Nur 101 Unit 2 Flashcards
Conversions
5ml =
1tsp
Conversions
1tbs =
3tsp = 15ml
Conversions
2 tbs =
1oz
Conversions
1oz =
30ml
Conversions
8oz =
1 cup
Conversions
16oz =
1pint = 2cups
Conversions
32oz =
1qt = 2 pints
Conversions
4qts =
1 gal
Conversions
1000ml =
1L = 1qt
Conversions
1000 mcg =
1mg
Conversions
1000mg =
1 gm
Conversions
1000 gm =
1 kg
Conversions
60mg =
1 gr (grain)
Conversions
1kg =
2.2 lbs
Conversions
1 lbs =
454gm = 0.454 kg
Conversions
1lb =
16 oz
Conversions
28.4gm =
1oz
Conversions
1in =
2.54 cm
Factors to assess in evaluating nutrition and metabolism
Nutrition is Influenced by: ethnic heritage, experiences (+/-), media and community resources
Differences may explain other problems
Fluid intake
Problems r/t underweight/ obesity
Skin is the first defense against infection
HC treatment may interfere with cell metabolism
Nutrients
Supply the body with necessary elements for growth, maintenance, and repair.
- most nutrients and electrolytes are absorbed in the sm. intestine
Carbs, fats, proteins, and alcohol help provide energy and support metabolic processes
Essential nutrients, water, electrolyte, minerals, vitamins, and protein for tissue building.
Macronutrients
Carbohydrates
Protine
Fats
Macronutrients
Carbohydrates
Main energy source
Sources of CHO:
Fruits, veggies, grains, milk
Macronutrients
Protein
Essential in growth and repair of tissues
20 amino acids exist
10 essential amino acids
-not synthesized by body
-a compound protein food has all 10
Macronutrients
Fats
Main source of fatty acids
Essential for growth and development
Other functions:
Hormones, tissue structure, nerve impulse trans, insulation, protection
Macronutrients
Vitamins
Pg.W81
Water soluble
Fat soluble
Macronutrients
Minerals
Pg. W 81
Major
Essential
Metabolism
Process of producing and using energy within the body’s cells. The final process of nutrition
Fueled by nutrients :
- Energy produced
- energy used
- needs to be balanced for health
Thyroid hormone players a major role
Why is energy used in the body
To maintain essential life processes (BMR)
- breathing, circulation, NS function
To support non essential life activities
- running, working, handling stress, some energy is used for digestion and absorption
Basal Metabolic Rate
BMR
The amount of energy required for essential life processes
It’s measures when the body is physically, metabolically, and emotionally at rest
Influenced by activity, hormonal imbalance, temp. Stress, illness
Metabolic processes
Blood channeled to the liver is where metabolic process occur
Anabolism
Catabolism
Metabolic processes
Anabolism
- cell building
- excess stored as fat and can be used for body needs if nutritional intake isn’t sufficient
- fat excess= weight gain
(Lab assessment = positive balance )
Metabolic processes
Catabolism
- break down of cells and tissues
- necessary for a constant source of energy
- excess= decreased weight
-cont. excess = muscle wasting (ex diarrhea)
(Lab assessment = negative balance )
Lab assessment for metabolism
Positive balance
More consumed than excreted
- increased demand during pregnancy, growing, kids
- anabolic state
Lab assessment for metabolism
Negative balance
Intake less than output
-loss of protein in the form of muscle and other tissue.
- metabolic demands are not met
( catabolic state)
Lab assessment for metabolism
Lab test
24 hr urine
24 hr calorie counting, looking at the protein and nitrogen intake.
BUN blood test
Albumin and protein blood test to ck for deficiencies ( nessary for wound healing)
4 stages Pressure ulcers
-Skin deprived of oxygen
Stage 1
- Blood stasis
- Redness not relieved by massage or pressure relief
- warm to touch
4 stages Pressure ulcers
-skin deprived of oxygen
Stage 2
- Epidermal loss, possible damage to the dermis
- moist and depressed skin, erosion, abrasions, blister, shallow crater
- can heal ok R/t no blood vessel damage
4 stages Pressure ulcers
-skin deprived of oxygen
Stage 3
- full thickness skin loss
- ulcer can extend to subcutaneous layer
- drainage is common( suro-sanguinous or purulent)
- healing time is longer and needs regranulation
4 stages Pressure ulcers
-skin deprived of oxygen
Stage 4
- full thickness deep into CT, muscle, bone.
