skills lecture 6 Flashcards
nutrition is
-a basic component of health
-essential for normal growth and development, tissue maintenance and repair, cellular metabolism, and organ function
-
assessment of nutrition
-assess daily weight
-Laboratory tests: liver tests, kidney tests
-Assess thorough diet and health history
-assess hair skin and nails
what specific laboratory tests are used to assess nutrition?
-ast
-alt
-alp
-albumin
-total protein
-bun
-crt
-egfr
-glucose
if liver function is decreased what labs will be elevated and what labs will be decreased?
elevated labs - ast, alt, and alp
decreased - albumin and total protein
If patient’s have conditions that interfere with their ability to ingest, digest, or absorb adequate nutrients, they must be assessed thoroughly FOR
nausea
vomiting
diarrhea
fatigue
no appetite
?
what is dyshagia
difficulty swallowing
if a patient has difficulty swallow what is the first concern?
airway
signs of difficulty swallowing
cough during and after meals
inability to speak consistently
food pocketing
choking on food
regurgitation
Abnormal movements of the mouth, tongue, or lips
what type of liquids put a resident at a higher risk for choking?
thin liquids
patient is pocketing food and having difficulty with choking but still needs to eat what do we need to do?
possibly be NPO until evaluated
complications of dysphagia
-weight loss
-decreased nutritional status
-aspiration pneumonia
-dehydration
malnutrition significantly slows swallowing recover and may increase what?
mortality
if a resident is not practicing swallowing what happens?
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
Patients with dysphagiabecome frustrated with eating and show changes in _______ levels
albumin. if it is less than 3.5 we know there is something wrong with their nutritional intake
nursing role in nutritional changes
-Review ordered diet
-Advancing diets as tolerated by the patient
-Promoting appetite
-Assisting with oral feedings if necessary
-Use of weighted silverware
ways to encourage appetite
-oral care
-offer choices
types of ordered diets
-NPO
-CLEAR LIQUID
-FULL LIQUID
-Thickened Liquids, Pureed
-MECHANICAL SOFT
NPO DIET
-NOTHING BY MOUTH
CLEAR LIQUID DIET
ONLY CLEAR FLUIDS OR CLEAR SOLIDS THAT BECOME CLEAR LIQUIDS EASILY AT ROOM TEMP
-NO RED LIQUIDS
FULL LIQUID DIET
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
THICKENED LIQUIDS AND PUREED
MASHED POTATOES AND GRAVY
ANYTHING PUREED
MECHANICAL SOFT
Foods that are mashed up by a machine and made soft
dysphagia stages of ordered diets
thickened liquids and pureed foods
TYPES OF DIET RESTRICTIONS
-LOW SODIUM
-LOW CHOLESTEROL
-DIABETIC
-CARDIAC
-GLUTEN FREE
-REGULAR
LOW SODIUM DIET
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
LOW CHOLESTEROL DIET
300 mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction
DIABETIC DIET
Nutrition recommendations by the American Diabetes Association: focus on total energy, nutrient and food distribution; include a balanced intake of carbohydrates, fats, and proteins
GLUTEN FREE DIET
Eliminates wheat, oats, rye, barley, and their derivatives
CARDIAC DIET
LOW SODIUM
LOW CHOLESTEROL
NUTRITION THROUGH NG TUBE
Enteral Nutrition provides nutrients through the GI Tract
why would a feeding tube be placed?
-unable to swallow
-dysphagia
-in a coma
-lethargic
where is an ng tube placed?
the nose
where is a j-tube placed?
jejumun (small intestine)
where is a g-tube placed?
in the stomach
any patient with any type of feeding tube is at risk for what
aspiration
where is an orogastric tube placed
mouth
short term feeding tube placed in the acute care setting
gastric tubes
PURPOSES OF GASTRIC TUBES
-Enteral feeding & Medication administration
-Decompression (BOWEL OBSTRUCTION)(COMA)
-Lavage (POSION INGESTION), (ALCOHOL POISONING)
a patient with what kind of issue would not be fit for an ng tube?
facial structure issues
NG TUBE SIZES
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
A PATIENT WITH ACID REFLUX IS NEEDING A FEEDING TUBE PLACED, WHAT IS THE MOST APPROPRIATE AND WHY?
