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250 Cards in this Set
- Front
- Back
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List some things to ask concerning Nutritional History.
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-Diet recall
-Digestive symptoms -Appetite/change in weight -Allergies -Use of meds,alcohol,nicotine,caffeine -History of GI surgery or chronic disease -Chewing and swallowing problems -Socioeconomic factors |
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What tool can be very helpful concerning nutritional history?
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a food diary
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What are some questions you should ask regarding digestive symptoms when taking a nutritional history?
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any unpleasant symptoms they have: gas, heartburn, what foods don't agree with them.
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Questions to ask regarding Allergies?
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-to any food or fluids?
-what they do to make up for that need |
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Questions to ask regarding History of GI surgery or chronic disease?
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-diabetes
-COPD -endocrine disorders -heart failure |
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List some things to ask concerning Nutritional History.
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-Diet recall
-Digestive symptoms -Appetite/change in weight -Allergies -Use of meds,alcohol,nicotine,caffeine -History of GI surgery or chronic disease -Chewing and swallowing problems -Socioeconomic factors |
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What tool can be very helpful concerning nutritional history?
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a food diary
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What are some questions you should ask regarding digestive symptoms when taking a nutritional history?
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any unpleasant symptoms they have: gas, heartburn, what foods don't agree with them.
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Questions to ask regarding Allergies?
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-to any food or fluids?
-what they do to make up for that need |
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Questions to ask regarding History of GI surgery or chronic disease?
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-diabetes
-COPD -endocrine disorders -heart failure |
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Questions to ask conc. Use of meds when taking a Nutritional History?
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-any chemo
-many meds cause N/V |
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Questions to ask for chewing and swallowing problems?
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-dysphagia
-pain -denture problems |
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Questions to ask concerning socioeconomic factors when taking a nutritional history?
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-who buys/prepares food?
-food storage? -transportation? |
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What deficiency can increase the risk for pressure ulcers?
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protein deficiency
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What are 6 common lab tests to assess nutrition?
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-blood glucose
-serum albumin and prealbumin -tests for iron,transferrin -hemoglobin and hematocrit -BUN -creatinine |
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What does the blood glucose level indicate?
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the amount of fuel available for cellular energy.
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What is hypoglycemia?
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-blood glucose of < 70 mg/dL
-limits fuel supply to body,resulting in symptoms ranging from weakness to coma. |
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What is hyperglycemia?
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-blood glucose > 109 mg/dL fasting or > 126 mg/dL at random.
-sign of diabetes mellitus |
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What are normal blood glucose levels?
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70 mg/dL to 110 mg/dL
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What is albumin and why is it tested?
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-constitutes 60% of total body protein.
-low levels are assoc. w/ malnutrition,malabsorption,acute and chronic liver dz. -half-life is 18-21 days,will be a lag in detecting probs. |
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What lab values fluctuate daily and will give you better info conc acute change for nutritional status?
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pre-albumin levels
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Normal serum albumin levels?
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3.5-5 g/dL
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Normal pre-albumin levels?
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15-36 mg/dL
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What is transferrin and what does it detect?
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the protein that binds with iron.
-allows for faster detection of protein depletion than measuring albumin. |
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When would the TIBC be increased? decreased?
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-TIBC increased in person w/ iron deficiency
-TIBC decreased in person w/ anemia |
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Normal levels for transferrin?
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230-400 mg/dL
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What does the BUN indicate?
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liver and kidney function
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When is an elevated BUN seen?
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-impaired kidney function
-dehydration -excessive protein breakdown -excessive dietary protein intake |
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When are low BUN levels seen?
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-impaired liver function
-fluid overload -low protein intake |
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Normal BUN levels?
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8-20 mg/dL (slightly higher in elderly)
children: 5-18 mg/dL |
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What is creatinine?
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-end product of skeletal muscle metabolism
-excellent indicator of renal function |
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Normal levels for creatinine?
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0.5-1.2 mg/dL
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What are some dental factors that can affect nutrition?
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-loose/missing/decayed teeth
-poor denture fit -refuses to wear dentures -poor denture/oral hygiene -mouth pain -periodontal dz -food of inappropriate texture |
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What may decreased creatinine levels indicate?
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loss of muscle mass
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What can a low hemoglobin indicate?
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-inadequate iron intake
-chronic blood loss |
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What may a decreased globulin level indicate?
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-insufficient protein intake
-excessive protein loss |
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Normal hemoglobin levels?
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Male: 14-18 g/dL
Female: 12-16 g/dL Pregnant female: 11 g/dL |
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What is a nursing dx concerning weight loss?
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Imbalanced nutrition: less than body requirements
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What are some general factors that can influence nutrition?
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-dining environment/placement
-inadequate time -appearance and flavor of food -undignified feeding methods -lack of individual input into diets -restrictive therapeutic diets -infection: weight loss is sometimes a sign |
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Each degree of fever increases your caloric needs by __%?
