Antidiarrheal agents
How can a nurse promote normal defecation?
Proper sitting position
Positioning on bedpan
Carthartics have a _____ and ____ _____ effect on the intestines than laxatives
stronger and more rapid
Suppositories may act more ____ than oral meds
quickly
What is an example of Antidiarhheal agents?
Opiates used with caution
What are the different types of enemas?
Cleansing (tap water, normal saline, hypertonic solutions, soapsuds)
Oil retention
Carminative and Kayexalate
Explain Enema administration
Sterile technique is unnecessary
Wear gloves
Explain procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain solution
What is digital removal of stool?
Oil retention enema may soften
Last resort in managing severe constipation
What are the categories of NG tubes?
Fine- or small-bore for medication administration and enteral feedings
Large-bore (12-French and above) for gastric decompression or removal of gastric secretions
What is important for inserting and maintaining a nasogastric tube?
Clean technique
Maintaining comfort (assess for inflammation)
Maintain patency
What group assigns classification on the basis of a patient’s physiological condition independent of the proposed surgical procedure?
American Society of Anesthesiologist
Classification of surgery is a?
risk assessment that allows surgeons and anesthesia providers to consider factors that influence how surgery will be performed
ASA I is?
Normal healthy patient
ASA II is?
A patient with mild systemic diseases
ASA III is?
A patient with severe systemic disease
ASA IV is?
A patient with severe systemic disease that is a constant threat to life
ASA V is?
A moribund patient who is not expected to survive without the operation
ASA VI is?
A declared brain-dead patient whose organs are being removed for donor purposes
What are some surgical risk factors? (Related to the patient)
Smoking
Age
Nutrition
Obesity
Obstructive Sleep Apnea
Immunosuppresion
Fluid and Electrolyte Imbalance
Postoperative nausea and vomiting
Venous Thromboembolism
What information would you collect about the patient in the preop phase? (nursing process and assessment)
Through the patient eye’s (expectation/road to recovery)
Nursing history (advanced directives)
Medical history (screens for conditions that increase surgical risks)
Surgical history (complications prior to surgery)
Medications (inpatient vs outpatient)
Allergies (meds, topical agents, latex, food)
Smoking habits
Alcohol and substance use
Pregnancy
Perceptions and knowledge regarding surgery
Support sources
Occupation
Preop pain assesment
Review of emotional health (self-concept, body image, coping resources)
Cultural and spiritual factors
What conditions can you diagnose about a patient in the preop phase? (nursing diagnosis)
Impaired skin integrity
Risk for infection
Impaired Mobility related to incisional pain
Impaired Mobility related to decrease muscle strength
Impaired Airway Clearance
Anxiety
Acute Pain
Describe the Preop Phase: Implementation
(What actions are taken before surgery?)
Informed consent
Health promotion (preop teaching)
Postoperative activity resumption
Pain-relief measures
Rest
Feelings regarding surgery
Minimizing risk for surgical wound infection
Maintaining normal fluid and electrolyte balance
Preventing bowel incontinence and contamination
Preparation on day of surgery
What would you teach the client in the preop phase?
Reasons for preop instructions and exercise
Preoperative routines
Surgical procedure
Time of surgery
Postoperative unit and location of family during surgery and recovery
Anticipated postoperative monitoring and therapies
Sensory preparation
What are the nursing roles during surgery?
Circulating nurse (manages nursing process in OR)
Scrub Nurse (hand the surgeon tools)
Registered nurse first assistant
Assessments after surgery should include?
neurological functions
skin integrity and condition of wound
metabolism
genitourinary function
gastrointestinal function (mobility)
comfort and sleep
What is the goal for post op recovery?
help the patient return to the best possible level of functioning with a smooth transition to home, rehab, or long-term care
What does restorative and continuing care do?
Prepare for discharge
Provide patient education
Help patients adhere to exercise programs
Make referrals to home care as needed
Coughing and deep breathing may be contraindicated after what surgery
brain, spinal, head, neck, or eye
Patients who are severely obese sometimes have more improved lung function and vital capacity in what two positions
reverse trendelenburg or side-lying
Report any signs of what for immobile/surgical patients?
venous thromboembolism
Nutrition is essential for?
normal growth and development
tissue repair and maintenance
cellular metabolism
organ function
This type of therapy uses nutrition therapy and counseling to manage diseases
Medical nutrition therapy
Environmental factors influencing nutrition
*Lack of access to grocery stores.
*High cost of healthy foods.
*Less healthy foods in fast food restaurants.
*Advertising of junk foods.
*Lack of safe place to exercise.
