Foundations Exam Three

BMR

Number of calories required to fuel the activities of the body at rest after 12 hours

• Affected by growth, infections, emotional tension, environmental temps, hormones, sleep, aging

How to calculate BMI

Weight (kg) / height (m²)

1 meter = 3.28 ft

• 18.5-24.9 = normal

Waist to hip ratio

Waist circumference / hip circumference

• central obesity ( a higher number ) indicates more risk for health problems

Interventions for dysphagia

• 30-minute rest prior to mealtime

• 90 degree position during and 30-minutes after

• mouth care prior to meals

• don’t rush!

• consult nutrition for liquid consistency'

Nutritional nursing diagnoses

• Impaired nutritional status

• Impaired swallowing

• Body weight problem (obesity, malnutrition)

What supplements may vegetarians require?

Vitamin B12, A, and iron

Religious considerations

• Special preparation (kosher kitchens)

• Guidelines for animal slaughter (Islam, Judaism)

• Avoidance of stimulants (Mormonism, Islam)

• Vegetarianism (Seventh-day Adventists, Buddhism)

• Fasting for holidays (Ramadan, Ash Wednesday)

Clear Liquid Diet

• Clear liquids or foods that become fluid at body temperature

• Clear broths, coffee/tea, clear fruit juices, jell-o, popsicles

Indications: Prep for bowel surgery/endoscopy, initial post-op

Full liquid diet

• All foods that are liquid at room temperature

• Dairy, juices, refined strained cereals and puddings

Indications: transition from liquid to soft diet, post-op, acute gastritis

Use with caution in dysphagia unless thickened appropriately

Thickened liquid diet

Nectar-like: able to sip through straw

Honey-like: pourable, must be eaten with spoon

Spoon-thick: maintains shape, eaten with spoon

Pureed diet

• Foods blended to liquid form

• Indicated for severe dysphagia

Mechanical soft diet

Chopped, ground, mashed, soft foods

• Indicated for moderate dysphagia

• Excludes crunchy stuff

What are some considerations for enteral feeds?

• > 30 degrees for the feeding and 30-60 minutes after

• monitor blood glucose

• provide feedings at room temp

Hydrolyzed formula

• For those with a partially functioning GI tract and an impaired ability to absorb

• Composed of partially digested protein peptides and amino acids

When might a pt be considered for parenteral nutrition?

• After 7-10 days of enteral feeds

• Allows the bowels a chance to heal, provides high calories, for trauma victims.

• HIGHLY concentrated

Complications of parenteral nutrition

• Infection and sepsis

• Hyper, hypo-glycemia

• Air embolism, thromboembolism

• Electrolyte imbalances

1 cup =

240 mL

Where do you stick a glucometer?

On the outer aspect of 3rd and 4th fingers

• avoid pads and tips

• For babies, the outer heel

When is a glucometer the least accurate

During episodes of hypoglycemia

Treatment of hypoglycemia

• D₅₀W via IV push followed by D₅W

• Glucagon IM, SubQ, IV, followed by oral or IV carbohyrdrate

How often should you offer a bath/shower in acute care?

Every other day

How often should you offer a bath/shower in long-term care?

2x a week

When should showers be avoided?

• Pt is immunocompromised / critically ill

• Pt is frail

• Pt has skin loss / contraindicated surgery

• Mechanically ventilated pts

When should bubble baths be avoided

In female children for risk of UTI.

Self-help (assist) Bath

Nurse only assists with places the pt cannot reach

Partial bath

Areas that cause odor or discomfort are cleansed, usually assisted

• axillae, perineum

Often given when pt cannot tolerate a complete bath

What water should be used for therapeutic baths?

Distilled or sterile

How do you care for diabetic nails?

Use a nail file only, rounding the corners.

Podiatrists must cut their toe-nails.

Short bones

Wrist and ankle

Flat bones

Ribs and skull

Factors that influence mobility

• Developmental

• Physical Health

• Mental Health

• Lifestyle

• Attitude and Values

• Fatigue and Stress

• External Factors

Insensible losses

Loss that cannot be measured

• sweat, water, vapor from lungs

Net fluid balance

Intake - Output

Positive fluid balance

Indicates fluid retention

• edema

• pulmonary congestion

• hypertension

• worsening heart or renal failure

Negative fluid balance

Indicates dehydration or fluid loss

• hypotension

• electrolyte imbalances

• decreased perfusion

• risk of acute kidney injury

Isotonic solutions

Increases vascular volume

• 0.9% Sodium Chloride

• Lactated Ringers

• D5W

• Blood products

Who needs isotonic fluids?

• pts in hypovolemia

• volume replacement (hemorrhage, severe V/D, heavy drainage from wounds)

Hypotonic solutions

Lower the osmolarity of intravascular spaces (cells swell as fluid leaves the vasculature)

• 0.33% NS, 0.45% NS, 0.225% NS

Who needs hypotonic fluids?

Clients with intracellular dehydration

• diabetic ketoacidosis, hyperosmolar hyperglycemic state

• NEVER give to pts at risk for increased intracranial pressure, or to burn/trauma clients

Hypertonic solutions

Water moves into the intravascular compartment (cells shrink)

• 3-5% NS, D10, D5

Who needs hypertonic fluids?

