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Skills Lecture > skills lecture 6 > Flashcards

skills lecture 6 Flashcards

1
Q

nutrition is

A

-a basic component of health
-essential for normal growth and development, tissue maintenance and repair, cellular metabolism, and organ function
-

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2
Q

assessment of nutrition

A

-assess daily weight
-Laboratory tests: liver tests, kidney tests
-Assess thorough diet and health history
-assess hair skin and nails

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3
Q

what specific laboratory tests are used to assess nutrition?

A

-ast
-alt
-alp
-albumin
-total protein
-bun
-crt
-egfr
-glucose

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4
Q

if liver function is decreased what labs will be elevated and what labs will be decreased?

A

elevated labs - ast, alt, and alp
decreased - albumin and total protein

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5
Q

If patient’s have conditions that interfere with their ability to ingest, digest, or absorb adequate nutrients, they must be assessed thoroughly FOR

A

nausea
vomiting
diarrhea
fatigue
no appetite
?

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6
Q

what is dyshagia

A

difficulty swallowing

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7
Q

if a patient has difficulty swallow what is the first concern?

A

airway

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8
Q

signs of difficulty swallowing

A

cough during and after meals
inability to speak consistently
food pocketing
choking on food
regurgitation
Abnormal movements of the mouth, tongue, or lips

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9
Q

what type of liquids put a resident at a higher risk for choking?

A

thin liquids

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10
Q

patient is pocketing food and having difficulty with choking but still needs to eat what do we need to do?

A

possibly be NPO until evaluated

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11
Q

complications of dysphagia

A

-weight loss
-decreased nutritional status
-aspiration pneumonia
-dehydration

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12
Q

malnutrition significantly slows swallowing recover and may increase what?

A

mortality

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13
Q

if a resident is not practicing swallowing what happens?

A

they have more trouble every time they try to eat and it becomes more difficult
-they are scared to eat or to try to swallow

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14
Q

Patients with dysphagiabecome frustrated with eating and show changes in _______ levels

A

albumin. if it is less than 3.5 we know there is something wrong with their nutritional intake

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15
Q

nursing role in nutritional changes

A

-Review ordered diet
-Advancing diets as tolerated by the patient
-Promoting appetite
-Assisting with oral feedings if necessary
-Use of weighted silverware

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16
Q

ways to encourage appetite

A

-oral care
-offer choices

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17
Q

types of ordered diets

A

-NPO
-CLEAR LIQUID
-FULL LIQUID
-Thickened Liquids, Pureed
-MECHANICAL SOFT

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18
Q

NPO DIET

A

-NOTHING BY MOUTH

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19
Q

CLEAR LIQUID DIET

A

ONLY CLEAR FLUIDS OR CLEAR SOLIDS THAT BECOME CLEAR LIQUIDS EASILY AT ROOM TEMP
-NO RED LIQUIDS

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20
Q

FULL LIQUID DIET

A

As for clear liquid, 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

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21
Q

THICKENED LIQUIDS AND PUREED

A

MASHED POTATOES AND GRAVY
ANYTHING PUREED

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22
Q

MECHANICAL SOFT

A

Foods that are mashed up by a machine and made soft

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23
Q

dysphagia stages of ordered diets

A

thickened liquids and pureed foods

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24
Q

TYPES OF DIET RESTRICTIONS

A

-LOW SODIUM
-LOW CHOLESTEROL
-DIABETIC
-CARDIAC
-GLUTEN FREE
-REGULAR

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25
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

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26
Q

LOW CHOLESTEROL DIET

A

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

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27
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

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28
Q

GLUTEN FREE DIET

A

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

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29
Q

CARDIAC DIET

A

LOW SODIUM
LOW CHOLESTEROL

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30
Q

NUTRITION THROUGH NG TUBE

A

Enteral Nutrition provides nutrients through the GI Tract

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31
Q

why would a feeding tube be placed?

A

-unable to swallow
-dysphagia
-in a coma
-lethargic

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32
Q

where is an ng tube placed?

A

the nose

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33
Q

where is a j-tube placed?

A

jejumun (small intestine)

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34
Q

where is a g-tube placed?

A

in the stomach

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35
Q

any patient with any type of feeding tube is at risk for what

A

aspiration

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36
Q

where is an orogastric tube placed

A

mouth

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37
Q

short term feeding tube placed in the acute care setting

A

gastric tubes

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38
Q

PURPOSES OF GASTRIC TUBES

A

-Enteral feeding & Medication administration
-Decompression (BOWEL OBSTRUCTION)(COMA)
-Lavage (POSION INGESTION), (ALCOHOL POISONING)

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39
Q

a patient with what kind of issue would not be fit for an ng tube?

