Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
124 Cards in this Set
- Front
- Back
(Diet Therapies)
What is mechanical soft diet? |
used with clients having difficulty chewing or unable to throoughly chew food. It makes the food softer than the "soft diet".
-Pureed-blenderized to smooth consistency (like baby food) -low residue=reduced fiber and cellulose.(diverticulitis patients and crohn's disease) -High fiber=raw veg & fruits, seeds, plant fiber, whole grains.(patients with constipation or diarrhea) -liberal bland=free of chemical and mechanical food irritants(no acid, alcohol, caffeine, fried foods) -fat controlled=reduce toal fat(cardiac patients & weight loss patients) -sodium & potassium restriction=used for hypertension, cardiac and renal patients |
|
The evaluation of pain......
|
-Should be ongoing
-focuses on the client's subjective reports |
|
Clients taking pain medications will become addicted to the drug?
|
False
|
|
What type of nursing assessment is done for Sleep and rest disorder?
|
-Nature of problem
-quality of the problem -Environmental factors -Associated factors (food, activity, anxiety level, pain, routines) -Alleviating factors -Effect of the problem. |
|
What type of a diet would someone who has renal failure be on?
|
Sodium-restricted diet
and low potassium diet. |
|
What nursing diagnosis is used for Sleep/Rest problems?
|
Sleep Pattern Disturbance
|
|
What is the physiology of sleep?
|
It is controlled by the centers in the brain.
Influenced by routines and environmental factors |
|
(Common Sleep Disorders)
What are parasomnias? |
Activation of physiological systems-sleepwalking, bed wetting, teeth grinding.
|
|
What is bowel elimination?
|
Eliminates solid wastes
(80% of what you eat today is excreted in 5 days) |
|
What are the implementations for Pain?
|
pharmacologic: (medications) Start with non-narcotic and then go up
Nonpharmocologic: -Touch -Distraction -Relaxation tech. -Cutaneous stimulation (cryotherapy(heat/cold), TENS -Exercise |
|
What is regression?
|
Return to a less mature behavior to solve a conflict or problem.
|
|
What diet would somebody who has obesity be on?
|
low fat diet
|
|
After REM sleep the cycle starts over at what point?
|
NREM 2
|
|
Name the four stages of Non-rapid eye movement sleep.
|
Stage 1-light quality, lasts 10 min.
Stage 2-50% of normal adult sleep. Stage 3-medium-depth sleep Stage 4-Sleepwalking, night terrors (kids). * The growth hormone peaks between levels 3 and 4. |
|
Outcomes of stress are?
|
Adaptation:Ongoing process by which individuals adjust to stressors to achieve homeostasis (equilibrium between physiological,psychological, sociocultural, intellectual, and spiritual needs.
Maladaptation: When coping mechanisms are ineffective. Eustress: Results in positive outcomes. Distress: Ineffective response. |
|
What are the nursing interventions for elimination?
|
-Ensure adequate fluid intake (1.5-2 L/QD)
-Avoid bladder irritants (caffeine, juice) -Encourage regular elimination patterns -Encourage exercise(constipation) -Monitor skin itegrity -Increase fiber in the diet (constipation) -Assess for bladder distension and catheterization -Positioning: sitting vs. standing -teaching proper hygeine (wiping from front to back) - |
|
Most complaints of pain are purely psychological?
|
False
|
|
(Diet Therapies)
What is mechanical soft diet? |
used with clients having difficulty chewing or unable to throoughly chew food. It makes the food softer than the "soft diet".
(Example: Pureed, blenderized) |
|
Clients minimize pain behaviors because it isn't macho to show pain?
|
False
|
|
What are the nursing diagnosis for pain?
|
Acute pain-less than 6 months
Can be cured or eleviated. chronic pain-greater than 6 months. No anticipated end for chronic pain. |
|
Potential tissue damage is always associated with pain?
|
True
|
|
What is stress?
|
It is a univeral experience.
It can cause a positive change or discomfort and pain. *stress management necessary for the wellness of the nurse as well as the client. |
|
(Diet Therapies)
What is a high-fiber diet? |
Raw Veg & fruits, seeds, plan fiber, whole grains
(patient with constipation, or diarrhea) |
|
Defense Mechanisms to stress
are.......... |
Denial
Rationalization Repression Displacement Reaction formation Supression Projection Regression Undoing |
|
(Common Sleep Disorders)
Insomnia is defined as? |
Chronic inability to sleep.
|
|
What are the common alterations in bowel elimination?
|
-constipation(infrequent and difficult passage of stool)
-fecal impaction (stool hard) -diarrhea (liquid stool) -fecal incontinence (Involuntary loss of stool) -flatulence(gas) -hemorrhoids(Perianal variacosity of the hemorrhoidal veins) -ostomies |
|
How long does the sleep cycle last?
|
70-90 minutes.
|
|
What are the nursing implications for moderate anxiety?
|
Help the client to determine a cause-and-effect relationship between stressor and anxiety.
|
|
What is displacement?
|
Transferring the emotional feeling from one object to another.
|
|
(Diet Therapies)
What is a sodium and potassium restriction diet? |
It is used for hypertension, caridac and renal patients.
|
|
Clients with severe tissue damage experience severe pain; those with less damage have less pain?
|
False
|
|
regulation
sensory/perception/cognition feeling These are all pertain to what? |
Stess
|
|
(Diet Therapies)
What is a fat controlled diet? |
reduced total fat.