GASTROSTOMY IN THE INTESTINES NOT IN THE STOMACH DUE TO HIGH RISK OF ASPIRATION
what feeding tubes are surgically placed?
gastrostomy
jejunostomy
what feeding tubes can be placed at the bedside
ng tube
orogastric
nasoenteric tubes
nasogastric tube (ngt)
nasojejunal (njt)
what needs to be considered when choosing a feeding tube?
aspiration risk
TWO TYPES OF GASTRIC TUBES
SALEM SUMP
LEVIN
THE BIGGEST DIFFERENCE BETWEEN THE SALEM SUMP AND LEVIN IS WHAT
SALEM SUMP HAS A DOUBLE LUMEN
INSERTION RULES FOR NG TUBE
-HOLD
-ANCHOR
-KINK
-VERIFY
INSERTION OF NG TUBE ON MONDAY, NEW NURSE COMES IN ON THURSDAY FOR SHIFT WHAT SHOULD SHE CHECK FIRST?
CHECK FOR XRAY REPORT OF VERIFICATION OF NG TUBE PLACEMENT
what complications should you monitor for during ng tube insertion?
respiratory complications
what specific respiratory complications should you monitor during ng tube and what should you do if they arise?
-sob
-inability to speak
-color change
-if it happens you need to remove tube immediately
if necessary you can place the feeding tube in what so it is flexible for insertion?
room temp water prior to lubrications
if you are inserting the ng tube due to dysphagia you will not be able to have patient do what?
swallow water
DOCUMENTATION FOR NG TUBE INSERTION
-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
WHAT DO YOU DO BEFORE GIVING NG TUBE FEEDINGS OR MEDICATION?
ASPIRATE STOMACH CONTENTS
FLUSH 30ML OF WATER
WHAT DO YOU DO TO MONITOR NASOGASTRIC TUBE IN PLACE?
-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
IF A PATIENT HAS AN NG TUBE HOW SHOULD THEY BE IN BED?
HEAD ELEVATED ALWAYS EVEN WHEN SLEEPING AT LEAST A 30 DEGREE ANGLE
WHAT SHOULD YOU ALWAYS DO BEFORE AND AFTER USE OF NG TUBE
FLUSH AT LEAST 30ML OF WATER
A FLEXIBLE FEEDING TUBE PLACED THROUGHT THE ABDOMINAL WALL AND INTO THE STOMACH
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG TUBE)
PATIENTS WHO HAVE DIFFICULTY WITH WHAT ISSUES CAN BENEFIT FROM AA PEG TUBE?
-SWALLOWING
-PROBLEMS WITH THEIR APPETITE
-INABILITY TO TAKE ADEQUATE NUTRITION THROUGH THE MOUTH
HOW DO YOU MANAGE THE AREA OF A PEG TUBE
CLEAN THE SITE ONCE A DAY WITH DILUTED SOAP AND WATER OR NORMAL SALINE AND KEEP THE SITE DRY BETWEEN CLEANSINGS
THINGS TO MONITOR WHEN ASSESSING A PEG TUBE
-INFECTION
-BLEEDING
-WARM
-RED
-DISCAHRGE
-ODOR
-TENDER
COMPLICATIONS OF PEG TUBE
Pain at the PEG site
Leakage of stomach contents around the tube site
Dislodgment or malfunction of the tube
HOW LONG CAN PEG TUBE BE IN PLACE?
MONTHS TO YEARS
WHAT DO YOU NEED TO MAKE SURE OF WHEN PEG TUBE IS IN PLACED?
MAKE SURE THE CLAMP IS ALWAYS CLOSED
IF YOU NOTICE SIGNS AND SYMPTOMS OF INFECTION OF PEG TUBE IT CAN CHANGE WHAT?
