50 questions 1. Fluid overload – signs and symptoms 2. Grief and dying 3. GI/GU 4. Nutrition 5. Pain/perception/sensation 6. PMCE questions 7. Oxygenation/circulation/perfusion Fluid overload – signs and symptoms ● Excessive retention of sodium and water in the ECF increases osmotic pressure and causes fluid to shift from the cells into the ECF. Excess fluid volume (hypervolemia) can result from excessive salt intake, disease affecting kidney or liver function, or poor pumping action of the heart. ● Signs of Fluid Overload—Elevated blood pressure, bounding pulse, increased shallow respirations, and cool pale skin; distended neck veins. When excess ECF accumulates in the tissues, especially in dependent areas edema and rapid weight gain occur. ● In severe fluid overload, the patient develops moist crackles in the lungs, dyspnea, and ascites (excess peritoneal fluid). Hemodilution causes BUN, hematocrit, and specific gravity of the urine to decrease. Nutrition: Nutrients are: ● Building blocks for cells and tissues that supply energy, help manufacture, maintain, and repair cells ● Nutrient types that provide the body with energy: ○ Carbohydrates ○ Proteins ○ Lipids Which people need more protein in their diet? - Skin integrity issues (Pressure Ulcer) - Failure to thrive - Malnourished Which health complications require limited water intake? - CHF - Renal disease (Kidney) - Diabetes Illness, especially with fever, increases need for: - Protein - Water - Calories - Metabolic rate increases- demand is higher --> incontinence what are each type? Urge Incontinence overactive bladder is involuntary loss of larger amounts of urine by a strong urge to void Stress Incontinence involuntary loss of small amounts of urine w/ activities that increase abdominal pressure Mixed Incontinence Both urge & stress Overflow Incontinence Loss of urine w/ distended bladder Fecal impaction, enlarged prostate, neurological disorders Functional Incontinence Untimely loss of urine when no urinary cause is involved Physical disability, immobility, pain, external obstacles Reflex Incontinence Loss of urine when pt doesn't realize bladder is full & has no urge to void(CNS disorder) What are the nursing diagnoses associated with it? What is the risk for? ● Infection, Risk for ● Urinary Elimination, Impaired ● Urinary Elimination, Readiness for Enhanced ● Urinary Incontinence (functional, reflex, stress, urge, risk for urge) ● Urinary Retention ● Urinary Tract Injury, Risk for urinary incontinence? Urinary incontinence (UI) lack of voluntary control over urination skin impairment, obesity, UTIs, self-rated poor health, reduced mobility, & depression lead to social isolation increased caregiver burden ---> What is UTI? Urinary Tract Infection UTI: what are the signs and symptoms of urinary incontinence? ● Classic signs are urinary WBCs, pyuria, dysuria, urgency, & frequency ● Back pain ● Bladder spasms ● Chills ● Dysuria ● Edema ● Fever ● Foul smelling urine ● Hematuria ● N/V ● Pyuria ● Urgency ● Urinary frequency What is associated with urinary retention? Urinary retention inability to empty bladder completely obstruction, inflammation & swelling, neurological problems, medications, & anxiety ● microorganisms, Escherichia coli, which normally lives harmlessly in colon, enter urethra & begin to multiply, overwhelming normal flora ● infection limited to urethra is urethritis ● Cystitis occurs when bacteria travel up urethra into bladder, causing a bladder infection ● If not treated promptly, infection may progress superiorly (upward) to ureters or kidneys (pyelonephritis) What are the GU issues? ● Pathological conditions ● Bladder/kidney infections ● Kidney stones ● Hypertrophy of prostate (male) ● Mobility problems ● Decreased blood flow through glomeruli ● Neurological conditions ● Communication problems ● Alteration in cognition Why do we have to use a foley cath? Reason behind a foley? Indwelling catheter ● Foley or retention catheter ○ used for continuous bladder drainage ○ when bladder must be kept empty or when continuous urine measurement is needed ○ double-lumen tube: one lumen is used for urine drainage, & 2nd lumen is used to inflate balloon near tip of catheter ○ Inflated balloon holds catheter in place at neck of bladder. Balloon is sized according to volume of fluid used to