Foundations Exam 3 Study Guide PDF

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Study guide for exam 3...

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NUR 3130: Study Guide for Exam #3  ➢ Nutrition: ● BasalmetabolismIstheenergyrequiredtocarryontheinvoluntaryactivitiesofthe bodyatrest—theenergyneededtosustainthemetabolicactivitiesofcellsandtissues. ● Carbohydratescommonlyknownassugarsandstarches,areorganiccompounds composedofcarbon,hydrogen,andoxygen. ● Asincomeincreases,carbohydrateintakedecreasesandproteinintake,amoreexpensive formofenergy,increases. ● Carbohydratesareclassifiedassimple(monosaccharideanddisaccharide)orcomplex (polysaccharide)sugars. ● Allcarbohydratesareconvertedtoglucosefortransportthroughthebloodorforuseas energy. ● Bodyconvertsexcessglucosetofatandstoresitastriglyceridesinadiposetissue. ● Allcarbohydratesprovide4caloriespergram,regardlessofthesource. ● Atleast50to100gofcarbsareneededdailytopreventketosis. ● Proteinsarerequiredfortheformationofallbodystructures,includinggenes,enzymes, muscle,bonematrix,skin,andblood. ● Carbsandfatsarecomposedofcarbon,hydrogen,andoxygen. ● Proteinisonlycomposedofnitrogen. ● Ninetyfivepercentofthelipidsinthedietareintheformoftriglycerides. ● Cholesterolisafatlikesubstancefoundonlyinanimalproducts. ● Watersolublevitamins  includevitaminCandtheBcomplexvitamins,areabsorbed throughtheintestinalwalldirectlyintothebloodstream. ● VitaminsA,D,E,andK,thefatsolublevitamins , areabsorbedwithfatintothe lymphaticcirculation. ● Excessiveintake,particularlyofvitaminsAandD,istoxic. ● Waterisneededbothformucoussecretionsandformovementbetweenjoints.  ● Bodyweightstandards: ❏ BMI=Obesity ❏ BMIof40>=Extremeobesity   

 ● Nutritionalprinciples/FoodGuidePyramid: ❏ Thegoalsoftherecommendationsaretoincreasetheintakeofvitamins,minerals,and dietaryfiberandtolowertheintakeofsaturatedfats,transfats,andcholesterol.  ndbeing ❏ MyPyramidencourageseatingavarietyoffoodsfromallfoodgroups a physicallyactiveeveryday. ❏ Foodlabelsprovideasignificantamountofnutritionalinformationfortheconsumer.  ● Therapeuticdiets: 1. LiquidDiet(Full&clear): ❏ Liquiddietsareusedmostoftenastransitionaldietswheneatingresumesafter acuteillness,surgery,orparenteralnutrition. ❏

Often,medicalordersarewrittentobeginthepatientonaclearliquiddietand advancetoanotherdietastolerated

 2. Clearliquid: ❏ Fluids&Carbohydrates ❏ Contains onlyfoodsthatareclearliquidsatroomorbodytemperature—gelatin, fatfreebroth,bouillon,icepops,clearjuices,carbonatedbeverages,regularand decaffeinatedcoffee,andtea.  alories,protein,andmostnutrients. ❏ Doesnotcontain c  3. Fullliquid: ❏ Liquidsorfoodthatturnintoliquids@bodytemp. ❏ Contains alltheitemsonaclearliquiddietandmilkandmilkdrinks,puddings, custards,plainfrozendesserts,pasteurizedeggs,cerealgruels,vegetablejuices, andmilkandeggsubstitutes. ❏ Doesnotcontain  Highcalorie,highproteinsupplements  4. SoftDiet: ❏ Lowresidue(lowfiber,lowfat,lowseasoned) ❏ SoftdietLowinfiberandlightlyseasoned.Mayalsobeusedasatransition betweenliquidsandaregulardiet. ❏ MechanicaldietRegulardietwithmodificationsfortexture.Usedforpatients withlimitedchewingabilityorwhohavehadsurgerytothehead,neck,ormouth.

