NUR 116 Enteral Feeding, Pain, Sleep, Mobility, Delegation

Confirmation of ng tube placement

X-ray pH of gastric contents less than five monitor CO2 regularly check tube measurements

Gastrostomy tube

Placed in stomach that exits through abdominal wall, indications, impaired swallowing upper airway/upper G.I. obstruction, COPD, cystic fibrosis chronal renal failure, Crohn’s disease

Complications of enteral feeding

Aspiration NV distention nasal erosion pneumonia blockage diarrhea, feeding syndrome gastrostomy site infection

Acute pain

Protective body telling us something is diseased or damaged resolves when source is taken away/healed

Chronic pain

Male adaptive pain persist/recurrent greater than three months primary pain is disease itself secondary results from surgery/trauma/disease can be poorly localized

Cutaneous pain

Superficial involves skin and/or subcutaneous tissue

Somatic pain

Deep diffuse and scattered location is tendons, ligaments, bone, blood vessels, and nerves

Visceral pain

Poorly localized organs commonly produced by disease

Referred pain

Originates in one area, but felt in another

Nociceptive pain

Initiated by nociceptors activated by actual or threatened damage to non-neural tissue, normal pain process

Neuropathic pain

Lesion or disease of peripheral or central somatosensory, nervous system, burning, electric tingling or stabbing

Nociplastic pain

Altered nociceptive pain with no tissue damage chronic pain

OLDCARTS

Onset, location, duration character aggravating/relieving timing severity

Insomnia

Difficulty falling asleep intermittent sleep, difficulty maintaining sleep

Insomnia interventions

Cognitive behavioral therapy, relaxation techniques, stimulus control therapy, sleep, restriction therapy, limit caffeine and alcohol

Obstructive sleep apnea

Loud snoring, excessive daytime, sleepiness, fatigue, gasping for air during sleep

Hypersomnia

awakening disoriented, irritated, restless, slow speech, will still be sleepy despite sleeping a lot at night

hypersomnia interventions

stimulant medications, antidepressants, no alcohol, avoid work/social events at night, take naps PRN

narcolepsy

excessive daytime sleepiness and overwhelming urge to sleep no matter what is going on, cataplexy

cataplexy

involuntary loss of skeletal muscle tone for 1-2 minutes

narcolepsy interventions

CNS stimulants, tricyclics, SSRIs, modafinil

parasomnias

somnambulism (sleepwalking), REM sleep behavior disorder, sleep terrors/night terrors, nightmares, sleep enuresis, sleep paralysis, sleep-related eating disorder

parasomnia interventions

sleep hygiene, reduce stress, safety strategies

restless leg syndrome

legs feel itchy, burning, crawling, throbbing pain, try to relieve through movement

restless leg syndrome interventions

avoid caffeine and alcohol before bed, sleep hygiene, walking/stretching/massaging affected limb, relaxation techniques

cardiovascular effects of immobility

increased cardiac workload, increased risk for orthostatic hypotension, increased risk for venous thrombosis

respiratory effects of immobility

decreased depth and rate of respiration, pooling of secretions, impaired gas exchange

GI effects of immobility

disturbance in appetite, altered protein metabolism, altered digestion and utilization of nutrients, decreased peristalsis

Urinary effects of immobility

increased urinary stasis, increased risk for renal calculi and UTIs, decreased bladder muscle tone

musculoskeletal effects of immobility

decreased muscle size, tone, and strength, decreased joint mobility, and flexibility, bone demineralization, decreased endurance and stability, increased risk for contracture formation

metabolic effects of immobility

increased risk for electrolyte imbalance, altered exchange of nutrients and gases

integumentary effects of immobility

increased risk for skin breakdown and formation of pressure injuries

psychological effects of immobility

increased sense of powerlessness and risk for depression, decreased self-concept, social interaction, and sensory stimulation, altered sleep-wake pattern, risk for learned helplessness

the five rights of delegation

right task, right circumstance, right person, right direction, right supervision

right task

The task is within the scope of practice for that person

right circumstance

Match the complexity of the activity with the UAP/LPN competency with the right level of supervision available

right person

Person accepting the task is appropriate, verified based on evaluations of RN

right direction/communication

The RN individualizes communication to UAP/LPN regarding client situation and gives clear directions. The RN verifies comprehension and the UAP/LPN accepts task. UAP/LPN verbalizes acceptance of task and reports concerning findings immediately.

right supervision/evaluation

The nurse follows up, monitors performance and intervenes as necessary, obtain and provides feedback, and ensures proper documentation