inflate it. ○ triple-lumen indwelling catheter is used when pt requires intermittent or continuous bladder irrigation U/A Urinalysis ● “dipstick” testing or microscopic analysis ● determine pH & specific gravity & presence of protein, glucose, ketones, & occult blood ● Commercially prepared kits contain reagent designed to detect a specific substance ● Reagent may be paper test strip, fluid, tablet ● When contacted by urine, a chemical reaction causes a color change that you compare to color chart ● Follow manufacturer’s directions regarding amount of urine needed & time needed for reagent to develop. GU terminology Polyuria: excessive urination Anuria: absence of urine Dysuria: painful or difficult urination Nocturia: frequent urination after going to bed Hematuria: blood in urine Pyuria: pus in the urine Enuresis: involuntary loss of urine Micturition: Voiding --> to start the stream of urine to urinate How to do a clean catch? u/a : Clean catch ● cleanse genitalia before voiding & collect sample in midstream ● initial flow of urine may contain organisms from urethral meatus, distal urethra, & perineum ● midstream sample is free of contaminants Fecal occult blood testing – What is a false positive? What is an occult blood test? Testing for Fecal Occult Blood ● Blood from the GI tract may be visible to the eye or occult (hidden), especially when passed through the stool from higher up in the intestine. You can perform the test for occult blood at the bedside, although some institutions require that it be done in the laboratory. The test is called a guaiac or fecal occult blood test. It requires use of a special reagent that detects the presence of peroxidase, an enzyme present in hemoglobin. Only a small smear of stool is required. For home testing, remind patients to wash their hands before and after collecting stool. ● Some foods, such as red meat, chicken, fish, horseradish, turnips, or raw vegetables, may lead to a false-positive reading. Vitamin C in excess of 250 mg per day can produce a false-negative result. ● If the patient is taking medications, such as salicylates, nonsteroidal antiinflammatory drugs (NSAIDs), iron, oxidizing drugs (e.g., iodine salts, boric acid), reserpine, corticosteroids, anticoagulants, colchicines, consult with a physician. These medications may cause a false-positive reading. If possible, they will be discontinued for 7 days before the test. If the patient must have them, then the results must be interpreted taking use of these medications into consideration. ● Assess for the presence of hemorrhoids. ● Any source of blood may cause a false-positive result for intestinal bleeding. GI Bowel prep what is it for? colonoscopy? What is it for? Reason for? Preparation ● The colon and rectum must be empty and clean so the physician can view the linings during the exam. ● Practitioners have different colon-cleansing routines to achieve this, such as the following: ○ Instruct the patient to take strong cathartic and laxative (e.g., Dulcolax) tablets the day before the test and an enema on day of the test, until returns are clear. ○ Instruct the patient to consume a clear liquid diet for 24 to 48 hours before the test (nothing red or purple) and to remain NPO after midnight the night before the exam. ○ The patient will be sedated before the test, so she may need a ride home from someone. Colostomy signs and symptoms of a bad one? ● Assess the Stoma. Key Point: A healthy stoma ranges in color from deep pink to brick red, regardless of the patient’s skin color, and is shiny and moist. Pallor or a dusky blue color indicates ischemia, and a brown-black color indicates necrosis. ● Immediately after surgery the stoma will be swollen and enlarged. As the inflammation subsides and healing occurs, the stoma will shrink. ● By 6 to 8 weeks, it will be at its permanent size. Stoma size varies according to the size of the person and the part of the bowel that was externalized (see Fig. 29-5). ● The stoma will protrude above the level of the abdomen by approximately 1.3 to 2.5 cm (0.5 to 1 in.). ● An ileostomy stoma is generally smaller than a colostomy stoma. ● Assess the Output. Monitor the amount and type of drainage from the stoma. Output from an ileostomy stoma is liquid and contains digestive enzymes. An ostomy lower in the GI tract