Exam # 3 Intro to NP

Clear Liquid Diet

Should be clear, liquid foods.

Examples Include: broths, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, popsicles

Full Liquid Diet

Consists of clear liquids with the addition of smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, pureed vegetables, and all fruit juices

Pureed Food Diet

consists of foods that do not need to be chewed

full liquid diet with the addition of scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy

Mechanical Soft Diet

pureed diet with the addition of ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, or peanut butter

Regular Diet

no restrictions unless specified

Soft/low residue diet

low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, and deserts without nuts or coconut

Low Sodium Diet

specified as mild sodium restriction with no salt added to food (3-5 g sodium restriction), or moderate (1g) to severe (500 mg), requiring restricting or abstaining from high sodium foods.

Low Cholesterol Diet

Restricted to 300 mg/day of cholesterol

Diabetic Diet

recommended food exchanges by the American diabetic association - typically the caloric recommendations are around 1,800 calories

Hyponatremia

serum sodium levels less than 135 mEq/L

• two types, hypovolemic and hypervolemic

• signs and symptoms include lethargy, confusion, seizures, and muscle cramps

Hypokalemia

serum potassium levels less than 3.5 mEq/L

• S/S include: weak irregular pulse, fatigue, lethargy, muscle weakness, paresthesia, dysrhythmias,

Hypocalcemia

Serum calcium below 8.5 mg/dL

• S/S include: confusion, anxiety, numb/tingling extremities, MUSCLE CRAMPS, hyperactive reflexes, cardiac dysrhythmias, positive Chvostek and Troussea

• Causes: Hypoparathyroidism, low parathyroid hormone levels,

Proper Procedure for Urinary Catheterization

1.) Ensure you have an order to place catheter

2.) Ensure there is no betadine/iodine allergy

3.) Perform hand hygiene

4.) Open the kit while maintaining sterility

5.) Place drape under buttocks

6.) Clean area with betadine

7.) Apply jelly to tip of catheter and insert into urethra

• Once urine is seen, advance

catheter 1-2 inches more

• Attach prefilled syringe to balloon

port and inflate

• Pull back on catheter to ensure it is

place

• Anchor catheter to leg

• Keep bag below bladder level

Daily Catheter Care

• wash area with soap and water

• check for kinks in tubing

• empty when 2/3 full

• change catheter if debris or encrustation of the catheter is noted

UTI Symptoms and Signs

• dysuria

• frequent urination despite not having a lot of urine to pass

• confusion and change of mental status (in the elderly)

• lower back pain

• frothy urine, burning, or blood in urine

How to do an NG tube feeding an things to remember

• position patient at 30 degrees

• listen for audible bowel sounds

• check tube measurement marking

• make sure formula is warmed to room temperature

• test the pH if this is NOT the first feeding (if greater than 6, retake x-ray to confirm correct placement)

• instill 30 ml of air, then pull back in the syringe, pull back syringe, re-instill aspirated contents, then flush with 30 mL of sterile water

• connect to feeding

• flush w/ 30 mL of sterile water after feeding is complete

Assistance with feeding

• UAP can help with this

• position the patient to 90 degrees for eating

• no distractions

• cut food into small pieces

• remain upright (45 degrees) 1 hour after eating

• use assistive devices if needed (special silverware, cups, etc.)

Medications with enteral feedings

• Verify that the medication is compatible with EFT administration

• Elevate HOB to 30 degrees

• Pause tube feeding as policy states

• Confirm placement of the tube

• Aspirate gastric secretions

• Flush with 15-30ml sterile water

• Pour the medication into the syringe (you may need to mix medication with sterile water, can’t crush enteric coated or extended-release meds, sublingual medications)

• Flush with 15-30ml sterile water between medications

• Flush with 30-60ml sterile water after all medications

• Clamp the tube and reconnect to feeding if needed

Checks to follow for enteral or tube feedings

• Aspiration can still be risk of tube feedings:

• Verify the initial tube placement with an x-ray before initial use.

• Check the tube placement every 4 hours by checking the pH of the gastric contents.

• Check the client’s tube feeding tolerance every 4 hours by measuring the residual.

• Follow the facility policy for residuals greater than 250 mL.

• Maintain the head of the bed at 30° to 45° during feeding.

