CH.23
Complete proteins
A protein containing all of the essential amino acids.
Describe the nurse’s responsibilities for patients on special diets, including diabetics and their specific needs.
Nurses are responsible for monitoring the type of diet, percentage eaten, and whether or not the patient tolerated the meal. They are also responsible for advancing the patient’s diet when “Advance as tolerated” is ordered. Patients with diabetes have many special needs, and the nurse is responsible for teaching and assessing the patient for complications such as hypoglycemia and hyperglycemia
Correctly stage pressure injuries.
Pressure injuries are identified by stages, based on tissues involved and intact or nonintact skin. They are identified by one of the following: stages 1 to 4, unstageable, and DTPI. In addition, they may be determined to be medical device–related (which can be staged) or a mucosal membrane pressure injury (which cannot be staged).
Describe nursing care of patients with musculoskeletal conditions, including casts, traction, joint replacement, and amputation.
When caring for a patient in skeletal traction, clean the pin sites using sterile technique with the solution ordered. Observe them carefully for signs of infection because any infection at the pin site can easily invade the bone.When caring for a patient in traction, keep all ropes straight without kinks and aligned in pulleys, with weights hanging freely. Assess for skin breakdown beneath the traction boot or elastic bandage.
When caring for a patient with a lateral total hip replacement, keep the abductor pillow in place while the patient is in bed. When the patient transfers from the bed to a chair and while they are sitting in the chair, prevent them from flexing the hip more than 90 degrees. Adduction of the leg or flexion of the hip can cause dislocation of the hip prosthesis. When caring for a patient with a knee replacement, a CPM machine may be ordered. This passively exercises the knee with flexion and extension and must be set at the speed and degree of flexion ordered by the physician.
Pneumothorax
occurs when a hole allows air to enter the pleural space, also termed the pleural cavity, where there is supposed to be negative pressure.
Anabolism
The process by which the body uses components to build or reconstruct new components or tissue
Discuss methods to assist with meals and improve the patient eating experience in the hospital.
Methods for assisting with meals for patients in the hospital include preparing the environment and preparing the patient in addition to assisting the patient with eating, if needed.
Compare primary, secondary, and tertiary wound closures.
Primary Intention Healing
When the wound is clean with little tissue loss, such as a surgical incision, the edges are approximated.
Secondary Intention Healing
When there is greater tissue loss and the wound edges are irregular, the edges cannot be brought together. Examples of this are a pressure injury or a traumatic wound.
Tertiary Intention Healing
When tertiary intention healing, also known as delayed primary closure healing, is used, the wound is left open for a time to allow granulation tissue to form
Identify safety issues related to musculoskeletal care.
standing to far behind walkers can effect balance Bearing weight on the axilla can cause compression of nerves and can lead to nerve damage affecting the arm and hand.if the knee is flexed and the foot is held behind the crutches, it can affect the patient’s balance, causing them to fall backward.
Explain the mechanics of inhalation and exhalation.
This causes a sort of vacuum; air is pulled into the lungs until the pressure in the lungs equals the pressure outside the body. The term used to describe this is inhalation, also known as inspiration.
As these muscles relax, again in response to nerve stimulus, the size of the chest cavity decreases. The ribs come inward, the diaphragm rises upward, and the lungs are then compressed, forcing the air to go out. This is referred to as exhalation, also known as expiration.
Discuss the functions and importance of water in the body.
Maintains body temperature
Transports minerals, vitamins, and electrolytes
Cushions the brain and spinal cord
Lubricates joints
Carries toxins and excreted waste products out of the body
Moisturizes and lubricates the gastrointestinal tract to aid the passage of food through the intestines
List at least six guidelines to use in teaching patients with diabetes.
1. Eat a well-balanced diet, which includes carbohydrates, moderate protein, and fat in sparing amounts.
2. Know the differences between simple and complex carbohydrates:
Simple carbohydrates, which are found primarily in fruits, fruit juices, processed baked goods, and sugar, are quickly converted to glucose and can be used to rapidly raise the blood glucose. There is no need to totally eliminate them from the diet, but simple carbohydrates should be ingested in moderation, and carbohydrate intake should be consistent from day to day to maintain better balanced blood glucose.
Complex carbohydrates, which are found in whole grains, vegetables high in fiber, and legumes such as dried peas and beans, require the body to work harder to break them down to use for energy. This helps to maintain a more consistent blood glucose level. The majority of ingested carbohydrates should be complex carbohydrates rather than simple carbohydrates.