will have more solid output and fewer enzymes. The presence of enzymes in the effluent increases the likelihood of skin breakdown. ● Assess the Skin. Pay close attention to the skin surrounding a stoma for signs of irritation, such as redness, tenderness, skin breakdown, and/or drainage. Skin breakdown may lead to infection, pain, and leakage. What does it do for pt? ● Bowel diversion ● surgically created opening for elimination of digestive waste products ● Colostomy: surgical procedure in abdomen ● Closer the colostomy is to ascending colon ----> more liquid ● Colostomy closer to sigmoid colon ---> solid feces ● Colostomies near rectum, sigmoid colostomies, can be controlled by diet & irrigation What is the diagnostic test that is invasive and non invasive pertaining to pt GI tract? Nursing diagnosis pertaining to the patient? Direct visualization ● invasive procedures by Gastroenterologist ● Colonoscopy ● Sigmoidoscopy ● EGD Radiographic views ● Indirect visualization studies of lower GI tract ● Abdominal flat plate (anterior to posterior (AP) x-ray) ● Ultrasound ABD (NPO for 4 hr) IBS what is the difference b/t constipation and diarrhea? Irritable Bowel Syndrome ● Stress Have you ever heard the following phrase: “He puts his stress in his gut”? Stress has a major influence on motility of the GI tract. It may cause diarrhea or constipation, and it is a primary risk factor in the development of irritable bowel syndrome, a disorder associated with bloating, pain, and altered bowel function. Diarrhea ● passage of loose, unformed, or watery stools Constipation ● decrease in BMs frequency resulting in passage of hard, dry stool Matching Pain score What kind of pain – phantom/chronic/neuropathic/acute Matching Classifications of pain acute: Pain has short duration & is generally rapid in onset. Varies in intensity & may last up to 6months. Most frequently associated with injury or surgery. It is protective in that it indicates potential or actual tissue damage. Acute pain may absorb a pt’s physical & emotional energy for a short time, it is helpful for pt to know that it will generally disappear as tissues heal. neuropathic: complex & chronic pain that arises when injury to 1 or more nerves results in repeated transmission of pain signals even in absence of painful stimuli. Nerve injury may originate from any of a variety of conditions (poorly controlled DM, CVA, tumor, alcoholism, amputation, or viral infection) Nerve pain; no tissue damage Phantom: pain is perceived to originate from an area that has been surgically removed ex: Patient with amputated limbs may still perceive that the lab exists and experience burning, itching, and deep pain in that area chronic: Pain has lasted 6 months or longer & often interferes with daily activities. Pts may experience periods of remission & exacerbation. Often viewed as insignificant & may lead to withdrawal, depression, anger, frustration, & dependence Pain can cause ? ● *Sleep loss *Irritability *Cognitive impairment *Functional impairment *Immobility What is pain? ● an unpleasant sensory/emotional experience ● can have destructive effects ● can warn of potential injury ● a multidimensional experience Patient controlled analgesic What does it do for pt post-op? What is for? ● Patient-controlled analgesia (PCA) pumps: effective & safe way to deliver opioids by IV, epidural, or subcutaneous routes. Provides excellent pain relief & give pt a sense of control over the pain. System consists of programmable infusion pump, a syringe (or bag), IV tubing, & button that the pt presses to self-administer a dose Kugler Ross – Stages of grieving ● 1. Denial: Client refuses to believe the truth and this helps to lessen the pain of the loss ● 2. Anger: Client is trying to adjust to the loss and is feeling severe emotional distress, often asking "why me?" and suggesting "it's not fair" ● 3. Bargaining: Usually involves bargaining with a higher power by making a promise to do something in exchange for a different, better outcome ● 4. Depression: Reality sets in, and the loss of the loved one or thing is deeply felt ● 5. Acceptance: Client still feels the pain of the loss but realizes they will be all right Comfort care? What do we do as a nurse with a patient pn comfort care? We don’t treat but we take care of them[physical