Skills Exam 7 Flashcards
what is a basic component of life?
nutrition
nutrition is essential for?
- normal growth and development
- tissue maintenance and repair
- cellular metabolism
- organ function
adequate access to nutrition is ___?
imperative
assessments for nutrition
- daily weights
- lab tests
- health history and diet
what are the lab values you need to assess with nutrition?
- liver function
- kidney function
- glucose
what is dysphagia?
difficulty swallowing
what are signs of dysphagia?
- coughing during eating
- change in voice tone or quality after swallowing
- abnormal movements of the mouth, tongue, or lips
- slow, weak, imprecise, or uncoordinated speech
- inability to speak consistently
- abnormal gag, delayed swallowing
- incomplete oral clearance or pocketing
- regurgitation
- delayed or absent trigger of swallow
how do you assess for dysphagia?
attempt to have the pt take a small sip of water while sitting upright in bed
what are some complications of dysphagia?
- aspiration pneumonia
- dehydration
- decreased nutritional status
- weight loss
dysphagia often leads to what?
malnutrition
will dysphagia increase or decrease albumin levels?
decrease
what can the nurse do to help with dysphagia?
- review ordered diet
- gradually advance diets
- promote appetite
- assist with oral feedings if necessary
- use of weighted silverware
what is an NPO diet?
- nothing by mouth
- if NPO for a long period of time, ensure proper fluids are being administered via IV
what is a clear liquid diet?
- only clear fluids/solids that easily become liquids at room temp
ex: clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin/jello, fruit ices, popsicles, soda, tea, water
what is a full liquid diet?
as for clear liquids, with addition of smooth- textured dairy products (ice cream), strained or blended soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, pudding, frozen yogurt
what is a dysphagia stage diet?
- thickened liquids
- pureed
- same as clear and full liquid + scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy
what is a mechanical soft diet?
- foods that are mashed up by a machine and made soft
- as for clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)
what is a low sodium diet?
4-g, 2-g, 1-g, or 500-mg diets; vary from no-added-salt to sever sodium restriction which requires selective food purchases
what is a low cholesterol diet?
300mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction
what is a diabetic diet?
nutrition recommendations by the American Diabetes Association; focus on total energy, nutrients, and food distribution
what is a gluten free diet?
eliminates wheat, oats, rye, barley, and their derivatives
what is a regular diet?
no restrictions unless specified
why would you give nutrition through a NG tube?
- if pt is unable to swallow or have dysphagia
- aspiration risk
- not alert enough
where does an NG tube enter?
nose
where does a orogastric tube enter?
mouth
what are the purposes of gastric tubes?
- enteral feeding and med administration
- decompression
- lavage
what are the NG tube sizes?
12, 14, 16, and 18 french
what are the types of nasoenteric tubes?
- nasogastric tube
- nasojejunal tube
what is an orogastric tube?
usually chosen if the pt is intubated or has nasal trauma
what are the types of surgical tubes?
- gastrostomy tube
- jejunostomy tube
what tube would you use if a pt is at a high risk for aspiration?
a jejunal feeding tube
what is a salem sump?
- dual lumen
- blue tube is an airvent
- preferable, used more commonly
what is a levin tube?
single lumen
insertion of NG tube
review video on CANVAS
documentation of NGT insertion
- size of NGT
- which nare it was placed in
- where it was secured
- placement verification
- gastric content residuals
- pt tolerated? (w or w/ voiced complaints)
- current condition (clampes, suction, meds)
management of NGT
- verify tube position hasn’t moved
- keep tube secure to nostril or mouth
- ensure tube remains patent
- aspiration/safety precautions
- assess nares frequently for skin breakdown, lubricate nostrils PRN
- assess oral mucosa integrity and moisture, offer oral swabs and chapstick
PEG tube
- flexible feeding tube placed through the abdominal wall and into the stomach
- PEG allows nutrition, fluids, and/or meds to be put directly into the stomach, bypassing mouth and esophagus
- used for pt who have difficulty swallowing
how do you manage a PEG site?
- clean the site once a day with diluted soap and water or normal saline
- no special dressing covering the site is needed
what are some complications of a PEG tube?
- pain at the PEG site
- leakage of stomach contents around the tube site
- dislodgement or malfunction of the tube
med administration through NGT & PEG tube
- prep meds
- crush
- inspect, auscultate, palpate
- confirm placement of tube using syringe EVERY TIME
- flush tube with 30 mL of water
- administer meds
- flush tube with 30 mL of water again
- document meds
- keep pt in semi to high folwers position for at least an hour after administration
enteral tube feedings
same as medication administration, give foods per diet ordered
what are some complications of tube feedings?
- aspiration of contents
- inappropriate positioning after feeding
feedings can be continuous or ___?
bolus
continuous feedings may cause …
an increase in serum glucose levels
why would a gastric tube be removed?
- temporary tube being removed because permanent tube is being places
- bowel obstruction resolved
- out of coma
- lavage completed
- dysphagia resolved
gastric tube removal
- flush tube with 30 mL of air
- educate pt to hold breath during removal
- detach all tape
- remove
regular elimination of bowel waste products is ___ for normal body functioning.
essential
what is the flow of digestion through the body?
- mouth
- esophagus
- stomach
- small intestine
- large intestine
- anus
- defecation
what is peristalsis?
series of involuntary wave-like muscle contractions which move food along the digestive tract
digestion
begins in the mouth and ends in the small and large intestines
absorption
intestine is the primary area of absorption
elimination
chyme is moved through peristalsis and is changed into feces
mouth
digestion begins with mastication
esophagus
peristalsis moves food into the stomach
stomach
stores food; mixes food, liquid, and digestive juices; moves food into small intestines
small intestine
duodenum, jejunum, and ileum
large intestine
the primary organ of bowel elimination
anus
expels feces and flatus from the rectum
what are some factors that influence bowel elimination?