3. Eat three meals and an evening snack daily. Some health-care providers may prefer you to eat an additional snack in midmorning and midafternoon. Each of these should contain some protein.
4. Do not skip meals.
5. Increase your fiber intake.
6. Reduce your fat intake by baking, broiling, or grilling foods.
7. Lose weight if you are overweight. Studies show that even a loss of 5% to 10% of total body weight is significant to help lower blood glucose.
8. Wear a diabetic identification bracelet or necklace for emergencies.
Contrast contusion, abrasion, puncture, penetrating, laceration wounds and pressure injuries.
A contusion is a closed, discolored wound caused by blunt trauma,An abrasion is a superficial open wound. Abrasions include scrapes, scratches, or rub-type wounds where the skin is broken, such as a carpet burn or a skinned knee.,A puncture wound is an open wound that results when a sharp item, such as a needle, nail, or piece of wire, pierces the skin. A penetrating wound is similar to a puncture wound; the difference is that the offending object remains embedded in the tissue. A laceration is an open wound made by the accidental cutting or tearing of tissue.A pressure injury is a wound resulting from pressure and friction. The skin may be intact and erythemic (reddened),
what is RICE?
REST ICE COMPRESSION ELEVATION
Discuss the significance of selected diagnostic tests when caring for patients with impaired oxygenation.
SPUTUM SPECIMENS.
Pulmonary function tests-determines the lung capacity volume and rate.
Peak flow- measures the amount of air that can be exhaled
Chest X-ray- used to see visual field
TB skin test- determine reaction to the presence of tuberculin bacillus
Bronchoscopy-To visualize trachea and bronchi; to obtain biopsies of abnormal tissue; and to obtain samples of lung cells, fluids, and other material inside the air sacs.
Discuss fat and lipid deficiency and excess disorders.
possible for that individual to become deficient in fat-soluble vitamins because they are stored in the body fat.An overindulgence of saturated fats or eating more than 35% of the daily caloric intake in the form of fat is known to contribute to being overweight and obese
Describe nasogastric and nasointestinal tubes, including size, length, and lumens.
NG tubes are shorter than NI tubes because they go only to the stomach. NI tubes are usually smaller in diameter and more flexible than NG tubes. The double-lumen tube, also called a Salem sump, is used strictly for gastric decompression.
Accurately assess a wound and wound drainage.
length width depth color tissue around wound drainage color smell
how do you set up a CPM?
Review the physician’s order. Note the degrees of flexion and the speed ordered and the length of time the machine is to be in use. Assess the patient’s pain level. Place the sheepskin on the platform where the patient’s leg will rest, especially at the end near the gluteal fold to prevent pressure on the patient’s skin, which could lead to a pressure ulcer.Position the CPM machine so that the break in the platform is centered beneath the patient’s knee. Align the machine and the patient’s leg with the hips and torso of the patient’s body to prevent injury or muscle spasms.Carefully assist the patient to place the affected leg on the CPM platform.Set the degrees of flexion and speed as ordered by the physician.Turn on the CPM machine.Observe the machine as it flexes and extends the patient’s knee and ensure that the passive exercise is being well tolerated by the patient. Gentle passive exercise should not cause pain.Follow the Ending Implementation Steps located on the inside back cover.
Pleural effusion
(fluid in the chest cavity
Explain the types, functions, and digestion of proteins.
Nonessential amino acids, essential amino acids, complete proteins, protein digestion occurs in the small intestine, it begins in the stomach, where hydrochloric acid breaks down large proteins into amino acids, which are partially digested by the enzyme pepsin.
functions include new tissue rebuilding, heat and energy production, maintain acid base, formation antibodies, enzymes, and hormones.
Explain when and how nasogastric tubes are used for gastric decompression.
Gastric decompression is the process of reducing the pressure within the stomach by emptying it of its contents. An NG tube is inserted into the stomach and connected to low intermittent suction to accomplish this
Differentiate between clean, clean-contaminated, contaminated, infected, colonized, open, and closed wounds.
Clean: A wound that is not infected.
Clean-contaminated: A wound that was surgically made and is not infected, but it has direct contact with the normal flora in either the respiratory tract, urinary tract, or gastrointestinal tract. It has more potential to become infected.
Contaminated: This can be a surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis.
