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fundamentals of nurs. NU114 test 1 notes pt 1.

Terms in this set (182)

what factors influence adolescent dietary intake
body image
independance
fad diets
name 2 meds that may be administered to help stimulate appetite
periactin and
megace
what are the different types of diets
regular-nutritionally adequate
soft-easily digestible
clear liquid-tea,coffee,water,broth, bouillon, clear juice,see thru it
full liquid- all liquids,smooth text dairy,cooked cereal,veggie juice
mechanical soft-ground,finely chopped meats,patients w/o teeth
diet for age-3 months old get formula
vegetarian-diet consists of plant food, some eggs , milk, =anemia
high fiber-
diabetic-low sugar
low sodium
low residue-low ruffage.
what should you asses for as far as nutrition for school aged children
adequate intake of protein and vitamines A and C
what are the protein needs for pregnant and lactating clients, calcium, iron, and fluids needs per day?
proteins: 60 grams/day
calcium: 1000mg/day
iron: 27mg/day
iodine, B vitamins and at least 8 glasses of fluid per day
describe adult dietary needs
dietary needs are for energy maintenance and repair (need fewer kcals)
hypernatremia
greater than normal concentration of sodium in ECF that can be caused by excess water loss or an overall sodium excess
hyponatremia
lower than normal concentration of sodium in the blood that can occur with a net sodium loss or net water excess.
fat
form of stored energy
what are the basic nutrients that sustain the body
water-is a critical necessity in the body because cell function depends on a fluid environment 60-70% of total body wiehgt.
carbohydrates-main source of energy "fuel"
proteins- source of energy, essential for tissue growth, maintenance and repair
fats-body's form of stored energy. unsturated are the best.
vitamins-essential to normal metabolism and are pbatined through dietary intake.
a critical necessity in the body because cell function depends on a fluid environment
water
main source of energy in diet source of fuel
carbs
what does iron promote?
hemoglobins
enteral
tube feeding
why are imobolized clients at risk for fx (fractures)
being imobolized can cause calcium to leave the bones
how can you assist clients who are blind to eat?
foster independance
always ask what they would like to have offered
may relate food on the plate to that of a clock
how does the body obtain water?
how doe it lose water?
hypothalamus creates the desire for water=thirst
oral, IV
loss through skin, lungs, kidneys
how much do you lose of fluids through the lungs and what kind of loss is this
400mL
insensible loss
what constitutes a well nourished patient
turgor-skin snaps back when pinched
pink skin
good bowel movement
source of energy essential for tissue growth maintenance and repair
protein
affects the bodys ability to heal, fight infections may prolong confinement to the bed because of decreased energy level
malnutrition
examples of minerals
calcium- bone and teeth formation
phosphorus-bones and teeth formation
iron-carry oxygen in blood.
vitamin that can be stored by the body
lipid (fat) soluable i.e. ADEK
vitamin not able to be stored by body
water soluble i.e. C & B complex
what life cycle has rapid growth and high energy requirements
infants
what is average wt. @ birth
5 lbs. 8 oz. to 8 pounds 13 ounces
average: 7lbs to 7 lbs 8 ounces
An infant weight doubles by _____ and triples by_____
what should be included in the dietary intake of infants?
4-5 months
age 1
formula
what are the iron requirements for pregnant and lactating clients and how are they recieved?
27mg.
must be supplemented
what is normal weight gain for pregnant and lactating clients
22-35 lbs.
factors that affect dietary status of older adults
financial resources
ability to prepare meals
dental status
appetite decreases with age and may eat less but often are less active as well
older adults
when is calcium intake most important in pregnant and lactating clients
in the last trimester when the fetal bones are calcifying
examples of fluid output regulation
kidney
skin
lungs
GI tract
fluids lost exit by
intestines
lungs
skin
kidneys
why is a clear liquid diet usually given?
used for patients who are having a GI procedure
no red or purple (looks like blood)
what are some community resources to help with dietary resources to help with dietary intake?
