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320 Cards in this Set
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Nutrition
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o The study of nutrients, how they are absorbed & utilized by the human body.
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o Optimal nutrition is essential to maintain
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health & prevent illness.
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Nutrients
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• Chemical substances supplied by food
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Nutrients • Utilized by the body for:
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o Growth & development
o Activity o Maintenance for health o Recovery from illness or injury |
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Essential Nutrients
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not manufactured by the body in adequate amounts for optimal health; must be present in the diet
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2 types of Essential Nutrients
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o Macronutrients
o Micronutrients |
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o Macronutrients
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carbohydrates, fats, proteins
Build tissue and supply energy |
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o Micronutrients
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vitamins, minerals
Regulate and control bodily processes |
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• Nonessential
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either not required for body functioning or synthesized by the body in adequate amounts
o Not needed to be taken in the body through diet Eg: cholesterol – enough made by the liver without diet suppliment o Do not directly supply energy |
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6 Classes of Nutrients
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o Carbohydrates
o Protein o Lipids o Vitamins o Minerals o Water |
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Nutrients that Supply Energy & Build Tissue
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o Carbohydrates
o Protein o Lipids |
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Nutrients that Regulate & Control Body Processes
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o Vitamins
o Minerals o Water |
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Calories are
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Measurement of energy
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Measuremenst of energy
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• Carbohydrates = 4 cal/gm
• Proteins = 4 cal/gm • Fats = 9 cal/gm • Alcohol = 7 cal/gm |
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Metabolism
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• The sum of all physical & chemical changes that occur in the body
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Basal Metabolic Rate BMR
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• Amount of energy required to maintain involuntary bodily functions at rest.
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BMR Accounts for
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half the total energy requirements
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• Men have a higher
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BMR than women
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Carbohydrates
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• Main source of energy
• Break down rapidly • Sugars and starches • Organic compounds o Composed of carbon, hydrogen and o2 • Most abundant and least expensive source of calories • Originate from plants o Lactose is the only animal source |
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• Functions of Carbohydrates
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o Provide fuel & energy
o Spare body protein When the body does not get enough energy from carbs it breaks down proteins, therefore carbs keep this from happening o Prevent ketosis When there is inefficient fat metabolism o Enhance learning/memory |
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• RDA of carbohydrates
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50-100g/day to prevent ketosis
o 45-65% of total calories |
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• Simple vs Complex carbohydrates
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o Simple - monosaccharides & disaccharides
basic sugar o Complex - polysaccharides Starches, glycogen and fiber |
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characteristics of carbohydrates
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• Easily digested
• Converted to Glucose • Used as energy |
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Proteins
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• Vital components of every living cell•
Amino acids |
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• Amino acids
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o 9 Essential – must be ingested
o 13 Non-essential – made by the body |
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• Complete vs Incomplete protiens
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o Complete –
high quality • contain all of the amino acids needed to support tissue growth • Animal proteins o Eggs o Soy Not animal o Meats o cheese o Incomplete – low quality • deficient in 1 or more amino acids o include plant proteins grains legumes peanuts corn sunflowers sesame seeds |
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Metabolism Function
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o Tissue growth & repair
o Component of body framework & fluids Include • Bones • Tendons • BL vessels • Skin • Hair • Nails • Plasma proteins • blood o Helps regulate fluid & acid-base balance o Forms antibodies o Backup source of energy |
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RDA of protiens
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10-20% of total caloric intake
o 0.8g/kg of desire 56 gms for avg women 53 gms for avg man d body weight |
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Protien deficicency
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edema, retarded growth, mental apathy, atrophy, changes in hair & skin, poor wound healing
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Fats / Lipids
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• Insoluble in blood
• 95% triglycerides |
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Fats / Lipids Functions
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o Insulation & temperature control
o Cushion internal organs o Absorption of fat soluble vitamins o Provide energy – 9 calories/gm o Improve taste & satisfying value of food |
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Fats make up
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• 30% or less of total daily calories
NO RDA • Fats digested in the small intestine |
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Classification of Fats
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• Saturated –
• Unsaturated |
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• Saturated
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o animal fats;
solid at room temperature • bacon • red meat • egg yolks • poultry • seafood • dairy • Unsaturated – |
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• Unsaturated
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o vegetable fats;
liquid at room temperature |
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types of unsaturated fats
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o Monounsaturated – olive & canola oil
o Polyunsaturated – corn & sunflower oil |
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Trans-fatty Acids
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• Start as Unsaturated fats but are partially hydrogenated to become more solid & stable
• Increase serum cholesterol levels • Need to be counted as saturated fats o fried foods o Commercial baked goods o Margarines o Crackers |
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Omega Fatty Acids
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• Omega 3
• Omega 6 • Omega 9 |
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• Omega 3
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o Found in
• Ground flaxseed, flaxseed oil, salmon, tuna, mackerel, cod liver oil, walnuts o Benefits • Cardiovascular disease, antiinflammitory reduced risk of Alzheimer disease |
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• Omega 6
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o Vegetable oils
• corn, safflower, sunflower o Benefits • Prolong blood clotting, reducing incidence of MI or DVT |
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• Omega 9
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o Found in
• Olive oil, peanuts, almonds, avocados |
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Cholesterol
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• Fat like substance found in animal products
• Nonessential nutrient |
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Cholesterol • High serum levels associated with
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atherosclerosis
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Cholesterol Dietary Recommendations
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o Limit cholesterol intake to <300 mg / day
o Eat less total fat especially saturated & trans fats o Eat more unsaturated fat o Increase fiber intake Fiber helps to excrete cholesterol |
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Vitamins
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• Organic Compounds
• Needed for normal metabolism, growth, & maintenance • Very fragile o Destroyed be heat, light and air |
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Vitamins Water-soluble
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– B complex & C vitamins
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Vitamins Fat-soluble
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– Vitamins A, D, E, & K
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Minerals
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• Inorganic Elements
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Function of minerals
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o Provide body structure
o Regulation of body processes |
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• Macrominerals
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o bulk minerals
Calcium Phosphorus Sulfer Choloride Mg o >100mg/ day |
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• Microminerals
