Fundamentals of Nursing Exam 3

how would you approach a patient to talk about nutrition and weight loss

-First ask them if it is okay if you can talk about diet and weight with them
-Then ask what are their goals and what is their diet

nutrition for infant through school age

- breastfeeding
\--- for the first 6 months
\--- some moms cannot breastfeed; don't judge
- Introducing foods that have a high incidence of causing allergic reactions such as wheat, egg white, nuts, citrus juice, and chocolate should happen later in the infant's life
- The growth rate slows during toddler years (1 to 3 years)

nutrition for adolescents

- adolescents should be consuming more calcium, proteins, and carbohydrates
- common to see anorexia or bulima

nutrition for young and middle age adults

- maintain a normal health diet
- pregnancy: consume necessary nutrients to keep the baby healthy
- lactating women need a lot of nutrients

nutrition for older adults

- Make sure older adults have good fitting dentures
- Eat less because of loss of diet
- Medications can alter diet

mini nutritional assessment

- More for outpatient and urgent care
- Assess patients for malnutrition when they have conditions that interfere with their ability to ingest, digest, or absorb adequate nutrients
- 24-hour diet recall is is important to get from your patient

dysphagia

•Difficulty swallowing
•Check gag reflex (indicates that a person can swallow)
•Call the speech therapist if the patient is not able to swallow

ml to oz

30 mL \= 1 oz

aspirations precautions

- Feed in a 45-90-degree angle
- Sit up for 30 -90 min after
- Chin should be tucked down when eating

pts with decreased immune function

require special diets that decrease exposure to microorganisms and are higher in selected nutrients

can a nurse change a patient's diet

no, they need an order from the doctor. A nurse CAN delegate feeding to the UAP

clear liquid diet

- any thin liquid with no chunks of anything
- jello, water, tea, broth, black coffee, coke, popsicles

full liquid diet

- no chunks but thicker consistency
- tomato soup, custard ice-cream milk shake, cream soup

dysphasia stages, thickened liquids, pureed

- "baby food"
- can puree veggiesm chicken, scrambled eggs, mashed potatoes/gravy

mechanical soft

- Any food not hard to chew, cut up in bite size pieces
- ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)

soft/low residue diet

•Pt has problems w their teeth and need softer food (chicken and turkey)
- Foods that have low fiber (used for pt with Chrons disease, GI problems) (white bread)
- easily digested foods such as pastas, casseroles,
moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut

advancing diets

- Nurse can advance diet; start with NPO then clear diet, etc, etc
- If pt is not tolerating there will be signs like nausea, vomiting, coughing

enteral tube feeding

- Through an NG tube or through the stomach
- Can't swallow but have a working GI tract
- Should be a 30 degree angle when feeding (look for GI upset, abdominal bleeding NVD); stop feeding, call doctor and check for residual

complications of enteral tube feeding

- Pulmonary aspiration
- Diarrhea/Constipation
- Tube occlusion or displacement
- Abdominal cramping, nausea/vomiting
- Delayed gastric emptying
- Serum electrolyte imbalance
- Fluid overload

parental tube feeding

- a form of specialized nutritional support provided intravenously.
- Patients who are unable to digest/ no functioning GI tract or absorb EN benefit from PN
- Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therapy
- usually temporary

total parenteral nutrition (TPN)

- Providing 100% of a patient's nutrition intravenously. Used when a patient is unable to eat.
- will be on accuchecks because of the dextrose they are at risk for hyperglycemia so have to get even of they are not diabetic
- watch out for hypokalemia

nutrition for patients with gastrointestinal diseases

- Avoid spicy foods and caffeine
- More small foods instead of less big foods

nutrition for patients with diabetes mellitus

- Low sugar
- Complex carbs (30 grams of carbs a meal)
- Proteins help with wound healing

nutrition for patients with cardiovascular diseases

- Heart health diet (AHA)
- Lean means
- Limit saturated fat

nutrition for cancer and cancer treatment

- Want the patient to maintain weight so eat more calorie dense foods
- Season foods how the patient likes it

nutrition for patients with HIV/AIDS

- Trying to help them gain weight
- Higher fat foods like an avocado

safety guidelines for nursing skills (nutrition)

