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The "Fun" class > Skills Exam 7 > Flashcards

Skills Exam 7 Flashcards

1
Q

what is a basic component of life?

A

nutrition

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2
Q

nutrition is essential for?

A
  • normal growth and development
  • tissue maintenance and repair
  • cellular metabolism
  • organ function
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3
Q

adequate access to nutrition is ___?

A

imperative

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4
Q

assessments for nutrition

A
  • daily weights
  • lab tests
  • health history and diet
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5
Q

what are the lab values you need to assess with nutrition?

A
  • liver function
  • kidney function
  • glucose
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6
Q

what is dysphagia?

A

difficulty swallowing

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7
Q

what are signs of dysphagia?

A
  • 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
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8
Q

how do you assess for dysphagia?

A

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

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9
Q

what are some complications of dysphagia?

A
  • aspiration pneumonia
  • dehydration
  • decreased nutritional status
  • weight loss
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10
Q

dysphagia often leads to what?

A

malnutrition

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11
Q

will dysphagia increase or decrease albumin levels?

A

decrease

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12
Q

what can the nurse do to help with dysphagia?

A
  • review ordered diet
  • gradually advance diets
  • promote appetite
  • assist with oral feedings if necessary
  • use of weighted silverware
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13
Q

what is an NPO diet?

A
  • nothing by mouth

- if NPO for a long period of time, ensure proper fluids are being administered via IV

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14
Q

what is a clear liquid diet?

A
  • 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
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15
Q

what is a full liquid diet?

A

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

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16
Q

what is a dysphagia stage diet?

A
  • thickened liquids
  • pureed
  • same as clear and full liquid + scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy
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17
Q

what is a mechanical soft diet?

A
  • 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)
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18
Q

what is a low sodium diet?

A

4-g, 2-g, 1-g, or 500-mg diets; vary from no-added-salt to sever sodium restriction which requires selective food purchases

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19
Q

what is a low cholesterol diet?

A

300mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction

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20
Q

what is a diabetic diet?

A

nutrition recommendations by the American Diabetes Association; focus on total energy, nutrients, and food distribution

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21
Q

what is a gluten free diet?

A

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

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22
Q

what is a regular diet?

A

no restrictions unless specified

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23
Q

why would you give nutrition through a NG tube?

A
  • if pt is unable to swallow or have dysphagia
  • aspiration risk
  • not alert enough
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24
Q

where does an NG tube enter?

A

nose

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25
Q

where does a orogastric tube enter?

A

mouth

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26
Q

what are the purposes of gastric tubes?

A
  • enteral feeding and med administration
  • decompression
  • lavage
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27
Q

what are the NG tube sizes?

A

12, 14, 16, and 18 french

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28
Q

what are the types of nasoenteric tubes?

A
  • nasogastric tube

- nasojejunal tube

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29
Q

what is an orogastric tube?

A

usually chosen if the pt is intubated or has nasal trauma

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30
Q

what are the types of surgical tubes?

A
  • gastrostomy tube

- jejunostomy tube

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31
Q

what tube would you use if a pt is at a high risk for aspiration?

A

a jejunal feeding tube

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32
Q

what is a salem sump?

A
  • dual lumen
  • blue tube is an airvent
  • preferable, used more commonly
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33
Q

what is a levin tube?

A

single lumen

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34
Q

insertion of NG tube

A

review video on CANVAS

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35
Q

documentation of NGT insertion

A
  • 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)
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36
Q

management of NGT

A
  • 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
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37
Q

PEG tube

A
  • 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
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38
Q

how do you manage a PEG site?

A
  • clean the site once a day with diluted soap and water or normal saline
  • no special dressing covering the site is needed
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39
Q

what are some complications of a PEG tube?

A
  • pain at the PEG site
  • leakage of stomach contents around the tube site
  • dislodgement or malfunction of the tube
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40
Q

med administration through NGT & PEG tube

A
  • 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
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41
Q

enteral tube feedings

A

same as medication administration, give foods per diet ordered

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42
Q

what are some complications of tube feedings?

A
  • aspiration of contents

- inappropriate positioning after feeding

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43
Q

feedings can be continuous or ___?

A

bolus

44
Q

continuous feedings may cause …

A

an increase in serum glucose levels

45
Q

why would a gastric tube be removed?

A
  • temporary tube being removed because permanent tube is being places
  • bowel obstruction resolved
  • out of coma
  • lavage completed
  • dysphagia resolved
46
Q

gastric tube removal

A
  • flush tube with 30 mL of air
  • educate pt to hold breath during removal
  • detach all tape
  • remove
47
Q

regular elimination of bowel waste products is ___ for normal body functioning.

A

essential

48
Q

what is the flow of digestion through the body?

A
  • mouth
  • esophagus
  • stomach
  • small intestine
  • large intestine
  • anus
  • defecation
49
Q

what is peristalsis?