Infected: An infected wound is one in which the infectious process is already established, as evidenced by high numbers of microorganisms and either purulent (containing pus) drainage or necrotic (dead) tissue. The classic signs of infection include erythema (redness), increased warmth, edema (swelling), pain, odor, and drainage.
Colonized: A colonized wound differs from an infected wound in that it has a high number of microorganisms present but is without signs of infection.
how do you preform a Neurovascular check?
1. Follow the Initial Implementation Steps located on the inside back cover.
2. Ask the patient if they are experiencing numbness, burning, or tingling in the affected limb. Test sensation of the affected and unaffected limbs by touching each with a paper clip and asking the patient to tell you when they feel the sensation of the paper clip touching the limb. A decreased sensation in the affected limb may indicate impairment of sensory nerve function.
3. Assess for edema at the surgical site and distal to the site or cast. Compare the size of the distal aspect of the extremity to the unaffected extremity. Edema indicates impairment of circulation and should be monitored closely to determine whether it increases.
4. Touch the patient’s skin distal to the surgical site or cast with the back of your hand. Assess for warmth and compare to the warmth of the same area on the unaffected limb. Cooler temperature of the affected limb may indicate impairment of circulation.
5. Assess the color of the skin and nailbeds in the distal portion of the affected limb. These should be the same as in the unaffected limb; nailbeds should be pink. Pallor or cyanosis indicates impairment of circulation.
6. Test capillary refill in the nailbeds of the fingers or toes distal to the surgical site or cast. Compare it with that in the unaffected limb. Slower refill time in the affected limb or refill longer than 5 seconds indicates that circulation is impaired.
7. Ask the patient to move the fingers or toes of the affected extremity. Movement should be free of discomfort if motor nerves are unimpaired.
8. Palpate distal pulses if possible and compare with the pulses on the unaffected limb. Each should be present and equal if no circulatory impairment is present.
9. Ask the patient to describe their pain in the affected limb, including the type of pain and its intensity. Ask them to rate it on a scale of 0 to 10. Pain should gradually decrease in intensity as healing occurs. A sudden increase in pain could indicate infection or compression.
10. Follow the Ending Implementation Steps located on the inside back cover.
Explain the changes in physiological regulation of respiration in patients with chronic lung disease.
Chronic lung disease is also a cause of hypoxemia. Over time, the alveoli and airways are damaged, making them unable to expand and move air in and out, so oxygen does not cross into the alveolar capillaries to be taken to the body tissues.
Explain the types, functions, and digestion of carbohydrates and fiber.
Carbohydrates serve as the primary source for energy and are more quickly digested into a usable form than either proteins or fats. Carbohydrates may be simple or complex. Fiber is an indigestible carbohydrate and is needed by the body.
Describe the process for and importance of checking placement of nasogastric and nasointestinal tubes and checking residual gastric volume.
It is vital that you check the residual volume and tube placement before instilling each tube feeding.If the placement of a tube is not confirmed before administering a feeding or medication, there is a risk of instilling the formula or medication directly into the lungs via an NG tube or into the sterile peritoneal cavity via a PEG tube or J-tube.
Identify information to document concerning wounds.
Accurate documentation of wound care is extremely important. Describe the amount and color of drainage on the old dressing. Document the length, width or diameter, and depth of the wound. Refer to a clock face to describe the interior of the wound, including sinus tracts and their length. Describe the color of the wound and appearance of the surrounding skin. Document the type of dressing applied. It is helpful to say how many gauze 4 × 4s you used, for example, in a wet-to-damp dressing, so that the next nurse knows exactly what to prepare.
how do you apply a figure 8 elastic bandage on an ankle ?
wrap 2 turns around the instep of the foot. take the bandage around the inner ankle and behind the leg, the bring the bandage around the outer ankle around the front of the leg and to the instep, bring the bandage under the foot and then around the foot. repeat steps until the end of bandage a 1/4 in from where you started secure bandage.
Discuss safety measures to enforce when the patient is receiving supplemental oxygen.
require use of stringent safety precautions to prevent fire. no open flames no wool blankets
Identify sources and functions of minerals, in addition to symptoms of deficiencies and excesses of each.
Minerals are inorganic compounds needed in small amounts by the body. Major minerals are those we need to ingest 100 mg per day for optimal health. Trace minerals are those we require less of each day.