PureeddietAlsoknownasablenderizedliquiddietbecausethedietismadeup ofliquidsandfoodsblenderizedtoliquidform.Usedafteroralorfacialsurgery andforpatientswithchewingandswallowingdifficulties. 5. Regular: ❏ Normal,regular,orhousedietsprovidesalladequateamountofallnutrients ❏ Nofoodsareexcluded ❏ Portionsizesarenotlimited  ❏

 6. LowNa/K: ❏ Sodiumlimitmaybesetat5003000mg/day ❏ Forp.twithhypertension,heartfailure,acuteandchronicrenaldisease,liver disease.  7. ADA: ❏

Balancedmealsbasedontotalcaloriesandcarbohydratescounting(4560g/meal)

 ● Enteralnutrition:(NG,NI,PEG,&PEJ) ❏ EnteralnutritioninvolvespassingatubeintotheGItracttoadministeraformula containingadequatenutrients.  ● Parenteralnutrition:(TPN&PPN ) ❏ Administrationofnutritionalsupportviatheintravenousroute ❏ Intravenoussupplementationmaybeprescribedforpatientswhohavenonfunctional gastrointestinal(GI)tracts,whoarecomatose,orthosewhohavehighcaloricand nutritionalneedsduetoillnessorinjury;patientsundergoingaggressivecancertherapy andthoserecoveringfromextensiveburns,surgery,sepsis,ormultiplefractures. ❏ Parenteralnutritioncanbeadministeredcentrally,throughacentralvenousaccessdevice (TPN),orperipherally(PPN),throughashorttermintravenousaccessinaperipheral vein.  ● Typesoftubefeedings: 1. NG: ❏ Forshorttermuse(lessthan4weeks) ❏ Insertedthroughthenoseandintothestomach ❏ Patientswithadysfunctionalgagreflex,highriskofaspiration,gastricstasis, gastroesophagealreflux,nasalinjuries,andthosewhoareunabletohavethehead ofthebedelevatedduringfeedingsarenotcandidatesfornasogastricfeeding. 2. NI:

❏ ❏ ❏

Forshorttermuse(lessthan4weeks) Passedthroughthenoseandintotheupperportionofthesmallintestine. Itmaybeindicatedforapatientwithincreasedriskforaspirationduetoa diminishedgagreflexorslowgastricmotility.

 3. PEG: ❏ ❏ ❏

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Longtermperiod. Requiresanintact,functionalGItract. Enterostomaltubeisplacedthroughanopeningcreatedintothestomach (gastrostomy). PEGtubeinsertionisoftenusedbecauseitusuallydoesnotrequiregeneral anesthesia(useslocalanesthesia). 

 4. PEJ: ❏ ❏

Longtermfeedingsituationsinwhichgastricproblemsexist. Enterostomaltubeisplacedthroughanopeningcreatedintothejejunum (jejunostomy).

 5. TPN: ❏

Ahighlyconcentrated,hypertonicnutrientsolution.

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Providescalories,restoresnitrogenbalance,andreplacesessentialfluids, vitamins,electrolytes,minerals,andtraceelements. Canalsopromotetissueandwoundhealingandnormalmetabolicfunction. Itprovidesthebowelachancetohealandreducesactivityinthegallbladder,

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pancreas,andsmallintestine. ❏ AssessmentcriteriausedtodeterminetheneedforTPNincludeaninabilityto absorbnutrientsfromtheGItractformorethan10days. ❏ Complications:theuseofcentralvenousaccessdevices,suchaspneumothorax andthromboembolism•Infectionandsepsis•Metabolicalterations,suchas hyperglycemiaorhypoglycemia•Fluid,electrolyte,andacid–baseimbalances• Phlebitis•Hyperlipidemia•Liverandgallbladderdisease.  6.PPN: ❏

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Alessconcentratednutrientsolutionsometimesprescribedforpatientswhohave amalfunctioninggastrointestinaltractandneedshorttermnutritionlastingless than2weeks. Administeredthroughaperipheralvein.

 ● Riskfactorsforalterednutrition: ❏ Amisplacedfeedingtubeinthelungsorpulmonarytissueplacesthepatientatriskfor aspiration.  ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏

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Cloggedtube Nasalerosion Diarrhea Stomainfection Unplannedextubation Nausea,vomiting,distension Placementmustbecheckedfrequentlywhilethetubeisinplace CheckbyradiographyorbymeasuringthepHoftheaspirate Anotherwaytoverifytubeplacementistomeasurethelengthoftheexposedtubeafter insertionanddocumentthismeasurement. Aftercheckingplacement,flushtubewith30to50mLofwaterbeforeandaftereach feedingorintroductionofmedications,atleastevery4hoursduringacontinuous feeding.

