Health Assessment Lab Wk2 D2

food consumption charting steps

observe tray before patient eats, count the number of food items served and assign one point per item, estimate food consumed and assign point value, divide points consumed by points served, multiply by 100 to get percentage of food consumed

items worth no points

black coffee, tea, water, jello with no fruit, tube feeding

dysphasia

difficulty speaking

dysphagia

difficulty swallowing; mist common cause of aspiration

dysarthria

slurred speech

signs of dysphagia

multiple attempts at swallowing, reports of food getting stuck, poor lip and tongue control, thin liquids most difficult to swallow

items that affect appetite

illness, need to be fed, quality of environment, odors, need for oral hygiene, need for elimination, pain, need brief change

consider when preparing patients for meals

type of assistance needed, swallowing difficulty, risk of aspiration, special needs, restrictions

observations to document after meals

amount of diet consumed (food %, ml liquid), I&O, difficulty eating, decreased appetite, nausea

NGT

nasogastric tube

GT

gastric tube

PEG

percutaneous endoscopic gastrostomy tube; can be in the stomach, duodenum, and jejunum

g-tube

tube placed in the stomach only

bolus feeding (intermittent)

all at once

continuous feeding

though machine (kangaroo pump), over time

check GT placement

confirm tube placement, check residual (then re-feed), flush the tube with water

position of patient with a tube

a least 30 degrees elevated, never flat

if residual is greater than desired

wait an hour, check residual again; if still greater than desired, notify doctor

intake

measured in ml

output

measured in ml or # of briefs

weighing

same time of day, same clothing, after urination, same scale

compression socks (antiembolism)

improve veinous return, MD order, indications for use, immobility, pitting edema, knee or thigh length

sequential compression device (SCD)

sequentially compress with air whole on bedrest, often used after surgery, knee or thigh length

applying bandage

apply form distal to proximal end, use ½ the width in each wrap, observe for circulation (not too tight)

cold/heat compress

20 min on, 40 min off, protect skin with barrier to prevent freeze/burn, assess skin integrity q10 min, call bell in reach