A

facial structure issues

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40
Q

NG TUBE SIZES

A

Small-bore: <12 French
for medication administration and enteral feedings
Large-bore: 12, 14, 16, 18 French
Large-bore (12-French and above) for gastric decompression or removal of gastric contents

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41
Q

A PATIENT WITH ACID REFLUX IS NEEDING A FEEDING TUBE PLACED, WHAT IS THE MOST APPROPRIATE AND WHY?

A

GASTROSTOMY IN THE INTESTINES NOT IN THE STOMACH DUE TO HIGH RISK OF ASPIRATION

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42
Q

what feeding tubes are surgically placed?

A

gastrostomy
jejunostomy

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43
Q

what feeding tubes can be placed at the bedside

A

ng tube
orogastric

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44
Q

nasoenteric tubes

A

nasogastric tube (ngt)
nasojejunal (njt)

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45
Q

what needs to be considered when choosing a feeding tube?

A

aspiration risk

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46
Q

TWO TYPES OF GASTRIC TUBES

A

SALEM SUMP
LEVIN

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47
Q

THE BIGGEST DIFFERENCE BETWEEN THE SALEM SUMP AND LEVIN IS WHAT

A

SALEM SUMP HAS A DOUBLE LUMEN

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48
Q

INSERTION RULES FOR NG TUBE

A

-HOLD
-ANCHOR
-KINK
-VERIFY

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49
Q

INSERTION OF NG TUBE ON MONDAY, NEW NURSE COMES IN ON THURSDAY FOR SHIFT WHAT SHOULD SHE CHECK FIRST?

A

CHECK FOR XRAY REPORT OF VERIFICATION OF NG TUBE PLACEMENT

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50
Q

what complications should you monitor for during ng tube insertion?

A

respiratory complications

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51
Q

what specific respiratory complications should you monitor during ng tube and what should you do if they arise?

A

-sob
-inability to speak
-color change
-if it happens you need to remove tube immediately

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52
Q

if necessary you can place the feeding tube in what so it is flexible for insertion?

A

room temp water prior to lubrications

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53
Q

if you are inserting the ng tube due to dysphagia you will not be able to have patient do what?

A

swallow water

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54
Q

DOCUMENTATION FOR NG TUBE INSERTION

A

-SIZE OF NG TUBE
-WHICH NARE WAS IT PLACED IN
-Where it was secured (how many centimeters
- Placement verification
-Gastric content residuals
-Patient tolerated
-Current condition

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55
Q

WHAT DO YOU DO BEFORE GIVING NG TUBE FEEDINGS OR MEDICATION?

A

ASPIRATE STOMACH CONTENTS
FLUSH 30ML OF WATER

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56
Q

WHAT DO YOU DO TO MONITOR NASOGASTRIC TUBE IN PLACE?

A

-VERIFY THE TUBE POSITION HASNT MOVED
-KEEP TUBE SECURED TO THE NOSTRIL OR MOUTH
-ENSURE TUBE REMAINS PATENT
-ASPIRATION/SAFETY PRECAUTIONS
-ASSESS NARES FREQUENTLY FOR SKIN BREAKDOWN, LUBRICATE NOSTRILS
-ASS ORAL MUCOSA INTEGRITY AND MOISTURE OFFER ORAL SWABS AND CHAPSTICK

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57
Q

IF A PATIENT HAS AN NG TUBE HOW SHOULD THEY BE IN BED?

A

HEAD ELEVATED ALWAYS EVEN WHEN SLEEPING AT LEAST A 30 DEGREE ANGLE

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58
Q

WHAT SHOULD YOU ALWAYS DO BEFORE AND AFTER USE OF NG TUBE

A

FLUSH AT LEAST 30ML OF WATER

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59
Q

A FLEXIBLE FEEDING TUBE PLACED THROUGHT THE ABDOMINAL WALL AND INTO THE STOMACH

A

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG TUBE)

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60
Q

PATIENTS WHO HAVE DIFFICULTY WITH WHAT ISSUES CAN BENEFIT FROM AA PEG TUBE?

A

-SWALLOWING
-PROBLEMS WITH THEIR APPETITE
-INABILITY TO TAKE ADEQUATE NUTRITION THROUGH THE MOUTH

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61
Q

HOW DO YOU MANAGE THE AREA OF A PEG TUBE

A

CLEAN THE SITE ONCE A DAY WITH DILUTED SOAP AND WATER OR NORMAL SALINE AND KEEP THE SITE DRY BETWEEN CLEANSINGS

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62
Q

THINGS TO MONITOR WHEN ASSESSING A PEG TUBE

A

-INFECTION
-BLEEDING
-WARM
-RED
-DISCAHRGE
-ODOR
-TENDER

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63
Q

COMPLICATIONS OF PEG TUBE

A

Pain at the PEG site
Leakage of stomach contents around the tube site
Dislodgment or malfunction of the tube

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64
Q

HOW LONG CAN PEG TUBE BE IN PLACE?