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7%
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What are some Planning/Goals for Weight loss?
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-progressively gains weight toward desired goals
-lab values(albumin,H&H) are within normal limits |
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What are some interventions for Weight Loss?
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-consult w/other professionals
*dietician *occupational,speech,physical -high protein supplements -community resources:if can't prepare own food -alternative feeding methods(enteral) |
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What should be documented concrning decreased nutritional staus due to weight loss?
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-Intake records
*percentage eaten *other -calorie counts -specific probs,symptoms:not eating protein,etc. -referrals |
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NPO Diet
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-Prep for Diagnostic tests
-Prep for surgery -R/T surgery or illness-can't tolerate food or food would cause harm ex:GI surgery or pancreatitis -communicate to pt,family,staff -be aware when NPO status is over and order appropriate diet for pt |
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Clear Liquid Diet
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(can see through)
-provides hydration and simple carbs for energy needs -does not provide protein,enough calories and other nutrients are missing -water -tea,coffee-no cream -clear juice:apple,grape,cranberry -broth and jello |
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When can pt be progressed from clear liquid to full liquid diet?
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When pt reports no nausea and has normal bowel sounds
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Full Liquid Diet
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-all clear liquids plus any food items that are liquid at room temp
-cream soups,milk,milkshake,puddings,custards,yogurt,some hot cereals -high protein,high calorie supplements can be added to help w/nutrition |
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Mechanical Soft
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-for chewing difficulties:missing teeth,jaw problems,severe fatigue
-inculdes all items on full liquid diet plus: soft veggies and fruits breads,eggs,cheese,chopped,ground or shredded meat |
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Pureed Diet
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Any food item blended-often liquid added
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Calorie restricted diet
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-for weight loss
-# of calories specified ex: 1800 calorie diet |
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Sodium Restricted Diet
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-for bld pressure,fluid balance problems
-no salt added (NSA) -Amount specified ex:2 g Na |
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Fat Restricted Diet
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for clients w/ elevated cholesterol or triglyceride levels
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Diabetic Diet
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-used to manage calories and carbs
-ex: 1800 cal. ADA diet |
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Renal Diet
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-used to manage electrolytes and fluid
-pts may be on fluid restriction |
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Protein Controlled Diet
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-used to manage liver and kidney dz
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Antigen avoidance diets
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-for food allergies
-for food intolerances ex: gluten-free,lactose |
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Calorie-Protein Push
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-wound healing
-for maintaining or increasing weight -protein and fat added -supplements may be addes |
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Supplements
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-high calorie,high protein supplements
-in-house shakes -canned preps (ensure) -powdered mix added to juice,or mixed with water and added to feeding tubes -between meal and bedtime snacks |
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What are the nursing dx's related to dysphagia?
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-Impaired swallowing
-Risk for aspiration |
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Interventions related to Dysohagia?
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Speak w/ doc about consult w/ speech-language pathologist.(can give exercises to help swallowing)
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What are the 3 types of consistency for thickened liquids?
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-nectar
-honey -pudding |
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Positions for Feeding if pt has dysphagia?
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-sitting upright 90 degrees
-head flexed slightly forward -remain at 45 degrees or higher for 10-20 minutes following the meal -other positions may be prescribed by speech therapists |
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What are the 7 Levels of Activity?
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-Complete Bed rest
-bed rest w/ BRP(bathroom privileges only) -bed rest w/bedside commode -dangle on side of bed -up to bedside chair -OOB ad lib -OOB w/ assistance |
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What are some reasons for bed rest?
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-to decrease O2 comsumption
-weakness -safety -to rest a body part and prevent damage -equipment that needs to be on -severity of condition |
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What is Hypercalcemia?
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-elevated levels of calcium in the ECF
-calcium leaves the bone 4m lack of weight bearing and moves into the ECF czing hypercalcemia |
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What does Hypercalcemia cause and what does it lead to?
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-causes "cellular sedation" : depressed nerve and muscle activity which can lead to:
-generalized muscle weakness -altered myocardial function -cardiac dysrhythmias -decreased GI motility(constipation, N/V) -mental status changes(lethargy,confusion) |
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Contracture?
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-permanent shortening of the muscle (bc not constantly doing ROM)
-limits ROM of a joint. at some point tendons,ligaments,and joint capsules are involved. -only surgery can reverse. |
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What is Orthostatic Hypotension?
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-a positional drop of 20 points mmHg when client moves 4m a horizontal to a vertical position.
-lying to sitting or sitting to standing -often heart rate goes up |
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What could a position change cz in a person w/ orthostatic hypotension?
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-dizziness
-lightheadedness -fainting -pallor -nausea |
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Who is orthostatic hypotension common in?
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-elderly
-those who are immobilized -blood volume depletion -certain meds. |
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How do you measure orthostatic hypotension?