• Severe hyponatremia (low sodium)

• Increased cerebral pressure (removes edema)

• Intravascular dehydration

give slowly

S/S of fluid volume deficit

• decreased BP, skin turgor

• dry mucous membranes/skin

• increased HR, temp, thirst

• weight loss w V/D, weak pulses, altered LOC

Third-space fluid shift

When an overload of fluid shifts to transcellular compartments such as the

• pleural, peritoneal, pericardial spaces

• joints

S/S of fluid volume excess

• crackles in lungs, SOB

• pitting edema, rapid weight gain

• JVD, bounding pulses, high BP

Water

50-60% of healthy person’s body weight

Sodium

Regulates extracellular fluid volume

• follows water

Intake: diet

Output: GI tract, kidneys, skin

Hyponatremia S/S

• muscle cramps

• twitching

• seizures

Caused by V/D, sweating, diuretic use

Hypernatremia S/S

• restlessness, agitation

• dry, swollen tongue

• sticky mucous membranes

caused by fluid deprivation, diarrhea, insensible water loss

Chloride

Major component of interstitial and lymph fluid

• acts with sodium to maintain osmotic pressure

• direct correlation with potassium and sodium

Intake: diet

Output: kidneys

Hypochloremia S/S

• tetany

• muscle cramps

Causes: V/D, diuretic usage, trauma

Hyperchloremia S/S

• diminished cognitive ability

• dysrhythmias

caused by metabolic ketoacidosis, chloride retention

Potassium

Major component of intracellular fluid

• regulates cellular activity

• large impact on cardiac functioning

• potassium ❤ sodium

Intake: diet

Output: kidneys, stool

Hypokalemia S/S

• Leg cramping, dysrhythmias

Caused by diuretics, vomiting

Hyperkalemia S/S

• muscle weakness

• dysrhythmias

caused by renal failure, medications

Calcium

most abundant electrolyte in the body

• muscle contraction / relaxation

• teeth & bones

• inverse relationship with phosphorus

Intake: diet (needs vitamin D to absorb)

Output: GI, kidneys

Hypocalcemia S/S

• tetany

• muscle cramps

• Trousseau’s sign, Chvostek’s sign

caused by inadequate diet, impaired absorption, excessive loss

Hypercalcemia S/S

• GI upset

• bone pain

• lethargy, slurred speech. excessive urination/thirst

caused by cancer, hyperparathyroidism

Magnesium

second most abundant electrolyte

• neuromuscular function

• cardiovascular vasodilation

Intake: diet

Output: kidneys

Hypomegnesemia S/S

• hyperactive DTRs

• arrhythmias

caused by diarrhea, chronic alcohol use, nasogastric suction, trauma

Hypermegnesemia S/S

• hypoactive DTRs

• respiratory depression

caused by kidney malfunction, excessive intake

*can be used to prevent pre-term labor!

Phosphate

role in muscle and RBC function

• inverse relationship with calcium

Intake: diet

Output: kidneys, parathyroid regulation

Hypophosphatemia S/S

• muscle weakness

• confusion

• dysphagia

caused by alcohol withdrawal, diuretic use, etc

Hyperphosphatemia S/S

• long-term: precipitation of calcium phosphate in non-osseous sites like kidneys, joints, skin, arteries

caused by kidney disease, hypoparathyroidism

Normal blood plasma levels

7.35-7.45

Acidosis

• Excessive H+ ions

• Loss of bicarbonate

• pH < 7.35

caused by hypoventilation, excercise, renal failure

Alkalosis

• Loss of H+ ions

• Excess bicarbonate

• pH > 7.45

Carbonic Acid - Sodium Bicarbonate buffer system

Lungs

• regulates production of carbonic acid

Kidneys

• regulates production of bicarbonate

What do ABGs measure

pH, PaCO₂, PaO₂, HCO₃^-

Metabolic acidosis overview

• Decreased pH and HCO₃^-

• Results from a loss of bicarb OR excessive acid

Metabolic acidosis S/S

• Decreased BP (vasoodilation)

• Flushing

• Hyperkalemia

• N/V (to get rid of acid)

• Kussmaul Respirations

Causes of metabolic acidosis

• Diarrhea (lose base from butt)

• Renal failure

• Diabetic ketoacidosis

Metabolic alkalosis overview

• increased pH and HCO₃^-

• excessive acid loss

• increased base consumption

Metabolic alkalosis S/S

• N/V/D

• Tachycardia (from hypokalemia)

• Hypoventilation (compensation)

• Dizziness/irritability

Causes of metabolic alkalosis

• vomiting

• gastric suction

• hypokalemia

  • K+ wasting diuretics

• alkali ingestion (antacids)

Respiratory acidosis overview

• Low pH and high CO₂ (carbonic acid)

• Results from inadequate ventilation

Respiratory acidosis S/S

• hypoventilation

• low BP

• pale-cyanotic skin

• increased K+ (dysrhythmias)

• disorientation

Causes of respiratory acidosis

• respiratory disease

• aspiration

• overdose of sedative

Respiratory alkalosis overview

• high pH, low CO2

• results from hyperventilation

Respiratory alkalosis S/S

• hyperventilation

• tachycardia

• hypokalemia

• numbness & tingling

• increased anxiety and irritability

Causes of respiratory alkalosis

• hyperventilation

• extreme anxiety

• early sepsis

• hypoxemia

ROME mnemonic

Respiratory

Opposite

Metabolic

Equal

SBAR

Situation - what is happening right now, why are they here?

Background - clinical context (history)

Assessment - what are the problems and findings that back it up?

Recommendation - what do you suggest to fix it?

CUS method

C - i’m concerned

U - i’m uncomfortable

S - this is unSafe