- Anticoagulation and bleeding disorders pose a risk for epistaxis during nasal tube placement.
\--- Check for nasal polyps because they can bleed bad when ruptured
- nasal tubes are associated with sinusitis, otitis, vocal cord paralysis, and medical device-related pressure injuries to the nose.
- Use ENFit connectors for all enteral nutrition sets, syringes, and feeding tubes.
- Use aseptic technique when preparing and delivering enteral feedings.
- Position the patient upright or elevate the head of the bed unless medically contraindicated for patients receiving enteral feedings.
- Refer to manufacturer guidelines to determine hang time for enteral feedings.

function of dreams

- Used to let out psychological and emotional stress
- Outlet for anxiety

resless legs syndrom (RLS)

- occurs before sleep onset
- recurrent, rhythmical movements of the feet and legs

insomnia

- chronic difficulty in falling asleep, frequent awakenings from sleep, and/or a short sleep or nonrestorative sleep
- commonly experienced by individuals diagnosed with depression

sleep apnea

- a disorder in which an individual is unable to breathe and sleep at the same time
- There is a lack of airflow through the nose and mouth for periods from 10 seconds to 1 to 2 minutes in length.
- linked with excessive daytime sleepiness

narcolepsy

- Dysfunction of the processes that regulate sleep and wake states
- Uncontrollable feeling where sleep just overcomes them
- Encourage frequent naps (20 min)
- avoid factors that increase drowsiness such as alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms

sleep deprivation

- a decrease in the quantity or quality of sleep and/or an inconsistency in the timing of sleep
- Can cause acute confusion, hallucinations psychosis

parasomnias

- sleep problems that are more common in children than adults and occur during non-REM or REM sleep
- Somnambulism (sleep walking; safety is top concern), nocturnal enuresis (bed wetting), body rocking, and bruxism (teeth grinding)

pharmacological approaches to sleep

- Ambien resets the sleep cycle
- Be careful taking magnesium with a heart condition
- The recommended dose for melatonin is 0.3 to 3 mg taken 2 hours before bedtime
- Valerian is effective in mild insomnia and RLS

promoting safety (sleep)

- get a night light
- lower the bed to prevent falls
- declutter a room
- install a bell system in the room
- do not startle sleepwalkers

promoting activity (sleep)

plan rigorous exercise at least 2 to 3 hours before bedtime

stress reduction (sleep)

- encourage a patient who has difficulty in falling asleep to get up and pursue a relaxing activity
- when a child has nightmares, talk to the child briefly about fears to provide a cooling-down period
- keep a night light in the room for children

bedtime snacks

- A dairy product such as warm milk or cocoa that contains L- tryptophan is often helpful in promoting sleep
- Warn patients against drinking or eating foods high in sugar or with caffeine before bedtime (they are stimulants)
- Tell parents not to give infants boles in bed.

promoting bedtime routines

- No electronics for 30 min before
- Don't eat or drink 2-3 hours before
- Light exercise before bed is good
- Wear pajamas to bed
- deep breathing for 1 or 2 minutes to relieve tension

sleep hygiene

practices that a patient associates with sleep

acute/transient pain

- has limited tissue damage and emotional response
- threatens a patient's recovery by hampering his or her ability to become active and involved in self-care

chronic/persistent noncancer pain

- Lasts longer than 3-6 months; don't know the underlying cause
- Examples of chronic noncancer pain include arthritis, low back pain, headache, fibromyalgia, and peripheral neuropathy
- usually non-life threatening. In some cases an injured area healed long ago, yet the pain is ongoing and does not respond to treatment.

chronic episodic pain

- Chronic conditions with exacerbations
- Sickle cell, MS

cancer pain

- More of a multimodal approach
- Pt will most likely to get a PCA pump with pain meds
- usually caused by tumor progression and related pathological processes, invasive procedures, toxicities of chemotherapy, and infection

idiopathic pain

chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition

nonmodifiable risk factors for pain

-Disease process
-Reaction to the disease
-Age

modifiable risk factors for pain

-Medication
-Positioning

timing of the pain

When did it begin? How long has it lasted? Does it occur at the same time each day?