WIC
food stamps
churches
special groups
hospitals
private dietician
what are some Psychological assistance for helping patient to eat
sit with them when eating
family sit in when eating
homeostasis
the psychological balance of fluid intake hormonal controls and fluid output that regulate body fluids
describe the growth rate and calorie and protein needs of toddlers and pre-schoolers
slowed growth rate decrease in calorie needs increased intake of protein needed. b/c they are growing
signs of poor nutrition
under weight
sunken eyes
change in level of conscience
pale
sluggish movement and bowel sounds
the wt. or degree of concentration of a substance compared with an equal volume of water
specific gravity
what is specific
1.005 to 1.030 most common
1.010 to 1.025 ideal range
insensible loss
600mL of loss of fluids per day that is continuous and non conceived by the person that is difficult to measure
sensible loss
loss of fluid perceived by person that averages 0 to 5,000mL/day
how much fluid do you lose thru the kidneys and what kind of loss it it?
150 to 250mL (adult)
50 to 200 mL (child ) sensible
how much water can the body absorb
2.5 L
what is the only true way to assess fluid gain
weigh them
essential to normal metabolism and are obtained through dietary intake
vitamins
how do you promote elimination
scheduled regularity
proper food and fluid intake
plenty of fiber
exercise regularly
maintain comfort
maintain skin integrity
maintain self concept
factor that decrease incontinence
decrease caffiene
dont give negative reinforcement
head urge
go every 2 hours.
factors of bowel training
maintain schedule
take time to head the urge
excercise everyday
provide privacy
what is normal glucose level in urine
none
what is the normal level of RBC's in urine
up to 2
what is the normal level of WBC's in urine
0-4 per low power field
volume of urine remaining after voiding
residual urine
greater than ___ per hr. urination is too much
60mL
less then __mL per hr. urination is not enough
30 mL
phenazopyridine
colors urine bright orange to rust
causes green or blue discoloration of urine
amitriptyline
discolors urine to brown or black
levodopa
accumulation of urine resulting from an inability of the bladder to empty properly
urinary retention
what happend when a bladder is overfull
bladder pressure exceeds sphincter pressure and involuntary leakage can occur.
damage to the spinal cord above the sacral region causes loss of voluntary control of urination but the micturition reglex pathway oftern remaons intact allowing urination to occur w/o the sensation of the need to void
reflex incontinence
a urinary stoma that directs the flow of urine from the kidneys directly to the abdominal suface
urinary diversion
temporaray large stomas constructed in the transverse colon
loop colostomy
double barrel colostomy
...
end colostomy
...
nephrostomy
...
ileal loop
...
what are the characterisitics of a patients urine clarity with renal disease
freshly voided will appear cloudy or foamy because of high protein concentrations
what can cause the inability of the sphincter to maintain tone during increased abdominal pressure.
weak abdominal and pelvic floor muscles
taking temp with an electronic thermometer
to accurately measure a patient's temp via the oral rectal axillary or temporal artery routs using and electronic thermometer
to provide a baseline temp as part of the patient's vital signs
to obtain a subsequent temp for later comparison with the baseline measurement
radial pulse assessment
assess the heart rate and indirectly help determine the intergrity of the cardiovascular system
evaluate cardiac output by assessing the rate rhythm and strength of the radial pulse (a palpable wave of blood flow from the heart to the extremeties)
assses blood perfusion to the area distributed by the pulse
to obtain a baseline radial pulse measurement that serves as a basis for comparison with subsequent values
apical pulse assessment
assess the heart rate and rhythm directly and in the mpost accurate noninvasive way
to evaluate cardiac output and function by auscultating the number and quality of apical pulses (s1 and s2 sounds) per minute
assessing the apical radial pulse
to measure a patient's apical and radial pulse rates simultaneously
to detect a pulse deficit --a peripheral pulse that is two or more beats per minute less than the apical pulse
to detect dysrhythmias and help identify decreased cardiac output
dysrhythmia: irregular with pattern and irregularly irregular with no pattern
assessing respirations
to accurately measure the rate depth and rhythm of respiratory movements-normal movementsof thoracic and abdominal structures--and assess the effort required for breathing
to obtain a respiratory rate as part of the patient's baseline vital signs or a s part of a subsequent assesment for later comparison to the baseline.
to detect signs of respiratory and other disorders such as
tachypnea: greater than 20 per minute
bradypnea: less than 12 breaths per minute
altered respiratory patterns,
dyspnea : shortness of breath, labored breathing
othopnea: shortness of breath when laying down
tachypnea
increased respiratory rate
bradypnea
decreased respiratory rate
dyspnea
altered respiratory pattern due to difficulty breathing
othopnea
altered respiratory pattern due to difficulty breathing when laying flat
explain the purpose of obtaining Blood pressure
accurately measure the systolic and diastolic blood pressure
assess hemodynamic status including cardiac output peripheral resistance blood volume blood viscosity and vessel wall elasticity
to obtain a blood pressure measurement as part of a patient's basline vital signs or as part of a subsequent assessment for later comparison with the baseline.