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o trace elements
Iron Iodine Zinc Chromium Copper Serlinum Floride o <100mg/day |
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Water makes up
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• 50-60% of total body weight
o 2/3 intracellular fluid o 1/3 extracellular fluid |
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• Function of water
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o Solvent
Aids in digestion, circulation, absorption and secretion o Temperature regulation of the body o Lubricant Needed for mucous secretions, movement of the joints |
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Dietary Guidelines for Americans
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• Eat a variety of nutrient dense foods
• Balance food with physical activity • Increase fruits, vegetables, & whole grains • Decrease saturated fats, trans fats, & cholesterol o <10% from saturated fats o <3% from cholesterol • Diet moderate in sugar o Too many calories o Too few nutrients o Causes tooth decay • Diet moderate in salt and sodium o <2300 mg/ day 1 tsp total o Hypertention <1500 mg/day • Alcoholic beverages in moderation o Women 1 drink/day o Men 2 drinks/day |
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Factors Influencing Nutrient Requirement
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• Developmental
o Children and teens in growth period • Sex o Gender differences o Men can consume more calories and have higher protein needs o Women have greater iron needs o Folic acid prevents spina bifita for women • State of Health o Fever > calories o Chronic diseases o Cancer pts anorexia • Alcohol Consumption o Destroys intestinal mucosa o Increases need for vit B and thiamin • Medications • Religion • Economics • Psychosocial • Cultural |
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Nutritional Assessment
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• Identification of actual/potential needs
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Nutritional Assessment• Obtained through
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o History – dietary, medical & socioeconomic
o Physical Assessment o Labs (Box 42-6) |
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Nutritional Assessment Methods
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• Dietary Intake
• Medical Data • Physical Exam • Laboratory Tests – |
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Assessment of Dietary Intake
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o 24-hour recall
o Food diaries o Food frequency |
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Assessment of Medical Data
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o Illnesses
o Drug use/abuse o Ability to chew/swallow o Appetite |
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Assessment of nutrition with physical exam
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o Anthropometric data
o Clinical data…Table 42-8 |
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o Anthropometric data
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Height & weight
BMI Waist measurement Triceps skinfold Midarm circumference |
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Assessment of nutrition with Laboratory Tests
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o protein levels
o CBC o 24-hour urine o Creatinine |
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Obesity
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• Body weight > 20% above ideal weight or BMI =/> 30
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Obesity Causes include
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o excess caloric intake
o decrease physical expenditure o genetic factors o physiologic factors o psychological factors |
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Malnutrition
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Poor nutrition related to malabsorption, poor diet, or overeating
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Anorexia
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Lack of appetite
• BMI <18.5 considered underweight |
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Anorexia Causes include:
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o diseases
o psychological o fear, anxiety, depression o medications o financial |
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Nutritional Support
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• Appetite Stimulation
• Assisting with eating |
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• Appetite Stimulation
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o small, frequent meals
o determine and provide food preferences o pleasant eating environment o control pain, anxiety, or nausea o encourage or provide oral hygiene |
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• Assisting with eating
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o Involve person
o Pleasant conversation o Use napkins, not bibs |
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Enteral Nutrition
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• The passage of a tube into the gastrointestinal tract to administer a formula containing adequate nutrients.
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Short-term Nutritional Support
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• Considered < 6 weeks
• Advantages o Provides nutrional support • Disadvantages o High risk of aspiration • Nasogastric (NG) or Orogastric tube (OG) o OG is not common o Risk of aspiration • Nasointestinal (NI) o Minimal risk of aspiration Because its going way past the stomach o disadvantage Dumping syndrome • Overdistention of SI o Caused by pyloric bypass no slowing transit of food • Symptoms o Gas o Bloating o Cramping o Hyperparastalsis o Weak o <BP o > HR o Can cause hypoglycemia |
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Long-term Nutritional Support
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• Gastrostomy
• Jejunostomy • Percutaneous Endoscopic Gastrostomy (PEG) tube |
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Patient Safety During Enteral Feedings
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• Check tube placement!
• Avoid blue dye • Check residual • Assess for bowel sounds & gastric distention • HOB elevated 30-degrees • Prevent feeding contamination • Medication administration |
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Preventing Complications of Enteral Feedings
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• Aspiration
• Clogged Tube • Diarrhea • Unplanned Extubation • Nasal Erosion • Stoma Infection • Refeeding Syndrome • Providing Comfort Measures • Frequent oral hygiene • Nares clean • Control local tube irritation • Encourage patient verbalization of concerns |
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Parenteral Nutrition
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• Administration of nutritional support via the intravenous route
o May be needed from • Purpose o Calories o Proteins o Carbs o Fats o Nutrition balance o Nitrogen balance o Replaces fluids o Vitamins o Electrolytes o Trace elements o Gives bowels chance to heal |
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Total Parenteral Nutrition (TPN)
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• Highly concentrated hypertonic solution……..
o 25% glucose solution o needs central line o for long term use • AKA…Hyperalimentation |
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Peripheral Parenteral Nutrition (PPN)
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• Isotonic….
o peripheral line cannot tolerate highly concentrated solution • dextrose solution is 10%< |
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Nursing Considerations with TPN
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• Identify the line & use a pump
• Administer 10% dextrose solution if TPN interrupted • Change bags every 24 hours • Vital signs q4 hours • Blood glucose q6 hours • Aseptic technique when changing solutions, dressings, or lines • Connections taped securely • Daily weights….weight gain should not exceed 3 lbs/week • Monitor serum protein and electrolytes |
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Vitamin A• 2 Forms:
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o Preformed - Retinol
o Provitamin - Carotene |
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o Preformed Vitamin A
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Already in complete state in ingested food
70-90% is absorbed if consumed with 10g fat • Reason for not having a “no fat diet” |
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o Provitamin Vitamin A
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Not in complete state
• Converts to retinol in the intestine • Precursor to complete vitamin Body can stores a year supply of Vitamin A • 90% in the liver • Excess carotene stored in adipose tissue Less issues because of where it is stored |
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• Excretion of Vit A
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o 40% in feces
o 60% in urine |
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Vitamin A stored in
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o 90% in the liver
o Excess carotene stored in adipose tissue |
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Vitamin A Functions. . .
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o Vision
Dim light and night vision o Health of Epithelial Tissue Integrity of mucosa and surface of tissues • Skin, surface of eye, lining of GI tract o Believed that it plays a role in the prevention and treatment of cx o Growth & Development of Bones & Teeth Children with deficiency have been noted to have a slowing of growth o Energy Regulation o Heat production & energy balance |
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Vitamin A Deficiency
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• Night Blindness
• Bone Growth Ceases o Can lead to brain & spinal injuries • Epithelial Tissue Disorders • Xerophthalmia o Thickening & drying of outer surface of eye; can cause blindness • Increased susceptibility to infection |
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• Xerophthalmia
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o Thickening & drying of outer surface of eye; can cause blindness
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Vitamin A Dietary Sources • Retinol
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(animal sources)
o Liver o Egg yolks o Fortified Milk Products |
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Vitamin A Dietary Sources• Carotene
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(plant sources) think yellow
o Carrots o Sweet Potatoes o Squash o Spinach o Broccoli |
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Vitamin A Toxicity. . .