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-client supine for 2-5 minutes or more. Take BP and pulse.
-Repeat readings w/ pt sitting and standing |
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What is atelectasis?
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-collapse of alveoli in the lungs
-czs decreased 02 transport to tissues |
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What is throboembolism?
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-thrombus: a bld clot that adheres to the wall of a bld vessel or organ
-thromboembolism: blocking of a bld vessel by a clot(or part of a clot) that has broken off 4m the place where it formed and traveled to another organ |
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What can be a big risk factor for an Immobile person?
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thromboembolism
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General nursing care of client w/ Mobility Problem?
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~Recognizing hazards of immobility
~Preventing complications -assessment -using techniques and equip. |
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What is Impaired Physical Mobility?
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limitation in independent,purposeful physical mvmt of the body/extremity
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Assessment for Impaired Physical Mobility?
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-limited ROM
-slowed mvmt:uncoordinated or jerky -gait changes -postural instability -mvmt induced SOB |
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Assoc. Nursing DX for Pyshosocial R/T Immobility
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-Impaired social interaction
-Grieving -body image disturbance -self esteem disturbance -hopelessness -coping -older adults are at rick for confusion,depression,& disorientation and are especially susceptible to the hazards of immobility. |
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What does SCD stand for?
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Sequential Compression Devices
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Explain Dysphagia Screening at Bedside by RN
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-done bc of danger to aspiration(may be silent)
~In the following order: -Ask pt to say name -Offer sip of water -Offer pudding -Give cracker -Keep NPO until screening completed or if pt cannot manage any of the above |
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PN(TPN)
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-total parenteral nutrition
-formulated by metabolic team -contains protein,higher conc. of carbs,vitamins,minerals,electrolytes -lipids may be given as well(milky-white looking) |
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Interventions for TPN
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Monitor:
-tube insertion site -weight -glucose -diuresis and dehydration -lab values |
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Parenteral Nutrition
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commonly used IV fluids are low calorie and don't have protein or fat. Vitamins may be added(fluid looks yellow)
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Enteral Feedings
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-GI tract has to be functioning
-Relatively easy to give in home settings -Less expensive than parenteral -Able to give a relatively balanced diet -Some ppl eat a diet po and the enteral feedings are supplemental |
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Nasogastric(NG) tube
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-large bore
-small bore(Dubhoff) -short term less than 6 wks |
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Gastric tube (G tube)
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-4m incision in abdomen to stomach
-gastrostomy -PEG(percutaneous endoscopic gastrostomy) |
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Intestinal
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-nasointestinal
-jejunostomy(J tube):4m incision in abdomen to intestine -PEJ(percutaneous endoscopic jejunostomy) |
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What are the safety concerns for feeding tubes?
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-placement issues
-aspiration -adequate nutrition -dehydration -tissue breakdown -bacterial contamination |
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Placement of Feeding Tubes
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-potential of formula entering lungs w/ all types of tubes
-most reliable method of determining placement is X-ray verification -checking for placement differs w/ diff types of tubes |
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Markings to check on Nasogastric tubes
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-check permanent markings
-check that tape is secure on nose |
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Markings to check on G tubes and J tubes
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-check markings or measure length of tube protruding out of the abdomen
-check for intact sutures if present |
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Methods before using a feeding tube
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-Insert air into NG tube while listening over gastric area w/ stethoscope
-Withdrawing stomach aspirate -check for color -determine pH |
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What is the normal pH for Stomach, Lungs and Intestine?
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Normal Stomach pH is 0-4
Normal Lung pH is > 6 (bronchial tree) Normal Intestine pH is 6-8 -Meds can raise stomach pH |
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What are the contributing factors of Dehydration?
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-Mobility
-mental status -decreased intake -NPO -enteral feedings don't supply enough water -many of the same factors as inadequate food intake |
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Assessment for Dehydration?
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-decreased urine output
-dark,conc urine -weight loss -thirst:late indicator -decreased skin turgor -dry,mucous membranes -decreased venous filling -decreased pulse volume -mental status -elevated Hct,elevated BUN |
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Nursing Dx for Dehydration
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-Deficient fluid volume
-Risk for deficient fluid volume |
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Interventions for Dehydration
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-fresh water at bedside
-offer fluids regularly -schedule for offering fluids in between meals -offer fluids that appeal to pts -keep record of and assess I&O -monitor urine for amt and color |
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What is the Main way to prevent aspiration?
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Check Residual
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About residual
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-Check residual,withhold feedings,and notify physician if residual too high
-100-150 mL for bolus feedings or greater than 1/2 the amt of previously delivered feeding or 1-2 X the hourly rate for continous |
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Bed elevation to prevent aspiration for tube feedings?
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-elevate head of bed at least 30-45 degrees during all feedings and for at least 1 hr. after discontinuation
-at all times for continuous feedings |
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Pay attention to conc tube feeding?