A

MONTHS TO YEARS

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65
Q

WHAT DO YOU NEED TO MAKE SURE OF WHEN PEG TUBE IS IN PLACED?

A

MAKE SURE THE CLAMP IS ALWAYS CLOSED

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66
Q

IF YOU NOTICE SIGNS AND SYMPTOMS OF INFECTION OF PEG TUBE IT CAN CHANGE WHAT?

A

BOWEL ISSUES

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67
Q

WHO CAN USE A PEG TUBE

A

Patients who have difficulty swallowing, problems with their appetite or an inability to takeadequate nutrition through the mouth can benefit from this procedure

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68
Q

NG AND PEG TUBE MEDICATION ADMINISTRATION

A

-PREPARE MEDS
-GI ASSESSMENT
-CONFIRM PLACEMENT (ASPIRATE AND THEN FLUSH 30ML)
-CHECK FOR RESIDUALS BEFORE EACH FEEDING AND MED ADMINISTRATION

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69
Q

PREPARING MEDICATIONS FOR FEEDING TUBES

A

-USE MEDS IN THE FORM OF LIQUID IF POSSIBLE
-DISSOLVE MEDCATION IF POSSIBLE
-ADMINSTER MEDICATION USING THE ENTERAL TUBE SYRINGE (60ML SYRINGE)

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70
Q

HOW CAN YOU CONFIRM PLACEMENT OF TUBE AFTER IT HAS BEEN CONFIRMED BY XRAY

A

-ASPIRATE 30 ML GASTRIC CONTENTS AND ASSESS COLOR/CONSITENCY
-FLUSH 30 ML OF AIR AND LISTEN FOR “AIR SWOOSH” UTILIZING STETHOSCOPE

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71
Q

HOW DO YOU CHECK RESIDUAL OF FEELING TUBE

A

CONNECT SYRINGE TO PORT AND PULLING BACK CONTENTS

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72
Q

WHAT ARE RESIDUALS

A

LIQUIDS CURRENTLY IN THE STOMACH
UNDIGESTED CONTENTS

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73
Q

WHEN DO YOU HOLD A MEDICATION OR FEEDING AND FOR HOW LONG?

A

WHEN YOU GET MORE THAN 500 ML OF RESIDUAL YOU HOLD THE MED OR FEEDING FOR 2 HOURS

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74
Q

Keep patient in semi to high fowlers position for at least a/an ______ after medications have been given

A

hour

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75
Q

MEDICATIONS GIVEN IN A FEEDING TUBE SHOULD BE GIVEN AT WHAT TEMP?

A

ROOM TEMP

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76
Q

EACH TIME YOU DISCONNECT THE SYRINGE FFROM THE PORT OF THE GASTRIC TUBE DONT FORGET TO WHAT?

A

CLAMP

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77
Q

AFTER YOU ADMINSTER MEDS OR FEEDING YOU HAVE TO WAIT HOW LONG TO SUCTION PATIENT AND WHY

A

AT LEAST 30 MINUTES SO PT CAN ABSORB OR DIGEST THE FOOD OR MEDICATION

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78
Q

when are enteral tube feedings appropriate?

A

When patients are unable to ingest food by mouth but are still able to digest and absorb nutrients, the use of enteral tube feeding is supported

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79
Q

ENTERAL FORMULA ORDERED IS BASED ON WHAT

A

THE PATIENTS CONDITION AND NEEDS

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80
Q

Feedings can be continuous or bolus whats the difference?

A

continuous - pump
bolus- syringe

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81
Q

FEEDING DELIVERED OVER THE COURSE OF HOURS, WITH A SMALL AMOUNT GIVEN EACH HOUR

A

CONTINUOUS

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82
Q

Feedings can cause what if they are being administered too quickly

A

abdominal cramping/discomfort

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83
Q

WHAT ARE THE NURSES RESPONSIBILITIES WITH A CONTINUOUS FEEDING?

A

-ASSESS PATIENT DURING FEEDINGS
-CHECK RESIDUALS
-INCREASE FEEDINGS PER ORDERS AS TOLERATED BY PT

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84
Q

IF A PATIENT IS GETTING CONTINUOUS FEEDINGS WHAT CONDITION ARE THEY AT RISK FOR? WHAT ARE THE NURSING INTERVENTIONS FOR THIS?

A

HYPERGLYCEMIA
THE NURSE WILL MONITOR BLOOD GLUCOSE LEVELS ABOUT EVERY 4-6 HOURS

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85
Q

A PATIENT IS RECIEVING CONTINUOUS FEEDINGS AND LABS ARE NOT BACK YET BUT PATIENT IS THIRSTY, HUNGRY, URINATING FREQUENTLY AND HOT AND DRY WHAT COULD BE THE PROBLEM?

