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250 Cards in this Set

  • Front
  • Back
List some things to ask concerning Nutritional History.
-Diet recall
-Digestive symptoms
-Appetite/change in weight
-Use of meds,alcohol,nicotine,caffeine
-History of GI surgery or chronic disease
-Chewing and swallowing problems
-Socioeconomic factors
What tool can be very helpful concerning nutritional history?
a food diary
What are some questions you should ask regarding digestive symptoms when taking a nutritional history?
any unpleasant symptoms they have: gas, heartburn, what foods don't agree with them.
Questions to ask regarding Allergies?
-to any food or fluids?
-what they do to make up for that need
Questions to ask regarding History of GI surgery or chronic disease?
-endocrine disorders
-heart failure
List some things to ask concerning Nutritional History.
-Diet recall
-Digestive symptoms
-Appetite/change in weight
-Use of meds,alcohol,nicotine,caffeine
-History of GI surgery or chronic disease
-Chewing and swallowing problems
-Socioeconomic factors
What tool can be very helpful concerning nutritional history?
a food diary
What are some questions you should ask regarding digestive symptoms when taking a nutritional history?
any unpleasant symptoms they have: gas, heartburn, what foods don't agree with them.
Questions to ask regarding Allergies?
-to any food or fluids?
-what they do to make up for that need
Questions to ask regarding History of GI surgery or chronic disease?
-endocrine disorders
-heart failure
Questions to ask conc. Use of meds when taking a Nutritional History?
-any chemo
-many meds cause N/V
Questions to ask for chewing and swallowing problems?
-denture problems
Questions to ask concerning socioeconomic factors when taking a nutritional history?
-who buys/prepares food?
-food storage?
What deficiency can increase the risk for pressure ulcers?
protein deficiency
What are 6 common lab tests to assess nutrition?
-blood glucose
-serum albumin and prealbumin
-tests for iron,transferrin
-hemoglobin and hematocrit
What does the blood glucose level indicate?
the amount of fuel available for cellular energy.
What is hypoglycemia?
-blood glucose of < 70 mg/dL
-limits fuel supply to body,resulting in symptoms ranging from weakness to coma.
What is hyperglycemia?
-blood glucose > 109 mg/dL fasting or > 126 mg/dL at random.
-sign of diabetes mellitus
What are normal blood glucose levels?
70 mg/dL to 110 mg/dL
What is albumin and why is it tested?
-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.
What lab values fluctuate daily and will give you better info conc acute change for nutritional status?
pre-albumin levels
Normal serum albumin levels?
3.5-5 g/dL
Normal pre-albumin levels?
15-36 mg/dL
What is transferrin and what does it detect?
the protein that binds with iron.
-allows for faster detection of protein depletion than measuring albumin.
When would the TIBC be increased? decreased?
-TIBC increased in person w/ iron deficiency
-TIBC decreased in person w/ anemia
Normal levels for transferrin?
230-400 mg/dL
What does the BUN indicate?
liver and kidney function
When is an elevated BUN seen?
-impaired kidney function
-excessive protein breakdown
-excessive dietary protein intake
When are low BUN levels seen?
-impaired liver function
-fluid overload
-low protein intake
Normal BUN levels?
8-20 mg/dL (slightly higher in elderly)
children: 5-18 mg/dL
What is creatinine?
-end product of skeletal muscle metabolism
-excellent indicator of renal function
Normal levels for creatinine?
0.5-1.2 mg/dL
What are some dental factors that can affect nutrition?
-loose/missing/decayed teeth
-poor denture fit
-refuses to wear dentures
-poor denture/oral hygiene
-mouth pain
-periodontal dz
-food of inappropriate texture
What may decreased creatinine levels indicate?
loss of muscle mass
What can a low hemoglobin indicate?
-inadequate iron intake
-chronic blood loss
What may a decreased globulin level indicate?
-insufficient protein intake
-excessive protein loss
Normal hemoglobin levels?
Male: 14-18 g/dL
Female: 12-16 g/dL
Pregnant female: 11 g/dL
What is a nursing dx concerning weight loss?
Imbalanced nutrition: less than body requirements
What are some general factors that can influence nutrition?
