NURS134 Exam #2

factors that increase BMR

growth, fever, infections, emotions, temp

factors that decrease BMR

aging, fasting, sleep

Body Mass Index (BMI)

• ratio of weight→height

• estimate of total body fat

BMI ranges for adults

underweight <18.5

normal 18.5-25.9

overweight 25.0-29.9

obesity (class I) 30.0-34.9

obesity (class II) 35.0-39.9

extreme obesity >40

BMI percentile ranges for teens and children

underweight <5th %

healthy weight 5-85th %

overweight 85-95th %

obese >95th %

percentage of energy nutrients in diet

carbohydrates: 45-65% total caloric intake

protein: 10-35% total caloric intake

fats: no more than 20-35% total caloric intake

vitamins

• organic compounds

• most are coenzymes

• water soluble

  • C and B complex

• fat soluble

  • A, D, E, K

minerals

• inorganic compounds

• major (>5g)

  • Ca, P, SO4, Na, Cl, K, Mg

• trace (<5g)

  • Fe, Zn, Mn, Se, F, I

water

• more vital than food

• 50-60% of body weight

• 2/3 ICF

• 1/3 ECF

• 2,600mL daily

factors affecting food habits

• stage of development

• state of health

• medications

• economic stability

• hc/education access

• culture and religion

• food ideology (comfort food)

MyPlate

considerations for nutritional needs

growth: infancy, adolescence, and pregnancy

activity: increases nutritional needs

illness: increase when combating illness

age: related changes in metabolism and body composition decrease nutritional need

nutritional assessment

• nutritional screening

• dietary intake

• medical/socioeconomic data

• anthropometric data: measurements

  • BMI & waist circumference

• clinical data: S/S of altered nutrition

• biochemical data: labs; protein, vit/min

nursing interventions: nutrition

• teaching nutritional information

• monitoring nutritional status

  • weight, diet, etc.

types of diets

clear liquid: minimal digestion; minimal residue

full liquid: everything clear liquid+milk, pudding, custard

pureed: liquids and foods blenderized

mechanically altered: foods chopped, ground, mashed, etc.

stimulating appetite

• pain, meds, anxiety can decrease appetite

• stimulate appetite by:

  • small portions

  • food preferences

  • food from home

  • pleasant environment

  • food appearance

  • pain control

  • accessibility

  • positioning

assisting with eating

• involve pt

• napkin (not bib)

• dentures, glasses, hearing aids

• sit at eye level

• make conversation

assisting a pt with dementia eat

• change meal environments

• limit distractions

• finger foods

• stroker underside of chin→promote swallowing

• 1-2 foods/time

assisting a pt with dysphagia eat

• 30 mins rest AC

• sitting upright

• mouth care AC

• avoid rushing

abduction/adduction

away/towards

circumduction

around

flexion, extension, hyperextension

dorsiflexion, plantar flexion

foot towards knee

pointed toes

rotation (internal/external)

inversion/eversion

factors affecting mobility

• developmental considerations

• physical/mental health

• lifestyle

• attitude/values

• fatigue/stress

• external factors

supine

flat on back

prone

face down

right lateral/ left lateral recumbent

lying on right/left side

trendelenburg

HOB is low; FOB is raised→ venous return

Fowler’s

HOB elevated

• normal: 45-60 deg

• high: 90 deg

• low: 30 deg

proper working bed height

height of caregivers elbows

sensory perception

• visual

• auditory

• tactile (touch)

• olfactory (smell)

• gustatory (taste)

