Quiz 2 14A fundamentals

Physical and mental factors nutrition affects

glucose regulation, immunity, clotting, tissue integrity, thermoregulation, development and perfusion, cognition, comfort, elimination, culture, spirituality

risk factors for malnutrition

• physical and mental disorders causing loss of appetite and difficulty chewing/swallowing

• GI defects: deficits in salvia, gastric enzymes, bile, motility

• Risk populations: children, elderly and marginalizes

• any organ failure

Signs of dehydration and malnutrition

• lethargy and confusion: electrolyte imbalances malnutrition related cognitive decline

• weakness and fatigue: muscle wasting from protein deficiency and low energy stores

• dry mucous membranes: dehydration and potentially poor oral hygiene

• oliguria and dark urine: dehydration, potential kidney dysfunction

daily weights

• best indicator of weight gain or loss

• check at the same time everyday

• can measure nutritional status

mucous membranes physical assessment

moisture, color, integrity. should have sufficient saliva and sputum without dryness or stickyness, eye moisture.

skin turgor physical assessment

assess sternum for hydration status, poor turgor can show dehydration

labs that can indicate nutrient levels

albumin, prealbumin, electrolytes, glucose, hemoglobin

normotensive

stable bp with adequate circulation

clinical signs of dehydration

• orthostatic hypotension (bp drops when standing)

• weak thready pulse, indicating low circulating volume

• normal to slightly elevated respirations bc compensatory mechanisms

• decreased skin turgor

• dry mucous membranes

• thirst- can be present or absent depending on severity

• decreased urine output

• constipation

• dark urine

early signs of dehydration

thirst, restlessness, headache, difficulty concentrating

intake of fluids

iv fluids, tpn, blood products, medications, hydration solutions, fluid used to irrigate catheter, ng tube, wound irrigation (if you didn’t suction after)

output of fluids

• vomit: color, consistence, volume

• diarrhea

• urine output: measure in mL

• tube drainage: ng tubes, chest tubes etc.

• wound drainage: JP drains, hemovacs, surgical sites

benefit of protein for healing

wound healing, immune function, tissue regeneration

benefit of vitamin C for healing

collagen formation, wound healing

benefit of iron for healing

prevents anemia, supports oxygen transport, aids energy levels post-surgery

benefit of fluids and electrolytes for healing

prevent dehydration, esp after anesthesia and blood loss

benefit of healthy fats for healing

supports cell repair and absorption of fat soluble vitamins

cognition includes

perception, attention, memory, problem-solving, adaptive behavior, metacognition, social cognition, motor coordination, executive function, communication

left brain

analysis, logic, idea, facts, math, training, language

right brain

creativity, intuition, arts, creation, feeling, imagination

metacognition

• thinking about one’s own thinking processes

• self awareness and self regulation

outcomes of cognition

• survival and adaptation

• social functions

• doing meaningful activities

4 questions for assessing orientation

1. Person - can you tell me your name?

2. Place - can you tell me where you are right now?

3. Time - What is the day/date, who is president, what was the most recent big holiday?

4. Situation - Why are you here

A&O x 4 if answered all correctly

things that can affect attention

age, fatigue, sleep, medications, stress or anxiety, neurological changes, environmental distractions, genetics, cultural norms,

sensory memory

lasts a few seconds, data from senses (sight, touch sound)

short term memory

temporary storage, holds info for 15-30 seconds

working memory

temporarily holds and actively process information in your mind (mental math, instructions, remembering a sentence)

executive function

• selective focus

• planning, organizing

• problem solving

• purposeful actions

• make decisions

look for changes in __ to recognize altered cognition

• orientation

• attention

• memory

• communication

• judgement

• problem solving

• behavior

• level of sonsciousness

cognition is affected by

• oxygenation

• perfusion

• glucose, nutrition

• sleep

• mobility

• sensory function

• medications

• stress

• safety

how to promote healthy cognition

• sleep and rest

• activity

• nutrition and hydration

• familiar routines

• glasses and hearing aids

• clocks and calenders

• social interaction

• reducing distractions

how to assess cognition

• appearance and behavior

• speech and communication

• orientation

• memory

• attention

• ability to follow directions

• judgement and problem-solving

• changes from baseline

how to support altered cognition pt

• maintain pt safety

• reorient calmly

• keep enviorment simple

• reduce noise and distractions

• use short, clear instructions

• provide clocks, calendars, updated boards

• glasses and hearing aids

• familiar routines

• monitor changes, report worsening cognition

5 clinical levels of consciousness (LOC)

• alert awake and aware, AxO x4 usually

• lethargic drowsy or sleepy, slow responses

• obtunded difficult to arouse and sleeps a lot, uninterested in surrounding, needs a lot of prompting to follow commands (repeating, touching)

• stuporous deep, sleep like state, only wake up briefly to painful or vigorous stimulation, usually groans or grimaces and slips back