A

HYPERGLYCEMIA

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86
Q

FEEDINGS GIVEN BY SYRINGE, TO THE FLOW OF GRAVITY

A

BOLUS

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87
Q

The NGT was placed a few hours ago. You receive an order to begin enteral tube feedings. The first step is to:
A. place the patient in a prone position.
B. irrigate the tube with normal saline.
C. check to see that the tube is properly placed via x-ray.
D. introduce a small amount of fluid into the tube before feeding.

A

D INTRODUCE SMALL AMOUNT OF FLUID INTO THE TUBE BEFORE THE FEEDING

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88
Q

INDICATIONS ON WHY A GASTRIC TUBE SHOULD 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

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89
Q

GASTRIC TUBAL REMOVAL STEPS

A

-PUSH 30 ML OF AIR
-Educate the patient to hold their breath during removal
-Detach all tape while holding tube securely
-Swiftly remove tube while patient holds breath, coiling in hand

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90
Q

WHAT IS THE MOST IMPORTANT THING TO REMEMBER WHEN REMOVING A GASTRIC TUBE?

A

DO NOT TAKE HANDS OFF OF TUBE UNTIL IT IS COMPLETELY OUT

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91
Q

REGULAR ELIMINATION OF BOWEL WASTE PRODUCTS IS ESSENTIAL FOR WHAT

A

NORMAL BODY FUNCTIONING

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92
Q

LARGE INTESTINE PARTS AND FUNCTION

A

The primary organ of bowel elimination
ASCENDING, TRANSVERSE, DESCENDING AND SIGMOID COLON

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93
Q

SUPPORTIVE NURSING CARE RESPECTS A PATIENTS WHAT DURING BOWEL ELIMINATION

A

PRIVACY AND EMOTIONAL NEEDS

94
Q

CONTAINS MILLIONS OF NON-HARMFUL BACTERIA

A

NORMAL FLORA

95
Q

PART OF THE DIGESTIVE SYSTEM

A

MOUTH, ESOPHAGUS, STOMACH, SMALL INTESTINE, LARGE INTESTINE, ANUS

96
Q

DIGESTION BEGINS WITH MASTICATION

A

MOUTH

97
Q

PERISTALSIS MOVES FOOD INTO THE STOMACH VIA THE WHAT

A

ESOPHAGUS

98
Q

STORES FOOD; MIXES FOOD, LIQUID, AND DIGESTIVE JUICES; MOVES FOOD INTO SMALL INTESTINES

A

STOMACH

99
Q

Small intestine

A

Duodenum, jejunum, and ileum

100
Q

THE PRIMARY ORGAN OF BOWEL ELIMINATION

A

LARGE INTESTINE

101
Q

EXPELS FECES AND FLATUS FROM THE RECTUM

A

ANUS

102
Q

DIGESTTION STARTS WITH _________ AND ENDS WITH __________

A

PARASTALSIS, ELIMINATION

103
Q

BEGINS IN THE MOUTH AND ENDS IN THE SMALL AND LARGE INTESTINES

A

DIGESTION

104
Q

CHYME IS MOVED THROUGH PERISALSIS AND IS CHANGED INTO FECES

A

ELIMINATION

105
Q

the primary absorption site for nutrients

A

The small intestine, lined with fingerlike projections called villi

106
Q

MECHANICAL BREAKDOWN THAT RESULTS FROM CHEWING, CHURNING, AND MIXING WITH FLUID AND CHEMICAL REACTIONS IN WHICH FOOD REDUCES TO ITS SIMPLEST FORM

A

DIGESTION

107
Q

ABSORPTION OF WHAT OCCURS IN THE SMALL INTESTINES

A

CARBOHYDRATES
PROTEIN
MINERALS
WATER-SOLUBLE VITAMINS

108
Q

WHAT CAN INCREASE PARASTALSIS?

A

STRESS AND ANXIETY

109
Q

WHAT IS PERISTALSIS?

A

SERIES OF INVOLUNTARY WAVE-LIKE MUSCLE CONTRACTIONS WHICH MOVE FOOD ALONG THE DIGESTIVE TRACT

110
Q

ALL BIOCHEMICAL REACTIONS WITHIN THE CELLS OF THE BODY

A

METABOLISM

111
Q

WHAT ARE THE TWO REACTION PROCESSES OF METABOLISM

A

ANABOLIC AND CATABOLIC

112
Q

CHYME MOVES BY PERISTALTIC ACTION THROUGH THE ILEOCECAL VALVE INTO THE LARGE INTESTINE, WHERE IF BECOMES FECES, WATER ABSORBS IN THE MUCOSA AS FECES MOVE TOWARD THE RECTUM