needs] mouth care, skin care, hygiene] respiration and HR Hospice Care ● The administration of medical care to support the client who has a terminal illness, so they can live the last days of their life as best as they can, as long as they can. ● Provided when treatment will no longer cure or control the illness. ● Originally offered only to clients diagnosed with terminal cancer but has grown to include any client with a life- limiting illness. ● Interprofessional, holistic care that treats the whole person, including caregivers and family members Breathing ● Eupnea: easy or normal breathing ● Bradypnea: slow respirations <10 breaths per min ● Cheyne's stokes: an irregular respiratory rate fluctuating between several quick breaths and periods of apnea ● Tachypnea: fast shallow breathing >24 breaths/min ● Kussmaul’s: Regular but increased in rate & abnormally deep respirations ● Apnea: absence of breathing Respiratory fluids - why do we have tell patients to drink fluids, cough and drink fluid? ● Why we drink water: to thin out secretions. ● Cough & deep breathing for mobilization of secretions & open airways. ● Deep breathing to expand lungs ● prevent atelectasis. What happens to the patients if they cough and drink fluid? Risk for aspiration? More terminology: external respiration: alveolar-capillary gas exchange occurs in alveoli of lungs internal respiration: capillary gas exchange in body tissues Hyperventilation: When a person breathes fast & deeply to move large amount of air through lungs, causing too much CO2 to be removed by alveoli. Mild hyperventilation occur in response to hypoxemia (low level of O2 in blood). When blood O2 is low, ventilation increases to draw additional air into lungs. As ventilation increases, CO2 levels fall. It is triggered by meds, CNS abnormalities, high altitude, heat, exercise, panic, fear, or anxiety. Hypoventilation: When a decreased rate or shallow breathing moves only a small amount of air into & out of lungs. It can lead to hypoxemia because less air (carrying O2) reaches alveoli. Hypoxemia will progress to hypoxia (O2 deficiency in body tissues) Respiratory infection: influenza virus: is usually more severe than the common cold and often involves lower airways-although some types. may not respiratory syncytial virus: A highly contagious virus that causes an infection of the upper and lower respiratory system. COPD: chronic obstructive pulmonary disease - increase the risk for respiratory depression with opioid use What's strep throat? ● Pharyngitis—sore throat. May be viral or bacterial. “Strep” throat, caused by Streptococcus pyogenes,is the most common cause of infectious pharyngitis. It cannot be differentiated from a viral sore throat by any one sign or symptom, so pharyngeal cultures or rapid antigen tests are conducted. What’s stimulus for breathing? Normally the blood CO2 level provides the primary stimulus to breath. How breathing is controlled? chemoreceptors and lung receptors? Chemoreceptors: located in the medulla of the brainstem, the carotid arteries, and the aorta, detect changes in blood pH, O2, and CO2 levels and send messages back to the central respiratory center in the brainstem. In response, the respiratory center increases or decreases ventilation to maintain normal blood levels of pH, O2 (PO2), and CO2 (PCO2). Lung Receptors: located in the lung and chest wall, are sensitive to breathing patterns, lung expansion, lung compliance, airway resistance, and respiratory irritants. The respiratory center uses feedback from the lung receptors to adjust ventilation. For example, if the lung receptors sense respiratory irritants such as dust, cold air, or tobacco smoke, the respiratory center triggers airway constriction and a more rapid, shallow pattern of breathing. Cyanotic mucus membranes. What are they for? Cyanosis is a medical condition characterized by blue colored skin and mucous membranes, which occurs as the result of inadequate amounts of oxygenated hemoglobin -- the molecule which carries oxygen to the body tissues -- or due to hemoglobin abnormalities. What is your partial rebreather mask? Your venturi mask, nonrebreather mask, nasal canula? Partial rebreather mask: A type of oxygen delivery device that collects and rebreathes some of the exhaled air, while delivering supplemental oxygen