hollistic 2 pre midterm 1

impacts on nutritional status

• genetic predisposition

• determinants of health (esp income and socioeconomic status)

nutritional status

balance btwn intake and requirements

optimal nutritional status

nutrients consumed that support daily requirements- persons with optimal nutritional status are generally more active, healthier and live longer

undernutrition

reserves are depleted or inadequate intake

overnutrition

consuming excess nutrients (calories, sodium, fat) above requirements

• bmi is used

BMI

BMI = kg/m²

• used to determine health risks associated with under and over weight

• BMI not used for muscle builders, long distance athletes, pregnant women, young children, or elderly

  • bc bmi doesn’t consider if weight is fat or muscle

  • can be used with waist circumfrence for a better look on health of the person

health risks with body weight

waist circumfrence

indicator of health risks associated with excess abdominal fat

development consideration for nutrition: adolescents

• rapid physical growth- increased protein and energy

• bone, muscle growth (menarche in females)- calcium and iron

• boys- grow taller and body fat replaced with muscle

• girls- increase in fat (25%)

• societal importance on physical appearance can lead to pressure to diet

• eating disorders

development consideration for nutrition: adults

• growth stabilises

• lifestyle and diet contribute to illness

• nutrition counselling is important in overweight and obesity

development consideration for nutrition: pregnancy and lactation

• requires sufficient calories, protein, vitamins and minerals to support the synthesis of maternal and fetal tissues

• recommended weight gain is 11.5-16kg

• nutritional risks

  • adolescents: anemia, hypertension, pre eclampsia, renal, depressive, higher infant mortality, preterm, lower birth weight

  • pregnancy close together (<18 months)

  • use of tobacco, alcohol, drugs

  • multiple births (twins or triplets)

  • restrictive diets cause inadequate weight gain

  • manage weight by eating regular meals and snacks

  • folic acid supplements taken to prevent neural tube defects

development consideration for nutrition: older adults

• prone to undernutrition or overnutrition (poor physical and mental health, poverty, polypharmacy)

• after age 50 energy requirements decrease by 5% per decade

• decreased metabolic rate and inactivity overnutrition

• lowest mortality risk for those older than 70 yrs with BMI 25-32

• risk factors- affect nutritional status

  • poor dentition, decreased visual acuity, decreased saliva production, slowed gi mobility, decreased gi absorption, polypharmacy challenges, diminished olfactory and taste sensitivity

  • access- meal prep, access to grocery store, limited income, social isolation

  • over 50 requires daily vit d supplement (400 IU) bc of decreased vit d synthesis

cultural diversity in dietary practices

• suggest traditional and store bought foods that fit within pt’s cultural practices

• new immigrants may have challenges to new or unfamiliar foods (storage, preparation, access to familiar foods)

• cultural factors

  • definition of food, frequency/# of meals, eating away from home, ceremonial meals, food prep methods, amt and types of food

• ask the pt and avoid cultural stereotyping

risk for malnutrition

screening: identify individuals at risk- unintentional weight loss, inadequate food intake or recent illness

ways to assess nutritional intake

• 24 hr recall (better for diff populations)

• food frequency (times eaten certain foods per day, week or month)

• food diaries (record everything eaten during time periods, to identify patterns and such (ex- working vs non working))

• direct observations (detection of problems not identified, watch feeding technique and interaction with care giver, most accurate assessment)

subjective data or nutrition

objective data on nutrition

lab values and nutritional status

do not need to memorise

keys to healthy diet

• variety of foods

• recomended amts

• limit intake of saturated fats, trans fats, added sugars, starch, cholesterol, salt and alcohol

• match energy intake with energy expended

• engage in moderate physical activity

• follow food safety guidelines for handling preparing and storing foods

• For questions consult with registered dietitian

nasal and oral tubes

endotracheal tube

• short term <14 days

• can suction bc pt can’t cough

• ensure balloon is filled so air doesn’t leave the mouth

tracheostomy needed for:

• prolonged mechanical ventilation

• upper airway obstruction (tumours, difficulty with airway clearance after spinal cord injuries or neuromuscular disease)

tracheostomy

• hole cut into trachea to bypass upper airway

• can be surgically closed if not needed anymore

pros of tracheostomy compared to ET tube

• decreased risk of tissue injury

• access for oral hygiene

• can be long term or permanent

• easily replaced if damaged or dislodged

• family/pt can care for tracheostomy tube

• may be able to cough secretions out of trach tube

parts of tracheostomy tube

some have cuff and some don’t, uncuffed trach patients will be able to speak and cough on their own

tracheostomy assessment

• soiled or loose ties or dressing

• non stable tube

• excessive secretions, skin assessment

• assess for signs and symptoms assciated with hypoxia and hypercapnia

• objective: vital signs- o2 sats, resp rate and effort, lung sounds and pt ability to cough

tracheostomy safety

at bedside

• suction

• tracheostomy obturator (for when trach has been pulled out)

• tracheostomy tube or inner cannula (usually just inner cannula)

*in emergency nurse can reestablish airway, put obturator inside spare trach to put spare trach in and then take obturator out, and call for help and pt will probably go to operating room

tracheostomy suctioning

• follow facility policy (check if clean or sterile)

• donne PPE as needed

• connect catheter to suction per policy (less than 150mmhg in adults)

• lubricate catheter by suctioning small amt of normal saline or water

• provide supplemental oxygen before and after each suctioning

• without applying suction, gently insert catheter using dominant thumb and forefinger into artificial airway, go until resistance is met or patient coughs, then pull back 1cm

• intermittent suction for less than 10 seconds, place and release non dominant thumb over vent

• slowly withdraw catheter while rotating it back and forth btwn dominant thumb and forefinger

• encourage pt to cough, watch pt for respiratory distress

• wait 1 full minute btwn attempts, do 3 attempts, make sure to oxygenate patient, if more than 3 attempts are needed, call RT (respiratory therapist)

• assess pt’s resp status before, during and after care (measure o2 sats always)

respiratory-inhalation device

aerosol inhalers- metered dose inhalers (MDI) and soft mist inhalers (SMI)

• MDI asthma medication suspended in a propellant

• measured dose of med is released when pressed

• spacer increases amt of med goes into airway rather than mouth and throat

• med relaxes constricted muscles within minutes

• SMI provide a measured dose suspended in water based mist

dry powder inhalers DPI

• dry powder med given directly into lungs as they breath

• contain albuterol which bind to beta-adrenergic receptors on smooth muscle cell surface lining airways and muscles relax causing airways become less constricted

• 2 types

  • turbuhalers: turn the dial on bottom on the unit until it clicks, user presses button to release then inhales

  • diskus inhalers: disc shaped inhalers contain powdered med, doses taken by opening device, sliding the loading lever and inhaling dose through mouthpiece

• easier to breath in medication

• spacers cant be used for dry powder

how do inhalers work

• non invasive

• absence of first pass med effect

• pulmonary route delivers high concentration of med

when to use which inhaler

using MDI with spacer

• spacer requires a more low inspiratory effort and doesn’t need to be synced to breathing, better for children and older adults

using a MDI no spacer

dry powder inhaler

subjective female health exam

past medical: prev issues, surgeries (breast or pelvic), pelvic pain, cancer

family history: breast and ovarian cancer

meds: oral contraceptives (gives higher risk of blood clots, higher risk of breast cancer), hormone replacement therapy (risk of stroke, cancer, blood clots)

female health topics: breasts, vaginal discharge, sexual practices, menstrual cycle, obstetrical history, menopause or urinary symptoms

breast specific subjective

• breast pain (mastalgia): location, timing (menses), provocative (excersise, intercourse, bra)

• swelling (menses, pregnancy, breast feeding)

• trauma

• lump (location, when noticed, related to menses, change to overlying skin)

• nipple discharge: how long, colour, consistency, odour

  • galactorrhea milky (white discharge from breast)

• self care: screening, self exam (know your breasts)

subjective vaginal discharge

• amt

• how long

• colour and character (white, yellow, green, grey, cottage cheese like)

• odour

• symptoms: itching, rash, pain during intercourse (dyspareunia)