A

ELIMINATION

113
Q

FACTORS INFLUENCING BOWEL ELIMINATION

A

-AGE
-DIET
-FLUID INTAKE
-PHYSICAL ACTIVITY
-PSYCHOLOGICAL FACTORS
-PERSONAL HABITS
-POSITION DURING DEFECATION
-PAIN
-SURGERY AND ANESTHESIA
-MEDICATIONS

114
Q

COMMON BOWEL ELIMINATION PROBLEMS

A

-CONSTIPATION
-DIARRHEA
-FLATULENCE
-IMPACTION
-INCONTINENCE
-HEMORRHOIDS

115
Q

A SYMPTOM NOT A DISEASE, INFREQUENT STOOL AND/OR HARD, DRY, SMALL STOOLS THAT ARE DIFFICULT TO ELIMINATE

A

CONSTIPATION

116
Q

AN INCREASE IN THE NUMBER OF STOOLS AND THE PASSAGE OF LIQUID, UNFORMED FECES

A

DIARRHEA

117
Q

ACCUMULATION OF GAS IN THE INTESTINES CAUSING THE WALLS TO STRETCH

A

FLATULENCE

118
Q

RESULTS FROM UNRELIEVED CONSTIPATION, A COLLECTION OF HARDENED FECES WEDGED IN THE RECTUM THAT A PERSON CANNOT EXPEL

A

IMPACTION

119
Q

INABILITY TO CONTROL PASSAGE OF FECES AND GAS TO THE ANUS

A

INCONTINENCE

120
Q

DILATED ENGORGED VEINS IN THE LINING OF THE RECTUM

A

HEMORRHOIDS

121
Q

TEMPORARY OR PERMANENT ARTIFICIAL OPENING IN THE ABDOMINAL WALL

A

STOMA

122
Q

SURGICAL OPENING IN THE ILEUM OR COLON

A

ILEOSTOMY (ILEUM/SMALL INTESTINES)
COLOSTOMY (COLON/LARGE INTESTINES)

123
Q

BOWEL DIVERSION THAT GOES IN THE ABDOMINAL WALL

A

STOMA

124
Q

BOWEL DIVERSION THAT GOES IN THE ILEUM/SMALL INTESTINE

A

ILEOSTOMY

125
Q

BOWEL DIVERSION THAT GOES IN THE COLON/LARGE INTESTINE

A

COLOSTOMY

126
Q

HOW LONG CAN A PERSON GO WITHOUT A BOWEL MOVEMENT BEFORE YOU GET CONCERNED?

A

3 DAYS

127
Q

IF SOMEONE IS HAVING DIARRHEA AND ARE ALREADY IN THE HOSPITAL WHAT IS THE BIGGEST CONCERN FOR THIS PATIENT?

A

SAFETY/FALL RISK DUE TO RUSHING TO THE BATHROOM SO THEY ARE NOT INCONTINENT

128
Q

BOWEL DIVERSIONS ARE WHAT

A

-Temporary or permanent artificial opening in the abdominal wall FORMING A STOMA STOOL MORE FORMED
-Surgical opening in the ileum or colon
Ileostomy (ileum/small intestine) or colostomy (colon/large intestine) - STOOL WILL BE THINNER/LIQUIDY

129
Q

WHAT WOULD YOU DO IF YOU SAW BLOOD IN THE STOOL?

A

NOTIFY THE DOCTOR

130
Q

OSTOMY LOCATIONS AND STOOL CONSISTENCIES

A

SMALL INTESTINE/ILEOSTOMY - THIN TO THICK LIQUID
LARGE INTESTINES TRANSVERSE COLOSTOMY - THICK LIQUID TO SOFT CONSISTENCY
SIGMOID COLOSTOMY - MORE FORMED STOOL

131
Q

THREE TYPES OF OSTOMIES

A

COLOSTOMY
ILEOSTOMY
UROSTOMY

132
Q

COLOSTOMY TYPES

A

TRANSVERSE
ASCENDING
DESCENDING
SIGMOID

133
Q

AN EFFECTIVE POUCHING SYSTEM PROTECTS THE SKIN, CONTAINS FECAL MATERIAL, REMAINS ODOR FREE, AND IS COMFORTABLE AND INCONSPICUOUS

A

OSTOMY BAG

134
Q

NUTRITIONAL CONSIDERATIONS FOR OSTOMIES

A

-LOW FIBER DIET
-EAT SLOWLY
-FLUID
-AVOID GASSY FOODS

135
Q

PSYCHOLOGICAL CONSIDERATIONS FOR OSTOMY BAGS

A

SELF-IMAGE
INTIMACY NEEDS
ODOR

136
Q

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.