to detect hypertension or hypotension
hypertension range
systolic 140 or up
diastolic 90 or up
hypotension
systolic of 90 or less
purpose of obtaining O2 saturation with pulse oximetry
to noninvasivley measure arterial blood oxygen saturation --percentage to which hemoglobin is bound to oxygen refered to as SpO2
to reduce the risks accociated wit arterial blood gas l(ABG0 sampling
to provide data that can guide oxygen therapy
assessing pain
to evaluate the level of pain based on the patients report and behavior
to obtain basline pain lebel or subsequent pain level for comparison with base line
to probide a basis for evaluating the effectiveness of pain relief methods
to identiry and acceptable level of pain that allows for maximum patient functioning.
to promote optimal pain relief
to evaluate the effects of apin on the patients life
define vital signs
indicators of health status, these measure indicate the effectiveness of
circulatory
respiratory
neural
endocrine
becuase all are vital to the health of the patient they are called vital signs
thermoregulation
physiological and behavioral mechanisms regulate the balance between heat lost and heat produced. ---internal thermostat.
nueral an vascular control of body temperature is done by
the hypothalamus
what organ senses minor changes in blody temperature
hypothalamus
what part of your temp. regulation system controls heat loss
anterior hypothalamus
like sweating to cool the body down
what part of the temp. regulation system controls heat production
posterior hypohthalamus
goose bumps, shiverng
BMR
basal metabolic rate--the heat produced by the body at rest.
nonshivering thermogensises
mainly in neonates, newborns are unable to shiver, they are born with a limited amount of vascular brown tissue that is metabolized for heat.
radiation
heat transferred from the surface of one to the surface of another.
conduction
transfer heat of one object with direct contact of another.
convection
transfer of heat away by air movement
evaporation
transfer of heat energy when a liquid is changed to gas.
like propane
boiling water
diaphoresis
sweat
1 hour of exercise in hot conditions = 1 Liter of fluid loss
heat loss in newborns
they lose approx 30% of their body heat through the head.
normal body temp. is 95.9F-99.5F
adult body temp.
average adult body temp is 98.6F
in cold climates or older adults 95F
circadium rythm
body temp normally changes .5 degrees to 1 degree Celcius during a 24 hour period. generally temp is at its lowest around 1 a.m. and 4 a.m.
pyrexia
fever is a heat loss mechanism
pyrogens
antigens that trigger immune system response. such as bacterial or viral infections
febrile
fever
afebrile
with out fever
hyperthermia
elevated body temperature
hypothermia
when skin temp drops below 95 degrees F.
below 94 cyanosis
sites for temperature measurement
oral
tympanic
rectal
axilla
skin
temporal artery
respiratory range for adults are
12-20 per minute
you can do this by counting breaths for 30 sec x 2= breaths per minute. if less than 12 or more than 20. recount for a full minute for accuracy.
newborn ranges of respiratory rate
35-40
infants 6 months respiratory range
30-50
toddlers 2 years old respiratory range
25-32
child respiratory range
20-30
adolescent respiratory range
16-20
adult respiratory range
12-20
when do we take vital signs
on admission
after procedure
at time of discharge
how do we measure vital signs
sphygmamonometer, fingers, palpation, stethoscope
what is an indication for retaking vital signs?
when something doesn't seem right.
when does the nurse report VS and to whom?
when VS may indicate some intervention. Nurse reports to nurse practitioner, physician assistance, health care provider, charge nurse. some else who is over you...
what are the RN's responsibilities in regards to VS
understand and interpret the values
report findings: repor the response to the medications, other symptoms Bp, etc.
start interventions
follow up: next treatment or pain meds. that you have done.
evidence based pratice
patient changing vitals
temperature
heat produced-heat lost=body temp
core
nurses do most of these vitals.
normal ranges of body temp
96.8-100.4
temperature sites for measurement
axillary, anal,oral, temporal
methods of measuring temperature
electronic, thermo tapes, scanner, digital
variations in temperature due to hypothermia
below normal temp. low temp.
use warm bath blankets, cotton blankets then a sheet over the blanket
variations in temperature due to hyperthermia
above normal temperature, high temp.