 ● Feedingpatients: ❏ Checktubeplacementbeforeadministeringanyfluids,medications,orfeedingusing multipletechniques:xray,pHtesting,aspiratecharacteristics,externallengthmarking, andcarbondioxidemonitoring. ❏ Checkresidual(feedingremaininginthestomach)beforeeachfeedingorevery4to6 hoursduringacontinuousfeeding. ❏ ContinuousfeedingsallowgradualintroductionoftheformulaintotheGItract, promotingmaximalabsorption. ❏ Continuousfeedingintothestomach,however,iscontroversialbecauseoftheriskfor refluxandaspiration. ❏ Intermittentfeedingsarethepreferredmethodforgastricfeeding.Intermittentfeedings aredeliveredatregularintervalsinequalportions,introducingtheformulagraduallyover asetperiodoftimeviagravityorafeedingpump. ❏ Bolusintermittentfeedings,whereasyringeisusedtodelivertheformulaquicklyinto ❏

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thestomach,mayplacethepatientatriskforaspirationorcausedistention. Cyclicfeedingallowsthepatienttoattempteatingregularmealsduringtheday,ifthisis possible,makingambulationandactivityeasier. Startingthefeedingataslowerrateandprogressingslowlyimprovestolerance.

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Successfultubefeedingsfocusonpatientsafety,monitoringforcomplications,comfort, andeducation. Medicationsmaybeadministeredthroughafeedingtube,butnevergivethemwhilea feedingisbeinginfused. Preventcontaminationduringenteralfeedingsbymaintainingtheintegrityofthefeeding systemandusingpropertechnique. Makesurethepatientisasuprightaspossibleduringfeeding. Assesstheabdomenforabnormalitiesandassessforbowelsounds.

 ● Assessment: ❏ Anapproachusedtoidentifythepatient’sactualorpotentialneeds,formulateaplanto meetthoseneeds,initiatetheplanorassignotherstoimplementit,andevaluatethe effectivenessoftheplan. ❏ Nursescancollectassessmentdatathroughhistorytaking,physicalassessments,and laboratorydata. ❏ Nutritionalscreeningisanimportantpartofthenursingassessment. ❏

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Dietarydatamaybecollectedfromthepatientorfamilyandcanbeevaluatedaccording totheDietaryGuidelines,RDA,ortheMyPyramidFoodGuide. Theacronym“DETERMINE”canbeusedtoscreenforwarningsignsofpoornutritional health:

1. 2. 3. 4.

Disease Eatingpoorly Toothloss/mouthpain Economichardship

5. 6. 7. 8. 9.

Reducedsocialcontact Multiplemedicines Involuntaryweightloss/gain Needsassistanceinselfcare Elderyearsaboveage80

 ● Diagnosis: ❏ Assessmentdatamayrevealactualorpotentialnutritionalproblems. ❏

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Assoonasproblemsareidentified,referthepatienttoappropriateservices,includinga dietitian. Datathatthenursecollectsmayleadtothedevelopmentofseveralnursingdiagnoses relatedtonutrition.

● Planning: ❏ Expectedoutcomesarederivedfromtheactualorpotentialnutritionalproblems diagnosed. ❏ Thegoalistomaintainorrestoreoptimalnutritionalstatususingfoodsthepatientslike andtolerateasappropriatefortheirsituation. ❏ Goalsshouldalsoincludethosetoalleviatesymptomsorsideeffectsofdiseaseor treatmentandtopreventcomplicationsordietrelatedchronicdiseases.     ● Implementation: ❏ Providingproperandadequatenourishmenttothepatientisateameffortimplementedin avarietyofsettings. ❏ Thenursemayalsoberesponsibleforscreeningpatientsathomewhoareatnutritional risk,observingintakeandappetite,evaluatingthepatient’stolerance,assistingthepatient witheating,administeringenteralandparenteralfeedings,consultingwiththedietitian andphysicianwhendietaryproblemsarise,addressingthepotentialfordrug–nutrient reactions,obtainingmorefoodorsnacksforthepatientwhenappropriate,monitoring foodbroughtbyvisitors,andparticipatinginnutritioneducationefforts.  ● Evaluation: ❏ Evaluatesthepatient’sprogresstowardmeetingnutritionaloutcomes. ❏ Evaluatesthepatient’stoleranceandadherencetothediet,whenappropriate. ❏