-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
Each degree of fever increases your caloric needs by __%?
What are some Planning/Goals for Weight loss?
-progressively gains weight toward desired goals
-lab values(albumin,H&H) are within normal limits
What are some interventions for Weight Loss?
-consult w/other professionals
-high protein supplements
-community resources:if can't prepare own food
-alternative feeding methods(enteral)
What should be documented concrning decreased nutritional staus due to weight loss?
-Intake records
*percentage eaten
-calorie counts
-specific probs,symptoms:not eating protein,etc.
NPO Diet
-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
Clear Liquid Diet
(can see through)
-provides hydration and simple carbs for energy needs
-does not provide protein,enough calories and other nutrients are missing
-tea,coffee-no cream
-clear juice:apple,grape,cranberry
-broth and jello
When can pt be progressed from clear liquid to full liquid diet?
When pt reports no nausea and has normal bowel sounds
Full Liquid Diet
-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
Mechanical Soft
-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
Pureed Diet
Any food item blended-often liquid added
Calorie restricted diet
-for weight loss
-# of calories specified
ex: 1800 calorie diet
Sodium Restricted Diet
-for bld pressure,fluid balance problems
-no salt added (NSA)
-Amount specified ex:2 g Na
Fat Restricted Diet
for clients w/ elevated cholesterol or triglyceride levels
Diabetic Diet
-used to manage calories and carbs
-ex: 1800 cal. ADA diet
Renal Diet
-used to manage electrolytes and fluid
-pts may be on fluid restriction
Protein Controlled Diet
-used to manage liver and kidney dz
Antigen avoidance diets
-for food allergies
-for food intolerances ex: gluten-free,lactose
Calorie-Protein Push
-wound healing
-for maintaining or increasing weight
-protein and fat added
-supplements may be addes
-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
What are the nursing dx's related to dysphagia?
-Impaired swallowing
-Risk for aspiration
Interventions related to Dysohagia?
Speak w/ doc about consult w/ speech-language pathologist.(can give exercises to help swallowing)
What are the 3 types of consistency for thickened liquids?
Positions for Feeding if pt has dysphagia?
-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
What are the 7 Levels of Activity?
-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
What are some reasons for bed rest?
-to decrease O2 comsumption
-to rest a body part and prevent damage
-equipment that needs to be on
-severity of condition
What is Hypercalcemia?
-elevated levels of calcium in the ECF
-calcium leaves the bone 4m lack of weight bearing and moves into the ECF czing hypercalcemia
What does Hypercalcemia cause and what does it lead to?
-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)
-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.
What is Orthostatic Hypotension?
-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
What could a position change cz in a person w/ orthostatic hypotension?
Who is orthostatic hypotension common in?
-those who are immobilized
-blood volume depletion
-certain meds.
How do you measure orthostatic hypotension?
-client supine for 2-5 minutes or more. Take BP and pulse.
-Repeat readings w/ pt sitting and standing
What is atelectasis?
-collapse of alveoli in the lungs
-czs decreased 02 transport to tissues
What is throboembolism?
-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
What can be a big risk factor for an Immobile person?
General nursing care of client w/ Mobility Problem?
~Recognizing hazards of immobility
~Preventing complications
-using techniques and equip.
What is Impaired Physical Mobility?
limitation in independent,purposeful physical mvmt of the body/extremity
Assessment for Impaired Physical Mobility?
-limited ROM
-slowed mvmt:uncoordinated or jerky
-gait changes
-postural instability
-mvmt induced SOB
Assoc. Nursing DX for Pyshosocial R/T Immobility
-Impaired social interaction
-body image disturbance
-self esteem disturbance
-older adults are at rick for confusion,depression,& disorientation and are especially susceptible to the hazards of immobility.
What does SCD stand for?
Sequential Compression Devices
Explain Dysphagia Screening at Bedside by RN
-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
-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)
Interventions for TPN
-tube insertion site
-diuresis and dehydration
-lab values
Parenteral Nutrition
commonly used IV fluids are low calorie and don't have protein or fat. Vitamins may be added(fluid looks yellow)
Enteral Feedings
-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
Nasogastric(NG) tube
-large bore
-small bore(Dubhoff)
-short term less than 6 wks
Gastric tube (G tube)
-4m incision in abdomen to stomach
-PEG(percutaneous endoscopic gastrostomy)
-jejunostomy(J tube):4m incision in abdomen to intestine
-PEJ(percutaneous endoscopic jejunostomy)
What are the safety concerns for feeding tubes?