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• Carotenemia
• Hypervitaminosis A |
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• Carotenemia
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excess carotene
Causes • Yellowing of skin; • starts with hands & soles of feet • Sclera is not affected If excess carotene is stopped s/s reverse w/in a few weeks |
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• Hypervitaminosis A
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excess retinol
S/S that are similar to increased intracranial pressure – • headache, blurred vision Bone & joint pain Dry skin Can result in liver failure • Most significant result |
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Vitamin D Functions. . .
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o Main function is to promotion of Bone Mineralization
Happens in 3 ways • Increases intestinal absorption of calcium & phosphorous • Stimulates bone cells to build & maintain bone tissue • Stimulates kidneys to return calcium to the blood o Also have receptors around Heart BL vessels Tissues Brain Immune system o Decreased urinary excretion of calcium One of the key factors in preventing osteoporosis |
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Vitamin D Deficiency . .
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• o Rickets
In children Bones fail to calcify & bend (bow) in an effort to support the body’s weight Eg: bow legged o Osteomalacia Soft fragile bones More common in adults “rickets” for adults Decrease in the mineralization Most common in women • Decreased calcium intake • Sun exposure o Osteoporosis Reduced bone density Normal mineralization of the bones Caused by vit d inadequacy |
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Vitamin D Sources . . .
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• Sunlight
o 15 minutes exposure of face, hands, arms twice weekly without sunscreen of SPF 8 or higher • Dietary Sources o Fortified milk, dairy products o Salmon, tuna, sardines • Supplements o Cod Liver Oil o Vitamin supplements |
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Vitamin D Toxicity . . .
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MOST TOXIC OF ALL VITAMINS
S/S of Hypervitaminosis D • Calcium deposits on kidney, heart & brain • Loss of appetite • Polyuria – frequent urination • Muscular weakness • Constipation |
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Vitamin E
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Least Known Vitamin
• ost stored in the adipose tissue • Unclear if Vitamin E is related to the prevention of cardiovascular disease & cancer |
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Vitamin E Functions
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o Antioxidant
Deactivation of free radicals Cell membrane stability • Able to fight them off more o Barrier against air pollution in the lungs o Promotes RBC stability o Role in immunity Still being researched o Helps for scar healing |
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Vitamin E Deficiency
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• Progressive Peripheral Neuropathy
o Immune System Suppression • Hemolytic Anemia o RBC hemolysis • CNS Effects o Ataxia & changes in mental status |
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Vitamin E Dietary Sources
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• Vegetable Oils
o Olive & Canola • Whole Grains & Wheat Germ • Nuts – almonds, sunflower seeds, hazelnuts • Eggs, Meats & Fish • Green Leafy Vegetables |
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Vitamin E Toxicity
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• Excessive Bleeding
• Impaired Wound Healing • Depression |
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Vitamin K. . .
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Vitamin that Acts Like a Medication
Prescribed to treat bleeding disorders • INR is too high • Prior to surgery o Most is synthesized in intestinal tract to create bacteria |
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Functions of Vitamin K
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• Regulates Blood Coagulation
o Necessary for liver to make prothrombin & other clotting factors • Bone Metabolism o Facilitates synthesis of calcium binding protein |
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Vitamin K Deficiency. . .
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• Deficiencies associated with disease processes & medication treatment
o Fat absorption disorders interfere with absorption of Vitamin K o Antibiotics kill bacteria needed to synthesize Vitamin K • Symptoms of Deficiency o Prolonged Clotting Time o Poor Bone Health |
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Vitamin K Sources. . .
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o Intestinal Synthesis
About one-half body’s need o Food Sources Green leafy vegetables • Broccoli • spinach Cabbage Liver Milk fruits • Bananas • Strawberries • cantaloupes |
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Water Soluble Vitamins
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• B Vitamins and Vitamin C
• Can be dissolved in water • Can be stored by the body in large amounts o Any excess is excreted in the urine Toxic reaction are rare because of this This also makes a need for daily requirements |
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B Complex Vitamins
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• B1 Thiamin
• B2 Riboflavin • B3 Niacin • B6 Pyridoxine • B9 Folic Acid • B12 Cyanocobalamin |
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Thiamin. . . B1
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o Functions
Coenzyme in Carb metabolism Converts glucose to energy Important for nerve conduction o Deficiency = Beriberi • Creates a lot of neurologica symptoms o Mental confusion o Fatigue Wernickes-Korsikoff syndrome • Cerebral beriberi • Affects cardiac fatigue, paralysis o Sources = Pork, beef, liver, whole or enriched grains o Cronic alcoholism affects thiamine uptake Thiamin and folate are the two that alcoholics are deficient in s • Sources = Pork, beef, liver, whole or enriched grains |
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Riboflavin . . .B2
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o Functions
Coenzyme to protein metabolism • And metabolism of other Vit o Deficiency = mouth lesions, skin changes eg: • seborrheaic dermatitis, dandruff o Sources = Beef liver, milk, legumes, whole or enriched grains o Turns urine bright yellow |
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Niacin . . . B3
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o Functions
Coenzyme in energy metabolism • Glucose metabolism Involved in the synthesis of fatty acids Cholesterol-lowering agent o Deficiency = Pellagra… (3 d’s) • dermatitis, • diarrhea, • dementia o Sources = meats, fish, poultry, liver, peanuts, coffee |
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Pyridoxine . . .B6
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o Functions
Coenzyme in the synthesis & catabolism of amino acids Metabolism of over 100 enzymes Synthesis of • Epinephrine o energy • dopamine, & serotonin o neurotransmitters Antibody production o Deficiency = Unlikely • Large amounts in a normal diet • Birth control can remove B6 s/s • Anemia, • impaired immune function, • neurological abnormalities o confusion o depression o Sources = Beef • steak liver, bananas, potatoes, whole grains • fortified ceral |
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Folic Acid. . .Folate…B9
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o Functions
Protein synthesis Formation of DNA RBC maturation o Deficiency = r/t • Anemia, fatigue, red, smooth, swollen tongue, heartburn, diarrhea Alcoholics & pregnant women are at most risk • Linked to fetal neural tube defects o Eg: spina bifida o Sources = Beef, liver, spinach, asparagus, broccoli, cantaloupe, |
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Cyanocobalamin. . .B12
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o Functions
Use of folic acid in DNA replication & RBC production Maintenance of CNS including brain & spinal cord Known as the extrinsic factor • Protected by the intrinsic factor produced in the stomach lining o Deficiency – pernicious anemia • Numbness/tingling of hands & feet, RBC changes, moodiness, confusion, depression o Sources = meats, milk, cheese, eggs o Folic acid cannot stimulate production of RBC’s with out B12 |
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Vitamin C . . .