• kinesthetic: awareness of positioning and body parts

• visceral: pertains to inner organs

• proprioception: position and balance→ limbs

sensory overload

too much sensory stimuli→ out of control

sensory deprivation

decrease in sensory input→ hallucinations

sensory deficits

impaired/absent senses

sensory poverty

due to technology we aren’t experiencing events as much as we used to

factors of sensory alteration

• developmental considerations

• cultures

• personality/lifestyle

• stress/ illness

• medication

conscious states of arousal

• delirium

• dementia

• confusion

• somnolence

• minimally conscious

• locked in syndrome

unconscious states

• asleep

• stupor

• coma

• vegetative state

delirium

disorientation, restlessness, confusion, hallucination

dementia

difficulty with spatial orientation, memory, language, personality changes

confusion

reduced awareness, easily distracted

somnolence

extreme drowsiness

minimally conscious

part consciousness; in and out

locked in syndrome

full consciousness; quadriplegic

asleep

respond to normal stimuli

stupor

respond to extreme/repeated stimuli

coma

cannot be aroused or respond

vegetative state

cannot be aroused, sleep-wake cycles, nonpurposeful movement

prevent alterations and improve sensory function

• stimulate mind

• promote comfort/rest

• promote stimulation

• teach pts and family

• self care

• interact therapeutically

working with visually impaired patients

• acknowledge presence

• normal tone

• explain reasons before touching

• call light

• clear path/walk beside not behind

• indicate when leaving

working with hearing impaired patients

• orient pt

• light on face

• don’t chew gum, cover mouth, turn away

working with a confused patient

• face to face

• orient/reorient

• time, place, person

• explain everything multiple times PRN

working with an unconscious patient

• hearing→ last sense lost

• speak to pt before touching

fall risk factors

• >65 years old

• previous falls

• medication

• postural/orthostatic hypotension

• slowed reaction time

• unfamiliar environment

• specific hazards

nursing interventions for fall risks

• risk assessment

• bed→ low

• wheels→ locked

• call bell

• night light

• non skid socks

fall risk assessment

• assess for history of falls or accidents

• note assistive devices

• drug/alcohol abuse

• family support systems

• orient→ hospital setting

if pt falls…

1. stay with pt and call for help

2. assess client status, injury, cognition

3. provide intervention; don’t get up until they’re ready

4. document on incident report

safety events report

• after any accident/incident

• details, circumstances, outcome

• NOT part of medical record

• should NOT be mentioned in documentation

functions of water

• transporting nutrients to cells; wastes from cells

• transporting hormones, enzymes, blood platelets, RBC, WBC

• facilitating cellular metabolism

• acting as a solvent

• maintain body temperature

• facilitating digestion and elimination

• tissue lubricant

fluid compartments

• ICF: within cells (70%)-40% of total weight

• ECF: outside cells (30%)-20% of total weight

  • includes intravascular and interstitial fluids

electrolytes

ions

• cations: positive charge

  • ex. Na+, K+, Ca+, H+, Mg+

• anions: negative charge

  • ex. Cl-, HCO3-, PO4-

homeostasis: cations=anions

Na

regulates ECF volume

K

regulator of cellular enzyme activity; transmission of electrical impulse

Ca

nerve impulse, blood clotting, muscle contraction, bones and teeth

Mg

metabolism of carbs and proteins; neuromuscular;

→ vasodilation

Cl

with sodium→ osmotic pressure

HCO3

acid-base balance

PO4

acid-base, energy storage, metabolism, muscle and RBC function

solvents

liquids that hold a substance in solution

solutes

substances dissolved in solution

osmosis

water from high concentration→ low concentration

diffusion

solutes move downhill

active transport

requires energy; through cell membrane; low→ high; ex. ATP

osmolarity

concentration of particles in a solution

hypotonic

lesser concentration of particles than plasma→ shriveled

isotonic

same concentration of particles and plasma- normal saline

hypertonic

greater concentration of particles than plasma→ swollen

fluid intake

• ingested liquids (1300mL)

• foods (1000 mL)

• metabolism (300mL)

total: 2600 mL

fluid output

• kidneys-urine (1500 mL)

• intestines-feces (200 mL)

• skin-perspiration (600 mL)

• insensible water loss-lungs (300 mL) btwn 40-800

total: 2600 mL

organs involved in fluid/electrolyte balance

• kidneys-filter

• cardiovascular system-pumps

• lungs-regulate O2 and CO2

• adrenal glands-conserve Na; excrete K

• pituitary gland-stores/releases ADH

• thyroid gland-inc. blood flow

• nervous system-inhibits and stimulates balance

• parathyroid gland-regulates Ca

• GI tract-absorbs water & nutrients

fluid volume deficit

hypovolemia: deficiency of water and electrolytes in ECF; loss of ECF>intake of fluid

dehydration: decreased volume of water and electrolyte change

third space fluid shift: distributional shift of body fluids into potential body spaces

fluid volume excess

hypervolemia: retention of water and sodium in ECF
overhydration: above normal amt of water in EC spaces

edema: excessive ECF accumulates in tissue spaces

interstitial to plasma shift: movement of fluid surrounding cells in blood

can be a result of kidney or heart failure

nursing assessment for fluid balance

• history and physical assessment

• I & Os

• daily weight

• labs

parameters for fluid assessment

• skin turgor (elasticity)

• tongue turgor

• moisture in oral cavity

• tearing/salivation

• edema

vitals shifts with fluid imbalance

pulse: increased with FVE; decreased with FVD

respirations: rapid→ acidosis; slow→ alkalosis

BP: hypotension with FVD

→orthostatic BP

nursing interventions for FVD/FVE

• encourage/restrict fluids

  • divide throughout shift

• 24 hr I & Os

• educate and monitor

factors that affect voiding

• development

• food/fluid intake

• psychological

• activity/muscle tone

• pathology and medications

developmental considerations of voiding

children: toilet training 2-3 yrs; enuresis (bed wetting)

effects of aging

• nocturia

• muscular degeneration→ inc. frequency

• physical problems→ voluntary control

  • bladder tip→ pooling (female)

  • enlarged prostate (male)

normal urine output for adults

30 mL/ hour or 240 mL/8 hours

promoting urine elimination

• maintain regular voiding habits

  • schedule, urge, privacy, position, hygiene

• promote fluid intake

• strengthen muscle tone

• assist with toileting

anuria

24 hr urine output <50 mL

failure of kidneys to produce urine

oliguria

24 hr urine output <400 mL

pyuria

pus in the urine

polyuria

(diuresis): excessive output of urine

bowel elimination considerations

• developmental considerations

• daily patterns

• food intake

• activity, muscle tone; lifestyle

• physiological

• pathologic conditions

• medications

• diagnosis; surgery

developmental consideration of bowel elimination

infants: dependent on formula or breast feeding

toddler: physiologic maturity→ toilet training

child, adolescent, adult: varies

older adult: constipation→ chronic; changes→ diarrhea

→ constipation is not a normal part of aging

food that impact digestive health

constipating: cheese, lean meat, eggs, pasta

laxative: fruits/vegs, bran, chocolate, alcohol, coffee

gas: onions, cabbage, beans, cauliflower

bowel promotion

• timing

• positioning

• privacy

• nutrition

• exercise

  • motility