A

B CONSTIPATION

137
Q

PSHYICAL ASSESSMENT WHEN ASSESSING BOWEL

A

Mouth
Abdomen
Identifying normal and abnormal patterns, habits, and the patient’s perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient’s problems
Laboratory Tests
Fecal specimens
Test stool for blood, parasites, etc.
Diagnostic examinations

138
Q

COLLECTION OF A STOOL SAMPLE STEPS

A

-HAVE PT DEFECATE INTO A HAT OR GET FROM BRIEF
-WEAR GLOVES
-COLLECT THE STOLL IN A DRY, CLEAN, LEAK-PROOF CONTAINER
-SEAL THE SPECIMEN WELL
-DATE/TIME/INITIAL CONTAINER
-PLACE THE SPECIMEN IN A BIOHAZARD BAG FOR TRANSPORT

139
Q

WHAT SHOUDL YOU LOOK FOR IN A STOOL SAMPLE

A

-PARASITES
-OVUM
-BLOOD
-BLACK/TARRY STOOL

140
Q

IMPLEMENTATION OF PROMOTION OF NORMAL DEFECATION

A

SITTING POSITION
POSITIONING ON BEDPAN
DEVELOP AND PROMOTE ROUTINE
PRIVACY
SAFETY

141
Q

WHEN YOU ARE CARING FOR A PATIENT WITH C-DIFF WHAT SHOULD YOU DO?

A

-WASH HANDS WITH SOAP AND WATER
-ALWAYS WEAR GLOVES
-WEAR A GOWN

142
Q

MEDICATIONS THAT HELP WITH BOWEL MOVEMENTS

A

-Cathartics and laxatives - HELP YOU GO
-Antidiarrheal agents - SLOWS THE BOWELS
-Enemas - HELPS YOU GO

143
Q

RECTAL SUPPOSITORY ADMINISTRATION STEPS

A

Explain the procedure
Position the patient laying on the left side
Hand hygiene & apply gloves.
Lubricate finger & medication
Insert approximately one inch, or once you feel the medication bypass the sphincter
Medication will melt when it reaches body temperature and will able to be absorbed

144
Q

COMMON MEDICATIONS GIVEN VIA SUPPOSITORY

A

Acetaminophen, Dulcolax

145
Q

ENEMA ADMINSTRATION

A

Wear gloves.
Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.
Position patient in left-side lying position with top leg bent upwards (Sim’s position)
LUBE THE TIP AND INSERT INTO RECTUM

146
Q

DIGITAL REMOVAL OF STOOL

A

-PROVIDER OR NURSE REMOVES STOOL WITH FINGER
-MUST HAVE ORDER
-PURPOSE IS TO BREAK UP FECAL MATTER FOR REMOVAL

147
Q

DIGITAL REMOVAL OF STOOL INSTRUCTIONS

A

Assess heart rate before performing as baseline, GET FULL SET OF VITALS
Position patient side lying, educate, hand hygiene, don gloves
Lubricate finger, insert into rectum slowly
Gently loosen fecal mass by massaging around it and remove small pieces slowly
What are the characteristics of the initial stool pieces being removed with disimpaction?
What are the characteristic of the stool after the hard fecal mass has been removed?
Patient should be able to have a bowel movement voluntarily!

148
Q

COMPLICATIONS OF DIGITAL REMOVAL OF STOOL

A

Irritation to mucosa
Possible stimulation of vagus nerve (causes bradycardia); if this happens, the nurse must stop the procedure

149
Q

performed with patient’s who have chronic constipation or fecal incontinence secondary to cognitive impairment

A

BOWEL TRAINING

150
Q

HOW TO BOWEL TRAIN?

A

-ROUTINE - SCHEDULE
-DIET INCREASED FLUIDS
-PROMOTION OF REGULAR EXERCISE - IMPROVES PERISTALIS
-MANAGEMENT OF HEMORRHOIDS - NOT AVOIDING BOWELS
-SKIN INTEGRITY

151
Q

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.

A

b MASS COLONIC PERISTALSIS OCCURS AT THIS TIME

152
Q

TOP LAYER OF THE SKIN

A

EPIDERMIS

153
Q

INNER LAYER OF THE SKIN, COLLAGEN

A

DERMIS

154
Q

Separates dermis and epidermis

A

Dermal–epidermal junction

155
Q

WHEN IS A SKIN ASSESSMENT DONE?

A

EVERY TIME YOU ARE WITH A PATIENT

156
Q

HOW TO Perform thorough skin assessment

A

-Assess all areas of skin in a systematic manner during head to toe
-Critically think when performing assessment – may have to assess various areas of skin during different stages of assessment/care
-Lift up folds
-Turn patient and assess backside

157
Q

EXAMPLES OF INTERRUPTION OF THE INTEGRITY OF THE SKIN

A

SURGICAL WOUNDS
NONSURGICAL WOUNDS

158
Q

If skin is reddened, showing signs of breakdown , what do you need to do?

A

notify provider and intervene appropriately to prevent further issues!