• self care: douche- cleaning inside of vagina (alters flora, advise against), talcum powder (causes ovarian cancer), panty hose/nylon underwear (local irritation), last cervical screening test and results

subjective female sexual practices

• intercourse in last 6 months

• # of partners

• any contraceptives for intercourse or oral

• history of STI

subjective, menstrual specific

• last menstrual period (LMP)

• age at first period (menarche), around 12-13, differs based on endocrine or weight

  • amenorrhea: absence

• how often/how long (18-45 day cycles, around 3-7 days)

• usual flow: light, medium, heavy, pads/tampons used day/hour

  • menorrhagia: heave menses

• clotting: heavy flow

• spotting between menses (dysmenorrhea)

• pain/cramps before, does it interfere with activities

• associated symptoms: bloating, breast tenderness, moodiness

subjective obstetrical

G- gravida (number of pregnancies)

T- term (deliveries at term)

P- preterm (delivered early)

A- abortions (medically induced or spontaneous abortions/miscarriage)

L- living children

*any complication during pregnancy or delivery

subjective menopause/urinary

Menopause

• change in periods

• associated symptoms: hot flashes, sleep disruptions, mood changes, decreased sexual function

• treatment for symptoms

• hormone replacement

Urinary

• after menopause more risk of utis bc decreased estrogen

• frequency, burning, nocturia, hematuria, cloudy, foul smelling, incontinence (stress)

objective breast exam

• normal: slight asymmetry, left slightly larger

• upper outer quadrant- most breast lumps and tumors

• nipples usually protrude, can be flat or inverted

• changes during menses, sometimes tender

• discharge: try to collect discharge

• supernumerary nipple normal

• view in various positions: hands above head, on hips, palms together, lean forward (use pillow for those with large breasts)- do breast exams in all different positions, make sure to check all the way up to armpit

• signs to watch: lump, skin dimpling, changes in colour or texture, change in how nipple looks, clear or bloody fluid that leaks

objective female armpit and lymph nodes

• examine axillae for rash or infection

• palpate axilla for swollen lymph nodes

• palpate breast- supine with arm over head, pad under side- fllattens breast and displaces

• large breast can use bimanual

• if discharge reported: press nipple (vertical strip pattern)

objective physical exam prep female

• lithotomy position and draping

• measures to enhance comfort during exam

• mirror pelvic examination

• cervix

  • nullipara (no babies): smaller

  • primipara/multipara (one or more babies): larger

development of breasts

• full development average of 3 yrs (1.5-6 yrs)

• breasts of non pregnant women change with hormones during menses

Tanner stages of sexual maturity ratings in girls

stage 1-stage 5

development of breasts during pregnancy

• changes start during second month

• expansion of ductal system and fatty tissue

• development of true secretory alveoli

• breasts enlarge and become more nodular

• nipples: larger, darker, venous pattern prominent

• fourth month: colostrum produced (protein, no lactose no fat), given before breast milk produced

• milk production (lactation): 1 to 3 days post partum (more emulsified fats and calcium)

development of pregnancy

• missed period

• cervix softens (goodell’s sign): 4-6 weeks

• vaginal mucosa and cervixs looks cyanotic (chadwich signs): 6-8 weeks

• isthmus softens (lower segment) (Hegar’s sign): 6-8 weeks

• uterus growth - bladder, urinary frequency

  • 10-12 weeks- uterus globular

  • 20-24 weeks- uterus oval shape, almost to liver

• mucous plug cervical canal: protects fetus from infection, as does change in discharge PH, during pregnancy risk for yeast infections

fetal growth

development of female aging

• menopause: cessation of menses, around 48-51 years

  • preceding 1-2 years- decline in ovarian function, irregular menses, ovarias stop producing progesterone and estrogen reproductive tract estrogen dependant

• after menopause- ovarian secretion of estrogen and progesterone decreases middle age- 80-90s

• decrease breast size and elasticity (drooping or sagging)

• around nipple: lactiferous ducts are more palpable and feel firm and stringy because of fobrosis and calcification

• axillary hair decreases

female genital cutting

• removal of parts/all of external female genitalia

• prepubertal girls

• most common in africa, asia, middle east (200 million girls and women)