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Ascorbic Acid
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Vitamin C Functions:
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• Aids in wound, burn & fracture healing
• Antioxidant • Synthesis of steroid hormones & neurotransmitters • Iron absorption • Folic acid conversion • Collagen formation |
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Vitamin C………….
• Deficiency |
o Sore, tender gums that bleed
o Ecchymosis o Delayed wound healing o Scurvy |
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Vitamin C • Sources
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o Citrus fruits, Orange & grapefruit juice, cantaloupe, strawberries
o Peppers, broccoli, tomatoes, potatoes |
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Vitamin C• Smoking
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Depletion of Vitamin C stores
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Vitamin C• Toxicity
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o Abdominal cramps, nausea & vomiting
o False positive urine glucose o False negative guiuac testing |
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Vitamins as Medicine
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Remember. . .nutritious foods, not supplements, are the BEST sources of vitamins !
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Minerals
Major: |
Calcium
Sodium Potassium Magnesium Chloride Sulfur |
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Calcium Functions
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Structure of bones & teeth
o Metabolic functions in nervous, muscular, and cardiovascular systems o Muscle contraction o Blood clotting |
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Calcium Sources
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Milk, milk products are best
o Sardines, clams, oysters, salmon o Spinach, broccoli |
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Calcium Deficiency
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• Osteopenia vs Osteoporosis
o causes o risk factors o treatment • Hypocalcemia • Tetany – nervousness, irritability, numbness & tingling around mouth, muscle cramps |
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Phosphorus• Component of:
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o Bones & Teeth
o DNA, RNA, o Storage forms of energy - ADP, ADT o Cell structure & most enzymes o Blood buffer system (pH 7.35-7.45) |
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Phosphorus• Deficiency
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muscle weakness, increased calcium excretion
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Phosphorus• Excess–
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– tetany, convulsions, renal insufficiency
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Phosphorus• Sources
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lean meat, fish, poultry, milk, eggs, nuts, legumes
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Sodium• Functions
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o Fluid balance
o Nerve/muscle electrochemical impulse transmission |
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Sodium• Deficiency
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irritability, muscle twitching, seizures
o related to diarrhea, vomiting, heavy sweating, kidney disease |
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Sodium• Excess
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- increased thirst, fatigue, agitation
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Sodium• Sources
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o Table salt, milk & milk products, vegetables, processed foods
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Potassium• Functions
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o Fluid balance
o Nerve impulse conduction o Muscle contraction (esp. the heart) o Electrolyte & acid-base balance (pH) o Glucose-glycogen conversion |
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Potassium• Sources
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, cantaloupe, green vegetables, legumes, potatoes with skin
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• Hypokalemia
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related to diuretics, diarrhea, vomiting
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• Hyperkalemia
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caused by supplements or renal failure
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Magnesium• Functions
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o Nerve impulse transmission
o Relaxation of skeletal muscle o Activates enzymes for CHO, protein, & glucose metabolism o Cofactor in calcium utilization |
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Magnesium• Sources
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o Green vegetables, whole grains, coffee
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Trace Minerals
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• Iron
• Iodine • Fluoride • Zinc |
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Iron• Functions
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o Hemoglobin formation
o Component of myoglobin o Component of enzymes that oxidize glucose for energy o Synthesis of myelin & neurotransmitters serotonin & dopamine |
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Iron• Deficiency
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fatigue & anemia
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Iron• Sources
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o Liver, red meats, dark green leafy vegetables
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Iron• Supplements
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side effects & risks
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Iodine• Function
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Component of thyroid hormones
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Iodine• Deficiency
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• Deficiency – thyroid dysfunction, goiter
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Iodine• Sources
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• Sources – iodized salt & saltwater seafood
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Fluoride• Function
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• Function –Strengthens teeth
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Fluoride• Deficiency
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• Deficiency – dental caries
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Fluoride• Toxicity
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• Toxicity – mottled discoloration of teeth, dental caries
o –Dangerous for children – bone & kidney dysfunction |
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Fluoride• Sources
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• Sources – fluorinated water & toothpaste, seafood
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Zinc• Functions
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o –Component of all body tissue
o –DNA/RNA synthesis o –Component of insulin o –Necessary for collagen formation needed in wound healing o –Role in immunity |
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Zinc• Deficiency
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o –Skin lesions, hypopigmentation of hair, impaired wound healing, corneal edema, patchy alopecia
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Zinc• Sources
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o Shellfish, oysters, red meat, cheese, fortified cereals
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Special Diets• Include:
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o Nutrient Adjustments
o Caloric Adjustments o Texture or Consistency Adjustments o Seasoning Restrictions |
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Special Diets• Purpose
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o Restore or maintain nutritional status
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Clear Liquid Diet
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• Any transparent liquid that can be poured at room temperature
o Provides energy & fluid with minimal digestive action o Indications o Limit undigested food in GI tract o Fluid & electrolyte replacement in acute illness o 1st step in reestablishing oral nutrition |
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Clear Liquid Diet• Foods
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o Gelatin, broth, tea, coffee
o Some juices - apple, cranberry, grape juice o Carbonated beverages – ginger ale, 7-Up o Clear nutritional supplements – high protein broth |
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Full Liquid
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• Foods & beverages that are liquid at body temperature
o Can be adequate in all nutrients o Nutritional supplements – Boost, Ensure |