location of pain

- describe or point to all areas of discomfort to assess pain location
- ask about referred pain

severity/intensity of pain

- use pain scales
- use FACES scale for children

quality of pain

description of the pain, such as stabbing, crampy, dull, or sharp

aggravating and precipitating factors

what makes the pain worse and what makes the pain better

numerical pain rating scale

patients to rate pain on an 11- point line of 0 to 10, with 0 representing no pain and 10 representing the worst pain the patient can imagine (Fig. 44.5A). The scale has been found to be very effective in many populations, including youth with disabilities

verbal descriptive scale

- consists of a line with two- to six-word descriptors equally spaced along the line
- Show a patient the scale and ask him or her to choose the descriptor that best represents the severity of pain

visual analog scale

consists of a straight line without labeled subdivisions. The straight line shows a continuum of intensity and has labeled end points. A patient indicates pain by marking the appropriate point on the line.

Wong-Baker Faces Pain Rating Scale

- the "faces" scale has been shown through research to be very reliable and valid in measuring pain severity. - "faces" scale to be preferred over the NRS

diagnosis that may be related to pain

- Difficulty Coping
- Fatigue
- impaired Mobility
- impaired Sleep
- Social Isolation

non-pharmacological pain relief methods

- Distraction, prayer, mindfulness, relaxation, guided imagery, music, and biofeedback are examples of therapies frequently initiated by nurses

pharmacological pain therapies

- PCA pump: only the patient can press the pump, commonly used for hip and knee replacements
- analgesics: non-opioids, opioids, adjuvants/coanelgesics

safety guidelines for pain

- Monitor the patient for signs and symptoms of oversedation and respiratory depression.
- Monitor for potential side effects of opioid analgesics.

blanchable hyperemia

- visible skin redness that becomes pale or white when pressure is applied and reddens when pressure is relieved
- may result from normal reactive hyperemia that should disappear within several hours or from inflammatory erythema with an intact capillary bed

nonblanchable erythema

visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary bed/microcirculation. This is an indication for a stage 1 pressure injury

blanchable

occurs when the normal red tones of the light-skinned patient are absent.

tissue tolerance

The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures

risk factors for pressure injuries

- impaired sensory perception
- impaired mobility
- alteration in level of consciousness
- friction, shear, moisture

shear

almost like ripping the subcutaneous fat from the skin when the pt slides down the bed

friction

- affect the epidermis or top layer of the skin (superficial skin loss).
- The denuded skin appears red and painful and is sometimes referred to as a sheet burn
- occurs in patients who are restless, in those who have uncontrollable movements such as spastic conditions, and in those whose skin is dragged rather than lifted from the bed surface during position changes or transfer to a stretcher.

moisture

- reduces the resistance of the skin to other physical factors such as pressure, friction, or shear
- Prolonged moisture softens skin, making it more susceptible to damage

stage 1 pressure injury

- Nonblanchable erythema of intact skin
- Doesn't turn a lighter color

stage 2 pressure injury

- Partial-thickness skin loss with exposed dermis
- wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister.
- Losing the first couple layers of skin, not too deep
- Clear drainage

stage 3 pressure injury

- Full-thickness skin loss
- granulation tissue and epibole (rolled wound edges) are often present
- fat present
- Goes all through the skin
- Slough/ eschar present
- tunneling and undermining may occur

stage 4 pressure injury

- Full-thickness skin and tissue loss
- exposed or directly palpable
fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
- Slough and/or eschar may be visible
- tunneling and undermining ofter occur
- necrosis present

deep tissue pressure injury

- Persistent nonblanchable deep red, maroon, or purple discoloration
- Localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister
- closer to stage 3 or 4