(cardiac patients or patient who want to loose weight) |
|
Stress related disorders..........
|
either occur or increase during periods of stress.
|
|
What are the safety considerations for nutritional support?
|
-assess the client for signs of gastric retention.
-Monitor feeding tube placement. -Assess client for pulmonary aspiration.(color & consistency of the sputum. -keep the client in a high Flowler's position. -dlute feedings to half strength and slow the feeding time to prevent diarrhea. |
|
What are some factors affecting sleep and rest?
|
Degree of comfort
Anxiety Environment Lifestyle Diet Drugs Culture Age |
|
What is the reaction formation?
|
Develops conscious attitudes opposite of real unconscious attitudes.
|
|
Nursing Interventions for Nutrition are?
|
-Weigh patient daily (same time each day)
-Record I & O -Promote patient participation in dietary planning. (are they able to put the food in their mouths?) -Encourage the client to verbalize feeling concerning food (encourage meal planning) -provide nutritional support as needed (some hospitals requre an order for a dietician) -Discuss realistic goals for weight loss. -Discharge planning (can they go buy the food themselves? Or can food be delivered? call social services for "Meals on wheels" |
|
What are the nursing diagnosis for elimination problems?
|
-altered urinary elmination
-bowel incontinence -constipation -diarrhea -incontinence (functional, stress, etc.) -urinary retention -self-esteem disturbance -knowledge deficit -risk for infection -skin integrity -self care deficit: toileting |
|
lab value for BUN?
|
10-20mg/dl
|
|
What is the definition of stress?
|
Stress is the reaction of the body to any stimulus. The wear and tear on the body.
|
|
What is a stressor?
|
Any situation, event or agent that threatens a person's security.
a. Evokes need to adapt |
|
What is the pattern of the sleep cycle?
|
NREM 1
NREM 2 NREM 3 NREM 4 NREM 3 NREM 2 REM |
|
What is projection?
|
Denies the problem as well as blames others.
|
|
Can a person with hemorrhoids still have a rectal temperature taken?
|
Yes. Incombant position
|
|
How do you determine which route of nutrition support to use?
|
-The patients GI function
-Expected duration of therapy -Aspiration risk -Potential for or actual development of organ dysfunction. |
|
Common alterations in Urinary elimination are:
|
-urinary retention
-urinary tact infection (UTI) -Urinary incontinence (inability to control urine) -Enuresis(uncontrollable release of urine) -Ureterostomies -nocturia (urination during sleep) -polyuria(frequent urination) -oliguria (low urination) -anuria (no urine) -hematuria (blood in urine) -proteinuria (protein in urine) -pyuria (puss in urine) -bacteriuia (bacteria in urine) |
|
Nursing Diagnosis used for Nutrition are?
|
-Altered nutrition: less than body requirements.
-Altered nutrition: more than body requirements. -Other diagnosis: skin integrity impaired R/T inadequate intake of proteins. |
|
What are the nursing implications for severe anxiety?
|
Encourage verbalization, Engage in motor activity,
Give specific directions. |
|
Clients minimize pain behaviors because they want to be a good patient?
|
True
|
|
(Common Sleep Disorders)
What is sleep deprivation? |
Prolonged inadequate quality/quantity of sleep
|
|
What are the two routs of nutritional support?
|
Enteral nutrition
Parental nutrition |
|
What does a nurse Assess when she is doing a pain Assessment?
|
-Intensity(1-20 scale, Oucher, Wong-Baker)
-Location(What to treat, help DX, help with testing and meds.) -quality(sharp, dull, continuous) -Associated manifistations -Aggravating factors (what makes it worse?) -Alleviating factors (What makes it better?) -Scales |
|
If pain is ignored, it will go away?
|
False
|
|
(Common Sleep Disorders)
What is sleep apnea? |
pauses in breathing of 30-60 seconds with loud snoring episodes.
|
|
When clients are exhausted, they have increased pain?
|
True
|
|
(Impact of Illness and Treatment)
Change evokes stress response and any change results from? |
Change in environment
Loss of control Dependence on others |
|
How many stages of sleep are there?
|
Two stages of sleep
Non-Rapid Eye Movement (NREM) has four stages Rapid Eye Movement (REM) has one stage only |
|
Distraction does not work for pain?
|
False. It does work
|
|
(Diet Therapies)
What is NPO? |
Nothing by mouth
|
|
(Impact of Illness and Treatment)
*Change evokes stress response |
Example: hospitalization, surgery, family problems, lack of income, test.
|
|
What is Crisis?
|
It is an acute state of disorganization.