• comatose unarousable and doesn’t respond, immobile

glasgow coma scale 3 factors

eye opening, verbal response, motor response (EVM)

glasgow coma scale eye opening

spontaneous = 4

to verbal stimuli = 3

to pain = 2

no response = 1

glasgow coma scale verbal response

oriented w words to person, place, time = 5

confused = 4

inappropriate words or verbal response = 3

incomprehensible speech = 2

no response = 1

glasgow coma scale motor response

obeys commands = 6

localizes pain = 5

withdraws to pain = 4

flexion to pain = 3

extension to pain = 2

no response = 1

glasgow coma scale

15- fully alert and awake

mild brain injury- 13-15

moderate brain injury- 9-12

severe brain injury 8 or less

coma or unresponsive- 3

decorticate

flexion towards core for pain

decerebrate

extension towards pain (limbs straighten)

nasal cannula flow rate, fiO2, and use

1-6 L/min, fio2 24-44%, mild hypoxia, stable pts, allows eating and talking

simple face mask flow rate, fiO2, and use

6-10L/min, 40-60%, moderate hypoxia (minimum of 6L/min)

ventilation

movement of air in and out of lungs

venturi mask flow rate, fiO2, and use

flow rate can be changed, 24-60%, COPD, precise oxygen control, prevents oxygen overdose

Non-rebreather mask flow rate, fiO2, and use

10-15L/min 60-95%, emergency, severe hypoxia. highest oxygen w/out intubation

respiration

exchange of o2 and co2 at cellular level

partial rebreather mask flow rate, fiO2, and use

6-10L/min 50-70%, moderate-severe hypoxia

high flow nasal cannula flow rate, fiO2, and use

up to 60/Lmin, up to 100%, acute respiratory failure, moderate-severe. heated humidified oxygen

bag valve mask flow rate, fiO2, and use

15L/min, 100% cardiac arrest, resuscitation

normal oxygenation requires

patent airway, effective gas exchange in alveoli, adequate hemoglobin to carry oxygen, proper circulation and perfusion, normal respiratory rate and depth

medulla & pons

regulate breathing rate and depth

hypoxemia

low levels of oxygen in the blood

early signs of hypoxemia

anxiety, restlessness, discomfort, fatigue, RETRACTIONS

late signs of hypoxemia

cyanosis, confusion, organ dysfunction

retractions

skin and tissue around chest sink inwhard when inhaling, early sign

FIO2

percentage or concentration of oxygen that a person is inhaling

room air oxygen amount

21% oxygen

early signs of dehydration

thirst, restlessness, headache, and inability to concentrate.

severe signs of dehydration

cold, clammy skin, weak thready pulse, confusion, and decreased urine output (oliguria), higher respirations

intakes

Parenteral Fluids – Includes

IV fluids, total parenteral

nutrition (TPN), blood products

• Intravenous (IV) Fluids –

Medications, hydration solutions

• Fluid Used for Irrigation –

Catheter, NG tube, wound

irrigation (only counted if not

removed via suction)

outputs

Vomit (Emesis) – Measure

and document color, consistency,

and volume

• Liquid Feces (Diarrhea) –

Must be recorded, especially in

C. diff or GI infections

• Urine Output – Measured in

mL from urinal, foley catheter,

or bedpan

• Tube Drainage – From

nasogastric (NG) tubes, chest

tubes

• Wound Drainage – From JP

drains, Hemovacs, surgical site

Fat-Soluble Vitamins

(A, D, E, & K)

Water-Soluble Vitamins

(C & B-complex)

full liquid diet

Milk, yogurt, pudding, ice cream, cream-based soups Fruit juice, coffee, tea Smooth cereals (cream of

wheat, grits) Custard, gelatin, protein shake

clear liquid diet

Water, broth, clear juices apple, cranberry, grape) Gelatin (Jell-O), popsicles,

tea, black coffee Electrolyte drinks (Pedialyte, sports drinks

sacral spinal cord (S2-S4) controls

bladder contraction, sphincter relaxation

Pontine Micturition Center (PMC)

acts as the control center in the brainstem, determining when urination should occur.

cerebral cortex

controls voluntary urination

Nocturia causes

aging, diuretics, (UTIs), heart failure, or diabetes mellitus

Polyuria amount

more than 2.5 L/day in adults

oligouria amount

less than 400ml

Diabetes Mellitus cause on urination

High blood sugar levels cause the kidneys to excrete excess glucose to increased urine output (polyuria) and higher UTI risk due to sugar in the urine

what acidify urine, making it less hospitable for

bacteria

Cranberry Juice & Vitamin C

how to record ice chips

if they fill a 200ml cup, record as 100, so half of the volume

foods to measure as fluid intake

custard, icecream, jello, they become liquid at room temp

mechanical soft diet

food is chopped, ground, or mashed but maintains some texture. for people with jaw, dental or oral problems. can swallow but cant chew

pureed diet

pts w difficulty swallowing and chewing, neurological issues, stroke, severe dysphagia

Tap Water Enema

(Hypotonic Solution)

Exerts lower osmotic pressure

than body fluids. Water moves into tissues, stimulating bowel movement. Risk: Can cause fluid overload if repeated frequently

Normal Saline Enema (Isotonic Solution)

Safest option – Matches body’s osmotic pressure. Prevents fluid shift into or out of

intestinal walls

Soap Suds Enema

irritates intestinal mucosa, stimulating peristalsis. Risk: May cause cramping or rectal irritation