to the patient. Venturi mask: A type of oxygen delivery device that delivers a specific concentration of oxygen by mixing oxygen with room air through a series of ports or valves. Nonrebreather mask: A type of oxygen delivery device that delivers high concentrations of oxygen to the patient and has a one-way valve that prevents the patient from rebreathing exhaled air. Nasal cannula: A type of oxygen delivery device that consists of two small prongs that fit into the nostrils and deliver a low to moderate concentration of oxygen. What’s PPD? What does it mean when it is positive? ● PPD stands for purified protein derivative which is a substance used in a skin test called the Mantoux test to determine if a person has been exposed to the bacterium *mycobacterium tuberculosis* that causes tuberculosis (TB). ● A positive PPD test indicates that a person has been infected with the TB bacterium, but it does not necessarily mean they have active tuberculosis disease. ● It's important to note that a positive PPD test may not cause any symptoms, and a person with a positive result may not even know they have been infected with TB. However, without treatment, latent TB infection can progress to active TB disease, which can be serious and potentially life-threatening if left untreated. CPR: Perform CPR - cardiopulmonary resuscitation ● perform CPR in event pt experiences respiratory, cardiac, or cardiopulmonary arrest ● Cardiac arrest is cessation of heart function ● Signs of cardiac arrest are: ○ pale, cool, grayish skin ○ absence of femoral or carotid pulses ○ apnea ○ pupil dilation ○ only have 4-6min before the brain is damaged by lack of O2 ● Respiratory (pulmonary) arrest is cessation of breathing. ○ Caused by a blocked airway or occurs after a cardiac arrest ○ May be sudden or preceded by increasingly labored breathing the sequences of the electrical impulses of the heart. Starting with SA node ● the sequences of the electrical impulses of the heart. Starting with SA node, goes to AV nodes, goes to bundle if HIS, then to purkinje fibers. Electrical Conduction ● The heart contains specialized areas of nerve tissue that initiate electrical impulses without external nervous system stimulation. ● The sinoatrial (SA) node acts as the pacemaker. Located in the right atrium, it initiates an impulse that triggers each heartbeat. The impulse travels rapidly down the atrial conduction system so that both atria contract as a unit. ● At the atrioventricular (AV) node, there is a slight delay. From the AV node, impulses pass into the left and right bundles of His and into the Purkinje fibers to the ventricles. ● In this way, myocardial fibers are electrically stimulated almost simultaneously to create a unified cardiac muscle contraction strong enough to pump blood out of a heart chamber. This spontaneous rhythm of the heart is called automaticity. ● If there are defects in this electrical system, impulses travel more slowly through the heart, and some areas contract before others. This can lead to ineffective heart pumping and decreased cardiac output. For more information, see the Example Problem: Decreased Cardiac Output, later in this chapter. ● Normally, the SA node is in charge and initiates a rate of 60 to 100 beats/min, depending on the body’s oxygen needs. ● If the SA node fails, the AV node can take over as the pacemaker, but it generally triggers a slower heart rate. ● If both the SA and AV nodes fail, the conduction fibers in the myocardium can initiate impulses. Ventricular conduction generates a very slow rate, usually less than 40 beats/min; however, this can be lifesaving if no other node or fiber is initiating an impulse. Cardiac function in the elderly. What happens to their heart? ● Cardiac efficiency gradually declines as ○ the heart muscle loses contractile strength; ○ heart valves become thicker and more rigid; and ○ the peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. ● As a result of these changes, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. For example, in response to exercise, an older adult’s heart rate does not increase as much as a younger person’s, but it does remain elevated longer. Thus, older adults have lower exercise tolerance, need more rest after exercise, and are more prone to orthostatic hypotension. ● Key Point: Keep in mind, though, that endurance training and regular exercise slow the rate of these changes. In fact, an older person who is physically conditioned by regular exercise may have better heart and circulatory function than a younger adult who is not well conditioned Cardiac diagnosis Dysrhythmia: (alterations in heart rate or rhythm) can lower cardiac output, decrease tissue oxygenation, and increase the risk of stroke. Cardiomyopathy: is a heart muscle disorder that results in heart enlargement and impaired cardiac contractility. Heart failure: occurs when the heart becomes an inefficient pump and is unable to meet the body’s demands. Blood is oxygenated when it passes through the lungs, but it is not well circulated to the organs and tissues. Impaired circulation leads to systemic and pulmonary edema, which further impairs gas exchange. Right-sided heart failure occurs when the right ventricle does not pump sufficient amounts of blood to the lungs for oxygenation, and blood backs up into the peripheral veins. Left-sided heart failure occurs when the left ventricle does not pump sufficient amounts of blood to body organs and tissues. Both right-sided and left-sided heart failure reduce the amount of oxygenated blood available to organs and tissues, resulting in fatigue and organ dysfunction. Coronary Artery disease: a leading cause of cardiac ischemia, is a condition in which plaque builds up inside the coronary arteries. Plaque narrows the arteries, reducing blood flow to the heart muscle and making it more likely that clots will form and block the arteries. Cardiac ischemia: occurs when oxygen requirements of the heart are unmet. Prolonged ischemia leads to myocardial infarction (MI) as parts of the heart necrose (die) from inadequate oxygen. Angina pectoris is transient chest pain due to myocardial ischemia. The tissue becomes injured but does not necrose. Cardiovascular systems Arteries: have thick, elastic walls that allow them to stretch during cardiac contraction (systole) and to recoil when the heart relaxes (diastole). Arterioles: are smaller branches of arteries. They are primarily smooth muscle and thinner than arteries. They are controlled by the sympathetic nervous system. Arterioles constrict or dilate to vary the amount of blood flowing into capillaries and help maintain blood pressure. Capillaries: are microscopic vessels, created as arterioles branch into smaller and smaller vessels. Capillaries connect the arterial and venous systems and carry blood from arterioles to venules. Because they are only one cell thick, capillaries facilitate the exchange of gases, nutrients, and wastes between the tissue cells and the blood. Billions of capillaries provide blood flow to every cell in the body. Veins/Venules: Veins and venules have thin, muscular, but inelastic walls that collapse easily. These walls contract or relax in response to feedback from the sympathetic nervous system: When blood volume is low, the veins contract to provide a smaller space for smaller volume of blood; when blood volume is high, veins relax and enlarge to accommodate increased volume of blood. Think of the venous system as a holding tank for fluctuations in blood volume. ----> One causes vasodilation and one causes vasoconstriction <---- Know!!! Chemoreceptors: chemical sensors in the brain and blood vessels that identify changing levels of oxygen and carbon dioxide Proprioceptors: in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable us to sense the position of our body in space (proprioception). Photoreceptors: located in the retina of the eyes detect visible light. Mechanoreceptors: in the skin and hair follicles detect touch, pressure, and vibration. How do you reduce the risk for clot formation? ● Measures that promote venous return increase the flow of blood back to the vena cava and the right side of the heart. ● Elevate the patient’s legs above the level of the heart. Gravity promotes venous return from the feet and legs. ● Have the patient sit in a recliner that elevates the legs rather than sitting upright in a chair with legs elevated on a stool. Flexion of the hips, legs, and knees constricts the veins and slows venous blood flow. ● Teach patients not to sit with the legs crossed; doing so interferes with blood flow. ● Encourage and support