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skills exams > skills exam 7 > Flashcards

skills exam 7 Flashcards

1
Q

BUN normal value

A

10-20

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2
Q

Crt (creatinine) normal value

A

0.6-1.2

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3
Q

eGFR normal value

A

> 60

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4
Q

Glucose normal value

A

70-100

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5
Q

AST normal value

A

0-35

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6
Q

ALT normal value

A

4-36

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7
Q

ALP normal value

A

30-120

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8
Q

Albumin normal value

A

3.5-5.0 (same as potassium)

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9
Q

Total protein normal value

A

6.4-8.3

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10
Q

Define dysphagia

A

difficulty swallowing

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11
Q

Signs of dysphagia

A
  • Cough 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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12
Q

Complications of dysphagia

A
  • Aspiration pneumonia
  • Dehydration
  • Decreased nutritional status
  • Weight loss
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13
Q

How to assess nutrition?

A
  • Assess daily weights
  • Laboratory tests: liver function, kidney function, and glucose
  • Assess diet and health history
  • Assess ability to ingest, digest, or absorb nutrients (and possible conditions that interfere with this)
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14
Q

Nursing role in nutrition?

A
  • Review ordered diet
  • Advance diet as tolerated by patient (Gradual progression of dietary intake or therapeutic diet to manage illness)
  • Assist with oral feedings if necessary, but promote independence
  • Use weighted silverware
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15
Q

NPO ordered diet

A
  • Nothing by mouth
  • If a patient is NPO for a prolonged period of time, ensure they are receiving fluids intravenously to maintain hydration status
  • Part of “advance as tolerated” diet
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16
Q

Clear liquid ordered diet

A
  • Only clear fluids or clear solids that become clear liquids easily at room temperature
  • Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin/jello, fruit ices, popsicles, soda, tea, water
  • Part of “advance as tolerated” diet
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17
Q

Full liquid ordered diet

A
  • Same as clear liquid (clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin/jello, fruit ices, popsicles, soda, tea, water)
  • With addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt
  • Part of “advance as tolerated” diet
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18
Q

Dysphagia Stages (Thickened Liquids, Pureed) diet

A
  • Patients with dysphagia have trouble chewing and swallowing without choking, so liquids need to be thickened
  • Clear liquid with thickener if patient is unable to tolerate (clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin/jello, fruit ices, popsicles, soda, tea, water)
  • Full liquid with thickener if patient is unable to tolerate (smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt)
  • With addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy
  • Not part of “advance as tolerated” diet, patient may be on this diet continuously
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19
Q

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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20
Q

Diabetic diet

A
  • Nutrition recommendations by the American Diabetes Association: 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 demands
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21
Q

Gluten free diet

A
  • Eliminates wheat, oats, rye, barley, and their derivatives
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22
Q

Kidney function labs

A

BUN, Crt, eGFR

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23
Q

Liver function labs

A

AST, ALT, ALP, Albumin, and total protein

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24
Q

Small-bore NG tube size and purpose

A
  • <12 French

- for medication administration and enteral feedings

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25
Q

Large-bore NG tube size and purpose

A
  • 12 French and above

- for gastric decompression or removal of gastric contents

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26
Q

Nasoenteric tubes

A
  • Nasogastric tube (NGT)

- Nasojejunal (NJT)

27
Q

What does the suffix “-ostomy” refer to?

A

The surgical creation of an opening in an organ

28
Q

What are the two types of gastric tubes and what is the difference between them?

A
  • Salem Sump: Dual Lumen, has an air vent, preferred/more commonly used
  • Levin: Single lumen
29
Q

What are the two types of gastric tubes and what is the difference between them?

A
  • Salem Sump: Dual Lumen, has an air vent, preferred/more commonly used
  • Levin: Single lumen
30
Q

What needs to be documented for NGT insertion?

A
  • Size of NGT (in French)
  • Which nare it was placed in
  • Where it was secured (how many centimeters)
  • Placement verification (by xraxy)
  • Gastric content residuals (color, consistency, amount)
  • Patient tolerated: Without voiced complaint? Reports pain?
  • Current condition: Clamped? Suction? Meds?
31
Q

What do you always need to check on a patient with an NG tube?

A
  • Verify tube position hasn’t moved (check measurement marking at nostril or gum line)
  • Keep tube secure to nostril or mouth
  • Ensure tube remains patent
  • Always flush tube with at least 30 mL water before and after use
  • Aspiration/Safety precautions
  • Ensure head of bed is elevated minimum of 30 degrees and tube stays above the stomach level
  • Assess nares frequently for skin breakdown, lubricate nostrils PRN
  • Assess oral mucosa integrity and moisture, offer oral swabs & chapstick PRN
32
Q

What does PEG stand for?

A

Percutaneous Endoscopic Gastronomy

33
Q

What is the benefit of a PEG tube compared to an NG tube?

A

PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus

34
Q

How long can PEG tubes last?

A
  • PEG tubes can last for months or years. They can break down or become clogged over extended periods of time & may need to be replaced
  • May see replacement of tube with a foley catheter
35
Q

What do you have to do before you can use the NGT or PEG tube? (hint: 60ml)

A

Confirm placement using enteral tube syringe (60mL). * Aspirate 30mL gastric contents and assess color/consistency and then flush 30mL of air and listen for “air swoosh” utilizing stethoscope (reminder, this can only be done after xray has confirmed placement).

36
Q

At what amount of residuals should you hold feeding and medications for 2 hours?

A

500mL

37
Q

Why would a gastric tube be removed?

A
  • Temporary tube being removed because permanent tube is being placed (-Ostomy tube)
  • Bowel obstruction resolved/Bowel sounds changed from absent to active
  • Out of coma
  • Lavage completed
  • Dysphagia resolved
38
Q

List the 4 steps of the digestion process.