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-pay attention to s/s of delayed gastric emptying
-abdominal distention -complaints of GI distress |
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Evaluate conc. tube feeding
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-evaluate bowel sounds
-evaluate lung sounds and watch for s/s of respiratory problems -SOB -increased temp -adventitious lung sounds |
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Tissue Breakdown R/T tube feedings?
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-assess skin around tube insertion sites for breakdown(acid can leak out)
-clean,apply dry dressings loosely or leave open to air -for PEG tubes,put dressing over the external bar. |
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Inadequate nutrition r/t tube feeding
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Evaluate intake
-monitor infusion regularly to make sure it's running at correct rate -tubes can become clogged -tubes can be left disconnected |
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Dehydration r/t tube feeding
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-assess for signs of dehydration
-monitor lab values BUN,Hct -give addtl water as ordered |
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Bacterial contamination r/t tube feeding
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-strict aseptic technique and handwashing
-rinse syringes after bolus feeding and delivery sets before adding new formula to continous infusion -hang formula for no more than 8-12 hours -replace delivery bags and irrigation sets every 24 hrs or facility policy |
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Complications of tube feeding?
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-tube becomes clogged
-irrigate routinely,and before & after giving feedings and meds -tube can come out -constipation:not giving enough fluids w/feeding -hyperglycemia -diarrhea -start w/slower rate -dilute formula -obtain order for diff formula |
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Types of Nutritional Products
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Formulas for diff. purposes
-diabetic:glucerna -pulmonary probs:pulmocare ~Some have partially broken down proteins ~diff calorie densities ~check labels for type,expiration date ~give at room temp. |
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Stage 1 pressure ulcer?
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Nonblanchable erythema
-stays pink when blanched -skin may feel boggy |
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Stage 2 pressure ulcer?
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Partial-Thickness loss of epidermis.
-seen as blister -when blister pops,usually crater underneath |
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Stage 3 pressure ulcer?
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~Damaged to full-thickness of skin and into underlying tissue.
-NOT thru fascia. -won't really see undermining or tunneling |
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Stage 4 pressure ulcer?
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Full-thickness,tissue necrosis
-can extend to muscle and bone -often see undermining or tunneling |
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Transparent Wound Dressings
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use in superficial ulcers for little to no drainage; doesn't absorb much; can shower; impermeable to bacteria and water
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Gauze Wound Dressings?
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-sticks to wound,unless kept consistenly moist
-least effective -don't use if lots of drainage |
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Hyrocolloid wound dressings?
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-waterproof adhesive
-worn up to 7 days -provides gel over wound,waterproof barrier -good for autolytic debridement. -prob is can't see wound |
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Hydrogel Wound Dressings?
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-put in wounds
-absorbs exudate -oxygen permeable -require another dressing over it -good for pressure ulcer |
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Alginate Wound Dressings?
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-conform to wound surface
-can absorb up to 80% of exudate |
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Foam wound dressing?
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-offers padding and absorption
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3 Basic concepts of Oxygenation?
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-Get O2 into the body
*O2 is needed to sustain life -Circulate O2 thru the body -Use O2 properly and rid body of CO2 *cardiac and respiratory system functions |
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Oxygen?
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FIO2-% of O2 in inspired air
(fraction of inspired oxygen) -normal atmospheric air has an FIO2 of 21% -supplemental O2 delivery systems can increase FIO2 from 24 to almost 100% |
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What is airway resistance?
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-pressure diff b/w the mouth and the alveoli
-Influenced by: *airway obstruction *asthma *tracheal edema |
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Accessory Muscles?
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-Increase lung vol. during inspiration
-Elevation of clavicles *emphysema |
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What is the goal of ventilation?
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-arterial CO2 tension(PaCO2) b/w 35 and 45 mmHg
-arterial O2 tension(PaO2) b/w 95 and 100 mmHg -O2 saturation(SaO2) range of 95-100% |
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What is hyperventilation?
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-ventilation > that which is required to eliminate normal CO2 levels
-Anxiety,inf,drugs -excess CO2 exhalation can lead to loss of consciousness |
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What does oxygen transport depend on?
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-Ventilation(the amt of O2 entering the lungs)
-Perfusion(bld flow to the lungs) -O2-carrying capacity:adequate hemoglobin |
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How is breathing controlled?
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-respiratory centers in the brain stem drive breathing based on feedback 4m
-chemoreceptors and lung receptors -chemoreceptors in the medulla,the carotid arteries and the aorta detect chanes in the bld pH,O2 levels and CO2 levels -lung receptors send feedback to the brain to adjust ventilation |
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O2 Carrying Capacity?