early and frequent ambulation (e.g., after surgery). Contraction of the muscles in the legs moves blood upward against gravity. ● Encourage or provide range-of-motion (ROM) exercises, which increase venous blood flow through rhythmic massaging of the veins by the active muscles (see Chapter 32 to review ROM). ● Apply compression devices. ● Antiembolism stockings (TED hose) are elastic stockings that compress superficial leg veins and promote venous return. ● Sequential compression devices (SCDs), also called pneumatic compression devices, are cuffs that surround the legs and alternately inflate and deflate to promote venous return to the heart. ● Antiembolism stockings and SCDs are frequently used in perioperative patients to promote venous return and prevent clot formation (Woo & Cowie, 2013). See Chapter 39 for further discussion and instructions on how to apply these stockings and appropriate follow-up care. ● Turn patients frequently; teach patients to change positions frequently. This prevents vessel injury from prolonged pressure in one position. ● Use scrupulous sterile technique for intravenous therapy. This prevents infection that can damage the vessel lumens. ● Be sure IV medications are adequately diluted. This prevents chemical irritation of veins. ● Promote adequate hydration (i.e., monitor intake and output, assess hydration, manage fluid intake, teach patients to drink plenty of fluids). Unless contraindicated, adult fluid intake should be approximately 2,000 mL per day to keep urine output at about 1,500 mL per day. Adequate hydration keeps respiratory secretions thin but also keeps the blood from becoming viscous (“thick”). Viscous blood clots more readily. ● Promote smoking cessation. Nicotine increases the risk for thrombus formation because of its constricting effects on vessel walls. Patient risk for falling - what is it? ● Assess all inpatients for falls risk when they are admitted. ● Identify modifiable risk factors (Different conditions require different nursing interventions.). ● For clients at risk for falls, repeat the risk assessment every 8 hours, and increase the frequency of monitoring. ● Identify medications that increase the risk for falling (e.g., opioid analgesics, sedatives, and antihypertensives). ● Use standardized tools, such as the Get Up and Go test, the Timed Up and Go test Patients who are at risk: ● History of falls ● Age >80 years ● Impaired vision ● Weakness/dizziness (e.g., from disease or therapy) ● Gait or balance problems ● Pain ● Hypotension ● Orthostatic hypotension ● Cognitive impairment ● Chronic conditions (e.g. arthritis) ● Medication side effects (e.g., drowsiness) ● Polypharmacy ● Home hazards ● Unfamiliar environment ● Alcohol use Immobility - what are the findings of patients who are immobile? Prolonged immobilization causes physiological changes in nearly every body system as well as psychologically. Nasogastric tubes - a few questions on the procedures. NGT Briefly Explain the procedure for the Nasogastric tube: ● Measure the length of the tube to be inserted by measuring from the tip of the nose to the earlobe, and from the earlobe to the end of the sternum at the xiphoid process. ● Mark the length with tape or indelible ink at the narishow to give meds. ● Instruct pt to hold her head straight up and extend her neck back against the pillow (slightly hyperextended). ● Carefully insert the tube along the floor of the nasal passage, on the lateral side, aiming toward the ear. ● You will feel slight resistance when the tube reaches the nasopharynx; use gentle pressure, but do not force the tube to advance. The patient’s eyes may tear; if so, provide tissues. ● Continue inserting the tube until just past the nasopharynx by gently rotating the tube toward the client’s opposite naris. ● Instruct the patient to flex her head toward her chest, take a small sip of water, and swallow. ● Direct the patient to sip and swallow the water as you slowly advance the tube. (If the patient is not allowed water, instruct her to dry-swallow or suck air through a straw.) Advance the tube 5 to 10 cm (2 to 4 in.) with each swallow. ● Moving the tube with each swallow uses normal peristaltic movement to help advance the tube into the stomach. Swallowing closes the epiglottis so that the tube cannot advance into the