• harmful and violation of human rights

• health implications: pain, hemorrhage, urinary retention, infection, sepsis, death, urinary and genitcal tract dysfunction, painful menstruation, sexual birth control difficulties, infertility, difficulties during pregnancy/childbirth and psychological difficulties

• fgc- illegal in canada and most wester countries

HPV vaccine

• human papillomavirus (genital warts)

• most prevalent STI in Canada

• vaccine-gardasil or vervarix hpv vaccine

  • grade 7 school based program

  • approved for women up to 45 yrs (user-pay)

• HPV can lead to cancers: cervix, vulva, vagina, for male: penile, for both: anal and oropharyngeal

cervical cancer screening

• anyone with a cervix

• cervical screening every 5 years starting at 25 years or later depending on sexual activity

• stop at age 70 or if 3 or more normal tests in last 10 years

• low risk: feel healthy/no symptoms, no longer sexually active, had 1 sexual partner, same sex relationship, menopause, no family history of cervical cancer, recieved HPV vaccine

cervical cancer risk

• almost all cases are from HPV

• risk reduction

  • reduce exposure, multiple sexual partners,

    • use condoms/diaphragms

  • smoking cessation

  • immunisation

  • regular screenings

breast cancer screening

• 40-74 every 2 years- mammography

• 30-69 for high risk- annual mamography & breast magnetic resonance imaging or utz (if cant have MRI)

  • gene mutation: BRCA1, BRCA2, TP53, PTEN, CDH1

  • first degree relative with gene mutation

  • personal or family history of breast/ovarian cancer

  • radiation therapy chest- before age 30 and atleast 8 years ago

• modifiable risk cancer: nulliparity or first child after age 30 yrs

• hormonal contraceptive use

• HRT

• alcohol intake of over 1 drink faily

• obesity

• high socioeconomic status

PCP exam- canadian cancer society: know your breasts

abnormal breast findings

• retraction- dimple

• lymphatic obstruction- edema, orange peel look

• fixation- asymmetry, distortion, decreased mobility

• nipple deviation- fibrosis in mammary duct, pulls nipple toward it

documenting lump on breast

differentiating breast lumps

vaginal inflammation/infection (non sti)

female trichomoniasis

chlamydia female

gonorrhea female

herpes simplex virus female

pediculosis pubis female

whats a catheter

• into urinary bladder through urethra

• types: indwelling (foley) & intermittent (in and out)

• indications: patient is retaining urine for some reasong (ex- pregnancy with epidural, can’t feel down there, or surgery for 10+ hrs, sedation causes unable to urinate, need urine sample from someone who is incontinent and unable to follow directions)

• foley catheter requires balloon to be inflated to hold in place, intermittent doesn’t need balloon

short term indications for foley

• less than 14 days

  • surgical prodcedures

  • monitoring of urine output in critical patients

  • prolonged immobilisation

  • urinary retention/bladder outlet obstruction (prostate)

  • instillation medications/irrigation

  • end of life care- comfort

long term indications for foley

• over 14 days

  • bladder outlet obstruction pending surgery

  • chronic retention (neurological disease)

  • stage 3 or 4 pressure injury or perineal skin breakdown incontinent patients

  • urinary incontinence if alternate approaches (stress incontinence)

risk of catheters

• high risk of UTIs

• utis are among most common healthcare associated infections in canada

• attributed to indwelling catheters bc bacteria ascending catheter tubing

• remember: avoid unnecessary catheterisation, timely removal, appropriate peri care and draining of catheter

types of catheters

coude tip- amab pt with enlarged prostate, curve helps to get around prostate

foley- double lumen with balloon

straight catheter- for in and out

3 way catheter- for pts who have had surgery to shave off parts of the prostate, one port to drain urine, one to drain blood and prevent blood clots, one to irrigate the bladder with normal saline and break up blood clots (CBI- continuous blood irrigation)

catheterisation measurments

• unit is the French (my foley is size 12 french)

• smaller # is smaller catheter

• Fr 8-10 for children

• Fr 10-12 for adult female

• Fr for adult male

• hematuria with clots will need Fr 20-24 with 3 way to irrigate with normal saline

catheterisation

• requires physican orders/medical directive/hospital policy

• check allergies (latex, tape, lubricant, betadine)