Developmental needs to nutrition for infants through school age?
infants through school age (breastfeeding, formula, solid foods)
What is the nursing process for nutrition?
Assessment (nutritional history)
Screening
Dysphagia
How do you alternate food patterns?
Based on religion, cultural background, ethics, health beliefs, and preference
What are components of a nutritional assessment?
food or nutrition-related history
biochemical data, medical tests, and procedures
anthropometric measurements
nutrition-focused physical findings
client history
What are changes in nutrition needs over the lifespan?
Older adults generally have lower calories needs, but similar or even increased nutrient needs compared to younger adults. This is often due to less physical activity, changes in metabolism, or age-related loss of bone and muscle mass
How do you initiate an enteral feeding?
verify initial tube placement by radiography
initial feeds begin at 10-40 mL/hr for adults
advance 10-20 mL/hr q 8-10 hrs as tolerated (start slow, increasing gradually)
usual max rate for adults is 125 mL/hr
What are interventions for an enteral feeding? (during the feeding)
monitor the patient for feeding intolerance. Assess abdomen by auscultating bowel sounds and palpating for rigidity, distention, and tenderness.
Know that patients who complain of fullness or nausea after a feeding starts may have a higher GRV.
What are some Nursing diagnosis applicable to nutritional problems?
Risk for aspiration
Overweight
Impaired low nutritional intake
Impaired self feeding
Impaired swallowing
What is GRV?
gastric residual volume
What gauge is the green needle?
18g
What is the green needle best used for?
Surgery (also good for giving blood to adults)
What gauge is the yellow needle?
24g
What is the yellow needle best used for?
PEDS, neonate. or elderly
What gauge is the blue needle?
22g
What is the blue needle used for?
General use
What gauge is the pink needle?
20g
What is the pink needle used for?
administering a bolus
What guage is the grey needle?
16g
What are the grey and orange needles used for?
Inserted into AC (for major blood loss)
What gauge is the orange needle?
14g
What does AC stand for?
Antecubital
How long can an IV stay in?
72-96 hours
How long can an IV bag be used for?
24 hours
What is the antidote for malignant hyperthermia?
Dantrolene
Who gives informed consent?
The provider
When does discharge teaching begin?
At admission
Define digestion
Mechanical breakdown resulting from chewing, churning, and mixing food with fluid and chemical reactions reducing food to its simplest form
Define absorption
The body absorbs nutrients via passive diffusion, active transport, and pinocytosis.
Define metabolism
All the biochemical reactions within the cells of the body
Define elimination
Chyme moves by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces.
What are some environmental factors influencing nutrition?
Lack of access to grocery stores. High cost of healthy foods. Less healthy foods in fast food restaurants. Advertising of junk foods. Lack of safe place to exercise.
Define a fruitarian
Consumes fruit, nuts, honey, and olive oil
Define a vegan
Consumes only plant food
Define a lactovegetarian
Avoids meat, fish, and poultry. eats eggs and milk
What are some nursing diagnosis applicable to nutritional problems?
Aspiration risk, overweight, impaired low nutritional intake, impaired self feeding, impaired swallowing.
What angle should the head of the bed be for eating?
30-45 degrees
If someone has difficulty swallowing what should we avoid?
Straws, and thin liquids
Define a low sodium diet
4g (no added salt), 2g, 1g, or 500mg sodium deits; vary from no added salt to severe sodium restrictions (500mg sodium diet).
Define low residue diet
Easily digest foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or cocnut.
Define a low fat diet
mostly plant foods (such as vegetables, fruits, and whole grains) and a moderate amount of lean and low-fat, animal-based food (meat and dairy products)
Define low cholesterol diets
(what food is included?)
300mg a day cholesterol. seafood, legumes like beans and peas, nuts, seeds, lean meats, poultry, and eggs
Define a gluten free diet
Eliminates wheat, oats, rye, barley, and their derivatives.Expensive
For I and O, are tube flushings counted?
Yes
Why do we check for residual during tube feedings?
There is a risk for aspiration. The stomach is full and the excess food can come back up.
What is the most common item to clog feeding tubes?
Crushed medicine. (Crushed enteric coated medicine)
What are some bowel interventiosn for immobility?
Assess bowel sounds, abdominal distention, and bowel patterns, for consistency and frequency.
What are some urinary interventions for immobility?
I&O every 24 hours. Assess type and amount of daily fluid intake. Assess color and consistency of urine daily.
What are tips for walking with a cane?
Hold the cane on the unaffected side. Injured leg goes with the cane.
Keep cane on the stronger side of the body.
Place can forward 6 to 10 inches keeping body weight divided on both legs.
Weaker leg moves forward, divide weight between stronger leg and cane.