- age
- diet
- fluid intake
- physical activity
- psychological factors
- personal habits
- position during defecation
- pain
- surgery and anesthesia
- medications
constipation
infrequent stools and/or hard, dry, small stools that are difficult to eliminate
impaction
results from unrelieved constipation; a collection of hardened feces wedged in the rectum
diarrhea
an increase in the number of stools
incontinence
inability to control passage of feces and gas to the anus
flatulence
accumulation of gas in the intestines causing the walls to stretch
hemorrhoids
dilated, engorged veins in the lining of the rectum
bowel diversions
- temporary or permanent artificial openings in the abdominal wall (stoma)
- surgical opening in the ileum or colon
- location of ostomy determines stool consistency
- ileostomy= thin to thick
- sigmoid= more formed stool
- transverse= thick liquid to soft consistency
ostomies
- an effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous
nutritional considerations for ostomies
- consume low fiber for the first weeks
- eat slowly and chew food completely
- drink 10-12 glasses of water daily
- pt may choose to avoid gassy foods
what are some psychological considerations with ostomies?
- serious body changes/ self image
- intimacy needs
- odor
assessment for ostomies
- nursing history
- physical assessment
- lab tests
- fecal specimens
- diagnostic examinations
collection of stool sample
- have pt defecate into hat or obtain from brief
- wear gloves
- collect stool
- seal well
- place in bag for transport
- send to the lab
what are some ways we can encourage pt to defecate?
- proper positioning
- privacy
- safety
bedpan use
- positioning on bedpan
- raise hips when on bedpan
cathartics and laxatives
- meds that initiate and facilitate stool passage
- empty the bowel
- cathartics are stronger than laxatives
antidiarrheal agents
decrease intestinal muscle tone to slow passage of feces
enemas
- instillation of a liquid solution into the rectum and sigmoid colon
- promotes defacation by stimulating peristalsis
- fluid breaks up fecal mass, stretches rectal wall and initiates the defecation reflux
- can also give meds via eneman route
rectal suppository administration
- does NOT require sterile technique
- explain procedure
- position in left lateral sims position
- hand hygiene and apply gloves
- lubricate finger and medication
- insert approximately one inch, or once you feel med bypass sphincter
- med will melt when it reaches body temp
what are common meds to administer via suppository routes?
- acetaminophen
- dulcolax
enema administration
- does NOT require sterile technique
- wear gloves
- explain procedure, positioning, precautions to avoid discomfort, length until removed
- position pt in left side lying position with top leg bent upwards
digital removal of stool
- physically remove stool
- used as a last resort
what is the purpose of digital removal?
to break up fecal mass and remove it so pt is able to voluntarily pass stool on their own
how do you perform digital removal?
- assess heart rate
- position pt, educate, don gloves
- lubricate fingers, insert slowly
- gently locate fecal mass by massaging around and remove slowly
what are some risks or complications of digital removal?
- irritation to mucosa, bleeding
- possible stimulation of vagus nerve
bowel training
- performed when pt have chronic constipation or fecal incontinence secondary to cognitive impairment
- it keeps pt on a schedule with bowel movements
- increase fluids
epidermis
top layer of skin
dermis
inner layer of skin
dermal- epidermal junction
separates dermis and epidermis
skin assessment
- assess all areas in a head to toe manner
- critically think when you are able to assess these things
- lift up skin folds
- turn pt and assess backside
what is a wound?
an interruption of the integrity of the skin
what kinds of wounds are there?
- incisions
- cuts
- skin tears
- ulcers
assessing wound characteristics
- location
- color
- size
- drainage
- odor
- pain
- skin around wound
- old dressing? remove it
- drainage on old dressing
what are factors that influence the healing process?
- nutrition
- tissue perfusion
- infection
- age
- stress
skin tears
- when layers of the skin separate or peel back
causes?
- bumping skin on hard objects
- wound dressing change
- aggressive washing
care of skin tears
- control bleeding
- apply saline or warm water and clean area gently
- pat dry with clean gauze
- measure size of skin tear
- add steri strips to site
- cover skin with dressing
- use stockinettes instead of dressings
- document skin tear location, size, clean of dressing
simple wound cleaning
- if unsure, ask for help!
- leave dressing on unless visibly soiled
- assess old dressing, remove
- assess wound characteristics
- clean wound per order
- apply any topical ointments
- apply top dressing securely
- document
adhesives
- be gentle
- be cautious when removing
pressure injuries
- impaired skin integrity related to unrelieved, prolonged pressure
- localized damage to the skin and underlying soft tissue
- injury may present as intact skin, a blister, or an open ulcer
- pt at risk for pressure injuries
risk factors for pressure ulcer development
- impaired sensory perception
- alterations in level of consciousness
- impaired mobility
- shear
- friction
- moisture
risk factors for pressure ulcer development
- impaired sensory perception
- impaired mobility
- alteration in LOC
- shear
- friction
- moisture
what are some ways we can prevent pressure ulcers?
- protect bony prominences
- skin barriers
- positioning
- pillows
- seat cushions
- special mattresses
what is the braden scale?
it evaluates the following
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
a score of <19 indicates the pt is at risk for skin breakdown
15-18 = mild risk
13-14 = moderate risk
10-12 = high risk
less than 9 = severe risk
classification of pressure ulcers
stage 1: intact skin with nonblanchable 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
what is the nursing role with wound management?
- identify risk factors for pressure ulcer development
- thorough skin assessment
- identify infection if present
- identify any change in skin assessment
- keep wounds clean and dressed per orders
- communicate