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-Hemoglobin carries 97% of diffused O2
-O2 + hemoglobin=oxyhemoglobin -O2 carrying capacity is decreased by: *Anemia *Toxic Inhalants -carbon monoxide |
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Oxygen Saturation(SaO2)
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-oxyhemoglobin saturation
-%age of hemoglobin combined w/ O2 |
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Hyperventilation/Hypoventilation
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-don't refer to respiratory rate, although rate is affected
-a person can hyperventilate w/ a slow respiratory rate |
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Hypoventilation?
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-ventilation inadequate to meet O2 demands or eliminate sufficient CO2
*Atelectasis:collapsed alveoli *COPD |
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Hypoxemia?
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-deficiency of O2 in the bld
-most reliable method of measuring is blood gas analysis -determines the partial pressure of O2 in arterial bld(PaO2) |
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Hypoxia?
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-inadequate tissue oxygenation at cellular level
-results 4m deficiency in O2 delivery or O2 utilization -clinical signs: *early sign:restlessness *late sign: cyanosis -life threatinin if not txed |
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Pulmonary edema?
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accumulation of fluid in lungs; will hear crackles in all lung fields
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[Blood Flow Regulation]
-Cardiac Output(CO) |
-4-7 L/min
-changes according to O2 demand -Cardiac Output=Stroke Volume X Heart Rate |
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[Blood Flow Regulation]
-Cardiac Index(CI) |
-adequacy of cardiac output for individual
-obtained by dividing CO by BSA |
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[Blood Flow Regulation]
Stroke Volume |
-amt of bld ejected 4m L. ventricle w/ each contraction
-affected by preload and afterload |
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[Bld Flow Regulation]
Preload |
-end diastolic volume
-ventricles stretch:more stretch=greater contraction & greater stroke vol.=Starling's law |
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[Bld Flow Regulation]
Afterload |
resistance to L ventricular ejection
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Bradycardia
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< 60 beats/min; can be healthy in athletes
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Tachycardia
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> 100 beats/min
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Disturbances in Conduction
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-Dysrhythmias
*deviation 4m normal sinus heart rhythm *electrical impulses that don't result 4m the SA node -Can result in: *tachycardia *bradycardia *premature beats *blocked beats(absent or delayed) |
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Alterations in Cardiac Function?
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-disturbances in conduction:electrical discharge didn't go thru
-altered cardiac output -impaired valvular function -myocardial ischemia |
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Myocardial Ischemia?
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-insufficient O2 to myocardium
-angina pectoris -MI -acute coronary syndrome |
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Myocardial Infarction?
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-occurs when there is a:
*sudden decrease in coronary bld flow OR *increased myocardial O2 demand w/ inadequate coronary perfusion -Decreased bld supply czes: *ischemia:lack of O2(reversible) *necrosis:tissue death(irreversible) |
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MI Pain:Men
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-crushing,squeezing,stabbing
-retrosternal & L precordial -may radiate down L arm,to neck,jaws,teeth,back,or epigastric area -occurs on activity or at rest -lasts > 30 minutes -unrelieved by NTG |
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MI Pain:Women
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-angina usually 1st symptom
-c/o epigastric pain -radiates thru to back & into jaw -fewer Q wave and ST segment changes -may present w/ SOB & vasospasm |
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What does Acute Coronary Syndrome(ACS) include?
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-unstable angina
-Non-ST segment elevation MI -ST segment elevation MI -imbalance of O2 supply and demand to myocardium |
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Causes of Acute Coronary Syndrome?
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-nonocclusive thrombus
-coronary vasospasm -arterial narrowing -infl or inf -2ndary unstable angina *anemia *fever *hypoxemia |
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Risk Factors for Acute Coronary Syndrome?
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-Male
-Over 70 w/: *diatebetes mellitus(DM) *extracardiac vascular dz(PVD) *fixed Q waves *previous abnormal ST segment and T wave changes |
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Pulse Oximetry?
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-measures SaO2:reflects the % of hemoglobin molecules carrying O2
-normal:95-100% -place probe on nail bed,earlobe,nose or forehead:remove nail polish |
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Diagnostic Tests for Visual Respiratory Structures?
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-chest x-ray:shows structure of lungs
-bronchoscopy:tube thru trachea to lung fields;can remove foreign objects,biopsy -lung scan:CAT scan,dye |
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Diagnostic Tests for Abnormal Cells or Infection?
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-throat cultures
-sputum specimens -skin testing:TB -thoracentesis:fluid removal 4m pleural cavity w/a needle,usually done @ bedside |
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What is respiration?
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the exchange of gases(O2 & CO2) in the lungs.
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What is ventilation?
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mvmt of air into and out of the lungs thru the act of breathing.
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What does the work of breathing depend on?
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-rate and depth of breathing
-compliance -airway resistance -accessory muscles:will see bulging neck muscles,intercostal contraction |
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What can the ability of the lungs to expand by affected by?
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certains meds,conditions,etc
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Compliance?