-placement issues
-adequate nutrition
-tissue breakdown
-bacterial contamination
Placement of Feeding Tubes
-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
Markings to check on Nasogastric tubes
-check permanent markings
-check that tape is secure on nose
Markings to check on G tubes and J tubes
-check markings or measure length of tube protruding out of the abdomen
-check for intact sutures if present
Methods before using a feeding tube
-Insert air into NG tube while listening over gastric area w/ stethoscope
-Withdrawing stomach aspirate
-check for color
-determine pH
What is the normal pH for Stomach, Lungs and Intestine?
Normal Stomach pH is 0-4
Normal Lung pH is > 6 (bronchial tree)
Normal Intestine pH is 6-8
-Meds can raise stomach pH
What are the contributing factors of Dehydration?
-mental status
-decreased intake
-enteral feedings don't supply enough water
-many of the same factors as inadequate food intake
Assessment for Dehydration?
-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
Nursing Dx for Dehydration
-Deficient fluid volume
-Risk for deficient fluid volume
Interventions for Dehydration
-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
What is the Main way to prevent aspiration?
Check Residual
About residual
-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
Bed elevation to prevent aspiration for tube feedings?
-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
Pay attention to conc tube feeding?
-pay attention to s/s of delayed gastric emptying
-abdominal distention
-complaints of GI distress
Evaluate conc. tube feeding
-evaluate bowel sounds
-evaluate lung sounds and watch for s/s of respiratory problems
-increased temp
-adventitious lung sounds
Tissue Breakdown R/T tube feedings?
-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.
Inadequate nutrition r/t tube feeding
Evaluate intake
-monitor infusion regularly to make sure it's running at correct rate
-tubes can become clogged
-tubes can be left disconnected
Dehydration r/t tube feeding
-assess for signs of dehydration
-monitor lab values BUN,Hct
-give addtl water as ordered
Bacterial contamination r/t tube feeding
-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
Complications of tube feeding?
-tube becomes clogged
-irrigate routinely,and before & after giving feedings and meds
-tube can come out
-constipation:not giving enough fluids w/feeding
-start w/slower rate
-dilute formula
-obtain order for diff formula
Types of Nutritional Products
Formulas for diff. purposes
-pulmonary probs:pulmocare
~Some have partially broken down proteins
~diff calorie densities
~check labels for type,expiration date
~give at room temp.
Stage 1 pressure ulcer?
Nonblanchable erythema
-stays pink when blanched
-skin may feel boggy
Stage 2 pressure ulcer?
Partial-Thickness loss of epidermis.
-seen as blister
-when blister pops,usually crater underneath
Stage 3 pressure ulcer?
~Damaged to full-thickness of skin and into underlying tissue.
-NOT thru fascia.
-won't really see undermining or tunneling
Stage 4 pressure ulcer?
Full-thickness,tissue necrosis
-can extend to muscle and bone
-often see undermining or tunneling
Transparent Wound Dressings
use in superficial ulcers for little to no drainage; doesn't absorb much; can shower; impermeable to bacteria and water
Gauze Wound Dressings?
-sticks to wound,unless kept consistenly moist
-least effective
-don't use if lots of drainage
Hyrocolloid wound dressings?
-waterproof adhesive
-worn up to 7 days
-provides gel over wound,waterproof barrier
-good for autolytic debridement.
-prob is can't see wound
Hydrogel Wound Dressings?
-put in wounds
-absorbs exudate
-oxygen permeable
-require another dressing over it
-good for pressure ulcer
Alginate Wound Dressings?
-conform to wound surface
-can absorb up to 80% of exudate
Foam wound dressing?
-offers padding and absorption
3 Basic concepts of Oxygenation?
-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
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%
What is airway resistance?
-pressure diff b/w the mouth and the alveoli
-Influenced by:
*airway obstruction
*tracheal edema
Accessory Muscles?