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Full Liquid• Indications
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o Progression between clear liquid & soft diet
o Inability to tolerate solid foods |
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Full Liquid• Foods
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o Milk, all fruit juices, ice cream, custard
o Thinned hot cereals (cream of wheat) |
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Soft Diet• Indications
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o Swallowing or chewing difficulties
o Easily digested foods required |
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Pureed vs Mechanical Soft
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o Mechanical soft – semi-solid foods easily digested
o Pureed – food run through a blender |
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Dysphagia Diets
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• Provide graduated steps from most easily managed foods to the most difficult
o Liquids range from thick to thin o Solids range form pureed to regular o Liquids & solids may progress independently o High protein/calorie supplements |
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• Dysphagia Level I
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o Pureed to consistency of baby food
o Requires minimum chewing |
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• Dysphagia Level II
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o Mechanically altered soft, moist foods
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Thickened Liquids
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• Nectar - similar to that of V8 juice
o Does not hold its shape if poured on a plate • Honey – mounds a bit on a spoon o Still drinkable from a cup • Pudding – thick like pudding o Holds its shape o Served on a spoon |
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Aspirations Precautions
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• HOB elevated during meal & 1 hour after meal
• Head tilted forward – tuck & swallow • No straws • Need to swallow more than 1 time • Food gets stuck in mouth or esophagus • Observe for signs of aspiration o Coughing, gargling sounds |
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Renal Diet
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• Prevention of hyperkalemia, hyperphosphatemia, & fluid overload
• Restricts potassium, sodium, phosphorus & fluid intake • Raw vegetables & fruit • Dairy products • Convenience & fast foods • Look for low-sodium versions of foods • Everything that melts at room temperature counts as fluid intake |
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Low Fat Diet
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• Management of chronic pancreatitis, gall bladder disease & other diseases involving fat malabsorption
• Total dietary fat restricted to 40-50 grams daily • Prepare meats by baking, broiling, roasting, or stewing; avoid frying • Skim milk • Limit meat to 6 oz/ day • Limit added fat to 3 servings / day |
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Fluid Restrictions
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• Assist in management of fluid balance
• Excess fluid buildup causes edema, weight gain, & shortness of breath • Fluid restrictions stated in ounces or mL per day • Any food that is fluid at room temperature is counted |
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Cardiac Diet
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• Aid in lowering BP & cholesterol level; prevention of fluid retention
• Sodium intake limited to 2 g/day • Cholesterol limited to 300 mg/day • Intake of total fat & saturated fat are reduced • Mono- & polyunsaturated fats intake are increased |
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DASH Diet
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• Dietary Approaches to Stop Hypertension
• Developed by US National Institutes of Health • Goal to lower BP, reduce cholesterol, & insulin sensitivity • Based on eating plan rich in fruits, vegetables, & low-fat or nonfat dairy • Also includes grains, lean meats & fish, nuts & beans |
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Carbohydrate Controlled Diet
|
• Aimed to control blood glucose levels through consistent daily carbohydrate intake & weight management
• Meal frequency – every 4-5 hours • Limit concentrated sugars • Total amount of CHO in a feeding is more important than the source • One CHO serving = 15 grams of CHO • Meal planning approaches - My Pyramid - Exchange lists |
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Iatrogenic Malnutrition
|
• Induced malnutrition
o Excessive or deficit intake of one or more nutrients induced by the oversight or omissions of health-care workers • Prevention • Assessment • Communication • Interventions |
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Phases of the Perioperative Period
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Preoperative
Intraoperative Postoperative |
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Classification of Surgical Procedures
|
Urgency
Level of Risk Purpose |
|
URGENCY
|
Emergency
Urgent Elective Surgery |
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PURPOSE
|
Diagnostic
Ablative Palliative Re constructive Transplant Constructive |
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• ALL PATIENTS getting surgery have these things in common
|
o Progress through specific phase
o Require some form of anesthesia o Give informed consent |
|
o Preoperative
|
The decision that surgery is necessary and lasts until the pt is tx to the OR bed.
|
|
o Postoperative
|
From the recovery area until complete recovery
The longest period |
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o Intraoperative
|
The admission into the OR until the tx to the recovery area
|
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o Emergency
|
If it must be done immediately to preserve life, body part or body function
• Trauma |
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o Urgent
|
Needs to be done within a reasonable amount of time.
Necessary for clients health • Eg o Coronary bypass o Removal of tumor |
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o Elective Surgery
|
Preplanned. Based on pts choice to have done. Delaying will not have negative impact on pt.
Eg • Hip or joint replacement • Face lift |
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• Degree of Risk
|
o Minor surgery
o Major surgery |
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o Minor surgery
|
few complications
usually brief usually outpatient |
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Major surgery
|
higher degree of risk
complications prolonged hospitalization |
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• PURPOSE
|
o Diagnostic
o Ablative o Palliative o Reconstructive o Transplant o Constructive |
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• Outcomes for the Surgical Patient (Association of perioperative Registered Nurses – AORN)
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o Be free from injury and adverse effects
o Be free from infection o Maintain fluid and electrolyte balance & skin integrity o Demonstrate understanding of psychologic and physiological responses to surgery o Participate in rehabilitation process |
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o Diagnostic
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To make or confirm a dx
• Eg: biopsy |
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o Ablative
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To remove a diseased body part
• Eg: cholecystetectomy, appendectomy, amputation |
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o Palliative
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Relieve or reducing the intensity of a condition. Not intended to cure. Only relieve symptoms.
• Eg: removal of tumor (pt still has cx) |
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o Reconstructive
|
Restore function to traumatized or malfunctioning tissue
Already had functioning tissue that then needed to be fixed. • Eg: Breast reconstruction, skin graft |
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• PURPOSE
|
o Diagnostic
o Ablative o Palliative Reconstructive Transplant Constructive |
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o Reconstructive
|
Restore function to traumatized or malfunctioning tissue
Already had functioning tissue that then needed to be fixed. • Eg: Breast reconstruction, skin graft |
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o Transplant
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To replace organs or structures that are diseased or malfunctioning
• Eg: hip, joint |
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o Constructive
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To restore function in congenital anomalies
Was never there before • Eg: cleft lip |
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o Pre-op Nursing Assessment
|
VERY IMPORTANT!!