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-ability of lungs to expand to increased intraalveolar pressure
-influenced by: *pulmonary edema *pleural fibrosis *kyphosis *fractured ribs |
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Perfusion and Distribution?
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-circulation of bld to and from the surface of the alveoli for gas exchange
-dependent on R ventricle for pulmonary circulation and Systemic BP for venous return |
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Exchange of Respiratory Gases?
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-exchange occurs at alveoli and capillaries of body tissue
-method of transport is simple diffusion |
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Diffusion?
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-molecules move 4m area of greater to lesser conc
-affected by: *thickness of the membrane *cond of surface area:inflamed,inf,fluid,etc. |
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Carbon Dioxide Transport
|
-CO2 diffuses into RBCs
-is hydrated into carbonic acid(H2CO3)in the presence of carbonic anhydrase -dissociates into(H+) and (HCO3-) ions -(H+) ions are buffered by hemoglobin -(HCO3-) ions diffuse into plasma -reduced hemoglobin(deoxyhemoglobin)combines w/CO2 easier than hemoglobin,so most CO2 is carried in venous bld |
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Neural regulators of respiration
|
-CNS controls rate,depth,rhythm
*cerebral cortex:voluntary control *medulla oblongata: automatic control |
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Chemical Regulators of Respiration?
|
-CO2,O2 and hydrogen ions control rate and depth
*chemoreceptors in medulla,aortic body,and carotid body monitor chemical changes *stimulate neural regulators to adjust R and D to maintain normal arterial bld gases *occurs during exercise and some illness *short-term adaptive mechanism |
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3 alterations in respiratory function?
|
-hyperventilation
-hypoventilation -hypoxia |
|
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What are 8 factors that can affect oxygenation?
|
-physiological
-decreased inspired O2 conc. -hypovolemia -increased metabolic rate -conds affecting chest wall mvmt -developmental factors -behavioral factors -environmental factors |
|
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What are some physiological thigns that can affect oxygenation?
|
-myocardial hypoxia
-anemia -pregnancy |
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What is hypovolemia?
|
decreased bld volume,can be czed by trauma,occult bleeding
|
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What are some conds that can affect chest wall mvmt?
|
-chest trauma
-fractured ribs -spinal deformities |
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Behavioral factors that can affect oxygenation?
|
-exercise
-anxiety -panic attacks -smoking |
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Environmental factors that can affect oxygenation?
|
-air pollution
-high altitude -pollen -mold |
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How to assess risk for Impaired Oxygenation?
|
health history:smoke,diet,allergies,
workhistory,asthma,illness,chemical exposure? -respiratory history -cardiovascular history -environmental history -lifestyle |
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Assessment for Impaired Oxygenation? (history)
|
-History
*fatigue *dyspnea ~orthopnea *cough ~productive or nonproductive ~sputum-COCA ~hemoptysis - |
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General Assessment for Impaired Oxygenation?
|
-wheezing
-pain -environmental exposure -respiratory infs -risk factors -meds |
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Physical Exam for oxygenation status?
|
-Inspection
*color:of skin,nail beds,pallor *LOC:awake,alert,or groggy? *respiratory rate *breathing patterns:symmetrical |
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Breathing Patterns
|
-Eupnea:16-20 breaths/min
-Tachypnea: >35 -Bradypnea: <10 -Apnea:absence of resp >15 sec -Kussmaul's:usually >35,may be slow or normal -Cheyne-Stokes:per.of apnea,followed by rapid breathing.pt usually terminal |
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Assessment of respiratory effort?
|
-nasal flaring
-retractions -orthopnea -paroxysmal nocturnal dyspnea(PND) -conversational dyspnea -stridor -wheezing |
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What is paroxysmal nocturnal dyspnea(PND)?
|
sudden awakening due to SOB that begins during sleep
|
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Palpation for assessment of oxygenation status?
|
-peripheral pulses
*rate,rhythm,quality -skin temp:normal is warm,dry -capillary refill:normal is brsk |
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Percussion for assessment of oxygenation?
|
detects presence of abnormal fluid or air in the lungs
|
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Auscultation for assessment of oxygenation status?
|
-heart sounds:murmurs
-adventitious breath sounds -msmt of BP |
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Systemic BP?
|
-lateral force on wall of artery by pulsing bld under pressure 4m heart
-systolic *peak of max pressure when ventricles contract -diastolic *minimal pressure exerted at all times when ventricles relax |
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What does systemic BP reflect?
|
reflects interrelationship of:
-cardiac output -peripheral resistance -bld volume -viscosity -elasticity |
|
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Factors affecting systemic blood pressure?
|
-age:hardening of arteries,plaque=inc.BP,could lead to stroke
-stress -race -meds -diurnal variations -gender |
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How can diurnal variations affect systemic BP?
|
lower BP in AM,higher BP in PM
|
|
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How can gender affect systemic BP?