BOWEL ISSUES
WHO CAN USE A PEG TUBE
Patients who have difficulty swallowing, problems with their appetite or an inability to takeadequate nutrition through the mouth can benefit from this procedure
NG AND PEG TUBE MEDICATION ADMINISTRATION
-PREPARE MEDS
-GI ASSESSMENT
-CONFIRM PLACEMENT (ASPIRATE AND THEN FLUSH 30ML)
-CHECK FOR RESIDUALS BEFORE EACH FEEDING AND MED ADMINISTRATION
PREPARING MEDICATIONS FOR FEEDING TUBES
-USE MEDS IN THE FORM OF LIQUID IF POSSIBLE
-DISSOLVE MEDCATION IF POSSIBLE
-ADMINSTER MEDICATION USING THE ENTERAL TUBE SYRINGE (60ML SYRINGE)
HOW CAN YOU CONFIRM PLACEMENT OF TUBE AFTER IT HAS BEEN CONFIRMED BY XRAY
-ASPIRATE 30 ML GASTRIC CONTENTS AND ASSESS COLOR/CONSITENCY
-FLUSH 30 ML OF AIR AND LISTEN FOR “AIR SWOOSH” UTILIZING STETHOSCOPE
HOW DO YOU CHECK RESIDUAL OF FEELING TUBE
CONNECT SYRINGE TO PORT AND PULLING BACK CONTENTS
WHAT ARE RESIDUALS
LIQUIDS CURRENTLY IN THE STOMACH
UNDIGESTED CONTENTS
WHEN DO YOU HOLD A MEDICATION OR FEEDING AND FOR HOW LONG?
WHEN YOU GET MORE THAN 500 ML OF RESIDUAL YOU HOLD THE MED OR FEEDING FOR 2 HOURS
Keep patient in semi to high fowlers position for at least a/an ______ after medications have been given
hour
MEDICATIONS GIVEN IN A FEEDING TUBE SHOULD BE GIVEN AT WHAT TEMP?
ROOM TEMP
EACH TIME YOU DISCONNECT THE SYRINGE FFROM THE PORT OF THE GASTRIC TUBE DONT FORGET TO WHAT?
CLAMP
AFTER YOU ADMINSTER MEDS OR FEEDING YOU HAVE TO WAIT HOW LONG TO SUCTION PATIENT AND WHY
AT LEAST 30 MINUTES SO PT CAN ABSORB OR DIGEST THE FOOD OR MEDICATION
when are enteral tube feedings appropriate?
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
ENTERAL FORMULA ORDERED IS BASED ON WHAT
THE PATIENTS CONDITION AND NEEDS
Feedings can be continuous or bolus whats the difference?
continuous - pump
bolus- syringe
FEEDING DELIVERED OVER THE COURSE OF HOURS, WITH A SMALL AMOUNT GIVEN EACH HOUR
CONTINUOUS
Feedings can cause what if they are being administered too quickly
abdominal cramping/discomfort
WHAT ARE THE NURSES RESPONSIBILITIES WITH A CONTINUOUS FEEDING?
-ASSESS PATIENT DURING FEEDINGS
-CHECK RESIDUALS
-INCREASE FEEDINGS PER ORDERS AS TOLERATED BY PT
IF A PATIENT IS GETTING CONTINUOUS FEEDINGS WHAT CONDITION ARE THEY AT RISK FOR? WHAT ARE THE NURSING INTERVENTIONS FOR THIS?
HYPERGLYCEMIA
THE NURSE WILL MONITOR BLOOD GLUCOSE LEVELS ABOUT EVERY 4-6 HOURS
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?
HYPERGLYCEMIA
FEEDINGS GIVEN BY SYRINGE, TO THE FLOW OF GRAVITY
BOLUS
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.
D INTRODUCE SMALL AMOUNT OF FLUID INTO THE TUBE BEFORE THE FEEDING
INDICATIONS ON WHY A GASTRIC TUBE SHOULD BE REMOVED
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
GASTRIC TUBAL REMOVAL STEPS
-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
WHAT IS THE MOST IMPORTANT THING TO REMEMBER WHEN REMOVING A GASTRIC TUBE?