• check last voiding/catheterisation (may have q4h catheter) nurses note intake/output

• assess for distended bladder (need for catheter) (palpable/dull above symphysis) (use bladder scanner and check if above 500ccs)

• assess level of awareness and developmental stage

• mobility and physical limitations of client (affect position)

• clients age and gender determines size of catheter

prior to catheterisation procedure

• assess for pathological condition that may impair passage of catheter (ex enlarged prostate)

• explain procedure

• assess client’s knowledge of purpose for catheterisation

• gather equipment

• get additional personnel if required

• provide privacy

supplies for catheterisation

positioning for catheterisations

female: dorsal recumbent position (supine with knees flexed), ask pt to relax things, hips can be rotated externally, or side lying (sims) with upper leg flexed at hip if unable to assume other position, cover rectal area with drape to reduce chance of cross contamination

male: supine position with thighs slightly abducted

set up for catheterisation

• open collection bag placed over edge of bottom bed frame, bring drainage tube up btwn side rails and mattress

• raise bed to appropriate height

• light

• open kit

• organise sterile supplies

• add catheter to tray/sterile field

• lubricate catheter, anasthetic lubricant may be used with order

draping patient during catheterisation

female: apply fenestrated drape over perineum, exposing labia

male: apply fenestrated drape over thighs and drape it over penis

peri care pre catheterisation female

• retract labia to fully expose urethral meatus, non dominant hand spreads labia while dominant hand cleans and insert catheter

• clean perineal area from front to bath (clitoris toward anus)

• first swab far away from you, last swab is down the middle

• include both labial folds and directly over centre of urethral meatus as shown

peri care pre catheterisation male

not circumcised: retract foreskin with non dominant hand, maintain position throughout procedure, if foreskin doesn’t remain retracted during cleaning, procedure must be repeated

• cleanse in a circular motion from urethral meatus down to base of glans, repeat this 3 times

catheter insertion- female

• pick up catheter with dominant hand

• ask pt to bear down gently as if voiding

• slowly insert catheter through urethral meatus as shown

• advance catheter total of 5-7.5 cm or until urine flows out of catheter’s end

• when urine appears, advance catheter another 2.5-5cm

• do not force against resistance

• release labia, hold catheter with non dominant hand and inflate balloon (for indwelling) as shown

• gently tug to ensure proper location

catheter insertion male

• pick up catheter with dominant hand

• lift penis to position perpendicular to pt body and apply light traction

• ask pt to bear down as if voiding then insert catheter slowly through urethral meatus

• advance 17-22.5cm or until urine flows

• for indwelling, after urine appears advance catheter 2.5-5cm

• reduce or reposition foreskin

• do not force catheter against resistance

• gently tug to check position

post catheterisation

• collect urine as needed

• attach end of indwelling catheter to collecting tube of drainage system

• drainage bag must be below level of bladder (attach to bed frame, not side rails)

securing catheter

female: secure catheter tubing to inner thigh or abdomen using tape or product such as stat lock

male: secure catheter tubing to top of thigh or lower abdomen, with penis directed toward chest

***for both, allow for slack so movement doesn’t create tension

urine collection bag

documentation for catheterisation

• reason for catheterisation

• record type and size of catheter

• amt of fluid (mL) used to inflate the balloon (amt to use is written on catheter)

• characteristics of urine

• amt of urine

• specimen collection is appropriate

• pt response to procedure

• teaching (using leg bag, emptying drainage bag, etc)

• record intake and ouput

• if catheter is in bladder and no urine produced within 1 hour, report to MRP

caring indwelling catheter

• assess for inflammation, swelling and discharge

• not amt, color, odour and consistency of discharge

• ask pt any burning or discomfort

• clean perineal tissue and along 10 cm of cather as shown

• in uncircumsised males, reposition foreskin

removing indwelling catheter

• deflate balloon with syringe

• gently remove catheter

• provide peri care

• record and report discomfort, burning sensation, when voiding, bleeding and changes in vital signs (temp)

• check if pt is actually able to void after catheter removed (check that pt has voided 8 hrs after catheter is removed)