|
women after menopause usually have higher BP
-older men also have higher BP |
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|
3 Nursing DX for oxygenation?
|
-airway clearance,ineffective
-activity intolerance -tissue perfusion,inadequate |
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Planning r/t oxygenation Dx?
|
-develop plan of care for each nursing dx
*individualized *realistic and measurable |
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Nursing Intervention:Maintaining Airway
|
-deep breathing and coughing
-suctioning -artificial airways |
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Nursing Interventions: Mobilization of Secretions
|
-hydration:liquifies secretions
-humidification -nebulaization |
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Nursing Interventions:Promote Lung Expansion
|
-positioning:semi-fowler's is best
-incentive spirometry -chest physiotherapy *percussion and postural drainage -chest tubes:used in pts with: *pneumothorax *hemothorax:bld in lung |
|
|
3 Nursing DX for oxygenation?
|
-airway clearance,ineffective
-activity intolerance -tissue perfusion,inadequate |
|
|
Planning r/t oxygenation Dx?
|
-develop plan of care for each nursing dx
*individualized *realistic and measurable |
|
|
Nursing Intervention:Maintaining Airway
|
-deep breathing and coughing
-suctioning -artificial airways |
|
|
Nursing Interventions: Mobilization of Secretions
|
-hydration:liquifies secretions
-humidification -nebulaization |
|
|
Nursing Interventions:Promote Lung Expansion
|
-positioning:semi-fowler's is best
-incentive spirometry -chest physiotherapy *percussion and postural drainage -chest tubes:used in pts with: *pneumothorax *hemothorax:bld in lung |
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|
Incentive Spirometry
|
Goal:to max. inspiration-reinflate alveoli
-provides visual feedback to pt. |
|
|
Nursing Interventions for oxygen administration
|
-Safety
*no smoking *safe electrical equip *check portable tanks b4 transport *caution:pt w/chronic lung dz *6 rights of med admin -MD order,L/min,type |
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|
Nursing Interventions for promotion of oxygenation
|
-safety
-supply -nasal cannula -nasal catheter -oxygen masks -transtracheal |
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|
Administering O2
|
-O2 flow meter L/min:attach to source
-humidification(if needed) -set O2 to RXed amt -position nasal cannula,mask -monitor regularly -assess effectiveness -documnet:ongoing |
|
|
Nursing Interventions:Breathing Exercise
|
-deep breathing & coughing exercises
-pursed-lip breathing -diaphragmatic breathing |
|
|
Pursed-lip breathing?
|
-deep inspiration and prolonged expiration thru pursed lips
-prevents alveolar collapse -exhalation should be longer than inhalation |
|
|
Diaphragmatic breathing?
|
-expand diaphragm during controlled inspiration
-practice first,in supine position,then can sit up |
|
|
Nursing interventions:prevent embolism
|
-Pnuematic Compression Device
-TED hose -leg exercises:prevent venous stasis |
|
|
Pneumatic Compresssion Device
|
intermittent compression cycles to veins of legs to promote circulation,inflates and deflates using air pump
|
|
|
TED hose
|
elastic stockings-facilitate venous return
-foot to knee -foot to thigh |
|
|
ROM exercises
|
-Active vs Passive
-Techniques -Perform active/passive ROM 2-3 x day -encourage client to incorporate ROM into daily ADL's if able |
|
|
What are parasomnias?
|
sleep probs more common in kids than adults
|
|
|
List some parasomnias.
|
-SIDS
-somnambulism:sleepwalking -nocturnal enuresis:bedwetting -night terrors -bruxism |
|
|
Narcolepsy.
|
-CNS disorder
-sudden sleep attacks in waking periods -falling asleep several times thruout the day |
|
|
Sleep Apneas(general)
|
-lack of airflow thru the nose/mouth for periods of 10 sec or longer during sleep
|
|
|
Obstructive sleep apnea
|
-seen in middle-aged men and post-menopausal women
-usually need sleep study -most common form -upper airway becomes blocked -CPAP |
|
|
Central sleep apnea
|
dysfunction in the brain's respiratory center
|
|
|
What is a CPAP?
|
continuous positive airway pressure
-delivers O2 and keeps airway open when apnea occurs |
|
|
Behaviors of Sleep Deprivation
|
-irritability
-slurred speech -disorientation -decreased reasoning -deteriorated mental status -psychotic behaviors -decreased motivation -increased sensitivity to pain -stressful attitude |
|
|
ICU-itis
|
-constant RTC stimulation
-monitors beeping,suction,vents,lights,people,activity -unable to differentiate bw night and day -can become psychotic in behavior |
|
|
What is bruxism?
|
grinding and clenching of the teeth
|
|
|
Assessment for Sleep Disorders?