Stronger leg advanced past the cane, and weaker leg.
What is an example of ASA I?
Healthy, non-smoking, or no/minimal alcohol use.
What is an example of ASA II?
Mild disease without substantive funcitonal limitations. Smoker, social-alcohol drinker, pregnancy, controlled DM/HTN
What is an example of ASA III?
Substantive functional limitations. Alcohol-abuse, implanted pacemaker, COPD, morbid obesity, poorly controlled DM, HTN
What is an example of ASA IV?
MI, CVA, CAD/stents, severe valve dysfunction
What is an example of ASA V?
thoracic aneurism, intracranial bleed, multiple organ/system disfunction
How can you minimize risk for surgical wound infections?
antibiotics, skin antisepsis, clipping instead of shaving hair.
How do you maintain normal fluid and electrolyte balance before surgery?
Fasting, IV fluid replacement, parenteral nutrition.
What are some factors to consider about getting the client prepared for surgery?
Hygiene
Preparation of hair
removal of cosmetics
Removal of prosthesis
Safeguarding valuables
preparing the bowel and bladder
vital signs
Prevention of DVT
Administering pre-op medications
Documentation and hand-off
Eliminating wrong site and wrong prodecure surgery
What does the preanesthesia care unit nurse do?
Inserts IV catheter, administers pre-op medicines, monitor vital signs, inserts catheter
What are the four risk factors for fire assessed on a surgery patient?
- Is an alcohol based agent or other volatile chemical used in pre op?
- Procedure site above or below the xyphoid?
- Open oxygen source, face, mask, or nasal canula
- Ignition source in use cautery, laser, fiber optic light source, defibrillator, drill/saw/burr, lithotripsy
When conducting preoperative patient and family teaching, you demonstrate proper use of the incentive spirometer. You know that the patient understands the need for this intervention when the patient states, “I use this device to:
A. help my cough reflex.”
B. expand my lungs after surgery.”
C. increase my lung capacity.”
D. drain excess fluid from my lungs.”
B. expand my lungs after surgery.”
What actions should the nurse take for immediate post op recovery?
Hand-off communication
Conduct complete systems assessment
Once awake, expectorate the airway
Airway obstruction
Determine a patient’s status and eventual readiness for discharge from the PACU on the basis of vital sign stability
Postanesthesia recovery score (PARS)
Postoperatively, the nurse instructs the patient to perform leg exercises every hour to:
A. maintain muscle tone.
B. assess range of motion.
C. exercise fatigued muscles.
D. increase venous return.
D. increase venous return.
What is a diet for an obese patient?
Eating a reduced calorie diet that includes plenty of fruits and vegetables.
Limiting red meats, processed foods (chips, cookies, sugary cereals) and sugar-sweetened beverages like soda and juice.
Describe a diet for a diabetes patient
Focus on total energy, nutrient and food distribution; include a balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient’s metabolic dema/ds
Describe a diet for a patient with a stage 4 wound
Foods that are high in protein include meat, fish, eggs, dairy products, nuts, beans and pulses. Try to have at least one of these foods at each meal. Aim to have one pint of milk per day or a variety of milk and dairy foods such as milk puddings, cheese or yoghurts.
Describe a diet for a patient with heart disease
Eat less saturated fat. Cut back on fatty meats and high-fat dairy products. Limit foods like pizza, burgers, and creamy sauces or gravy.
Cut down on sodium (salt). choose foods that are lower in sodium. Look for foods labeled “low sodium” or “no salt added” — like some canned soups, canned vegetables, packaged meals, and snack foods.
Get more fiber. Eat vegetables, fruits, beans, and whole grains to add fiber to your diet.
Describe a diet for a patient with GI disease
Avoid:
Deep-fried foods. Deep-fried foods absorb copious amounts of fats — oil, shortening, or lard — during the cooking process. …
Processed foods. …
High-fat foods. …
Coffee. …
Spicy foods. …
Alcohol. …
Citrus fruits. …
Chocolate.
Describe parenteral nutrition
Nutrients are provided intravenously
Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states
Peripheral or central line
Initiating parenteral nutrition
Preventing complications
What is foot drop?
The foot is permanently stuck in plantar flexion (pointed down). The patient is unable to raise the toes up and is at risk for stumbling.
What is a joint contracture?
Anbormal fixation of a joint
What are s/s of malnutrition on someone’s general appearance?
Easily fatigued, no energy, falls asleep easily; looks tired, apathetic, cachectic
What are s/s of malnutrition on someones weight?
overweight, obese, or underweight; unplanned weight loss over period of time
What are the s/s of malnutrition on someones posture?