Gives Baselines History Risk Factors Psychosocial/Teaching Needs of patient and Family |
|
• Ambulatory Surgery
|
o Outpatient or Same Day
|
|
o NURSING HISTORY INCLUDES
|
Developmental considerations
Medical History Medications (allergies) Previous Surgeries Perceptions & Knowledge of Surgery Nutrition ETOH, Drug and Tobacco use ADL’s Occupation Coping Skills Support Systems Socio-cultural Needs |
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o Age
• Infants |
low blood volume.
hypo/hyperthermia effect of medications Do not have highly developed liver • At higher risk for effects from medication |
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o Age• Older Adults
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Chronic disease
Physiologic changes • < ability to handle effects of sx Prolonged wound healing |
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o Medical History
|
Need both current and past illness’
Provides Information about increased risk • Cardiovascular o Heart, CHF, hx of MI, CAD, hypertension, Dysrhythmia • Pulmonary o COPD, FV overload, pneumonia, smoking • Kidney & Liver Function • Endocrine o diabetic |
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Surgical risk is increased by drugs in the following categories:
|
• Anticoagulants
o Eg: Coumadin, heparin, aspirin, lovenox, plavix • Diuretics o Eg: Lasix, HTC, aldactone o Can cause electrolyte impbalance • Tranquilizers/sedatives o Cause an increase hypotensive reaction • Adrenal steroids o Eg; predinosne • Antibiotics in mycin group o Can cause respiratory paralysis when combined with certain drugs • Surgical History |
|
o Medication History
|
Medications – Need to ask about ALL
ANY ALLERGIES (Latex, Iodine, Tape) |
|
o Surgical History
|
Previous surgeries
Previous reactions to certain anesthetic agents from surgeries • Eg: malignant hyperthermia o The body’s temperature increases very high as a reaction to anesthesia. o Is genetic |
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Lifestyle Nutrition
|
• Malnutrition
o Increase risk for alteration in fluid and electrolyte balance o Wound healing o Wound infection • Obesity o Increased Cardiac Respiratory GI o Poor wound healing Lower blood supply in fatty tissue |
|
Lifestyle • Alcohol
|
o Pt’s need to be honest!
o Stays in longer than 24 hours is at risk of DT’s7 o Increased their threshold to medications Pain and anesthetic agents Higher bleeding risk • Illicit Drugs |
|
Lifestyle • Illicit Drugs
|
o At risk for drug interactions
|
|
Lifestyle• Tobacco
|
o Increased Risk for respiratory complications
o Smoking paralyzes cilia Not moving particles and mucous out. Causes chronic irritation Anesthesia can further irritate those agents in the mucosa o Smoking vasoconstricts the vascular system Altered wound healing |
|
Delrium Tremens
|
Shaking, confusion, seizures, lethargy
|
|
o Activities of Daily Living/Occupation
|
Financial concerns are the largest stress
|
|
• Preop Physical Assessment
o General Survey gathers a Baseline |
V/S
Skin Chest and Lungs Cardiovascular Abdomen Musculoskeletal Neurologic |
|
• Preoperative Diagnostic Screening
|
o Anything abnormal must be reported
o Urinalysis CBC Coagulation study Chemistry Profile/SMA6 ECG CXR o Type and cross match Other Tests |
|
o Urinalysis
|
Fluid imbalances
blood |
|
o CBC
|
WBC, hematocrit, Hemoglobin, RBC, platelet
|
|
o Coagulation study
|
Only done typically on people who are on anti-coagulant therapy
PTT |
|
o Kidney Function
|
Checked with BUN and creatine
|
|
o Chemistry Profile/SMA6
|
Looking at K and BUN and creatine
• Affects heart |
|
o Type and cross match
|
Know what blood type they are
Other Tests |
|
• Autolgis transfusion
|
o Take blood from self to receive back if needed after sx.
|
|
• PSYCHOLOGICAL
o Common Fears |
Waking up during sx
Dying Infection Complications • Paralysis Pain Surgical errors Body image DX (what will be found) future |
|
• PSYCHOLOGICAL o Therapeutic Nursing Responses
|
PREPARE PATIENT PSYCHOLOGICALLY
Establish and maintain a therapeutic relationship. Allow patient to verbalize Use active listening skills Use touch as appropriate Be prepared to respond to common patient questions about surgery |
|
PREPARE PATIENT PSYCHOLOGICALLY
Establish and maintain a therapeutic relationship. Allow patient to verbalize Use active listening skills Use touch as appropriate Be prepared to respond to common patient questions about surgery |
preoperatively
|
|
• Things that RNs need to teach
o Surgical Events and Sensations |
Who will be in the OR and what their roles are
Temperature Bright lights Equipment that will be used • EKG, O2 mask Affects of anesthesia What they can bring or cannot do prior If intubation is required • Will have a sore throat Preop medications • Dry mouth Equipment when leaving • Foley, PCBs Pain Loss feeling and or functioning temporarily |
|
• Things that RNs need to teach
o Pain Management |
What to expect
Know when to ask for pain • Prior to being in TOO much pain Splinting r/t coughing • A blanket or pillow is used over top of the incision while coughing to keep it from dehiscing. Things to reduce post op complications. |
|
Things that RNs need to teach
o Deep breathing, coughing, incentive spirometry, leg exercises, turning in bed, use of special equipment( |
Deep breathing
• Due to alveoli collapse o Atelaktisis Prevented by deep breathing. Coughing • Moves mucous out • Prevents pnsumonia • Explain to pt will cause pain • Try to medicate prior. IS • Gives incentive to aim for as taking deep breaths • Purpose is to help fully inhale so that the lungs are getting as much air as possible. o Pt breathes in and tries to keep the ball at certain level Turning • Prevents blood clots in legs • Increase parastalsis • Prevent skin breakdown PCBS • Prevents blood clots |
|
• Preoperative Patient Education
|
o Done preoperatively
o Assess! What does my pt need to know? o Objectives Verbalize instructions o Return Demonstration |
|
Informed Consent
|
• The patient’s voluntary agreement to undergo a particular procedure or treatment (patient has the Right To Refuse).
• Protects the patient, physician, and the healthcare institution. • A legal written document as well as an ethical imperative. |
|
Informed Consent• Contains
|
o Description of the procedure
o The underlying disease process o Name of person performing procedure o Explanation of risks o Explanation of patients rights of refusal and withdrawal |
|
Informed Consent RN does not
|
• Describe procedure
• Explain risks vs benefits |
|
Informed Consent• Who obtains
|
o Needs to be obtained by the person performing the procedure (usually the surgeon)
o The nurse may witness consent but needs to be sure that the patient does understand the procedure and information. |
|
• Advance Directives
|
o Allows patient to make healthcare wishes known if they should become unable to communicate these wishes postoperatively.