DO NOT TAKE HANDS OFF OF TUBE UNTIL IT IS COMPLETELY OUT
REGULAR ELIMINATION OF BOWEL WASTE PRODUCTS IS ESSENTIAL FOR WHAT
NORMAL BODY FUNCTIONING
LARGE INTESTINE PARTS AND FUNCTION
The primary organ of bowel elimination
ASCENDING, TRANSVERSE, DESCENDING AND SIGMOID COLON
SUPPORTIVE NURSING CARE RESPECTS A PATIENTS WHAT DURING BOWEL ELIMINATION
PRIVACY AND EMOTIONAL NEEDS
CONTAINS MILLIONS OF NON-HARMFUL BACTERIA
NORMAL FLORA
PART OF THE DIGESTIVE SYSTEM
MOUTH, ESOPHAGUS, STOMACH, SMALL INTESTINE, LARGE INTESTINE, ANUS
DIGESTION BEGINS WITH MASTICATION
MOUTH
PERISTALSIS MOVES FOOD INTO THE STOMACH VIA THE WHAT
ESOPHAGUS
STORES FOOD; MIXES FOOD, LIQUID, AND DIGESTIVE JUICES; MOVES FOOD INTO SMALL INTESTINES
STOMACH
Small intestine
Duodenum, jejunum, and ileum
THE PRIMARY ORGAN OF BOWEL ELIMINATION
LARGE INTESTINE
EXPELS FECES AND FLATUS FROM THE RECTUM
ANUS
DIGESTTION STARTS WITH _________ AND ENDS WITH __________
PARASTALSIS, ELIMINATION
BEGINS IN THE MOUTH AND ENDS IN THE SMALL AND LARGE INTESTINES
DIGESTION
CHYME IS MOVED THROUGH PERISALSIS AND IS CHANGED INTO FECES
ELIMINATION
the primary absorption site for nutrients
The small intestine, lined with fingerlike projections called villi
MECHANICAL BREAKDOWN THAT RESULTS FROM CHEWING, CHURNING, AND MIXING WITH FLUID AND CHEMICAL REACTIONS IN WHICH FOOD REDUCES TO ITS SIMPLEST FORM
DIGESTION
ABSORPTION OF WHAT OCCURS IN THE SMALL INTESTINES
CARBOHYDRATES
PROTEIN
MINERALS
WATER-SOLUBLE VITAMINS
WHAT CAN INCREASE PARASTALSIS?
STRESS AND ANXIETY
WHAT IS PERISTALSIS?
SERIES OF INVOLUNTARY WAVE-LIKE MUSCLE CONTRACTIONS WHICH MOVE FOOD ALONG THE DIGESTIVE TRACT
ALL BIOCHEMICAL REACTIONS WITHIN THE CELLS OF THE BODY
METABOLISM
WHAT ARE THE TWO REACTION PROCESSES OF METABOLISM
ANABOLIC AND CATABOLIC
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
ELIMINATION
FACTORS INFLUENCING BOWEL ELIMINATION
-AGE
-DIET
-FLUID INTAKE
-PHYSICAL ACTIVITY
-PSYCHOLOGICAL FACTORS
-PERSONAL HABITS
-POSITION DURING DEFECATION
-PAIN
-SURGERY AND ANESTHESIA
-MEDICATIONS
COMMON BOWEL ELIMINATION PROBLEMS
-CONSTIPATION
-DIARRHEA
-FLATULENCE
-IMPACTION
-INCONTINENCE
-HEMORRHOIDS
A SYMPTOM NOT A DISEASE, INFREQUENT STOOL AND/OR HARD, DRY, SMALL STOOLS THAT ARE DIFFICULT TO ELIMINATE
CONSTIPATION
AN INCREASE IN THE NUMBER OF STOOLS AND THE PASSAGE OF LIQUID, UNFORMED FECES
DIARRHEA
ACCUMULATION OF GAS IN THE INTESTINES CAUSING THE WALLS TO STRETCH
FLATULENCE
RESULTS FROM UNRELIEVED CONSTIPATION, A COLLECTION OF HARDENED FECES WEDGED IN THE RECTUM THAT A PERSON CANNOT EXPEL
IMPACTION
INABILITY TO CONTROL PASSAGE OF FECES AND GAS TO THE ANUS
INCONTINENCE
DILATED ENGORGED VEINS IN THE LINING OF THE RECTUM
HEMORRHOIDS
TEMPORARY OR PERMANENT ARTIFICIAL OPENING IN THE ABDOMINAL WALL
STOMA
SURGICAL OPENING IN THE ILEUM OR COLON
ILEOSTOMY (ILEUM/SMALL INTESTINES)
COLOSTOMY (COLON/LARGE INTESTINES)
BOWEL DIVERSION THAT GOES IN THE ABDOMINAL WALL
STOMA
BOWEL DIVERSION THAT GOES IN THE ILEUM/SMALL INTESTINE
ILEOSTOMY
BOWEL DIVERSION THAT GOES IN THE COLON/LARGE INTESTINE
COLOSTOMY
HOW LONG CAN A PERSON GO WITHOUT A BOWEL MOVEMENT BEFORE YOU GET CONCERNED?