- may have necrosis
- need adequate protein and albumin levels for healing( attn nutrition. Pt put on special diet)
- healing time is longer
- may need debridement
Debridement
2 types
Cut away necrotic tissue
Wet to dry dressing changes
Conversions
1ml =
15 drops
Lymphatic system
Lymph node examination
Palpation: roll up and down b/t fingers. Only visible if inflamed
Lymphatic system
Lymphadenitis
- Inflammation of lymph nodes
- painful
Lymphatic system
Lymphangitis
Inflammation along the course of the lymph vessel
Lymphatic system
Lymphadema
Tissue swelling
Thyroid gland
Secretes 3 hormones
T3
T4
Calcitonin
Thyroid gland hormone
T3
Increases BMR with increase oxygen consumption
Increases chem rxn rates
Stimulates metabolism of essential nutrients
Promotes human growth
Short lifespan
Thyroid gland hormone
T4
Same functions as T3
Can be converted into T3
Secreted in larger amounts
Longer life span than T3
Thyroid gland hormone
Calcitonin
Calcium metabolism
ParaThyroid glands
Located on the posterior surface of the thyroid gland
Regulates calcium phosphorus metabolism
Hyperthyroidism
- Exophthalmos
- weakness, fatigue
- diaphoresis(sweating)
- tachycardia, chest pain, dysrhythmias, increased BP
- weight loss, increases appetite, diarrhea or constipation
- restlessness, nervousness, insomnia, irritable, hyperactivity
Hypothyroidism
Myxedema
- decreased cardiac output and condition, enlarged heart, decreased BP
- atherosclerosis, increased colesterol
- lethargy, fatigue, slow speech, thick tongue, deep voice
- weight gain, decreased appetite, decreased peristalsis, constipation
- dry brittle hair
- facial edema
- memory impairment
- cold tolerance, cold extremities
Skin assessment tips
Use inspection and palpitation Good lighting Evaluate areas at risk(pressure points) Inspect all wounds, under skin folds Compare right to left Investigate any abn new finding and describe throughly
Other skin related problems:
• Diabetes:
chronic skin infections with ulcerations (especially on the feet), poor wound healing, yeast infection under breasts, between fingers and toes, axilla and genital area
Other skin related problems:
• Liver Disease:
jaundice, edema, ascites (fluid in abdomen), impaired protein metabolism with ETOH (alcohol), red palms and spider veins all over.
Other skin related problems:
• Renal Disease:
pallor (pale), platelet disfunction, jaundice, edema
Other skin related problems:
• Cancer:
of the skin
Other skin related problems:
• Fluid imbalance:
edema if excess; decreased turgor, dryness, wrinkles, brittle skin and nails if fluid intake inadequate.
Other skin related problems:
• Impaired O2:
pallor, cyanosis (blue lips, mouth, fingertips, toes), flushing, mottling (patches of blue/black areas), cold, clammy
Other skin related problems:
• Peripheral Vascular Disease (PVD):
not enough blood and O2; pale, mottling, necrosis, cold, ulcerations
Other skin related problems:
• Skin Infections:
fungal vs viral, herpes, cold sores, ringworms, scales, scabies, flaking, eggs, lice, nits, vesicles (blisters)
Interview questions regarding
Diet Weight problems Ingestion problems Food and fluid intake N/V Preferences Activity level Psychosocial, cultural and personal influence Nutrition knowledge (can they read food lables) Physical change
Physical assessment
Assess for…
Subcutaneous fat (palpitation) Muscle mass Hight and weight Skin integrity Hair Nails Oral cavity Abdomen (palpitation) Thyroid gland(palpitation) Body temperature (palpitation)
Skin assessment
Color pigment moisture Temp Thickness Texture Turgor Mobility Hygiene Lesions
Hair assessment
Color Pigment Quantity Texture Distribution Hygiene
Nail assessment
Shape Configuration Color Lesions Thickness Capillary refill -160 degree angle -clubbing( lack of O2) -spooning(illness and sickness) -cyanosis
Skin deviations
Edema
Excess fluid in tissue. Assess for pitting and timing to return back to normal positioning. Assessment and documentation of edema -trace -1+ =2mm -2+ =4mm -3+ =6mm -4+ =8mm Brawny = warm, shiney, tight, weeping
Skin deviations
Turgor
Elasticity(dehydration)
- brisk
- sluggish(ck for tenting of the skin)
Cognitive-perceptual
Describes the :
Ability to collect and use information
Decision making and other cognitive processes
Neurological system
Major biological support system
- neuro pathology affects this system
Cognition
The process of knowledge Involves: Intellectual function Learning Motivation Thinking Thought processes Problem solving
Perception
The process of acquiring info
Involves:
Using senses
Meaningful interpretation
Goals for assessing cognitive perception
Note status of all senses
Note awareness of self-surroundings
ID risk factors
Note ability and knowledge to manage health
Perception of pain /severe discomfort signals
Possible tissue damage
Pain
Is whatever the client says it is and exist wherever they say it is(subjective)
Interferes with life activities