• Maintain the head of the bed at 30° to 45° for at least 1 hour following bolus feeding

• S/S of aspiration: difficulty or painful breathing, wheezing, a productive cough, or a fever

of 38°C (100.4°F)

Assessment for urinary retention after the removal of a foley cath

• Can use bladder scanner to assess amount of retention

• If 300-500ml post void is seen, catheter may need to be reintroduced

Proper method and procedure for suctioning of a tracheostomy patient

• Adjust suction

• Don sterile gloves

• check function and suction of catheter

• On inhalation, insert catheter with no suction on until patient coughs or resistance is met, then pull back 1 cm

• Ask the client to cough and pull back on intermittent suction over 10-15 seconds

• suction out with rotating the catheter

• Wait 1 minute before resuctioning

• assess secretions and airway clearance

• If copious secretions, suction 3-4 times with 1 minute rest in between for patient to rest and reoxygenate

care and maintenance for a tracheostomy

• Sterile technique is used for the open system suctioning and aseptic technique for the closed system suctioning

• Hyperoxygenation before the catheter is placed inside the tracheostomy tube

• Tracheostomy care every 4 to 8 hours (sterile technique, use 0.9NaCl solution, if replacing ties, tie new ones before removing old ties)

• Tracheostomy twill ties cut into a patient’s skin, causing trauma and providing a site

  for infection. A Velcro tracheostomy tube holder is recommended, because it is easier

  to use by the patient and provider; it provides soft, cushioned support that prevents

  injury; and it is preferred by patients

  o New trach ties should be placed prior to removal of old trach ties

Prevention of constipation, causes, and interventions to promote bowel movements

Prevention: drink more water/fluids, eat more fiber, exercise more, and certain medications can help

Causes: diets with too little fiber, drinking too little water, medications, decreased activity

Preventing infections in catheterized patients

To prevent catheter-associated urinary tract infections (CAUTIs), catheters should be inserted according to the practice guidelines and

removed as quickly as possible. Anchoring the catheter to the patient’s leg minimizes pain, reduces the incidence of

infection, and skin damage, and helps to prevent the catheter from dislodging.

Interventions to improve oxygenation in a post-operative patient

Incentive spirometry benefits patients after abdominal surgery by promoting deep breath which can

decrease the incidence of pulmonary complications such as atelectasis and pneumonia.

Preoperatively, it is the nurse’s role to teach the patient how to use incentive spirometry correctly,

and postoperatively to encourage and monitor its use - recommended use is 10x/hr

Hypovolemia Signs and Symptoms + What will Lab Values Look Like

• First Stages: Dry Mucous Membranes, poor urinary output, poor skin turgor, tachycardia, blood vessels are constricted to reserve fluids in vital organs, flat neck veins, low BP

• If Untreated: cyanosis, change in alertness or consciousness, chest pain, palpitaion, no urine, tachypnea, weak pulse

• High and Dry Labs —> elevated BUN and Creatinine, decreased electrolytes, elevated lactate

Hypervolemia Signs + Symptoms + What will lab lab values look like

• Hypertension

• Tachycardia

• Weight Gain

• Congestion

• Edema

• Nausea

• Dyspnea

• Bounding Pulse

• Lower, Diluted Labs —> hyponatremia, low hematocrit,

• JVD

• Adventitious Lung Sounds

1 oz is how many mL’s

30 mL’s

Labs that may suggest malnutrition or low iron

• Ferritin Test + Transferrin: measures iron stores in the body and is crucial for diagnosing iron deficiency. Low ferritin is an indicator of anemia/deficiency

• Serum Albumin Test: indicates long-term nutritional status - low levels suggest malnutrition

• Prealbumin Test: reflects recent nutritional changes, low levels can indicate malnutrition - PROTEIN TEST

• ALBUMIN TEST - malnutrition

• HGB AND HEMATOCRIT - related to iron and dehydration

• BUN/CREAT - hydration status and kidney function

• Complete Blood Count: detects anemia from B12, iron, or folate deficiencies

What is informed consent

• A client’s full understanding and choice to have a treatment or procedure, including the risks involved, benefits, and other alternatives available, as well as the benefits and risks in-lieu of having the treatment or procedure.

• The RN is NOT responsible for obtaining consent.