-Increase lung vol. during inspiration
-Elevation of clavicles
What is the goal of ventilation?
-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%
What is hyperventilation?
-ventilation > that which is required to eliminate normal CO2 levels
-excess CO2 exhalation can lead to loss of consciousness
What does oxygen transport depend on?
-Ventilation(the amt of O2 entering the lungs)
-Perfusion(bld flow to the lungs)
-O2-carrying capacity:adequate hemoglobin
How is breathing controlled?
-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
O2 Carrying Capacity?
-Hemoglobin carries 97% of diffused O2
-O2 + hemoglobin=oxyhemoglobin
-O2 carrying capacity is decreased by:
*Toxic Inhalants
-carbon monoxide
Oxygen Saturation(SaO2)
-oxyhemoglobin saturation
-%age of hemoglobin combined w/ O2
-don't refer to respiratory rate, although rate is affected
-a person can hyperventilate w/ a slow respiratory rate
-ventilation inadequate to meet O2 demands or eliminate sufficient CO2
*Atelectasis:collapsed alveoli
-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)
-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
Pulmonary edema?
accumulation of fluid in lungs; will hear crackles in all lung fields
[Blood Flow Regulation]

-Cardiac Output(CO)
-4-7 L/min
-changes according to O2 demand
-Cardiac Output=Stroke Volume X Heart Rate
[Blood Flow Regulation]

-Cardiac Index(CI)
-adequacy of cardiac output for individual
-obtained by dividing CO by BSA
[Blood Flow Regulation]

Stroke Volume
-amt of bld ejected 4m L. ventricle w/ each contraction
-affected by preload and afterload
[Bld Flow Regulation]

-end diastolic volume
-ventricles stretch:more stretch=greater contraction & greater stroke vol.=Starling's law
[Bld Flow Regulation]

resistance to L ventricular ejection
< 60 beats/min; can be healthy in athletes
> 100 beats/min
Disturbances in Conduction
*deviation 4m normal sinus heart rhythm
*electrical impulses that don't result 4m the SA node
-Can result in:
*premature beats
*blocked beats(absent or delayed)
Alterations in Cardiac Function?
-disturbances in conduction:electrical discharge didn't go thru
-altered cardiac output
-impaired valvular function
-myocardial ischemia
Myocardial Ischemia?
-insufficient O2 to myocardium
-angina pectoris
-acute coronary syndrome
Myocardial Infarction?
-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)
MI Pain:Men
-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
MI Pain:Women
-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
What does Acute Coronary Syndrome(ACS) include?
-unstable angina
-Non-ST segment elevation MI
-ST segment elevation MI
-imbalance of O2 supply and demand to myocardium
Causes of Acute Coronary Syndrome?
-nonocclusive thrombus
-coronary vasospasm
-arterial narrowing
-infl or inf
-2ndary unstable angina
Risk Factors for Acute Coronary Syndrome?
-Over 70 w/:
*diatebetes mellitus(DM)
*extracardiac vascular dz(PVD)
*fixed Q waves
*previous abnormal ST segment and T wave changes
Pulse Oximetry?
-measures SaO2:reflects the % of hemoglobin molecules carrying O2
-place probe on nail bed,earlobe,nose or forehead:remove nail polish
Diagnostic Tests for Visual Respiratory Structures?
-chest x-ray:shows structure of lungs
-bronchoscopy:tube thru trachea to lung fields;can remove foreign objects,biopsy
-lung scan:CAT scan,dye
Diagnostic Tests for Abnormal Cells or Infection?
-throat cultures
-sputum specimens
-skin testing:TB
-thoracentesis:fluid removal 4m pleural cavity w/a needle,usually done @ bedside
What is respiration?
the exchange of gases(O2 & CO2) in the lungs.
What is ventilation?
mvmt of air into and out of the lungs thru the act of breathing.
What does the work of breathing depend on?
-rate and depth of breathing
-airway resistance
-accessory muscles:will see bulging neck muscles,intercostal contraction
What can the ability of the lungs to expand by affected by?
certains meds,conditions,etc
-ability of lungs to expand to increased intraalveolar pressure
-influenced by:
*pulmonary edema
*pleural fibrosis
*fractured ribs
Perfusion and Distribution?