o Can be suspended during sx |
|
• Living Wills
|
o Durable power of attorney for healthcare
A person that you have assigned that is allowed to make healthcare decisions for you. • Important for family to discuss BEFORE surgery |
|
Physical Preparation
|
• Hygiene and Skin
o Use of antimicrobial soap night before o Pt does not shave • Elimination o If bowel sx go through bowel prep o Foley cath placed • Nutrition o NPO To prevent aspiration if vomiting occurs • Rest and Sleep |
|
Prepare for Surgery
• Complete pre-op checklist |
o Insure consents signed
o Obtain Vital Signs o Ensure that abnormal results are reported o Insure Identification Band in place o Administer Pre-op Meds if any |
|
Post Surgery ANTICIPATORY NEEDS
|
• Prepare the patient’s room
o Have bed made with necessary items • Gather equipment o IV pole, IS • Family Needs o Expectations o Needs o Length of time in OR o Where they can wait and eat o How they will be contacted o Where and when they will be able to see the client again location of pt |
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INTRAOPERATIVE NURSING
|
o Begins with the admission of the patient to the surgical area and lasts until the patient is transferred to the PACU
|
|
INTRAOPERATIVE NURSING • NURSING ROLES
|
o SCRUB NURSES
o CIRCULATING NURSES o Expanded Role Anesthetist ACUTE CARE NURSE PRACTIONERS REGISTERED NURSE FIRST ASSISTANT |
|
• MEMBERS OF THE SURGICAL TEAM
|
Scrub person
Circulating nurse Surgeon Anesthesiologist Nurse Anesthetist Surgeon assistant |
|
o SCRUB PERSON
|
Nurse or surgical tech
Sets up sterile field/maintains asepsis Passes instruments to the surgeon Anticipates the surgeon’s needs Aware of surgeon’s preferences |
|
o CIRCULATING NURSE
|
Acts as patient advocate
Pre surgical assessment Documentation on the OR record Assists team members Counts instruments, needles, sponges |
|
INTRAOPERATIVE Journey
• In preop holding area |
o Identify patient
o Assess emotional and physical status o Verify information on pre-op checklist • past medical history • medications • allergies • surgery to be performed |
|
• Operating Room prior to starting
|
o Patient transferred into OR suite
o Patient transferred onto OR table o Patient identified o Connected to monitors, Given O2, Anesthesiologist and nurse anesthetist present o Documentation on the OR record by circulating RN |
|
o Documentation on the OR record by circulating RN
|
Allergies
Physical status Operative procedure Team members Position Skin integrity Tourniquet location/Timing Drains/catheters Pre and post dx Medicines administered Anesthesia administered Counts Specimens sent |
|
Anesthesia
|
• A drug induced state in which the CNS is altered to produce varying degrees of pain relief, depression of consciousness, skeletal muscle relaxation and diminished or absent reflexes.
|
|
• General Anesthesia
|
o Produces central nervous system depression
Experiences loss of consciousness • Has amnesia effects Rapid Requires placement of endotracheal tube • Due to respiratory depression o Given primarily by inhalation or intravenous routes o Administered by an Anesthesiologist (MD) or Certified Registered Nurse Anesthetist (CRNA) |
|
General Anesthesiao Desired effects:
|
analgesia, relaxed skeletal muscles, and depressed reflexes
can be used for any age pt and for any procedure • used for unknown reactions |
|
General Anesthesia Side Effects
|
Dose dependent
Respiratory depression Myocardial Depression • Slow down HR Hypotension Nausea & vomiting Confusion Toxicity/overdose Potentiation |
|
• Regional Anesthesia
|
o Renders a specific portion of the body insensitive to pain because it interferes with nerve transmission without causing loss of consciousness
o Will be responsive |
|
Regional Anesthesia Risks
|
Could rise up spinal column and cause paraylisis
Skin integrity Burns |
|
Regional Anesthesia Forms
|
Nerve blocks
Spinal anesthesia Caudal anesthesia Epidural |
|
Regional Anesthesia Types
|
Topical
Local Conscious Sedation MAC (Monitored Anesthesia Care |
|
Topical anesthesia
|
• Applied to skin or mucous membranes
|
|
Local anesthesia
|
• Applied to site
o Eg; tooth |
|
Conscious Sedation anesthesia
|
• Administered by Dr or nurse
o Eg: colonoscopy or endoscopy • A combination of drugs that decrease the awareness of what is happening but are still conscious. |
|
MAC (Monitored Anesthesia Care)
|
• Provided by Dr or RN
• Very easily arousable sleep • Pt maintains airway • Usually prophol |
|
• Positioning of the Patient during Surgery
|
o Supine- most common position
o Trendelenberg o Lateral o Prone o Lithotomy |
|
o Lithotomy position
|
Feet up in stirrups
Eg: gynecological, rectal or urital procedures |
|
• Transferring the Patient to the PACU
|
o Transfers are critical.
o WATCH INCISIONS CARDIOVASCULAR • Sever hypotension, arrest RESPIRATORY • arrest |
|
POST OP NURSING CARE
• TWO STAGES |
o Immediate
o Ongoing |
|
POST OP NURSING CARE Immediate Care
|
From nursing home to convalescent
Dr gives report to family Nursing takes over care of pt RESPIRATORY STATUS |
|
Most Common PACU emergency
|
Respiratory obstruction
|
|
• Respiratory obstruction can be caused by
|
o Secretion accumulation
o Tongue obstruction o Laryngospasm o Laryngeal edema |
|
• Signs of Respiratory Distress
|
o Restlessness, apprehension
o Unequal Chest Expansion o Shallow, noisy respirations o Cyanosis o Rapid pulse rate |
|
• R distress interventions
|
o Keep airway open!
o Endotracheal tube until reflexes return coughing o Proper positioning o Humidified O2 o Pulse Oximetry o Deep Breathing o Suctioning |
|
Post op o CARDIOVASCULAR
Assess: |
• Blood pressure
• Pulse • Electrocardiogram rate and rhythm • Skin color and condition • Respirations • Temperature • Wound |
|
Consciousness returns in order
|
reverse order
|
|
Order of consciousness return
|
• Unconsciousness
• Response to touch and sound • Drowsiness • Awake but not oriented • Awake and oriented |
|
o Fluid Status
Assess |
• Skin turgor
• Vital signs • intake and output • Wound drainage • IV intake • Fluid, rate |
|
o Large amt of drainage combined with other abnormal assessments may indicate
|
hemorrhage and hypovolemic shock
|
|
o WOUND STATUS
Assess Wound Dressing for |
• drainage:
o Amount o Color Consistency |
|
• OBJECTIVE & SUBJECTIVE signs of pain
|
o Objective signs
Rapid breathing Protection of wound o Subjective signs Pt statement of pain |
|
• PACU to Nursing Unit
o Transfer occurs when |
patient’s physical status and level of consciousness are considered stable
|
|
PACU to Nursing Unit
o Transfer Report • Includes |
name, procedure, allergies, vital signs, anesthesia, medications, I/O, wound, complications, PMH, review post op orders.