❏ ❏

Assessesthepatient’slevelofunderstandingofthedietandtheneedforfurtherdiet instructionorreinforcement. Communicatesfindingstoothermembersofthehealthcareteam. Revisestheplanofcare,asneeded,orterminatesnursingcare.

   ➢ DiagnosticTesting:ch.37,38? ● Assessment: ❏ Collectandanalyzesubjectiveandobjectivedataaboutthepatient’shealthproblem  ● Diagnosis:Statethehealthproblem ❏ Fear

❏ ❏ ❏

Anxiety Impairedphysicalmobility Deficientknowledge

 ● Planning: ❏ Writeacareplanthatincludesthenursinginterventionsdesignedtoachieveexpected outcomes.  ● Implementation: ❏ Putthecareplanintoaction ❏ Documenttheactionstakenandtheirresults  ● Evaluation: ❏ Criticallyexaminetheresultsachieved ❏ Reviewandrevisethecareplanasneeded  ● Typesofdiagnostictests: 1. Stoolspecimensusedtodetermine: ❏ Presenceofoccult(hidden)blood;guaiactest ❏ Dietaryproductsanddigestivesecretions;steatorrhea



Presenceofova&parasites ❏ Presenceofbacteriaorviruses 2. Urinetests(routineurinalysis,culture&sensitivity): ❏ Cleanvoidedspecimensforroutineanalysis ❏

Cleancatchormidstreamurinespecimenforurineculture ❏ Timedurinespecimensforvarietyofteststhatdependonclient’sspecifichealth probs. 3. Lumbarpuncture:AKASpinaltab(Looksformeningitis&otherneurological) ❏ Clientispositionedlaterallywithheadbenttowardchest ❏ Kneesflexedonabdomen ❏ Backatedgeofbedexaminingtable ❏ CSFpressurereadingtakenusingamanometer 4. Liverbiopsy: ❏ Sampleoflivertissueisaspirated  ❏ Clientexhales&holdsbreathwhileprimarycareproviderinsertsneedle ❏ Afterneedleisdrawn,nurseappliespressuretopreventbleeding ❏ Maypositionclientonthebiopsysite ❏

 5. Woundcultures: ❏ Useaculturekitorsterileculturetubeandcottonswab ❏ Swabdeepintothewoundandcollectanypus ❏ Placeswabinsterileculturetube  ntibioticsarestarted ❏ Specimenshouldbecollectedbefore a 6. EndoscopiesTubewithcamera ❏ Direct&Invasiveprocedure  ● Nurse’sroleindiagnostictesting: ❏ CollectionofData ❏ Assist ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏

Document Consent Schedulingtesting Education Safety Ethicallegal Preparationoftheclient Providingcarepre,intra,andpost Disposingusedequipment Careanddeliveryofspecimens

 ● Nurse’sresponsibilitiesindiagnostictesting: ❏ Provideclientcomfort,privacy,andsafety ❏ Explainpurposeofspecimencollectionandprocedure ❏ Usecorrectprocedureorensurethatclient/stafffollowscorrectprocedure ❏ Noterelevantinformationonlaboratoryrequisitionslip ❏ Transportspecimentolaboratorypromptly    ➢ CareoftheSurgicalPatient: ● Nursingcareprovidedforthepatientbefore,during,andaftersurgeryiscalled perioperativenursing. ● Theperioperativecontinuumencompassesthepreoperative,intraoperative,and postoperativephasesforthepatient.