lover temp. in room, less blankets but leave some blankets on, tepid bath
what factors influence what method you use to obtain a temperature reading on a patient?
eating, drinking status, their condition / able to cooperate, injury in the area.
pulse
palpable bounding of blood flow through the body
alterations in breathing patterns and rates are
tachypnea: greater than 20 per minute
bradypnea: less than 12 breaths per minute
altered respiratory patterns,
dyspnea : shortness of breath, labored breathing
othopnea: shortness of breath when laying down
factors influence the respiration rate
exercise: increased rate and depth
acute pain: shallow breathing
anxiety: increases respiration rate and depth
smoking: increased rate when resting
body position: erect posture allows for full chest expansion
medications: depress rate and depth if opiate, downers are taken
increases rate and depth if cocaine, amphetamines are taken.
neurological injury: to brainstem impairs /inhibits respiratory rate and rhythm.
hemoglobin function: anemia reduce oxygen carrying capacity=increased respiratory rate. such as sickle cell disease.
apnea
respirations cease for several seconds
cheyne-stokes respiration
respiration rate and depth are irregular
oxygen saturation
evaluate the respiratory processes of diffusion and perfusion by measuring this in the blood.
what factors influence how you obtain pulse from a patient
sleeping you dont want to wake them
medications
normal range of pulse
in adult: 60-100
infant: 120-160 180 if crying
what factors influence the pulse rate?
normal range is 60-100 adult
exercise-raise pulse
conditioned athlete- has lower than normal range 40-50
high altitude
stress
medications- is this intended effect or side effect of meds.
normal respirations adult
12-20 per minute
define blood pressure
force exerted on wall of artery by pulsing blood under pressure from heart.
systolic
maximum pressure during ejection--contraction of heart top number
diastolic
minimum pressure during relaxation of ventricle --bottom number
normal Bp range ideal
120/80
variations in BP
age
medications
pain
anxiety
what factors influence BP reading
if the cuff is on wrong or wrong size
if reading is taken from ankle: could show higher b/c it is distal.
oxygen saturation normal range
90-100
ideal is 95-100 percent
variations in oxygen saturation
well oxygenated: good skin color, capillary refill upon pressing on skin, lip color, family knows what's normal for their members
hypoxia: not enough oxygen, stat is 85 percent elevate the head of the bed. try other methods before requesting order for oxygen.
interventions: if oxygen is ordered monitor regularly.
what patients can not tolerate high amounts of oxygen
COPD patients.
what factors influence the O2 saturation of a patient?
smoking dark nail polish, cold fingers, clubbing of nails
alternate: use bridge of nose.
correct posture
head erect and mid-line, shoulders , hips straight and parallel, vertebral column straight, abdomen comfortable ticked in and knees and ankles slightly flexed, arms hang comfortable at sides, feet placed slightly apart to achieve a base of support and toes pointed forward.
sitting
head erect neck and vertebral colun in striahgt alignment, body weight evenly distrubuted on buttocks and thighs, thighs parallel and i horizontal plane. both feet supported on floor 1"-2" maintained between edge of seat and poplitelal space on posterior surface of knee --pressure on popliteal artery or nerve decreases circulation and impairs nerve functhion
forearms supported on arm rest, in lap or on table in front of the chair.
lying
vertebrae aligned, postion should not cause discomfort, use of supportive devices as needed. firm mattress
lifting and transfer guide lines
explain procedure to patient
wash hands 'provide privacy
lock wheel ,stabilize chair,etc,
elevate bed to comfortable working level.
lower side rail on side working on.
encourage patient to assist with move if possible
keep the weight to be lifted as close to the body as possible--place object in same plane as lifter and close to center of gravity for balance.
bend at knees: helps maintain center of gravity and uses stronger leg muscles to do the lifting. avoid twisting --can overload spine and cause serious injury.
tighten abdominal muscles and tuck the pelvis -- provides balance and helps protect the back.
maintain the trunk erect andknees bent so that multiple groups work together in coordinated manner.
assess for correct body alignment and pressure after each transfer.---wash hands
how can illness effect nutritional status
short term illness: cold/ no taste flu/ not hungry
chronic illness: cancer- HIV- low apetite for longer periods at risk of malnutrion
P&I: oral suplements like ensure, InG feedings, total parental nutrition TPN
NPO: nothing by mouth
how can a nurse improve the nutrition status of a patient lacking apetite?