|
|
Goals of Postoperative Nursing Care
|
• Maintenance of:
o Respiratory function o CV function o Neurological function o Fluid/electrolyte, nutrition, elimination • Promotion of: o Comfort/safety o Activity o Wound healing o Psychosocial Well Being • Preventing PostOp Complications |
|
• RESPIRATORY COMPLICATIONS
|
o Pneumonia
o Atelectasis |
|
o Pneumonia
|
Inflammation of the alveoli d/t infection or aspiration of foreign material
|
|
o Atelectasis
|
Collapsed alveoli
|
|
Pneumonia s/s
|
• cough
• fever • chills |
|
Atelectasis s/s
|
• cynaosis
• Dyspnea • Low pulse ox • Anxiety and restlessness |
|
• PREVENTION OF RESPIRATORY COMPLICATIONS
|
o Assess Vital Signs
o Cough o Deep breathing o Incentive Spirometry o Turning in bed o Ambulate/Positioning in bed o Maintain hydration o Monitor narcotic responses |
|
• CARDIOVASCULAR
o Assess |
document Vital Signs
Provide warmth Maintain Fluid Balance – Monitor I&O Monitor drainage Capillary refill Implement leg exercises Assist with ambulation Apply TEDS Administer anticoags Measure bilateral calf and thigh circumference Avoid poor positioning |
|
o Hemorrhage
|
Excessive blood loss
|
|
Hemorrhage can be
|
Internal or external
|
|
Hemorrhage • Internal
|
o Low BP
o Bruising o Weak, thready, rapid pulse |
|
Hemorrhage external
|
o May lead to shock
o Apply pressure dressing o Prepare for return to OR o Shock precautions |
|
o Shock precautions
|
Maintain airway
Place pt flat with legs raised • More venous return Administer O2 and fluids IV |
|
o HYPOVOLEMIC SHOCK
|
rapid loss of fluids
|
|
Shock is
|
a pt has lost control of their peripheral nervous system
|
|
o HYPOVOLEMIC SHOCK s/s
|
• Hypotension
• Cold, clammy skin • Weak, thready, rapid pulse • restlessness • Apprehension • increasedurine output (oliguria) • Cool, mottled extremities • Deep, rapid respirations • Thirst |
|
o Thrombophlebitis
|
Inflammation of a vein associated with a blood clot (thrombus formation).
• Pain and cramping at site. • inflamation and swelling • Elevated temp. • Increased circulation of involved extremity |
|
Treatment of Thrombophlebitis
• Goal: |
o Preventing a clot from breaking loose and traveling as an embolism
|
|
Thrombophlebitis • Nursing Interventions:
|
o TEDS, anticoagulants, antiinflammatories,
o analgesics, measuring, provide support. • DO NOT MASSAGE OR RUB LEGS COMPLETE BED REST |
|
• PULMONARY EMBOLUS
|
o An embolus lodged in the pulmonary vessels.
|
|
o PULMONARY EMBOLUS s/s
|
Dyspnea
Chest pain Cough Cyanosis Rapid respirations Tachycardia Anxiety/Feeling of impending doom |
|
• Sedation Scale
|
• S= Sleep, easily aroused
• 1= Awake and alert • 2= Occasionally drowsy, easy to arouse • 3= Frequently drowsy, arousable, drifts off to sleep during conversation. • 4= Somnolent, minimal or no response to stimuli |
|
• RULE OF THUMB:
|
o 24 hours= pulmonary infection.
o 48 hours= urinary tract infection. o 72 hours= wound infection. |
|
o DEHISCENCE
|
Partial or total disruption of wound layers
|
|
o EVISCERATION
|
Typical with abdominal wounds
Partial or total disruption of wound layers and protrusion of viscera |
|
BMR is needed to maintain
|
Circulatory
GI Renal Cells and tissues Respiratory |
|
o Involuntary functions that use BMR
|
Maintain body temp
Muscle tone Producing secretions Peristalsis Respritory functions Cardiac functions |
|
• As the amount of physical activity decreases
|
the BMR increases
|
|
• Some causes of increased BMR
|
o Childhood growth period
o Fever 7% / degree above 98.6 o Emotional stress o Extreme environmental temperatures o Elevated hormones Thyroid o Pregnancy |
|
• Decrease BMR causes
|
o Aging process
Decreases as get older o Prolonged fasting or dieting o Sleeping |
|
Classification of Fatty Acids
|
fatty acids:(2)
-saturated fats -unsaturated fats:(2) *polyunsaturated fats: (3) =trans fats =omega 3 =omega 6 * monounsaturated;(1) =omega 9 |
|
• Metabolism of dietary proteins
|
o Broken down into AA in the SI
Transported to the liver • AA then recombined into new proteins in the blood for protein synthesis in the cells |
|
Nutritional assessment • Dietary Intake
|
o 24-hour recall
o Food diaries Everything eaten throughout day Most reliable o Food frequency How often are these foods eaten |
|
Nutritional assessment • Medical Data
|
o Illnesses
o Drug use/abuse Medications that may affect appetite o Ability to chew/swallow Teeth? o Appetite Food intolerance Allergies Bowel patterns |
|
Nutritional assessment • Physical Exam o Anthropometric data
|
Height & weight
• Used to establish BMI • Increase or decrease can be r/t fluid retention BMI • Normal o 19-24 • Overweight o 25-29 • Obese o 30-39 • Extreme Obesity o 40+ Waist measurement • Men o <40 inches • Women o <30 inches Triceps skinfold Midarm circumference o Clinical data…Table 42-8 |
|
• Nutritional assessment Laboratory Tests
|
o protein levels
albumin levels • protein status HMG and crit • Plasma levels o Iron status Glucose triglycerides o CBC o 24-hour urine Creatinine • Proportional to body muscle mass • Low is indicative of severe malnutirion Urea nitrogen |
|
Obesity
|
• Body weight > 20% above ideal weight or BMI =/> 30
• Causes include o excess caloric intake o decrease physical expenditure o genetic factors o physiologic factors o psychological factors increased # of fat cells low BMR insulin resistant hormone imbalance • stats o 2 out of 3 adults are obese o 9 million children are obese o 400,000 deaths r/t obesity |
|
o B1
|
Thiamin
|
|
o B2
|
Riboflavin
|
|
o B3
|
Niacin
|
|
o B6
|
Pyridoxine
|
|
o B9
|
Folic Acid
|
|
o B12
|
Cyanocobalamin
|