Funds Exam 2

digestion

begins at mouth/ ends at small/large intestine

metabolism/ storage of nutrients

anabolic/ catabolic reactions

elimination

chyme moved through peristalsis into large intestine/ turned into feces

carbohydrates

starches/ sugars

proteins

amino acids

fats

saturated/ monounsaturated/ polyunsaturated

water

cells depend on fluid environment

vitamins

essential to metabolism

water soluble vitamins

B/ C

fat soluble vitamins

A/D/E/K

minerals

catalysts for biochemical reactions

NPO diet

nothing by mouth; feeding tube; can have ice chips; mouth care w/ suction

clear liquid diet

anything water based; might be on thickener

full liquid diet

defined by hospital

bland diet

GI issue; soft/low-fiber/mildly seasoned, soothe digestive tract/ reduce stomach acid

low residue diet

low fiber; Chron’s disease/ ulcerative colitis (prevents flare up)

controlled carbohydrate diet

DM; consistent carbs/ calculated by dietician

low fat/ cholesterol diet

heart problem (HTN, HF), prevents atherosclerosis; sodium level controlled

factors affecting nutritional status

absent gag reflex, taste/texture, finances, dentures, memory issues, medications

anorexia nervosa

restriction of calories; intense fear of gaining weight; underweight

bulimia nervosa

recurrent binge eating followed by compensatory behaviors; normal/ overweight

cultural considerations for diet

be mindful of culture/religion; promote adequate intake of food; plan diet based on what they like/ diet; diet restrictions; let provider know/ document fasting

dysphagia

difficulty swallowing; NG tube

complications of dysphagia

aspiration of pneumonia; dehydration; decreased nutriotional status; weight loss

nursing diagnoses to nutrition

risk for aspiration, overweight, impaired low nutritional intake, impaired self feeding, impaired swallowing

cachexia

severe thinness; muscle wasting

interventions for cachexia

Ensure to gain weight; NG/ gastrotomy tubes; TPN via IV

TPN

total parental nutrition; for patients w/ non-functioning GI tract; into a vein via IV

measure (nutritional status)…

Is/Os

Is/Os for tube feeding

flow rate; water flush

weigh patient…

daily; gives info about edema/ dehydration

important labs for nutritional status

albumin, glucose

albumin

determines nourishment status/ liver function

glucose

DM

observe (for nutritional status)

observe respiratory status/ comfort level

auscultate (nutritional status)…

bowel sounds

observe (patients w/ feeding tube)

skin breakdown/ level of tube insertion

nasogastric (NG) tube

nose to stomach/duodenum

decompression

after surgery; removal of fluid from surgical area

Salem-Sump tube

double lumen; large bore; decompression for esophageal varices; inserted in endoscopy unit

large bore tubes

feeding/ decompression; only time you can aspirate

Duo tube

weighted tube; feeding; measure insertion site to monitor

Levin catheter

single lumen/ small bore; medication/feeding

Dobhoff tube

small bore; weighted at end

Sengtaken-Blakemore (SB) tube

red tube used to slow/ stop bleeding from esophagus/ stomach

Minnesota tube

another variation of SB tube; decompress/ drain stomach to avoid NG tube

how to measure insertion of NG tube

measure tip of tube to tip of nose —> to ear lobe —> to xiphoid process

initial test for NG tube placement/ dislodgment

collect fluid —> test w/ pH paper

confirmatory test for NG tube placement/ dislodgment

x-ray of upper chest to abdomen

don’t (w/ NG tubes)…

push air to check for stomach gurgles for NG tube placement

conditions that increase of NG dislodgment

altered LOC, agitation, vomiting, respiratory distress

measure/ document (NG tube)…

length

pulse oximetry can show…

if a patient is aspirating —> < 90%

don’t use to flush w/

soda/ fruit juice

transfer w/ NG tube

x-ray to check placement

flush

every 4 hours w/ at least 30 mL

enteral tube feeding

named for destination of tube; ask how many lumen; look at labels for meds/feeding

indications for enteral feeding

critical illness/trauma, naurological disorders, muscular disorders, head/neck/GI cancer, GI disorders, inadequate oral intake

continuous tube feeding

24 hrs, slow rate, bag always hanging

cyclic/ intermittent feeding

over specific time period (need order for amount/time)

bolus feeding

x times a day; need order for amount/ frequency/ time

residuals

what’s left in stomach from NG tube feeding

what to do if there’s residuals…

aspirate peg tube —> measure/ document —> return back to stomach

when residuals are above the criteria level…

hold next feeding —> recheck after one hour

when residuals are low after rechecking…

administer next feeding

when residuals are high after rechecking…

skip next feeding/ notify provider

type of bore to check for residuals

large bore

process for medication administration w/ NG tube

flush w/ 30 mL —> med w/ 15 mL —> flush w/ 30 mL

administer medication…

one at a time

considerations for administering medications w/ small bore tube

make sure pills are crushed entirely

medications that can’t be crushed

capsules, ER, enteric coated

first action when unsure about prescription order

clarify w/ provider

how to prevent feeding tube from becoming clogged

flush w/ at least 30 mL water every 4 hours

what to do if patient develops nausea/vomiting w/ feeding tube

withhold feeding/ notify provider, check patency of tube, aspirate for gastric residual (only for large bore), auscultate for bowel sounds

what to do if patient develops cramping/ nausea w/ feeding tube

decrease flow rate

what to do if there’s a total clog in feeding tube

follow agency protocol

how to deal w/ hyperglycemia w/ feeding tube

measure blood glucose every 6 hours until maximum rate’s attained/ tolerated for 24 hours; should be a standing order

patient develops diarrhea > 3x in 24 hours

indicates possible intolerance; notify health care provider w/ documentation

what to do if patient aspirates on formula

stop feeding, turn patient to side, suction, provide oxygen, monitor temp/ pulse ox, auscultate breath sounds, notify provider, obtain x-ray

if patient’s tempeature is elevated then…

they probably have an infection

how to prevent skin irritation around tubing site

provide skin barrier; monitor tube’s placement; clean area

documentation must remain…

confidential

if it wasn’t docuemented…

it didn’t happen

purposes of health care record

facilitates interprofessional communication, provides a legal record of care, justifies financial billing/ reimbursement of care, supports process of need for quality/ performance improvement, serves as resource for education/ research

nurses can only access patient chart for…

patients only assigned to them

documentation is accurate

appropriate use of abbreviation

documentation is complete

all appropriate/ essential info

documentation is factual

record what you see/ hear/ feel/ smell; don’t use vague terms

documentation is organzed

EHR set up

records/ charts

confidential permanent legal document

reports

oral/ written; audiotaped exchange of info

consultations

professional caregiver providing formal advice to another caregiver

referrals

arrangement for services by another care provider

how to correct documenting mistake

modify/ correct; ID mistake w/ a single line for handwritten; don’t erase/ scratch out

narrative

traditional method, story-telling

PIE

specific nursing focus; problem, intervention, evaluation

DAR

report probrlems; data, action, response

SOAPIER

subjective, objective, assessment, plan, intervention, evaluation, revision

how to handle telephone order

repeat back to provider for accuracy

how to handle verbal order

carry it out/ have provider put order in before they leaves