Kosier Week #7

Front 1

Restricted

Back 1

– These may be necessary for clients with fluid restrictions secondary to CHF, renal failure or other fluidsdiseases (p 8)

Front 2

Specific gravity (S.G.)

Back 2

– the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water taken as a standard (Kozier p 1466)

Front 3

Third space accumulation (third spacing)

Back 3

– fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid
· fluid in inflamed tissue or in the bowel
· burns or ascites
· May cause fluid deficit
·Watch for overload as fluid shifts back into vascular compartments (p 3)

Front 4

Diagnostic test –

Back 4

·Specific gravity
·Serum potassium
·Serum chloride
·Hematocrit
·Serum sodium
·Arterial blood pH (p 8)

Front 5

Identify the major functions of water in the body

Back 5

·Medium for transporting substances
·Important for cellular metabolism
·Helps maintain normal body temperature
·Aids digestion and elimination
·Lubricates the joints
·Helps maintain cell shape
(p 1)

Front 6

Identify major functions of electrolytes

Back 6

–
· Regulate water distribution (sodium)
·Transmit nerve impulses (calcium, potassium)
·Govern acid / base balance
p 2)

Front 7

State the main fluid compartments of the body

Back 7

·Intracellular fluid – found within the cells of the body

·Extracellular fluid – found outside of the cells (p 1)

Front 8

. Identify the major electrolyte of the compartments of the body:

Back 8

Extracellular compartment: sodium (Na+) is the major cation of this compartment

Intracellular compartment: potassium (K+) is the major cation of this compartment (p 2)

Front 9

Identify sources of fluids and electrolytes for the healthy individual

Back 9

–
(K+) bananas, figs, IV fluids, medications, oranges
(Na+) processed foods, table salt, bacon, ham (p 2)

Front 10

Identify the recommended oral fluid intake for a healthy adult as

Back 10

2000 ml per 24 hours.
1500 ml/day – largest amount - take in the form of coffee, soda, tea
750 ml/day – foods (water in foods) fruits, vegetables, lean meats
150 – 250 ml/day – metabolic oxidation – chemical reaction or water is the end product of oxidation. Occurs during metabolism of food substances (p 3)

Front 11

Describe factors that affect fluid and electrolyte balance.

Back 11

·Age – infants / children –
·Elderly
·Gender / body size – fat cells – less water than lean
·Environmental temperature
·Lifestyle reactions
·Illness fever – more fluids
·Medicines

Front 12

Identify routes through which water and electrolytes are eliminated from the body.

Back 12

·Urine 1400 / 1500 ml/day
·Insensible losses
(not easily measured) lungs–350–400 ml/day,
skin – 350– 400 ml/day
·Sweat 100 ml/day
·Feces 100 – 200 ml/day
Total = 2300 – 2600 ml/day
(p 4)

Front 13

List and describe the body’s adaptive mechanisms that help maintain fluid
balance.

Back 13

·Kidneys – primary regulators of fluids and electrolytes – maintained by selective retention and excretion of the kidneys
·Thirst – the simplest mechanism for maintaining fluid balance. Thirst accurs in individuals even as the resuls of small fluid losses.
·ADH – antidiuretic hormone – the hypothalamus senses low blood volume and increases serum osmolarity and signals the pituitary gland. The pituitary gland secretes ADH into the bloodstream. ADH causes the kidneys to retain water. Water retention boosts blood volume and decreases serum osmolarity.
·Thyroid gland – the thyroid gland increases metabolic rates and therefore increases need for fluids
·GI tract – absorption of fluids occurs in the GI tract
·Cardiovascular – this system pumps blood and can adapt to fluid levels
·Lungs – important in the acid – base balance
·Renin-angistensin aldosterone system –vasoconstrictor regulates blood pressure
(p 8 & 9)

Front 14

Identify information to be collected during a nursing history when assessing the client’s fluid need

Back 14

– history, physical assessment, clinical measurements and review of labs (p 5)

Front 15

State scientific principles in measuring liquids

Back 15

– must measure at eye level, measure at lowest level of meniscus, measure on a flat surface (p 6)

Front 16

State the purpose and nursing responsibilities in recording intake and output

Back 16

– Measuring intake and output is essential for evaluating fluid status and balance.
·Watch for trends to develop over 24 – 48 hours
·Ideally I = O
·Use ml for measure
·Use proper facility I & O form
·Output + 40 – 80 ml/hr
·May check hourly in the ICU
·Remind client and family –anything given needs to be counted (p 5)

Front 17

State data indicative of dehydration.