Occurs when the usual coping mechanisms no longer work. Characterized by: Extreme anxiety Inability to function Disorganized behavior Crisis is usually time limited and intervention is necessary for a resolution. |
|
What is undoing?
|
An unconscious attempt to make up for the past actions.
|
|
Pain is a real experience that needs to be treated?
|
True
|
|
What is enteral nutrition?
|
It provides luqiefied food and nutrients orally or into the GI tract through a gastrointestinal tube.
(Ex: tube feedings, nasogastric, peg tub (stomach), Jejunum tube. |
|
(Diet Therapies)
What is mechanical soft diet? |
used with clients having difficulty chewing or unable to throoughly chew food. It makes the food softer than the "soft diet".
|
|
What are the factors affecting elimination:
|
-age
-diet -exercise -medications -personal elimination habits -disease process -emotional stress |
|
Pain is a subjective experience?
|
True
|
|
What is urinary elimination?
|
Filters & excretes urine, this maintaining fluid, electrolytes, and acid-base balance.
|
|
What are the two types of elimination?
|
Urinary
Bowel |
|
List the Food Guide Pyramid
|
-Bread, pasta, rice, cereal
(6-11 servings) -Fruit (2-4 servings) -Vegetables (3-5 servings) -Meat, poultry, fish, dry beans, eggs, nuts: (2-3 servings) -milk, yogurt, cheese (2-3 servings) -Fats, oils, sweets (use sparingly) |
|
What is sleep?
|
It is a state of altered consciousness
Minimal physical activity Slowing of the body's physiological process |
|
Most clients report honestly on their perception of pain?
|
True
|
|
(Common Sleep Disorders)
What is hypersomnia? |
Excessive daytime sleep
|
|
(Common Sleep Disorders)
What is narcolepsy? |
sudden, uncontrollable desire to fall asleep during the day-time.
|
|
(Nutrition)
What are the factors affecting nutrition? |
-Age
-Lifestyle -Culture -Religious practices -Economics -Health status (dentures, short of breath) |
|
What are the steps in assessment for elimination?
|
-Health history
-physical examination (bladder palpate bladder, distended bladders? skin integrit, rash, infection, drainage? -laboratory test (UTI,occult blood, O/P, WBC, CDIFF, Dip-stick) -diagnostic tests: *ultasound *renal scan *cystoscopy *biopsy *proctoscopy, sigmoidoscopy *urinalysis(culture & sensitivity) *X-ray-KUV *Barium enema |
|
What is a parental nutrition?
|
Nutrients entering the blood directly; infusion of a solution into the vein.
(TPN) Total parenteral nutrition (PPN) peripheral parenteral nutrition (short-term) lower concentration & lower glucose. |
|
Other nursing interventions to stress?
|
Stress management:
exercise relaxaton tech./biofeedback Guided imagery Thought reframing or thought stopping crisis intevention |
|
What are the nursing interventions for stress?
|
Teaching-stress management techniques; how to reduce their own levels of stress.
Meet basic needs (Ex: cold, hungry, in pain) Decrease environmental stimuli Involve family/significant others. |
|
(Diet Therapies)
What are soft diets? |
nuts, seeds, raw fruits & vegetables, fried, and whole grain foods avoided.
|
|
What is rest?
|
It is mental and physical.
State of relaxation, calmness Examples: Lying down, reading a book, quiet walk. |
|
(Diet Therapies)
What are full liquid diets? |
Any liquid
(Example: cream of wheat) |
|
What type of diet would a person with Gastritis be on?
|
bland diet
|
|
Why is a client advised to increase the amount of fiber-rich foods in the diet?
|
Dietary fiber may prevent constipation and increase the desire to defecate.
|
|
What food or substances may irritate the bladder?
|
-cafeinated beverages, carbonated beverages, and acidic fluids (coffee and tea)
-aspartame -citrus fruits and juices -foods containing tomatoes or tomato-bases sauces -chocolate -greasy or spicy foods. |
|
(Diet Therapies)
What is a liberal bland diet? |
free of chemical & mechanical food irritants (no acid, alcohol, caffeine, fried foods)
|
|
(Diet Therapies)
What is Low-residue? |
Reduced fiber and cellulose
(for client who has diverticulitis, Crohn's disease. |
|
(Diet Therapies)
Pureed is? |
blenderized to smooth consitency (like baby food)
|
|
What are the parts of the nutritional assessment?