• The RN is responsible for ensuring the consent is signed before the procedure begins

Measuring output from an NG tube to suction accounting for the irrigation solution

1.) Subtract the # of normal saline solution used for irrigation from the total volume in the NG cannister

2.) Use the correct equipment - an irrigation kit, solution bowl, emesis basin, and 30-50 mL syringe are necessary

3.) Perform the procedure: Pour the solution into a bowl, clamp the drainage tubing, and gently aspirate with a syringe to check for stomach contents.

4.) Fill the syringe, insert it into the NG tube, and unclamp the tube. Gently inject a small amount of solution. If fluid flows freely, the tube is open. Continue to irrigate until the prescribed amount has been injected.

By following these steps, nurses can ensure accurate measurement of output from an NG tube connected to suction, which is crucial for assessing a patient's fluid balance and digestive function.

Nasal Cannula

Delivers low concentration of O2 and is a preffered method. Settings vary from 1-6 L/min

• humidification is needed at 4 L

High Flow Nasal Cannula

forces the airway to remain open, needs humidification and a flowmeter

Simple face Mask

deliver oxygen at a medium concentration, 5-10L/min, can retain CO2 so not recommended for COPD, risk of skin breakdown

Nonrebreather Mask

high flow oxygen, 10-15L/min, ensure the reservoir bag does not completely deflate, CO2 retention risk, snug fitting mask, only temporary

Bag Valve Mask

used for emergency situations where no respirations are occurring

Home Considerations for Oxygen Therapy

• No smoking around oxygen

• Any products containing petroleum, oil, or grease should never be placed on the upper chest or face of the client using oxygen therapy

• No aerosol sprays, including air freshener and hair spray

• Bedding should be 100% cotton if oxygen is used while sleeping

• Oxygen containers should be kept upright and tubing should be 50 feet or less

What is Chvostek’s Sign

use the fingertips to tap the facial nerve, which is located 2 cm in

front of the tragus of the ear - a twitching of the facial muscles on

the same side being tapped is a positive Chvostek sign

What is a Trousseau Sign

Place a blood pressure cuff on the client’s arm and inflate it 20 mm Hg above the client’s systolic blood pressure for 3 to 5 minutes, which will cause irritability of the nerves in the arm. A positive result occurs with flexion of the wrist, thumb, and first joints of the fingers, combined with hyperextension of the fingers

Causes of Hypovolemia

• Sweating

• Burns

• Diuretics

• Inadequate fluid intake

• increased urination

What is Hypovolemic Shock

body has lost 20 % or 1/5 of its blood or fluid supply

Proper Procedure for collecting a Urine Specimen

• Use a clean catch cup

• Patient must use sanitary wipes beforeurinating

• Patient is to start urinating, stop, put specimen cup under, and then restart

urinating to collect specimen

• Send to lab

What to assess for every shift with an IV

• Patency (is the IV fluid flowing at the RX’d rate?)

• Site condition (redness, swelling)

• pain or tenderness

• skin temperature

• tissue integrity

• dressings and IV flow rate

Patency - define it + what you should look for

signs of patency: fluid is infusing at the correct rate, no swelling, redness or leakage, no pain and blood return may be present

nursing actions: flush per protocol, monitor regularly, maintain proper positioning of extremities

Infiltration - define it + what to look for

defined as: non vesicant IV fluid leaking into surrounding tissues (NOT into the vein)

signs and symptoms: cool, pale, skin, edema, tight skin, slowed or stopped infusion, possible discomfort

interventions: STOP Infusion immediately, remove IV, elevate extremity, apply warm or cool compress per company policy, restart IV in a different site, document findings

Infection - define it + what to look for

definition: microorganisms enter IV site and cause local or systemic infection

signs and sx’s: redness, warmth, swelling, pain or tenderness, purulent drainage, fever

interventions: STOP infusion

• Remove IV catheter

• Cleanse site

• Apply sterile dressing

• Notify provider if indicated

• May send catheter tip for culture (per order)

• Monitor for systemic infection

Procedures for collecting a stool sample

Collecting the Specimen

• Instruct patient to:

  • Void before defecating (prevents urine contamination)

  • Defecate into:

    • Bedpan

    • Commode hat

    • Clean container

❌ Do NOT collect from toilet water

Obtaining the Sample

• Use tongue blade to transfer stool to container

• Collect 2–5 cm (1–2 inches) or per facility policy

• If testing for blood or parasites, collect from different areas of stool