159
Q

what do you need to document when documenting a skin abnormality

A

size, color, shape

160
Q

WHAT IS INVOLVED IN ASSESSING WOUND CHARACTERISTICS

A

-LOCATION
-COLOR
-SIZE
-ODOR
-PAIN

161
Q

what do you do if you do not have tape measure with you to measure skin sore?

A

compare it to familiar object

162
Q

NO DRAINAGE OR EXUDATE PRESENT

A

ABSENT

163
Q

THE WOUND IS MOIST, EVEN THOUGH NO MEASURABLE AMOUNT OF EXUDATE APPEARS ON THE DRESSING

A

SCANT AMOUNT OF EXUDATE PRESENT

164
Q

EXUDATE COVERS LESS THAN 25% OF THE DRESSING

A

SMALL OR MINIMAL AMOUNT OF EXUDATE ON THE DRESSING

165
Q

WOUND TISSUES ARE WET, AND DRAINAGE INVOLVES 25% TO 75% OF THE DRESSING

A

MODERATE AMOUNT OF DRAINAGE

166
Q

WOUND TISSUE IS FILLED WITH FLUID AND EXUDATE COVERS MORE THAN 75% OF THE DRESSING

A

LARGE AMOUNT OF DRAINAGE

167
Q

WOUND TISSUE IS FILLED WITH FLUID, AND DRESSING IS SATURATE WITH EXUDATE

A

COPIOUS AMOUNT OF DRAINAGE

168
Q

how soon do you intervene if you notice a pressure sore and how do you intervene

A

asap
reposition

169
Q

if a patient has a non-surgical wound what do you assess first

A

ABCs

170
Q

Assessment of wound characteristics

A

location
color
size
odor
pain

171
Q

beefy red wound

A

indicates tissue and skin healing, appropriate blood supply

172
Q

pink wound

A

no active s/s of infection, blood supply isn’t ideal

173
Q

slough or infection of wound

A

yellow

174
Q

dead tissue, no blood supply

A

black

175
Q

drainage types of wounds

A

Sanguineous
Serosanguineous
Serous
Purulent

176
Q

when assessing a wound what else should you assess for other than actual wound?

A

old dressing
outside of wound where dressing is put on the skin

177
Q

how to document dressing change

A

removal
assessment of dressing
cleaning of wound
redressing

178
Q

drainage of wounds are not clear cut amount it can be considered _________

A

subjective

179
Q

Factors that influence the healing process

A

nutrition
tissue perfusion
infection
age
stress

180
Q

A SKIN TEAR OCCURS WHEN LAYERS OF THE SKIN WHAT

A

SEPARATE OR PEEL BACK

181
Q

labs to run to know about tissue perfusion

A

albumin
total protein

182
Q

if a resident has a wound what type of diet should they be on

A

high protein

183
Q

3 things that cause person to get a sore

A

-cant communicate they need to be moved
Cant move themselves
Don’t feel they need to be moved

184
Q

stress can ________ wound healing

A

decrease

185
Q

occurs when layers of the skin separate or peel back

A

skin tear

186
Q

What causes skin tears

A

removing adhesive bandages
drying or cleaning a resident aggressively
bumping into something

187
Q

how do we prevent skin tears

A

Be careful with thin, delicate skin
Place sleeves on individuals prone to skin tears
Decrease use of adhesive
Carefully remove adhesive

188
Q

steps in caring for a skin tear

A

Control the bleeding
Apply saline or warm water and clean area
Pat dry with clean gauze
Measure size of skin tear
Add steri strips across site, to approximate
Cover skin with nonadhesive dressing

189
Q

how to document skin tear

A

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
-document in chronological order

190
Q

OTHER THAN DOCUMENTING IN THE CHART WHAT ELSE SHOULD BE FILLED OUT WHEN A SKIN TEAR OCCURS

A

-INCIDENT REPORT

191
Q

SIMPLE WOUND CLEANING

A

-LEAVE DRESSING ON UNLESS VISABILY SOILED OR ORDERS
-ASSESS OLD DRESSING AND REMOVE IT
-ASSESS THE WOUND CHARATERISTICS
-CLEAN WOUND PER ORDERS
-APPLY ANY TOPICAL OINTMENTS OR SPECIAL MEDICATED DRESSINGS
-APPLY TOP DRESSING SECURELY
-DOCUMENT

192
Q

WHEN YOU APPLY A DRESSING TO A PT WHAT DO YOU NEED TO PUT ON IT?