Poor posture, sagging shoulders, sunken chest, humped back.
What are the s/s of malnutrition on someone’s muscles?
Flaccid, weak, poor tone, tender, wasted appearance, impaired mobility.
What are the s/s of malnutrition on someone’s mental status?
inattentive, irritable, confused
What are the s/s of malnutrition on someone’s neurological function?
burning and tingling of hands and feet, loss of position and vibratory sense, decrease or loss of ankle and knee reflecxes
What are the s/s of malnutrition on someone’s GI function?
Anorexia, indigestion, constipation or diarrhea, symptoms of malabsorption, liver or spleen enlargement, abdominal distention.
What are the s/s of malnutrition on someone’s cardiovascular function?
Tachycardia, abnormal rhythm, elevated blood pressure
What are the s/s of malnutrition on someone’s hair?
Stringy, dull, brittle, dry, thin and sparse, depigmented
What are the s/s of malnutrition on someone’s skin (general)?
Rough, dry, scaly, pale, pigmented, irritated, bruises, petechiae.
What are the s/s of malnutrition on someone’s face and neck?
Swollen, skin dark over cheeks and under eyes.
What are the s/s of malnutrition on someone’s lips?
dry, scaly, swollen; redness and swelling at the corners of the mouth (cheilosis); angular lesions at corners of mouth, fissures, or scars.
What are the s/s of malnutrition on someone’s mouth, oral, mucous membranes?
Swollen, deep red oral mucous membranes; oral lesions
What are the s/s of malnutrition on someone’s gums?
Spongy, bleed easily, inflamed, receding
What are the s/s of malnutrition on someone’s tongue?
Swelling, scarlet and raw, magenta color, beefy
What are the s/s of malnutrition on someone’s teeth?
Missing teeth, broken teeth
What are the s/s of malnutrition on someone’s eyes?
Eyes membranes pale, redness of membrane, dryness or infection
What are the s/s of malnutrition on someone’s nails?
spoon-shaped, brittle, ridged
What are the s/s of malnutrition on someone’s legs and feet?
Edema, tender calf, tingling, weakness, lesions
What are the s/s of malnutrition on someone’s skeleton?
Bowlegs, knock-knees, chest deformity at diaphragm, beaded ribs, prominent scapulas.
The nurse is assisting the client in caring for her ostomy. The client states, “Oh, this is so disgusting. I’ll never be able to touch this thing.” The nurse’s best response is
“I’m sure you will get used to taking care of it eventually.”
“Yes, it is pretty messy, so I’ll take care of it for you today.”
“It sounds like you are really upset.”
“You sound very angry. Should I call the chaplain for you?”
“It sounds like you are really upset.
A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with:
A. abnormal defecation.
B. constipation.
C. fecal impaction.
D. fecal incontinence.
B. constipation.
The nurse knows that the results of a fecal occult blood test can be inaccurate if
The client has had an excessive intake of red meat
The female client is menstruating
The client takes high doses of vitamin C
All of the above
D. All of the above
Which of the following medications listed in a patient’s medication history possibly causes gastrointestinal bleeding? (select all that apply)
Aspirin
Cathartics
Antidiarrheal opiate agents
Nonsteroidal anti-inflammatory drugs (NSAIDS
Aspirin
Cathartics
Antidiarrheal opiate agents
Nonsteroidal anti-inflammatory drugs (NSAIDS)
During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with?
Food allergy
Irritable bowel
Lactose intolerance
Increased peristalsis
- Lactose intolerance
A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first?
Administer pain medication.
Slows down the rate of instillation.
Tells the patient to breathe slowly and relax.
Stops the instillation and obtains vital signs
- Stop the instillation and obtains vital signs
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because:
A. the presence of food stimulates peristalsis.
B. mass colonic peristalsis occurs at this time.
C. irregularity helps to develop a habitual pattern.
D. neglecting the urge to defecate can cause diarrhea.
B. mass colonic peristalsis occurs at this time.
What are some diagnoses that apply to patients with bowel elimination problems?
Bowel Incontinence
Constipation
Risk for Constipation
Diarrhea
Lack of Knowledge of Dietary Regime
What is the fecal occult blood test commonly used for?
Colon cancer screening
What is a mechanical soft diet?
Clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese.
What is a full liquid diet?
Same as clear liquid but with addition of smooth textured dairy products i.e. ice cream
What is a clear liquid diet?
Clear fat free broth, coffee, tea, carbonated beverages, clear fruit juices, and gelatin.
How would you perform a bladder assessment?
Ensure the bladder is not palpable, and there is no pain.
Take the client’s health history.
Ask the client about any pain