3 DAYS
IF SOMEONE IS HAVING DIARRHEA AND ARE ALREADY IN THE HOSPITAL WHAT IS THE BIGGEST CONCERN FOR THIS PATIENT?
SAFETY/FALL RISK DUE TO RUSHING TO THE BATHROOM SO THEY ARE NOT INCONTINENT
BOWEL DIVERSIONS ARE WHAT
-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
WHAT WOULD YOU DO IF YOU SAW BLOOD IN THE STOOL?
NOTIFY THE DOCTOR
OSTOMY LOCATIONS AND STOOL CONSISTENCIES
SMALL INTESTINE/ILEOSTOMY - THIN TO THICK LIQUID
LARGE INTESTINES TRANSVERSE COLOSTOMY - THICK LIQUID TO SOFT CONSISTENCY
SIGMOID COLOSTOMY - MORE FORMED STOOL
THREE TYPES OF OSTOMIES
COLOSTOMY
ILEOSTOMY
UROSTOMY
COLOSTOMY TYPES
TRANSVERSE
ASCENDING
DESCENDING
SIGMOID
AN EFFECTIVE POUCHING SYSTEM PROTECTS THE SKIN, CONTAINS FECAL MATERIAL, REMAINS ODOR FREE, AND IS COMFORTABLE AND INCONSPICUOUS
OSTOMY BAG
NUTRITIONAL CONSIDERATIONS FOR OSTOMIES
-LOW FIBER DIET
-EAT SLOWLY
-FLUID
-AVOID GASSY FOODS
PSYCHOLOGICAL CONSIDERATIONS FOR OSTOMY BAGS
SELF-IMAGE
INTIMACY NEEDS
ODOR
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.
B CONSTIPATION
PSHYICAL ASSESSMENT WHEN ASSESSING BOWEL
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
COLLECTION OF A STOOL SAMPLE STEPS
-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
WHAT SHOUDL YOU LOOK FOR IN A STOOL SAMPLE
-PARASITES
-OVUM
-BLOOD
-BLACK/TARRY STOOL
IMPLEMENTATION OF PROMOTION OF NORMAL DEFECATION
SITTING POSITION
POSITIONING ON BEDPAN
DEVELOP AND PROMOTE ROUTINE
PRIVACY
SAFETY
WHEN YOU ARE CARING FOR A PATIENT WITH C-DIFF WHAT SHOULD YOU DO?
-WASH HANDS WITH SOAP AND WATER
-ALWAYS WEAR GLOVES
-WEAR A GOWN
MEDICATIONS THAT HELP WITH BOWEL MOVEMENTS
-Cathartics and laxatives - HELP YOU GO
-Antidiarrheal agents - SLOWS THE BOWELS
-Enemas - HELPS YOU GO
RECTAL SUPPOSITORY ADMINISTRATION STEPS
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
COMMON MEDICATIONS GIVEN VIA SUPPOSITORY
Acetaminophen, Dulcolax
ENEMA ADMINSTRATION
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
DIGITAL REMOVAL OF STOOL
-PROVIDER OR NURSE REMOVES STOOL WITH FINGER
-MUST HAVE ORDER
-PURPOSE IS TO BREAK UP FECAL MATTER FOR REMOVAL
DIGITAL REMOVAL OF STOOL INSTRUCTIONS
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!
