Test 4 Flashcards
Difficulty swallowing or the inability to swallow
Dysphagia
The misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract
Aspiration
For aspiration precautions which position should the patient sit in if receiving food orally?
Fowlers position
For aspiration precautions how should the patient be sitting for enteral feeding tube feeding
Semi fowler
for enteral food feeding what is the rationale for lowering the feeding
so that the patient does not aspirate
what do you for enteral or ng feeding first?
check residual because of vomiting
What are the assessments for dysphagia?
fever pnemonia coughing crackling in lung fields
gradual feeding on a timed pump
continuous
is a feeding that is giving all at once
bolus
How many mL of water are you supposed to flush after feeding?
30 mL
feeding that hangs like an IV can be made faster or slower depending of the position of the bag
gravity
feeding tube placed in opening of stomach
gastrostomy (peg) tube
Why is a PEG tube the best option and what clients is it ideal for ?
less risk for regurgitation and aspiration ; comatose
For gastrostomy (PEG) tube is it for short term or long term?
long term
What assessments would you do before a gastronomy (PEG) tube?
bowel sounds, vomiting, nausea, diarrhea
For a gastrostomy peg tube what should you do to ensure nothing is left behind and that it doesn’t get impacted
flush tube before and after feedings
Before inserting an NG tube what should you do?
assess for nasal obstructions and tissue irritation around nares
How do you check the placement of NG tube?
flush tube with air then withdrawal gastric fluid (check color consistency then put back in stomach then flush with 30 mL of water)
Steps for administering medication through enteral tube
Check medication order ( 3 checks)
gather materials
Aspirate residual then return it to stomach
flush 20 ml –> admin meds flush 5 mL between meds
Nursing process in promoting adequate nutrition
Assessment
assess for dietary data, bmi
Nursing process in promoting adequate nutrition
Analyze:
Analyze lab results and identify nutritional problem
Nursing process in promoting adequate nutrition
Planning/Outcome:
should be a SMART goal in filling nutritional void or keeping from an excess of nutritents through modified diets
Nursing process in promoting adequate nutrition
Implement:
teaching on nutritional information/rationale and modified diet
Nursing process in promoting adequate nutrition
Evaluation:
monitor nutritional status if goal is being reached
Requires minimal digestion and leaves minimal residue, includes coffee tea clear fruit juices clear broth gelatin popsicles
clear liquid diet
known as blenderized diet because the diet is made up of liquids and foods blenderized to liquid form all foods are allowed
pureed diet
regular diet with modifications for texture excludes most raw fruits and veggies foods are chopped ground mashed or soft
mechanically altered food
Protein lab range
240-480 mg/dl
Albumin lab range
3.5-5.5 g/dL
prealbumin range
23-43 mg/dL
iron normal range
12-18 g/dl
creatinine noraml range
0.4-1.5 mg/dl
decreased protein leads to?
anemia and protein deficency
decreased orealbumin leads to
malnutrition and protein depletion
increased creatinine means
dehydration
decreased creatinine means
severe malnutrition
measure of density of chemicals and particles in urine
specific gravity
Higher than normal specific gravity can indicate dehydration
concentrated urine
lower than normal specific gravity can indicate overhydration
diluted urine
discomfort when urinating
dysuria
excessive urine output
polyuria
strong desire to void
urgency
involuntary loss of urine
urinary incontinence
abnormally small amounts of urine
oligoria
pus in urine
pyuria
increase incidence of voiding
frequency
for single use taken out immediately after use
straight catheter
empties into bag that can attach to leg bed or wheel chair
indwelling (foley) catheter
bladder does not completely empty with urination
urinary retention
what are the assessments for urinary retention?
difficulty urinating, paid adominal distension, frequency
from coughing sneezing laughing
stress incont
strong need to urinate bu leaking occurs before client get to toilet
urge incont
leakage as a result of nerve damage
reflex
incomplete bladder emptying that results in the bladder overfilling when full leads to leakage
overflow
physical inability to reach toilet in time (wheelchair bound, arthritis)
functional incont
common in children but can occur in adults who have consumed too much alcohol
nocturnal enuresis
ways to promote bowel elimination
high fiber diet
laxatives if needed
enemas if needed
mobility
what are you looking for during an adominal assessment?
tenderness distension bowel sounds in all 4 quads
what re the risk factors of constipation?
age immobility low fiber diet hydration status mediations
what are different types of interventions for constipation
high fiber diet ecercise hydration bowel training stoool sofentig meds
this enema soften stools and is used for constipation
retntion
this enema has castile soap and is water based
cleansing enema
is a type of laxative that encourages peristalsis
stimulant
type of laxative that adds water to fecal matter in the gi tract to reduce compaction (colace)
stool softener
type of laxative that is not fdigested absorbe liquid to form soft bulky stool used to treat diarrhea
bulk forming
0.9% NaCl iv solution
isotonic
lacatated ringer solutionq
isotonic
5% dextrose in lactated ringer (d5lr)
hypertonic
0.33% NaCl normal saline iv soulution
hypotonic
0.45% NaCl
hypotonic
FLuid volume excess
hypervolemia
isotonic loss of water and solute lack of BV less blood prefusses to organs
hypovelemia
s & s includes edema weight gain crackles in lungs tachypnea dysphagia
hypervolemia
s & s includes dry mucous membranes excessive thirst dark urine tachycardia but low BP
hypovolemia
isotnic overload of water and solute bv is excessive fluid overload
hypervolemia
fluid excess in interstitial space
edmea
what is an intervention for edema
eleavte swollen area of body if possible
more water is taken into the body that Na+
overhydration
normal level for Na
136-145 mEq/L
normal level for K
3.5-5 mEq/L
normal level for Ca
9.0-10.5 mEq?L
normal level for Mg
1.3-2.1 mEq/L
Muscle weakness leg cramps fatigue dysrhythmias
Hypokalemia