A

INITIAL, DATE, TIME

193
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

194
Q

HOW MANY PEOPLE HOSPITALIZED WITH PRESSURE INJURIES

A

2.5 MILLION PEOPLE HOSPITALIZED

195
Q

PRESSURE Injury may present as:

A

SKIN INTACT (REDNESS)
BLISTER
OPEN ULCER

196
Q

Patients at risk for pressure injuries

A

Decreased mobility
Decreased sensory perception
Fecal or urinary incontinence
Poor nutrition

197
Q

Pressure applied over a capillary, occluding the vessel will cause

A

tissue ischemia

198
Q

When a patient has reduced sensation and cannot respond to the discomfort of ischemia it will cause what

A

tissue death

199
Q

blanchable or nonblachable

A

blanchable - good prefusion to tissues - color returns when you touch
non - bad prefusion - color does not return

200
Q

if the color is non blanchable it indicates:

A

Deep tissue damage is probable

201
Q

AFTER A PERIOD OF TISSUE ISCHEMIA WHEN THE PATIENT IS REPOSITIONED THE AREA SHOULD BE ASSESSED AND IF BLOOD FLOW HAS RETURNED TO THE AREA IT WILL TURN WHAT COLOR AND THIS IS DUE TO WHAT?

A

ERTHEMATIC IN COLOR DUE TO VASODILATION

202
Q

people who are at risk for not being able to move or communicate which cause sores

A

paralyzed, decrease LOC, dementia

203
Q

Both low pressure over a prolonged period and high intensity pressure over a short period can cause tissue damage

A

pressure duration

204
Q

Risk Factors for Pressure Ulcer Development

A

impaired sensory perception
alterations in level of consciousness
impaired mobility - not specific to older adults
shear
friction
moisture

205
Q

Risk Factors for Pressure Ulcer Development

A

-Impaired sensory perception
– unable to feel any part of body
-Impaired mobility
–Unable to independently change positions and move off of bony prominences
-Alteration in Level of Consciousness
–Comatose, confused, disoriented, aphasia

206
Q

Shear injury

A

Sliding movement of skin and subcutaneous tissue while underlying bone and muscle are stationary

207
Q

layering multiple chuck pads can cause what type of injury

A

shear injury

208
Q

Friction injury

A

Force of two surfaces moving across one another

209
Q

Moisture injury

A

Reduces the resistance of the skin, softens skin
More susceptible to damage
Wound drainage, urine or stool, perspiration, wound exudate, mucus, saliva

210
Q

what risk assessment is used for pressure ulcers

A

braden scale

211
Q

prevention of pressure injury

A

Protect bony prominences
Skin barriers for incontinence
Keep sheets under patient’s skin tight, don’t allow them to crease and bunch up
Keep absorbent pads to a minimum (per hospital policy; usually only use one!)
Change positions often
Support surfaces

212
Q

reposition how often

A

one - two hours minimum

213
Q

an evidenced based tool that allows health care professionals to predict a patient’s risk for developing a hospital acquired pressure ulcer

A

braden scale

214
Q

RISK FACTORS FOR PRESSURE ULCER DEVELOPMENT

A

-IMPAIRED SENSORY PERCEPTION
-IMPAIRED MOBILITY
-ALTERACTION IN LEVEL OF CONSCIOUSNESS

215
Q

The Braden Scale evaluates the patient in the following areas:

A

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear

216
Q

19-23 on braden scale

A

no risk

217
Q

A score < 19 on braden scale

A

indicates the patient is risk for skin breakdown

218
Q

15-18 on braden scale

A

mild risk

219
Q

13-14 on braden scale

A

moderate risk

220
Q

10-12 on braden scale

A

high risk

221
Q

less than 9 on braden scale

A

high risk

222
Q

THE STAGING SYSTEM DESCRIBES THE PRESSURE INJURY WHAT?

A

DEPTH AT THE INITIAL POINT OF ASSESSMENT

223
Q

WHAT IS THE DRAWBACK OF THE STAGING SYSTEM FOR PRESSURE ULCERS

A

WOUNDS WITH NECROTIC TISSUE CANNOT BE STAGED

224
Q

WHAT ARE THE DIFFERENT NURSING ROLES FOR WOUND STAGING

A

EXPERIENCED NURSES DETERMINE THE STAGING
NOVICE NURSES WILL NEED TO UNDERSTAND HOW THE SYSTEM WORKS AND DOCUMENT APPROPRITATE DETAILS ABOUT THE PRESSURE ULCER

225
Q

stage one pressure ulcer

A

Intact skin with nonblanchable redness

226
Q

stage 2 pressure ulcer

A

Partial-thickness skin loss involving epidermis, dermis, or both

227
Q

stage 3 pressure ulcer

A

Full-thickness tissue loss with visible fat

228
Q

stage 4 pressure ulcer

A

Full-thickness tissue loss with exposed bone, muscle, or tendon

229
Q

necrotic tissue cannot be staged

A

unstaged

230
Q

what are the nursing roles for management of wounds

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

231
Q

CHYME IS MOVED THROUGH PERISALSIS AND IS CHANGED INTO FECES

A

ELIMINATION

Skills Lecture (7 decks)

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