Results in stress and anxiety
Need to be documented per TJC
Identification and tx is important criterion of quality of care
Perception
Is a protective mechanism
-Vision hearing and touch contributes to
Enjoyment of people
Relationships
Appreciation of the world
-provides information used in higher cognitive processes
Mental health status assessment
LOC
Degree of
wakefulness
Arousability
Mental health status assessment
Awareness
Ability to
Understand
Think
Feel emotions
Mental health status assessment
Thought process
Abstract thinking Problem solving Insight Memory Judgment Attn span Understanding language Ability to follow directions
Mental health status assessment
Communication ability
Speech Comprehension of language Ability to Hear Answer simple questions Follow simple commands
Individual assessment includes
Adequate senses( hearing, taste, touch, smell, vision)
Compensation( glasses, hearing aids)
Pain management
Cognitive functional abilities (orientation, memory, reasoning, judgment, decision making)
Glascow coma scale
Standardized assessment tool for assessing LOC Cerebral dysfunction -assess eyes opening -Motor and verbal responses Burton p.430
Levels of consciousness
LOC
Fully awake Alert Lethargic Obtuned Stuporous/ semicomatose Comatose
Levels of consciousness
LOC
Fully awake
Highest level
Levels of consciousness
LOC
Alert
Awake and oriented
Responds to verbal commands
Levels of consciousness
LOC
Lethargic
Not fully alert Drowsy/sleepy Arousable Looses train of thought( disoriented ) Spontaneous movements
Levels of consciousness
LOC
Obtuned
Sleep most of the time
Few spontaneous movements
More rigorous stimulation to arouse
Decrease in appropriate responses to verbal commands
Levels of consciousness
LOC
Stuporous/ semicomatose
Unconscious most of the time No spontaneous motor activity Strong stimuli to arouse(pain) Verbal responses limited or absent( moans and groans) Rarely awake or oriented
Levels of consciousness
LOC
Comatose
Unable to arouse with painful stimuli
+ gag reflex
+ cough
If no reflexes, in deep coma
3 types of Posturing
Decorticate Flexor
Decerebrate Extension
Flaccid
3 types of Posturing
Decorticate Flexor posturing
Abn FLEXION posturing
May be in response to pain or may me spontaneous
Brain damage above the brainstem
3 types of posturing
Decerebrate extension posturing
Abn EXTENSION posturing
To stimulus or spontaneous
Damage IN brainstem
Ominous sign
3 types of posturing
Flacid
Limp
without muscle tone
Increased intracranial pressure
IICP
Decreased LOC and reflexes
HA, restless
Change in respiratory status
Increase or decrease in pulse
Increase in BP
Widening pulse pressure
Communication
Aphasia
Inability to express oneself properly thru speech
2 kinds
Expressive- can’t form words
Receptive- confused with words coming out.
Neuro assessment
PERRLA
Puples Equal Round React to Light Accommodation
Neuro assessment
Accommodation
Pupils constrict as objects come closer
Neuro assessment
Convergence
Eye cross as objects come close
Pain thershold
Point at which pain is felt
Pain tolerance
Pain endurance
Acute pain
Significant, severe
Recent onset
Damage or injury has occurred
Chronic pain
Consistent or intermittent
Persistent beyond expected healing time
Poorly defined
Problematic
Pain types
Somatic Visceral Phantom Neuralgia Causalgia
Pain types
Somatic
Can be localized originates in trunk, skin, or bone(external)
Pain types
Visceral
Internal organs ( ischemia, spasms, radiates from origin like with chest pain(referred) can’t be sharply localized( internal)
Pain types
Causalgia
Intense pain after trauma that involves peripheral nerves of an extremity
Diagnostic test
Sensory perception
Traumatic injury CVA fluid and electrolyte Imbalance Hypoxia Medications
Diagnostic test
Blood test
Blood sugar Blood urea nitrogen (BUN) Arterial blood gases (ABG's) Electrolytes Calcium Toxic substances (drug, ETOH)
Diagnostic test
X- Ray
Fractures
Motor dysfunction
Degenerative joint disease (DJD)
Diagnostic test
MRI
Trauma
Meligancy
Cerebral / spinal cord
Infractions
Diagnostic test
CT
Lesions
Malignancies
Diagnostic test
Cerebral angiogram
Dye test for blood vessel evaluation
Diagnostic test
Electromyography (EMG)
Assess nurse and muscle response to electrical stimulation
Diagnostic test
Electroencephalogram (EEG)
Recording of brain activity to do brain death or epilepsy
COGNITIVE -PERCEPTION Nursing DX
Acute pain Chronic pain Disturbed sensory perception Unilateral neglect Deficient knowledge Disturbed thought process Acute confusion Readiness for enhanced decision making Impaired environmental interpretation syndrome( common in CVA pt) Chronic confusion Readiness for enhanced knowledge Decision all conflict Impaired memory
Nutrition- metabolism nursing DX
Failure to thrive(adult) Imbalance nutrition: less than/ more than Breastfeeding - interrupted -ineffective -effective Impaired swallowing Nausea