trachea. ● Continue advancing the tube to the required distance. ● Secure with tape What is suctioning? ● low intermittent suction (25 mm Hg) to avoid erosion or tearing of the stomach lining, which can result from constant adherence of the tube’s lumen to the mucosal lining of the stomach. ● The nasogastric tube is connected to suction to facilitate decompression by removing stomach contents. Gastric decompression is indicated for bowel obstruction and paralytic ileus and when surgery is performed on the stomach or intestine. How do you check for placement? ● X-Ray ● Inspect the posterior pharynx for the presence of a coiled tube.Visualization confirms that the tube has gone beyond the oropharynx. ● Aspirate gently to withdraw stomach contents; measure aspirate pH. Aspirate gently over a period of up to 5 minutes, if necessary, to obtain gastric fluid. if it is alkaline, the tube may be in the lung.The pH of stomach contents is normally 1 to 5.5Take note of the amount, color, and consistency of the aspirate. What is the confirmed placement? ● x-ray confirmation of the tip of the feeding tube before each enteral feeding or once per shift for continuous feedings. Failure to verify placement could be disastrous because it may result in infusion of formula into the lungs. What are the two reasons you would give a pt NG tube? ● One is for decompression of the gastric. ● feeding (artificial nutrition) One question about spirituality: What is Spirituality? ● Spirituality is the day to day, moment by moment journey in life and living, involving personal subjective experiences that take place over time. Know different beliefs (Christianity, Judaism, Islam, Jehovah’s witness, Muslim) and what they prefer? What are a few dietary practices that christians may follow? ● Abstain from eating meat and alcohol on fridays and or during lent. ● Fast Which religion refuses to accept blood transfusion or blood products? Jehovah’s Witnesses What are the dietary practices for Jehovah’s Witnesses? Jehovah’s witnesses will not eat raw meat, red meat, or meat that has not been bled properly. T/F Jehovah’s Witnesses only celebrate the anniversary of the death of Christ. A pt is Islamic and the lunch menu has pork sausage, can the patient eat the sausage? No Would a male be able provide perineal care for a female Islamic patient? They prefer to be treated by a female staff and forbids to expose their bodies to or be touched by any man. Which religion is lacto vegetarian, consuming milk but no eggs. They will not eat beef and avoid bovine-derived medication because of the reincarnation of certain gods. Hinduism Which religion wears a “sacred thread” around the body or wrist. Do not remove or cut this thread without permission from the patient or next of kin Hinduism ****Jewish Patient’s require kosher meals**** ****Muslim patient’s do not eat pork and require halal meals**** Case scenario with vital signs - figure out what’s abnormal, improved, unchanged, worsened ● Know the difference between normal range bp, hr, temp and rr Patient safety. What do you have to provide when patients are unconscious? ● Continue orientation to reality. ● Safety measures ● Bed in low position ● Side rails up (maximum 3) ● Eye care ● Lubricating eyes with eyedrops ● Oral care How do you prevent sensory overload? And with sensory deprivation? Sensory deprivation ● A state of RAS depression caused by a lack of meaningful stimuli. ● When environmental stimuli are deficient, the remaining stimuli, can become overly noticeable or distorted, filling in the “sensory gap” & causing the pt a level of distress that is out of proportion to the intensity of the stimulus. Prevention: ● Focus is prevention. ● Support senses ● Orientation ● Provide stimuli. ● Regular contact; touch ● Television/radio ● Pet therapy ● Smells Sensory overload ● Complex sensory environment within the hospital can contribute to sensory overload. ● Monitor alarms; interruptions in rest & sleep by healthcare providers; medical therapies & procedures; pt care routines; & various odors, sounds, sights, & pain experiences can overwhelm the senses of pts in unfamiliar environments (hospital). Prevention: ● Minimize stimuli. ● Less light, noise ● Less television/radio ● Calm tone ● Reduce noxious odors. ● Provide rest. ● Teach stress reduction