CAlcium
Deficiency: Tetany of muscles, bone and tooth loss, osteoporosisExcess: Constipation, flatus, and kidney stones
Iron
Deficiency: Pallor, fatigue, shortness of breath, headache, increased irritability, anemia, and fainting Excess: Missed periods, discoloration of skin, and joint swelling and pain
Magnesium
Deficiency: May cause elevated blood pressure (BP), agitation, restless leg syndrome, hypotension, muscle spasms, insomnia, and arrhythmiasExcess: Increased calcium excretion, weakness, malaise, and GI symptoms
Describe NPO status, regular diets, and diets modified by consistency.
NPO is no food or liquid by mouth. bland and tasteless. Common diets with consistency modifications include clear liquid, full liquid, mechanical soft, and pureed.
Describe possible complications of wound healing and appropriate nursing care for each.
Inflammatory Phase-This phase occurs when the wound is fresh and includes both hemostasis and phagocytosis.
Reconstruction Phase-If it is irritated or abraded, it bleeds easily. When you measure a wound and find that it is getting smaller, filling with deep pink to light red tissue, you know that the wound is healing, or “granulating.”
Maturation Phase-his phase, also known as the remodeling phase, occurs when the wound contracts and the scar strengthens.
How do a spiral wrap on a leg or forearm.
Start at the narrower area of the lower leg or wrist area of the forearm. Wrap two turns to anchor the wrap.Wrap the bandage around the arm or leg, progressing up the limb with each turn at a 30-degree angle, overlapping the elastic bandage with each turn.Repeat these steps until bandaging is complete.Secure the Velcro bandage end against the elastic bandage.
Describe various artificial airways and how to suction the patient with the airway in place.
Artificial airways vary from small plastic devices inserted in the mouth to tubes inserted through the nose, mouth, or an incision into the trachea tracheostomies, you will remove the inner cannula to clean or replace it.Endotracheal-The sterile suction catheter is inserted using sterile technique through the endotracheal tube, and suction is applied as the catheter is pulled outward. Some suction catheters are inside a sleeve of clear plastic,
Catabolism
which the body reduces complex substances down to the simpler substances and sometimes releases energy as a result.
Total parenteral nutrition
A type of feeding administered through a central venous catheter (CVC) placed in a larger central vein.
Describe types of dressings and their uses.
Wet-to-Damp Dressings-Removing the gauze in the wound helps to gently débride necrotic tissue.
External fixator
are the wires, pins, tongs, and rods that may be used in skeletal traction
List inspection points in the assessment of a patient with impaired oxygenation.
Color of skin and mucous membranes
Respiratory effort
Cough
Chest appearance
Oxygenation status
Oxygen saturation
Simple carbohydrates
also known as simple sugars, are chemically made up of one or two sugar molecules that are absorbed rapidly. The following are four examples of simple sugars:
Glucose: our primary energy source, the most common form
Fructose: fruit sugar, the sweetest natural sugar
Sucrose: table sugar
Lactose: milk sugar, the least-sweet natural sugar
Anorexia nervosa
An eating disorder marked by relentless self-starvation in an effort to reduce the body weight below normal. This disorder is characterized by an excessive leanness or wasting of the body, known as emaciation.
Ischemia
reduced blood flow to the area
Skeletal traction
pins, screws, or tongs are surgically inserted into the bone.
Describe a tracheostomy tube and the nursing care needed to keep it patent.
When you clean a tracheostomy, you will remove the inner cannula and clean it in hydrogen peroxide mixed half-strength with saline and then rinse it in saline, dry it, and reinsert it. This is done every 8 hours using sterile technique to prevent introducing pathogens into the trachea and lungs. If the inner cannula is disposable, you will remove it and reinsert a new one rather than cleaning and reinserting. When a patient has a permanent tracheostomy and is caring for it at home, the technique used may be a clean procedure rather than a sterile one.
Antioxidant
Vitamins A, C, and E are known as antioxidants because they have been identified as helping to deactivate these free radicals before they can cause damage.
Bulimia nervosa
Commonly referred to as binge eating, this eating disorder is accompanied by behavior to get rid of some of the calories that were ingested while bingeing, such as self- or medication-induced vomiting (known as purging), excessive exercise, fasting, or the overuse of laxatives.
Eschar
Hard, dry, dead tissue that has a leathery appearance
Skin traction
The limb is wrapped with an elastic bandage or fitted with a Velcro wrap to which a frame is attached.
List tips for conservation of energy for patients with chronic lung disease.
Patients with impaired oxygen need to expand the lungs fully, which can be accomplished by turning, coughing, and deep breathing; use of an incentive spirometer; and nebulizer treatments with bronchodilators.