Back 17

·c/o dizziness
·decreased urine output
·increase thirst
·fever
·dry mucous membranes
·poor skin turgor
·specific gravity 1.030
·increased heart rate and decreased blood pressure
·increased HCT
·increased urine concentration (p 7)

Front 18

.Describe therapeutic nursing interventions that assist in preventing dehydration

Back 18

– teach warning signs to patient and family; identify those at risk - infants, elderly (p 7)

Front 19

Describe therapeutic nursing interventions which reduce the discomfort caused bydehydration

Back 19

·aim to replace missing fluids
·encourage oral fluids
·intravenous fluids prn
·monitor vital signs
·accurate intake and output
·insert foley catheter if needed
·daily weights
·oral and skin care (p 7)

Front 20

Describe the purpose of and nursing implications associated with weighing a
client

Back 20

– daily weights provide relatively accurate assessments of a client’s fluid status (p 5)

Front 21

Define the following nursing diagnoses and identify their defining characteristics or risk factors:

Fluid volume deficient

Back 21

– decreased intravascular, interstitial, and or intracellular fluid. This refers to dehydration.
·Extremes of age
·Knowledge deficit regarding fluid volume
·Medications
·Excessive losses through diarrhea
·Indwelling tubes (p 9 & 10)

Front 22

Fluid volume deficient:

Back 22

– hypovalemia - an abnormal reduction in blood volume (p 9) – at risk for experiencing vascular, risk for cellular or intracellular dehydration (p 10)

Front 23

Fluid volume excess

Back 23

– increased isotonic fluid retention
·Jugular vein distention
·Rapid weight gain
·Shortness of breath
·Abnormal lung sounds
·Restless
·Anxious
·Increased CVP
·Decreased HCT
·Impaired respiratory status (p 10)

Front 24

Identify therapeutic nursing interventions and scientific rationale that assist in
Fluid volume deficient:
Fluid volume excess
nursing diagnosis

Back 24

·Monitor daily weights for any sudden changes – body weight changes reflect changes in body fluid volume
·Monitor lung sounds for crackles – pulmonary edema results from excess shifting of fluid from the vascular space into the pulmonary interstitial space (p 10)

Front 25

Identify and describe the significance of diagnostic tests used to monitor fluid,
electrolyte, and/or acid-base balance:
urine specific gravity

Back 25

1.010-1.025
·Indicator of urine concentration
·Easily and quickly performed
·When concentration of solutes high, specific gravity increases (p 8)

Front 26

Identify and describe the significance of diagnostic tests used to monitor fluid,
electrolyte, and/or acid-base balance: hematocrit HCT

Back 26

35 – 50%
·Volume of RBC in plasma
·During dehydration, HCT increases
·During fluid overload, HCT decreases

Front 27

serum potassium (K)

Back 27

3.5 – 5.0 mEq/L

Front 28

serum sodium (Na)

Back 28

135 – 145 mEq/L

Front 29

serum chloride (Cl)

Back 29

95 – 105 mEq/L

Front 30

arterial blood pH

Back 30

7.35 – 7.45

Front 31

Aspiration: Defined-Risk for

Back 31

entry of gastrointestinal secretions, orpharyngeal secretions, solids or fluids into the tracheobronchial passages. [Conf pg 3]

Front 32

Aspiration: Risk factors

Back 32

- increased intragastric pressure; tube feedings; situations hindering elevation of upper body; reduced level of consciousness; presence of tracheostomy or endotracheal tube; medication administration; wired jaws; increased gastric residual; incomplete lower esophageal sphincter; impaired swallowing; gastrointestinal tubes; facial, oral, or neck surgery or trauma; depressed cough and gag reflexes; decreased gastrointestinal motility; delayed gastric emptying. [Conf pg 3]

Front 33

Self-care deficit: feeding:

Back 33

Defined Impaired ability to perform or complete feeding activities. [Conf pg 4]

Front 34

Self-care deficit: feeding:
Defining Characteristics-

Back 34

Inability to swallow food; inability to prepare food for ingestion; inability to handle utensils; inability to use assistive devices; inability to get food onto utensils; inability to open containers; inability to manipulate food in mouth; inability to complete a meal; inability to digest food in a socially acceptable manner; inability to pick up a cup or glass; inability to digest sufficient food. [Conf pg 4]

Front 35

·Preparing client for meals

Back 35

- Toilet client, assist with hand washing, oral care, transfer to the dining room. Cover clothing with napkin / protective cover. Decrease clutter, decrease odors, and increase light. Make sure glasses, hearing aid in place. Use dentures. [Conf pg 21]