COMPLICATIONS OF DIGITAL REMOVAL OF STOOL
Irritation to mucosa
Possible stimulation of vagus nerve (causes bradycardia); if this happens, the nurse must stop the procedure
performed with patient’s who have chronic constipation or fecal incontinence secondary to cognitive impairment
BOWEL TRAINING
HOW TO BOWEL TRAIN?
-ROUTINE - SCHEDULE
-DIET INCREASED FLUIDS
-PROMOTION OF REGULAR EXERCISE - IMPROVES PERISTALIS
-MANAGEMENT OF HEMORRHOIDS - NOT AVOIDING BOWELS
-SKIN INTEGRITY
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.
b MASS COLONIC PERISTALSIS OCCURS AT THIS TIME
TOP LAYER OF THE SKIN
EPIDERMIS
INNER LAYER OF THE SKIN, COLLAGEN
DERMIS
Separates dermis and epidermis
Dermal–epidermal junction
WHEN IS A SKIN ASSESSMENT DONE?
EVERY TIME YOU ARE WITH A PATIENT
HOW TO Perform thorough skin assessment
-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
EXAMPLES OF INTERRUPTION OF THE INTEGRITY OF THE SKIN
SURGICAL WOUNDS
NONSURGICAL WOUNDS
If skin is reddened, showing signs of breakdown , what do you need to do?
notify provider and intervene appropriately to prevent further issues!
what do you need to document when documenting a skin abnormality
size, color, shape
WHAT IS INVOLVED IN ASSESSING WOUND CHARACTERISTICS
-LOCATION
-COLOR
-SIZE
-ODOR
-PAIN
what do you do if you do not have tape measure with you to measure skin sore?
compare it to familiar object
NO DRAINAGE OR EXUDATE PRESENT
ABSENT
THE WOUND IS MOIST, EVEN THOUGH NO MEASURABLE AMOUNT OF EXUDATE APPEARS ON THE DRESSING
SCANT AMOUNT OF EXUDATE PRESENT
EXUDATE COVERS LESS THAN 25% OF THE DRESSING
SMALL OR MINIMAL AMOUNT OF EXUDATE ON THE DRESSING
WOUND TISSUES ARE WET, AND DRAINAGE INVOLVES 25% TO 75% OF THE DRESSING
MODERATE AMOUNT OF DRAINAGE
WOUND TISSUE IS FILLED WITH FLUID AND EXUDATE COVERS MORE THAN 75% OF THE DRESSING
LARGE AMOUNT OF DRAINAGE
WOUND TISSUE IS FILLED WITH FLUID, AND DRESSING IS SATURATE WITH EXUDATE
COPIOUS AMOUNT OF DRAINAGE
how soon do you intervene if you notice a pressure sore and how do you intervene
asap
reposition
if a patient has a non-surgical wound what do you assess first
ABCs
Assessment of wound characteristics
location
color
size
odor
pain
beefy red wound
indicates tissue and skin healing, appropriate blood supply
pink wound
no active s/s of infection, blood supply isn’t ideal
slough or infection of wound
yellow
dead tissue, no blood supply
black
drainage types of wounds
Sanguineous
Serosanguineous
Serous
Purulent
when assessing a wound what else should you assess for other than actual wound?
old dressing
outside of wound where dressing is put on the skin
how to document dressing change
removal
assessment of dressing
cleaning of wound
redressing
drainage of wounds are not clear cut amount it can be considered _________
subjective
Factors that influence the healing process
nutrition
tissue perfusion
infection
age
stress
A SKIN TEAR OCCURS WHEN LAYERS OF THE SKIN WHAT
SEPARATE OR PEEL BACK
labs to run to know about tissue perfusion
albumin
total protein
if a resident has a wound what type of diet should they be on
high protein
3 things that cause person to get a sore
-cant communicate they need to be moved
Cant move themselves
Don’t feel they need to be moved
stress can ________ wound healing
decrease
occurs when layers of the skin separate or peel back
skin tear
What causes skin tears
removing adhesive bandages
drying or cleaning a resident aggressively
bumping into something
how do we prevent skin tears
Be careful with thin, delicate skin
Place sleeves on individuals prone to skin tears
Decrease use of adhesive
Carefully remove adhesive
steps in caring for a skin tear
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
how to document skin tear
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
OTHER THAN DOCUMENTING IN THE CHART WHAT ELSE SHOULD BE FILLED OUT WHEN A SKIN TEAR OCCURS
-INCIDENT REPORT
SIMPLE WOUND CLEANING
-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
WHEN YOU APPLY A DRESSING TO A PT WHAT DO YOU NEED TO PUT ON IT?