-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
Exchange of Respiratory Gases?
-exchange occurs at alveoli and capillaries of body tissue
-method of transport is simple diffusion
-molecules move 4m area of greater to lesser conc
-affected by:
*thickness of the membrane
*cond of surface area:inflamed,inf,fluid,etc.
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
Neural regulators of respiration
-CNS controls rate,depth,rhythm
*cerebral cortex:voluntary control
*medulla oblongata: automatic control
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
3 alterations in respiratory function?
What are 8 factors that can affect oxygenation?
-decreased inspired O2 conc.
-increased metabolic rate
-conds affecting chest wall mvmt
-developmental factors
-behavioral factors
-environmental factors
What are some physiological thigns that can affect oxygenation?
-myocardial hypoxia
What is hypovolemia?
decreased bld volume,can be czed by trauma,occult bleeding
What are some conds that can affect chest wall mvmt?
-chest trauma
-fractured ribs
-spinal deformities
Behavioral factors that can affect oxygenation?
-panic attacks
Environmental factors that can affect oxygenation?
-air pollution
-high altitude
How to assess risk for Impaired Oxygenation?
health history:smoke,diet,allergies,
workhistory,asthma,illness,chemical exposure?
-respiratory history
-cardiovascular history
-environmental history
Assessment for Impaired Oxygenation? (history)
~productive or nonproductive
General Assessment for Impaired Oxygenation?
-environmental exposure
-respiratory infs
-risk factors
Physical Exam for oxygenation status?
*color:of skin,nail beds,pallor
*LOC:awake,alert,or groggy?
*respiratory rate
*breathing patterns:symmetrical
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
Assessment of respiratory effort?
-nasal flaring
-paroxysmal nocturnal dyspnea(PND)
-conversational dyspnea
What is paroxysmal nocturnal dyspnea(PND)?
sudden awakening due to SOB that begins during sleep
Palpation for assessment of oxygenation status?
-peripheral pulses
-skin temp:normal is warm,dry
-capillary refill:normal is brsk
Percussion for assessment of oxygenation?
detects presence of abnormal fluid or air in the lungs
Auscultation for assessment of oxygenation status?
-heart sounds:murmurs
-adventitious breath sounds
-msmt of BP
Systemic BP?
-lateral force on wall of artery by pulsing bld under pressure 4m heart
*peak of max pressure when ventricles contract
*minimal pressure exerted at all times when ventricles relax
What does systemic BP reflect?
reflects interrelationship of:
-cardiac output
-peripheral resistance
-bld volume
Factors affecting systemic blood pressure?
-age:hardening of arteries,plaque=inc.BP,could lead to stroke
-diurnal variations
How can diurnal variations affect systemic BP?
lower BP in AM,higher BP in PM
How can gender affect systemic BP?
women after menopause usually have higher BP
-older men also have higher BP
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
*realistic and measurable
Nursing Intervention:Maintaining Airway
-deep breathing and coughing
-artificial airways
Nursing Interventions: Mobilization of Secretions
-hydration:liquifies secretions
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:
*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
*realistic and measurable
Nursing Intervention:Maintaining Airway
-deep breathing and coughing
-artificial airways
Nursing Interventions: Mobilization of Secretions
-hydration:liquifies secretions
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:
*hemothorax:bld in lung
Incentive Spirometry
Goal:to max. inspiration-reinflate alveoli
-provides visual feedback to pt.
Nursing Interventions for oxygen administration
*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
Nursing Interventions for promotion of oxygenation
-nasal cannula
-nasal catheter
-oxygen masks
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
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
-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.
-nocturnal enuresis:bedwetting
-night terrors
-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
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
-slurred speech
-decreased reasoning
-deteriorated mental status
-psychotic behaviors
-decreased motivation
-increased sensitivity to pain
-stressful attitude
-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
*urinary frequency
*sensory overload
-coping,ineffective(fam or individual)
-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
-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
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
can mean internal organs involved
serous exudate drainage
clean wound
sanguineous drainage
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
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
-WBC count
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
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
-each side of body
nursing interventions r/t impaired skin integrity(necrotic material)
-remove necrotic material
*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
ntgomery straps