|
-Need to know diet history/ ability to chew/swallow
-24 hour recall of (intake) was this normal for them or abnormal for them? -height, weight, physical appearance. -lab date: albumin(3.5-4.8g/dl) hemoglobin (M=14-18gm/dl, F=12-16gm/dl) bun=(10-20mg/dl) |
|
Lab values for Albumin?
|
3.5-4.8g/dl
|
|
lab values for hemoglobin?
|
M=14-18gm/dl
F=12-16gm/dl |
|
What are the parts of the nutritional assessment?
|
-Need to know diet history/ ability to chew/swallow
-24 hour recall of (intake) was this normal for them or |
|
If a patient has poor fitting dentures, what type of diet would they be on?
|
mechanical soft
|
|
What is the Wong/Baker scale?
|
It is used for 3-12 year olds.
Also developmentally delayed Cultural differences. The Wong/Baker scale has faces that rate the pain on a scale of 0-5 |
|
What is 1-10 numeric pain scale?
|
It is another type of scale that shows the intensity of pain on a scale.
0-no pain 5-moderate pain 10-worst possible pain |
|
What is pain?
|
The presence of severe discomfort ad an uncomfortable sensation.
-It is the 5th vital sign. -Pain can aler regulation. -Pain is part of sensory/perception/cognition |
|
The nurse is the best judge of a client's pain?
|
False
|
|
Nursing Interventions for Sleep problems.
|
-Create a relaxing and comfortable environment.
-Establish a trusting nurse-client relationship. -Appropriate nutrition -Pharmacologic interventions (Ex: unrelieved pain) -Relaxation techniques -Client education. |
|
What happens during (REM)
rapid eye movement sleep? |
Adult nightmares
flaccid muscles dreams occur 20-25% of the sleep. |
|
What are the nursing implications for panic anxiety?
|
Provide limits and structure, maintain client safety (both physical and psychological).
|
|
Sleep and Rest are part of the Regulation category.
Sleep and rest varies with what? |
Age level
Activit level developmental level cultural norms |
|
(Stress and Illness)
What are stress related disorders? |
asthma, HTN, ulcer, hives, migraine headaches, GI distress.
|
|
Is anxiety healthy?
|
Yes. Some anxiety is healthy.
|
|
What are the nursing implications for mild anxiety?
|
This is an optimal time for client teaching because of heightened awareness and increased perceptual field.
|
|
What are the levels of anxiety?
|
Mild-Increased degree of alertness and increased vigilance.
Moderate-Subjective distress, decreased perception and attention Severe-Increased subjective distress, selective attention, distorted perception. Panic-Major perceptual distortion, Immobilization; inability to function, impaired communication. |
|
What is Denial?
|
Refuses to accept reality
|
|
Explain Anxiety.
|
It is the most common emotional (affective) response to stress. When feeling threatened (perceived or real)
Occurs on a continuum: some is healthy, until it impairs thinking & functioning. |
|
When does anxiety become unhealthy?
|
When it impairs thinking & functioning.
|
|
What is rationalization?
|
Explains or justifies feelings or behaviors.
|
|
What is suppression?
|
conscious attempt to forget or store painful thoughts.
|
|
What is repression?
|
Unconscious way of forgetting painful thoughts.
|
|
What type of diet would someone with diverticulitis be on?
|
low-residue diet
|
|
Stess is the physiological reponse and anxiety is the ..............response
|
psychological
|
|
What are the stages of GAS
(Selye's General Adaption Syndrome)? |
Alarm-(Fight or Flight Response). Activation of the sympathetic Nervous System.
Resistance: Physiolocal forces are mobilized to increase resistence to stress. This is when adaptation occurs. Exhaustion: disease, collapse,death. |
|
What is Selye's General Adaption Syndrome (GAS)?
|
It is the body's reponse to stress (physiological). GAS is the same whether the stressor is real or imagined, present, or potential.
*The mind can imagine a stessor, and the physiological response will be the same. |
|
Name dfferent types of stressors.
|
Internal (headache)
External (Well-Elder report) Physical (Impacted tooth) Pysiological (Diabetes) Psychological (sick child, divorce) |
|
Stressors are neither bad nor good because.....
|
The individual's perception determines if the outcome will be positive or negative
|
|
What determines if a stressor is bad or good?
|
Perception of the stress
|
|
What is stress response?
|
The psychological response. It is also anxiety.
|
|
What is anxiety?
|
It is a subjective response when a person feels threatened to their well-being; a diverse feeling of dread or apprehension.
|
|
What type of diet would someone with ulcerative colitis be on?
|
Low residue
|
|
What type of diet would someone with diverticulitis be on?
|
High fiber
|
|
(Diet Therapies)
What are clear liquid diets? |
No risidue liquids
(Example: 7-up, water, jello) Liquids that you can see thru |