Nutrition
While everyone has the potential to be at risk for impaired nutrition, what are 2 populations that are most at risk and why?
Elderly and very young
- Premature and LBW babies: immature suck/swallow, tube feeds
- Elderly: medical conditions, drug interactions, social isolation, institutionalized, impaired ADLs, loss of appetite
- Pregnant people
- People with tube feedings or GI surgery
- Vegan diet
What recommendation about bathing and temperature of bath water should be made for a child with atopic dermatitis?
To avoid drying out skin even more, bath water should not be too hot and bathing not too frequent. Lotions are also recommended to lock in moisture.
While everyone has the potential to be at risk for impaired sleep, what are 3 populations that are most at risk and why?
- Women more than men
- Elderly
- Chronic Illness and/or pain
- Hospitalized patients- especially critical care
A patient taking large doses of opioids each day for their arthritis is at risk for what elimination issue? Why?
Constipation; Opioids slow down peristalsis!
What vitamins should be increased in a patient with anemia?
Iron & B12
A child measures at the 80th percentile of the growth chart. What does this classify them as?
Normal healthy weight
<5th percentile: underweight
> 85th percentile: overweight
> 95th percentile: childhood obesity
How often/long are patients with burns instructed to wear their compression garments?
23 hrs/day for up to 2 years
Newborns need approximately _______ hours of sleep per day.
14-17 hours
What kind of patient might you recommend kegel exercises to and what are the benefits?
Postpartum people struggling with urinary incontinence; Kegels help to strengthen pelvic floor and decrease bladder leakage
What diet promotes tissue repair and healing?
High protein, high vitamin C
What is the recommended diet for an individual with pancreatitis?
High protein, low fat diet
You are assessing a patient's bed sore. You observe a deep crater-like ulcer with full-thickness skin loss involving the epidermis, dermis, and necrosis of subcutaneous tissue. You note 2 cm tunneling with minimal slough partially covering the wound.
What stage is this patient's pressure ulcer?
This is a stage 3 pressure ulcer.
Stage 3: Full thickness skin loss; Involves epidermis, dermis and damage or necrosis of subcutaneous tissue; Damage extends down to but not through fascia; Deep crater-like ulcer; Subcutaneous fat may be visible but not muscle, tendon, or bone, Slough (light, thin & stringy) may be present; Tunneling or undermining may be present
Stage 4: Full thickness of the skin has been lost; extensive destruction of underlying tissue; Tissue necrosis, and damage to bone, muscle, or other supporting structures that are exposed
How many sleep cycles do we pass through each night, and how long does each cycle last?
We usually pass through 4-5 sleep cycles per night; each sleep cycle lasts about 90-110 minutes
Which of the following patients is at the greatest risk for colon cancer?
1) A pregnant, obese 40-year-old woman in her 3rd trimester
2) A 6-year-old with a history of bed wetting
3) A 50-year-old man with a BMI of 29 who works a desk job
4) An obese 60-year-old man who drives 4 hours/day for work
4) Obese men over the age of 60 are at the greatest risk of colon cancer.
You are assessing a pressure ulcer on a patient's heel. You note the wound to be swollen, red, and blistering.
What stage is this pressure ulcer?
Stage 2
Skin is broken; partial thickness skin loss with loss of epidermis and some of the dermis
Appears as a shallow ulcer or crater; red-pink in color
Swollen and painful
No slough or necrotic tissue is present in the base
May appear as enclosed/open serum-filled blister
You are caring for a patient with laryngeal cancer. What are they at a high risk for during feedings, and what nursing intervention can minimize this risk?
Laryngeal patients are at high risk for aspiration. Nursing intervention: Elevate head of bed at least 30 degrees during and 30-45 mins after feedings!
A patient scores a 14 on the Braden Scale. What level of risk does this classify them as?
Moderate risk
Braden scale scoring: total range 6-23
19-23 = No Risk
15-18 = Mild risk
13-14 = Moderate risk
10-12 = High risk
< 9 = Very high risk
At what age is there a physiological shift in circadian rhythm? What does this result in?
Age 14; makes teenagers want to stay up late and sleep in
You are assessing a patient who recently underwent surgery involving bowel manipulation. They are concerned that they have not had a bowel movement in the last 4 days. What may be the underlying cause for the patient's constipation?
Paralytic ileus; This causes constipation and is much more likely to occur in patients who have recently had surgery and even more likely if bowel manipulation occurred.
How often should a patient be voiding (hourly/daily)?
Bladder pattern: empty bladder every 3-4 hours, 5-6 times daily
What are 3 important tertiary interventions for a patient with pancreatitis?
- NG tube w/ suction
- Pain meds
- NPO diet
- TPN feedings
- Bowel rest
What does each section of the ABCDE screening for skin cancer represent?
A: Asymmetry
B: Borders (uneven edges)
C: Color (dark black/diff colors)
D: Diameter (>6mm)
E: Evolving (size, shape, color)
During which stage of sleep does motor memory & motor skill development occur?
Nonrapid Eye Movement (NREM)- N2
NREM:
N1- light sleep, easily aroused
N2- motor memory/motor skills learning
Slow wave sleep:
N3 & N4– deepest stage of sleep, difficult to arouse, lasts 30-60 min
Retention and recall of newly learned facts; Restorative function; Sleepwalking
Rapid eye movement (REM):
Vivid dreams, rapidly moving eyes, difficult to arouse, lasts 20min; Creative memory domain– build associations, pattern recognition, removes emotion from facts
What medication would you expect a patient diagnosed with Clostridium difficile to be prescribed? What hand washing measure should you explain to the visiting family?
Antibiotics (specifically Vancomycin! Very common for C. diff)
Encourage patient to take probiotics to restore healthy gut bacteria
Inform visitors that they MUST thoroughly wash hands before exiting the room. Hand sanitizer will NOT kill C. diff!
What is REEDA used for and what does it stand for?
Used to measure wound appearance; Redness, Edema, Ecchymosis, Discharge/Drainage, Approximation