unstageable pressure injury

- Full-thickness skin and tissue loss obscured by slough or eschar

granulation tissue

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing

eschar

- a thick layer of dead tissue and tissue fluid that develops over a deep burn area
- Black, brown, tan or necrotic tissue

slough

- stringy substance attached to wound bed tan colored covering over a pressure injury
- must eventually be removed by a qualified clinician or by an appropriate wound dressing before the wound is able to heal
- deems a pressure injury unstageable if fully covered

primary intention

- A clean surgical incision is an example of a wound with little tissue loss
- The skin edges are approximated, or closed, and the risk of infection is low
- Surgery closed with sutures, glue, staples, etc
- Healing occurs quickly, with minimal scar formation

secondary intention

- a wound involving loss of tissue such as a burn, stage II pressure injury, or severe laceration heals by \_________
- The wound is left open until it becomes filled by scar tissue
- takes
longer for a wound to heal by secondary intention; thus the chance of infection is greater

partial thickness wound repair

- shallow in depth, moist, and painful, and the wound base generally appears red
- involve only a partial loss of skin layers (the epidermis and superficial dermal layers)
- heals by regeneration

full thickness wound repair

- extends into the subcutaneous layer, can be painful, and the depth and tissue type varies, depending on body location.
- involve total loss of the skin layers (epidermis and dermis)
- heals by forming new tissue, a process that can take longer

serous

clear, watery plasma

serous sanguineous

Pale, pink watery; mixture of clear and red fluid

sanguineous

Bright red; indicates active bleeding.

purulent

Thick, yellow, green, tan, or brown

infection

- Surgical site infections occur within 30 days of surgery
- If a surgical site infection occurs, the patient will have a fever, tenderness, and pain at the wound site and an elevated white blood cell count
- edges of the wound will appear inflamed
- purulent drainage

skin problems

- Continually assess skin for signs of breakdown and/or ulcer development
- Check albumin level
- assess all pressure points
- reposition q2
- Diabetes and PVD impair wound healing and make it harder to treat

braden scale

- score ranges from 6 to 23
- a lower total score indicates a higher risk for pressure injury development
- less than 9 high risk, less than 16 moderate risk

maceration

jagged wound edges

Aunt Mary Is Crazy

Assess
Measure (length, width, depth)
Irrigate (with saline)
Culture

dehiscence

- the partial or total separation of wound layers
- A patient who is at risk for poor wound healing (e.g., poor nutritional status, infection, or underlying diseases such as diabetes mellitus or peripheral vascular disease) is at risk
- When there is an increase in serosanguineous drainage from a wound in the first few days after surgery, be alert for this
- Surgical incision opens up; heals secondary intention; uses wound vac
- Popping feeling (stitches and staples come apart)

evisceration

- protrusion of visceral organs through a wound opening
- place sterile gauze soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues
- pt is NPO
- DO NOT PUSH THE ORGANS BACK IN
- Caused by internal swelling

Medical adhesive-related pressure injury

- an occurrence in which erythema and/or other manifestation of cutaneous abnormality (including but not limited to vesicle, bulla, erosion, or skin tear) persists 30 minutes or more after removal of the adhesive
- Skin stripping, or tape burns, from adhesives is the most commonly reported injury

Topical Skin Care and Incontinence Management

- Use cleaners with nonionic surfactants that are gentle to the skin

positioning

- elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces
- teach the patient to shift weight every 15 minutes while siing
- Rigid and donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia

debriedment

- the removal of nonviable, necrotic tissue.
- Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing
- Take off the top level of cells; peeling of skin

protection

- All wounds have to be covered to keep out bacteria
- place a folded thin blanket or pillow over an abdominal wound so that a patient can splint the area during coughin

education (wounds)

- Wash hands before
- Anyone who has a wound is eligible for home care

nutritional status (wounds)

- Hydration, good nutrition, more protein
- Vitamin C promotes collagen synthesis, capillary wall integrity, fibroblast function, and immunological function
- patient will need 30 to 35 calories/kg of body weight if a pressure injury is present and he or she is assessed to be at risk for malnutrition.
- Increased caloric intake helps replace subcutaneous tissue