A
  1. Digestion: Begins in the mouth and ends in the small and large intestines
  2. Absorption: Intestine is the primary area of absorption
  3. Metabolism and storage of nutrients
  4. Elimination: Chyme is moved through peristalsis and is changed into feces
39
Q

What are the three parts of the small intestine?

A

Duodenum, jejunum, and ileum

40
Q

What are factors influencing bowel elimination?

A
  • Age
  • Diet
  • Fluid intake
  • Physical activity
  • Psychological factors
  • Personal habits
  • Position during defecation
  • Pain
  • Surgery and anesthesia
  • Medications
41
Q

What are common bowel elimination problems?

A
  • Constipation: A symptom, not a disease; infrequent stool 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 that a person cannot expel
  • Diarrhea: an increase in the number of stools and the passage of liquid, unformed feces
  • 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
42
Q

What nutritional considerations need to be kept in mind for a patient with an ostomy?

A
  • Consume low fiber for the first weeks
  • Eat slowly and chew food completely
  • Drink 10 to 12 glasses of water daily
  • Patient may choose to avoid gassy foods
43
Q

What is the best way to position an immobile patient on a bedpan?

A

When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan

44
Q

What position should a patient be in for enema and rectal suppository administration?

A

Left lateral Sims position

45
Q

How is the digital removal of impacted stool similar to oxygen administration?

A

Both require a provider’s order. Digital removal of an impaction is a last resort in managing severe constipation due to the risks involved

46
Q

What is the difference between impaction and constipation?

A

A person is unable to relieve the impaction on their own

47
Q

What do you need to assess before performing the digital removal of stool?

A

Heart rate

48
Q

What do you need to assess before performing the digital removal of stool?

A

Heart rate

49
Q

What do different wound colors indicate?

A

Beefy Red – indicates tissue and skin healing, appropriate blood supply
Pink – no active s/s of infection, blood supply isn’t ideal
Yellow – slough or infection (Slough is the consistency of snot, indicates body ridding itself of bad tissue)
Black – dead tissue, no blood supply

50
Q

What causes skin tears?

A
  • Skin bumping into a hard object
  • Wound dressing changes & adhesive removal
  • Aggressively washing and/or drying the skin
51
Q

What do you do for a skin tear?

A
  • Control the bleeding
  • Apply saline or warm water and clean area while gently attempting to replace the torn skin back into the original position
  • Pat dry with clean gauze
  • Measure size of skin tear
  • Add steri strips across site, carefully
  • Cover skin with nonadhesive dressing
  • Adhesive dressings can continue to damage the skin tear
  • Use stockinette instead of adhesive dressing or tape if available
  • Document skin tear location, size, cleansing and dressing, how the patient tolerated
  • You can also document how the skin tear developed if that information is available
52
Q

How often should you change wound dressing?

A

Leave dressing on unless visibly soiled or orders indicate dressing needs changed. You may only need to change outer dressing. Some wounds may be left open to air and will require a cleaning only.

53
Q

What wound characteristics do you need to assess?

A
  • What kind of wound is it? How did it occur?
  • Location
  • Color
  • Size
  • Drainage/exudate type
  • Odor
  • Pain
  • Assess skin around the wound (irritated, warm, tender to touch, inflammation?)
  • Assess old dressing when removed for drainage
54
Q

What are the risks of adhesive use on skin?

A

Adhesives can cause further damage, especially on chronic wounds and thin, fragile skin
(Be cautious when removing adhesive and how much adhesive you’re using while applying dressing – this is not a UPS box we need to tape up and ship)

55
Q

Where do pressure injuries usually occur?

A

Usually occurs over a bony prominence or occurs secondary to a foreign object creating pressure on the skin

56
Q

Who is at risk for pressure injuries?

A

Patients with decreased mobility, decreased sensory perception, fecal or urinary incontinence, or poor nutrition

57
Q

What are the risk factors for pressure ulcer development?

A
  • Impaired sensory perception
  • Alterations in level of consciousness
  • Impaired mobility
  • Shear
  • Friction
  • Moisture
58
Q

What does the Braden Scale evaluate?

A
  • Sensory Perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and Shear

The health care provider gives the patient a score in each area based off of their assessment findings and the descriptions provided within each scoring category. The total score can range from 9 to 23; the lower the score, the greater the risk for developing a pressure ulcer.

  • 19-23 = no risk
  • A score < 19 indicates the patient is risk for skin breakdown
  • 15-18 = mild risk
  • 13-14 = moderate risk
  • 10-12= high risk
  • less than 9 = severe risk
59
Q

What are the four classifications of pressure ulcers?

A
  • Stage I: Intact skin with nonblanchable redness
  • Stage II: Partial-thickness skin loss involving epidermis, dermis, or both
  • Stage III: Full-thickness tissue loss with visible fat
  • Stage IV: Full-thickness tissue loss with exposed bone, muscle, or tendon
60
Q

Nursing role with wound management?

A
  • Identify risk factors for pressure ulcer development
  • Thorough skin assessment
  • Identify infection if present
  • Keep wounds clean and dressed per orders
  • Communicate
61
Q

Low sodium diet

A
  • 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no-added-salt to severe sodium restriction (500-mg sodium diet), which requires selective food purchases
62
Q

Low cholesterol diet

A
  • 300 mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction
63
Q

How can a patient prevent pressure ulcers?

A
  • Patient should make small changes in position every 10-15 minutes if capable
  • If patient is not able to reposition self: Turn every 1 to 2 hours (at minimum)

skills exams (7 decks)

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