A

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

50
Q

digestion

A

begins in the mouth and ends in the small and large intestines

51
Q

absorption

A

intestine is the primary area of absorption

52
Q

elimination

A

chyme is moved through peristalsis and is changed into feces

53
Q

mouth

A

digestion begins with mastication

54
Q

esophagus

A

peristalsis moves food into the stomach

55
Q

stomach

A

stores food; mixes food, liquid, and digestive juices; moves food into small intestines

56
Q

small intestine

A

duodenum, jejunum, and ileum

57
Q

large intestine

A

the primary organ of bowel elimination

58
Q

anus

A

expels feces and flatus from the rectum

59
Q

what are some factors that influence bowel elimination?

A
  • age
  • diet
  • fluid intake
  • physical activity
  • psychological factors
  • personal habits
  • position during defecation
  • pain
  • surgery and anesthesia
  • medications
60
Q

constipation

A

infrequent stools and/or hard, dry, small stools that are difficult to eliminate

61
Q

impaction

A

results from unrelieved constipation; a collection of hardened feces wedged in the rectum

62
Q

diarrhea

A

an increase in the number of stools

63
Q

incontinence

A

inability to control passage of feces and gas to the anus

64
Q

flatulence

A

accumulation of gas in the intestines causing the walls to stretch

65
Q

hemorrhoids

A

dilated, engorged veins in the lining of the rectum

66
Q

bowel diversions

A
  • 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
67
Q

ostomies

A
  • an effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous
68
Q

nutritional considerations for ostomies

A
  • 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
69
Q

what are some psychological considerations with ostomies?

A
  • serious body changes/ self image
  • intimacy needs
  • odor
70
Q

assessment for ostomies

A
  • nursing history
  • physical assessment
  • lab tests
  • fecal specimens
  • diagnostic examinations
71
Q

collection of stool sample

A
  • have pt defecate into hat or obtain from brief
  • wear gloves
  • collect stool
  • seal well
  • place in bag for transport
  • send to the lab
72
Q

what are some ways we can encourage pt to defecate?

A
  • proper positioning
  • privacy
  • safety
73
Q

bedpan use

A
  • positioning on bedpan

- raise hips when on bedpan

74
Q

cathartics and laxatives

A
  • meds that initiate and facilitate stool passage
  • empty the bowel
  • cathartics are stronger than laxatives
75
Q

antidiarrheal agents

A

decrease intestinal muscle tone to slow passage of feces

76
Q

enemas

A
  • 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
77
Q

rectal suppository administration

A
  • 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
78
Q

what are common meds to administer via suppository routes?

A
  • acetaminophen

- dulcolax

79
Q

enema administration

A
  • 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
80
Q

digital removal of stool

A
  • physically remove stool

- used as a last resort

81
Q

what is the purpose of digital removal?

A

to break up fecal mass and remove it so pt is able to voluntarily pass stool on their own

82
Q

how do you perform digital removal?

A
  • assess heart rate
  • position pt, educate, don gloves
  • lubricate fingers, insert slowly
  • gently locate fecal mass by massaging around and remove slowly
83
Q

what are some risks or complications of digital removal?

A
  • irritation to mucosa, bleeding

- possible stimulation of vagus nerve

84
Q

bowel training

A
  • performed when pt have chronic constipation or fecal incontinence secondary to cognitive impairment
  • it keeps pt on a schedule with bowel movements
  • increase fluids
85
Q

epidermis

A

top layer of skin

86
Q

dermis

A

inner layer of skin

87
Q

dermal- epidermal junction

A

separates dermis and epidermis

88
Q

skin assessment

A
  • 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
89
Q

what is a wound?

A

an interruption of the integrity of the skin

90
Q

what kinds of wounds are there?

A
  • incisions
  • cuts
  • skin tears
  • ulcers
91
Q

assessing wound characteristics

A
  • location
  • color
  • size
  • drainage
  • odor
  • pain
  • skin around wound
  • old dressing? remove it
  • drainage on old dressing
92
Q

what are factors that influence the healing process?

A
  • nutrition
  • tissue perfusion
  • infection
  • age
  • stress
93
Q

skin tears

A
  • when layers of the skin separate or peel back
94
Q

causes?

A
  • bumping skin on hard objects
  • wound dressing change
  • aggressive washing
95
Q

care of skin tears

A
  • 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
96
Q

simple wound cleaning

A
  • 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
97
Q

adhesives

A
  • be gentle

- be cautious when removing

98
Q

pressure injuries

A
  • 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
99
Q

risk factors for pressure ulcer development

A
  • impaired sensory perception
  • alterations in level of consciousness
  • impaired mobility
  • shear
  • friction
  • moisture
100
Q

risk factors for pressure ulcer development

A
  • impaired sensory perception
  • impaired mobility
  • alteration in LOC
  • shear
  • friction
  • moisture
101
Q

what are some ways we can prevent pressure ulcers?

A
  • protect bony prominences
  • skin barriers
  • positioning
  • pillows
  • seat cushions
  • special mattresses
102
Q

what is the braden scale?

A

it evaluates the following

  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction and shear
103
Q

a score of <19 indicates the pt is at risk for skin breakdown

A

15-18 = mild risk
13-14 = moderate risk
10-12 = high risk
less than 9 = severe risk

104
Q

classification of pressure ulcers

A

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

105
Q

what is the nursing role with wound management?

A
  • 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

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