|
-determine the client's current sleep pattern
-if sleep is adequate,assessment is brief -sleep is sujective -How did you sleep last night? -rvw factors affecting the client's sleep -eval the clients response to sleep disturbance |
|
|
Nursing Dx for Sleep Disorders
|
-Sleep pattern disturbance r/t
*pain *urinary frequency *nausea *incontinence *stress/anxiety *nightmares *sensory overload -Anxiety -coping,ineffective(fam or individual) -fear -hopelessness -diarrhea -urinary incontinence |
|
|
Planning for Sleep Disorders
|
-select nursing interventions that will promote sleep
-involve sleep partner as needed -plan activities that promote rest/sleep |
|
|
Implementation for Sleep Disorders
|
-environmental controls
-bedtime rituals -control symptoms which disturb sleep -techniques to promote comfort -interventions which maintain psychological well-being and reduce stress -routines -meds -client teaching |
|
|
Evaluation for Sleep Disorders
|
-return to clients usual sleeping pattern
-minimal sleep deprivation symptoms -clients knowledge of ways to promote sleep -ask client if expectations of care are not being met |
|
|
Open/closed wound
|
closed:bruise,hematoma
open:break in skin |
|
|
Acute/chronic wound
|
acute:heals in normal time frame
chronic:delayed healing |
|
|
Clean/contaminated/infected wound
|
clean:surgically made
contaminated:trauma,spill 4m GI tract,etc infected:evidence of inf |
|
|
superficial/partial or full-thickness wound
|
superficial:epidermis only
partial-thickness:extend thru epidermis into dermis full-thickness:subQ tissue and below |
|
|
penetrating wound
|
puncture
can mean internal organs involved |
|
|
serous exudate drainage
|
straw-colored
clean wound |
|
|
sanguineous drainage
|
bloody
|
|
|
serosanguineous drainage
|
mix of bloody and straw-colored
|
|
|
purulent drainage
|
yellow,contains pus
|
|
|
regeneration wound healing
|
-in epidermal wounds
-no scar |
|
|
primary intention wound healing
|
-clean surgical incision/edges approximated
-minimal scarring |
|
|
secondary intention wound healing
|
-usually has wound contamination so won't close it
-wound edges not approximated -tissue loss -heals from inner layer to surface |
|
|
tertiary intention wound healing
|
-started to heal by 2ndary intention
-granulating tissue brought together -delayed closure fo wound edges |
|
|
hemorrhage
|
mostly worried about internal hemorrhage
-should decrease each day -look for any swelling hematoma |
|
|
Nursing assessment for skin integrity (history)
|
-data on risk factors
-risk assessment scales |
|
|
nursing assessment for skin integrity (lab data)
|
-serum albumin & serum pre-albumin
-leukocyte -WBC count -hemoglobin -hematocrit |
|
|
nursing assessment for skin integrity (braden scale)
|
-numeric value for 6 risk factors r/t impaired skin integrity
-total score <_ 18=risk |
|
|
nursing assessment for skin integrity (physical exam)
|
-inspect skin:special focus on wounds and bony prominences
-assess mobility |
|
|
nursing assessment for skin integrity (wound assessment)
|
-want wound to look red,beefy,grainy
-location -size -appearance -drainage |
|
|
nursing interventions r/t impaired skin integrity(wound environment)
|
-provide a moist wound environment
-not the surrounding skin -change dressing before it gets moist/saturated |
|
|
nursing interventions r/t impaired skin integrity(drainage device)
|
monitor drainage device
*jackson-pratt;hemovac -each side of body |
|
|
nursing interventions r/t impaired skin integrity(necrotic material)
|
-remove necrotic material
*debridement:chemical,autol- ytic,surgical *goal:to have a clean,granu- lated wound base |
|
|
nursing interventions r/t impaired skin integrity(dead space)
|
-eliminate dead space:cavities must be packed loosely,overpacking will lead to pressure damage
-wounds should heal 4m bottom out |
|
|
nursing interventions r/t impaired skin integrity(cytotoxic agents)
|
-avoid cytotoxic agents
-things that destroy cell tissue;NS is best to clean |
|
|
nursing interventions r/t impaired skin integrity(irrigation pressures)
|
-use irrigation pressures w/in range
-between 4-15 psi |
|
|
nursing interventions r/t impaired skin integrity(tissue loads)
|
-manage tissue loads
-head of bed no more than 30 degrees;higher can cz shearing;use special pad if in wheelchair |
|
|
nursing interventions r/t impaired skin integrity(nutrition)
|
-provide nutritional support
-protein,vit A,vit C,zinc,copper |
|
|
nursing interventions r/t impaired skin integrity(wound bed)
|
-insulate and protect wound bed
-keep body temp,protect 4m friction and shear |
|
|
nursing interventions r/t impaired skin integrity(support)
|
-support/immobilize a wound
*binders/bandages,slings,Mo- ntgomery straps |