INITIAL, DATE, TIME
WHAT ARE THE RISKS OF ADHESIVE USE ON SKIN
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
HOW MANY PEOPLE HOSPITALIZED WITH PRESSURE INJURIES
2.5 MILLION PEOPLE HOSPITALIZED
PRESSURE Injury may present as:
SKIN INTACT (REDNESS)
BLISTER
OPEN ULCER
Patients at risk for pressure injuries
Decreased mobility
Decreased sensory perception
Fecal or urinary incontinence
Poor nutrition
Pressure applied over a capillary, occluding the vessel will cause
tissue ischemia
When a patient has reduced sensation and cannot respond to the discomfort of ischemia it will cause what
tissue death
blanchable or nonblachable
blanchable - good prefusion to tissues - color returns when you touch
non - bad prefusion - color does not return
if the color is non blanchable it indicates:
Deep tissue damage is probable
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?
ERTHEMATIC IN COLOR DUE TO VASODILATION
people who are at risk for not being able to move or communicate which cause sores
paralyzed, decrease LOC, dementia
Both low pressure over a prolonged period and high intensity pressure over a short period can cause tissue damage
pressure duration
Risk Factors for Pressure Ulcer Development
impaired sensory perception
alterations in level of consciousness
impaired mobility - not specific to older adults
shear
friction
moisture
Risk Factors for Pressure Ulcer Development
-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
Shear injury
Sliding movement of skin and subcutaneous tissue while underlying bone and muscle are stationary
layering multiple chuck pads can cause what type of injury
shear injury
Friction injury
Force of two surfaces moving across one another
Moisture injury
Reduces the resistance of the skin, softens skin
More susceptible to damage
Wound drainage, urine or stool, perspiration, wound exudate, mucus, saliva
what risk assessment is used for pressure ulcers
braden scale
prevention of pressure injury
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
reposition how often
one - two hours minimum
an evidenced based tool that allows health care professionals to predict a patient’s risk for developing a hospital acquired pressure ulcer
braden scale
RISK FACTORS FOR PRESSURE ULCER DEVELOPMENT
-IMPAIRED SENSORY PERCEPTION
-IMPAIRED MOBILITY
-ALTERACTION IN LEVEL OF CONSCIOUSNESS
The Braden Scale evaluates the patient in the following areas:
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
19-23 on braden scale
no risk
A score < 19 on braden scale
indicates the patient is risk for skin breakdown
15-18 on braden scale
mild risk
13-14 on braden scale
moderate risk
10-12 on braden scale
high risk
less than 9 on braden scale
high risk
THE STAGING SYSTEM DESCRIBES THE PRESSURE INJURY WHAT?
DEPTH AT THE INITIAL POINT OF ASSESSMENT
WHAT IS THE DRAWBACK OF THE STAGING SYSTEM FOR PRESSURE ULCERS
WOUNDS WITH NECROTIC TISSUE CANNOT BE STAGED
WHAT ARE THE DIFFERENT NURSING ROLES FOR WOUND STAGING
EXPERIENCED NURSES DETERMINE THE STAGING
NOVICE NURSES WILL NEED TO UNDERSTAND HOW THE SYSTEM WORKS AND DOCUMENT APPROPRITATE DETAILS ABOUT THE PRESSURE ULCER
stage one pressure ulcer
Intact skin with nonblanchable redness
stage 2 pressure ulcer
Partial-thickness skin loss involving epidermis, dermis, or both
stage 3 pressure ulcer
Full-thickness tissue loss with visible fat
stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon
necrotic tissue cannot be staged
unstaged
what are the nursing roles for management of wounds
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
CHYME IS MOVED THROUGH PERISALSIS AND IS CHANGED INTO FECES
ELIMINATION