assessment: ask their food preferences, the may hate hamburger meat or chicken. if they are just not hungry alter feedings to fit their appetite better. temperature of food. make sure they have their teeth in!
if room smells due to dirty commode.
meds to increase appetite
name two meds that stimulate appetite
Megace and Periactin
patient with physical impairments such as
blind clients: foster independence by offering favorite foods, relate food on plate like a clock.
immobilized patients: can cause calcium to leave the bones and increase the risk for fracture. excess calcium in blood can lead to bladder and kidney stones. encourage protein intake for tissue repair,increased fluid intake, ROM to reduce skin breakdown.
swallowing difficulties: increases risk for aspiration. may need SLP -service location protocol-to help with evaluation and management of eating. need to be upright seated position to eat, or HOB -head of bed elevated.
dysphagia: need smaller bites and eat more slowly. may need changed in the consistency of liquids -thin nectar like honey-like and spoon thick.
other reason for patients not eating properly
decreased financial resources. often only able to afford purchasing less expensive items leading to malnutrition.
what are some of the community resources that are available to clients?
churches hospitals, WIC, special groups,private dietician, food stamps.
advise to purchase generic brands, beans, frozen veggies, instead of fresh. supplements.
how does the mind effect how someone eats-phsycological influence?
social affair, sit i there with them while they eat if they are alone and won't eat. discuss with family what food they could bring to get them to eat.
how does evaluation impact nursing care of a client with a nutritional problem?
make sure that the nutritional goal is being achieved.
ask why they are not eating. maybe they want to have company while eating.
assess their weight before and current.
the bowels can absorb _____liters of water per day
2.5 Liters
how many mL of flatus can the bowel produce per day
400-700mL per day.
stool characteristics: what do you see?
infant: yellowish
adult: brown
odor: pungeant, usually affected by what you ingest.
pseudomonas: give you diarrhea
consistnecy: soft like yellow pudding
hard: fecal impaction
so loose: no control
frequency of stools per day
breat fed infants: 4-6 stoold per day
formula fed infants 1-3 per day
adults: 1-3 times per day.
stools consitancy
sometimes consists of undigested food.
floaters: fatty poop bile from gallbladder
cold= snotty stool
water in stool sometimes
urgency
feeling need to void immediately: full bladder, bladder irritation from infection, overactive bladder, psychological stress
dysuria
painful or difficult urination:
bladder inflimmation, trauma or inflammation of urethral sphincter
frequency
voiding at frequent intervals: less than 2 hours.
increased fluid intake, bladder inflammation, increased pressure on bladder /pregnancy, diuretic therapy
hesitancy
difficulty initiating urination.
prostate enlargement , anxiety, urethral edema
polyuria
voiding large amounts of urine:
excess fluid intake, diabetes mellitus or insipidus, use of diuretics, postobstructive diuresis, dehydration, renal failure, UTI, increased ADH secretion, heart failure.
oliguria
deminished urinary out put relative to intake : ususally 400ml/24 hours
hehydration, renal failure, UTI, increased ADH secretion, heart failure
nocturia
voiding one or more times at night
excessive fluid intake before bed: especially coffee or alcohol.
renal disease, aging process, prostate enlargement
dribbling
leakage of urine despite voluntary control of urination
stress incontinence overflow from urinary retention
incontinence
involuntary loss of urine
unstable urethra, loss of pelvic muscle tone, fecal impaction. neurological impairment, overactive bladder.
hematuria
blood in urine
glomerular disease infection of kidney or bladder, trauma to urinary structures
retention
accumulation of urine in bladder with inability of bladder to empty fully
urethral obstruction, decreased sensory activity
residual urine
volume of urine remaining after voiding.
inflammation or irritation of bladder from infection, prostate enlargement etc.
symptoms or causes of dehydrations
pale, sunken eyes, organs not function well, dry mouth, mucous membranes: caused by diarrhea, vomiting, alcohol, sweating
what are we measuring out put of?
urine, diarrhea, blood: anything liquid leaving their body.They should be close to equal input/output
How do we measure fluid intake?
IV, PO: anything liquid entering their body.They should be close to equal input/output
Edema-
fluid retention, feet, face, hands, sacral area from laying too long. Sodium intake
give an example of How culture can affect diet?
Jewish: Kosher diet
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