Front 36

· Preparing tray

Back 36

–Double check correct diet order on tray. Open packages, butter bread, cut portions up etc [Conf pg 21]

Front 37

·Feeding dependent client

Back 37

-offer food separately, alternate types of food offered; avoid rushing, nurse should sit at eye level. [Conf pg 21]

Front 38

·Using adaptive equipment as necessary

Back 38

–Use of straw if not contradicted or special/large handled cups, wide-handled/built-up utensils, skid proof/suction mat or bowel, scoop dishes, plate guards, rocker knives. [Conf pg 21]

Front 39

Describe and demonstrate the therapeutic nursing interventions involved in preparing the environment and preparing and / or assisting a client to meet the need for nutrition.

Back 39

Assist the client to a Fowlers position in bed or a sitting position in a chair, the normal position for eating. If a sitting position is contraindicated, a slightly elevated right side-lying position is acceptable. These positions enhance the gravitational flow of the solution and prevent aspiration of fluid into the lungs. [Kozier pg 1211]

Front 40

Describe the purpose of liquid thickness (Thick it).

Back 40

–Agent used to thicken the consistency of a liquid or food for clients with swallowing problems. These products, when mixed in liquid, produce the desired consistency quickly, easily and controllably without changing the taste or appearance of the liquid it thickens. These products are generally nonfat and low in sodium, but they do provide some carbohydrate calories. “Thick-it” is a brand name of a product used locally. The product is adjustable to make a nectar, honey or pudding consistency. [Conf pg 7]

Front 41

·Aspiration

Back 41

– At risk for entry of gastrointestinal secretions, orthopharyngeal secretions, solids, or fluids into the tracheobronchial passages. [Conf pg 3]
(The withdrawal of fluid that has abnormally collected (e.g. pleural cavity, abdominal cavity) or to obtain a specimen (e.g. cerebral spinal fluid)

Front 42

·Enteral feeding tube

Back 42

– Feeding administered through nasogastric and small-bore feeding tubes or through gastrostomy or jejunostomy tubes. [Conf pg 3]

Front 43

·Nutritional supplement

Back 43

– Vitamins and other nutrients that may not be necessary for health y adults with an adequate intake of nutrients but that may be necessary under certain circumstances for elderly adults or individuals in a debilitated or undernourished state. [Conf pg 3]

Front 44

·Nasogastric tube (N/G)-

Back 44

Inserted in through one of nostrils, down the nasopharynx and into the alimentary tract. [Conf pg 5]

Front 45

·Gastrostomy tube (G-tube)

Back 45

-Tube inserted directly into stomach by a surgical opening through
the abdominal wall. [Conf pg 5]
G-tubes are surgically inserted through the side of the abdominal wall. A small hole is created on the left side of the abdomen, leading directly into the stomach. A Foley catheter will likely be placed until the incision heals, at which time a more permanent and convenient button will be placed.

Front 46

·Jejunostomy tube (J-tube)

Back 46

– tube inserted into the jejunum by a surgical opening through the abdominal wall [Conf pg 5]J-tubes are surgically inserted through the side of the abdominal wall. Similar to the gastronomy a jejunostomy is performed by creating a small hole on the right side of the abdomen leading into the jejunum.

Front 47

·PEG tube

Back 47

–Catheter placed through the skin with the aid of an endoscope. Internal and external bumpers and a retention balloon are common components of the tube.

Front 48

What happens during the PEG procedure?

Back 48

During the procedure, a physician places an endoscope (a long, thin, flexible instrument about 1/2 inch in diameter) into your mouth. The endoscope is then advanced through your esophagus (the "food pipe" leading from your mouth into your stomach) and into your stomach. The endoscope is used to ensure correct positioning of the PEG tube (also called a feeding tube) in your stomach. The PEG tube rests in the stomach and exits through the skin of the abdomen

Front 49

Describe the care of the skin around a G-tube

Back 49

G-Tube-
·Ensure client safety.
·After the feeding, ask the client to remain in the sitting position, or a slightly elevated right lateral position for at least 30 minutes. This minimizes the risk of aspiration.
·Assess status of peristomal skin. Gastric or jejunal drainage contains digestive enzymes that can irritate the skin.
· Document any redness and broken skin areas.
·Check orders about cleaning the peristomal skin, applying appropriate dressings Generally, the peristomal skin is washed with mild soap and water at least once a daily.
·Petroleum, zinc oxide ointment or other skin protectant may be applied around the stoma, and pre-cut 4-in.x 4in. gauze squares, and the tube is coiled over them. [Kozier pg 1214-1215]

Front 50

Describe the care of the skin around a Nasogastric tube

Back 50

-
Establish a plan for providing daily nasogastric tube care.
Inspect nostril for discharge and irritation.
Clean the nostril and tube with moistened, cotton tipped applicator.
Apply water-soluble lubricant to the nostril if it appears dry or encrusted.
Change the adhesive tape as required.
Give frequent mouth care.
The client may breath through the mouth and cannot drink. [Conf pg 5]

Front 51

State the rationale for tube feedings.