● Threeofthesedomains,safety,physiologicresponses,andthepatientandfamily behavioralresponses,arecriticalforpatientcare.Thefourthdomain,healthsystem, representsthestructureelementsandothersystemactivitiesthatmustbepresentto supportsafe,effective,highqualitypatientcare. ● Thenursingprocessisusedduringeachphasetomeetphysicalandpsychosocialneeds andtofacilitatethepatient’sreturntohealth.  ● Typesofsurgery: 1. DiagnosticTomakeorconfirmadiagnosis Ex:Breastbiopsy,laparoscopy,bronchoscopy,exploratorylaparotomy. 2. AblativeToremoveadiseasedbodypart Ex:Appendectomy,subtotalthyroidectomy,partialgastrectomy,colonresection, amputation. 3. PalliativeTorelieveorreduceintensityofanillness;isnotcurative Ex:Colostomy,nerverootresection,débridementofnecrotictissue,balloon angioplasties,arthroscopy. 4. ReconstructiveTorestorefunctiontotraumatizedormalfunctioningtissueorto improveselfconcept. Ex:Scarrevision,plasticsurgery,skingraft,internalfixationofafracture,breast reconstruction. 5.TransplantationToreplaceorgansorstructuresthatarediseasedormalfunctioning. Ex:K  idney,liver,cornea,heart,joints. 6.ConstructiveTorestorefunctionincongenitalanomalies. Ex:Cleftpalaterepair,closureofatrial–septaldefect.   ● Informedconsent: ❏ Informedconsentisthepatient’svoluntaryagreementtoundergoaparticularprocedure ortreatmentafterhavingreceivedthefollowinginformation,whichshouldbeprovided inunderstandablewordsbytheproceduralphysician. ❏ Descriptionoftheprocedureortreatmentalongwithpotentialalternativetherapies ❏ Explanationoftherisksinvolved,includingriskfordamage,disfigurement,ordeath,and howoftentheyoccur. ❏ Explanationthatthepatienthastherighttorefusetreatmentandthatconsentcanbe withdrawn. ❏ Explanationofexpectedoutcome,recovery,andrehabilitationplanandcourse. ❏ Thenursemaysignasawitness,signifyingthatthepatientsignedtheconsentform withoutcoercionandwasalertandawareoftheact.

 ● 3Phasesoftheperioperativeperiod: 1. Preoperativephase=beginningwhenthepatientandsurgeonmutuallydecidethat surgeryisnecessaryandwilltakeplace.Itendswhenthepatientistransferredtothe operatingroom(OR)orproceduralbed. 2. Intraoperativephase=beginningwhenthepatientistransferredtotheORbed,also calledatable,untiltransfertothepostoperativerecoveryarea. 3. Postoperativephase=lastingfromadmissiontotherecoveryareatocompleterecovery fromsurgeryandthelastfollowupphysicianvisit.  ● 3Phasesofthepostoperativeperiod: 1. PhaseI=Providingpatientcarefromatotallyanesthetizedstatetoonerequiringless acutenursinginterventions. 2. PhaseII=PreparingthepatientforselforfamilycareorforcareinaphaseIIIextended careenvironment. 3. PhaseIII=Providingongoingcareforpatientsrequiringextendedobservationor interventionaftertransferordischargefromphaseIorII.  ● Surgerybasedonurgency: 1. Electivesurgeryisaprocedurethatispreplannedandbasedonthepatient’schoiceand availabilityofschedulingforthepatient,surgeon,andfacility.Thisisanonurgent procedurethatdoesnothavetobedoneimmediately. 2. Emergencysurgerymustbedoneimmediatelytopreservelife,abodypart,orfunction. 3. Urgentsurgerymustbedonewithinareasonablyshorttimeframetopreservehealth, butisnotanemergency. 4. Optionalsurgeryisnotcriticaltosurvivalorfunction.  ● Typesofanesthesia: 1. GeneralInvolvestheadministrationofdrugsbytheinhalationorintravenous(IV)route toproducecentralnervoussystemdepression. ❏ Thethreephases  ofgeneralanesthesiaare;induction,maintenance,andemergence. ❏ Induction  beginswithadministrationoftheanestheticagentandcontinuesuntilthe ❏ ❏

patientisreadyfortheincision. Maintenance  Continuesfromthispointuntilnearthecompletionoftheprocedure. Emergence Startsasthepatientbeginstoawakenfromthealteredstateinducedbythe anesthesiaandusuallyendswhenthepatientisreadytoleavetheoperatingroom.

2. SpinalAchievedbyinjectingalocalanestheticintothesubar...