Back 51

–When a client is unable to digest foods or the upper gastro intestinal tract is impaired and the transport of food to the small intestine is interrupted. [Conf pg 11]

Front 52

State therapeutic nursing interventions and associated rationale for administering a tube feeding via:
·Gravity
·pump

Back 52

- Often called a kangaroo pump, this type of infusion pump guarantees a constant flow rate
-

Front 53

Guidelines for administering medications via feeding tube [Conf pg 15]

Back 53

·Check to make certain that medication order contains the correct route “via feeding tube”.
·You cannot administer a medication ordered as “po” via a feeding tube as it is not administering the medication by the ordered route.
·You may need to have the medication order rewritten by the Primary Care Physician.
·Administer the medication in a liquid form when possible.
·Tablets should be finely crushed if crushing does not interfere with the medications actions. (Check with the pharmacist or medication guide)
·Dilute the crushed tablets adequately with warm water (not hot) before administration. Liquid meds. Are not diluted.
·Flush the tube with 30 ml of warm water prior to administering the medication and with a 30-50ml of warm water after all the medications have been administered.
·If administering multiple medications through the tube, it is recommended that they be administered separately. Flush after each medication with 5-10 ml. This prevents the medications from precipitating and possible clogging your tube.
·Don’t mix medications with the feeding formula. Continuous feedings should be stopped and tube flushed prior to medication administration.
·Remember, medications are a frequent cause of tube blockages

Front 54

Demonstrate tube feeding techniques:
-Enteral tube feeding using feeding bag / syringe
-Administration of a medication via a feeding tube
-Procedure Guidelines as done in Class [Conf pg 16]

Back 54

1.Verify medication order by checking medication, amount to be given, time and expiration date.
2.Select and prepare accurate medication.
3.Ensure identification of client.
4.Assess tube placement.
5.Check residual.
6.Remove plunger from syringe and connect syringe to clamped NG tube.
7.Flush tube with 30ml of warm water
8.Administer medication.
9.Follow medication with flush of 30-50ml of warm water
(Some hospital polices state to instill 10-20ml of air after the warm water.)

Front 55

State the therapeutic action, method of administration, side / adverse effects and Nursing implications of multiple vitamin preparations.
[Conf pg 9]

Back 55

·Therapeutic action: Prevention of vitamin deficiency or as a replacement of Vit. A, B, E, and most water-soluble Vitamins
·Method of administration: PO or IV infusions
·Side / adverse effects: Rare. Possible allergic Rx to preservatives, additives or colorants
·Nursing implication:
1.Assess for signs of nutritional deficiency throughout therapy
2.Chewable tablets should be crushed or chewed prior to swallowing
3.Liquid preps may be dropped directly into mouth or mixed with juice or cereal

Front 56

Identify therapeutic nursing interventions, which prevent aspiration from occurring.Therapeutic nursing interventions
prior to initiating tube feeding Assess:

Back 56

1.Vital signs Bowel signs
Abdominal distention
Placement
Gastric residual
Lung sounds
2.Color tube feeding blue or green to solution if agency procedure.

Front 57

Therapeutic nursing interventions during tube feeding

Back 57

1.Assess respiratory rate
Rhythm Quality
2.Check for nausea and vomiting, diarrhea
3.Position-HOB elevated 30’-40’
4.Assess for signs of impaired swallowing or aspiration
Coughing,Choking,Spitting,food
Excessive drooling

Front 58

Additional preventative therapeutic nursing interventions for
tube feeding

Back 58

1.Keep suction machine available, suction prn
2.Keep HOB up during and at least ½ hour after feeding
3.Stop feeding while turning or moving
4.Check secretions suctioned or coughed from respiratory tract that would indicate aspiration.

Front 59

Demonstrate how to measure a weight of an ambulatory client.

Back 59

-Wash hands
-Enter room and identify self to client
-Explain to client what you’re going to do
-Check that scale is balanced
-Assist client to step up to the scale and to stand without aides support
-Determine weight by adjusting weights until scale balances
-Report results within +1lb of reading
-Assist client off the scale [Conf pg 18]