Nutrition
Nutrients are substances found in food that are used by the body to promote normal growth, maintenance, and repair.
What is Nutrients?
How many times do you urinate during 24 hours? Has this pattern changed recently?
Do you need to get out of bed to void at night? How often?
What are some voiding pattern questions to ask clients?
Skin Hydration
What does turgor assess?
Visual acuity test
What does Rosenbaum test for?
Physiological needs, Safety needs, Social belonging(Love and Belonging), Esteem, and Self-actualization
What are the five levels of Maslow's Hierarchy of Basic needs?
Flaccid muscles, mental status change, dry, scaly skin, weakness and fatigue, changes in weight, dull eyes, etc.
What are some malnutrition findings?
>30 mL/hour
What is the minimal urine output?
The Braden Scale rates a client's risk for alternations in tissue integrity using six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
What is the Braden Scale?
Normal Findings: When the patient's head is flexed, the hips and knees should not flex upward
What are some normal findings for Brudzinski sign?
P-Provocation (Precipitating cause)Q-Quality R-Region S-Severity T-Timing
What does the mnemonic PQRST stand for?
25 to 29.0 is overweight
What is the BMI for overweight?
Alcohol, caffeinated beverages and foods, dairy (milk, cheese, cream and ice cream), spicy foods, beverages that contain fructose
What are some foods and beverages to avoid if the client is experiencing diarrhea?
Older adults, immobility, obesity, anemia, impaired circulation, fever, dehydration, impaired cognitive functioning, neurologic disorder
What are some risk factors for skin breakdown?
A Romberg test is positive when you have a loss of balance when you close your eyes during the test
What is a positive finding for Romberg test?
Hypothermia, Tachycardia, Thready weak pulse, Hypotension, Confusion, mucous membranes, weakness
What are some expected findings for dehydration?
Macronutrients and micronutrients
What are the essential nutrients?
An increase in sodium leads to decreased urination.
Caffeine and alcohol intake lead to increased urination.
How does diet affect urination?
Severe, 8mm, prolonged skin response
What does a pitting edema of 4+ mean?
Minimize overall stimuli, provide a private room, reduce lights and noises, limit visitors, ensure pain is adequately managed
What are some interventions for clients experiencing sensory overload?
Baked potatoes, banana, spinach, plain, nonfat yogurt, prune juice
What are some foods high in potassium?
Slow the instillation rate, notify the provider, confer with the dietitian, and provide skin care and protection
What interventions should be taken for a client receiving enteral feedings who is experiencing diarrhea 3 or more times in 24 hours?
Collect for 24 hr or other duration.
Discard the first voiding.
Collect all other urine. Refrigerate, label, and transport the specimen.
What is the nursing action for a Timed urine (24-hour)?
Assess head and shoulder for strength
What does the cranial nerve XI assess?
Tinnitus(ringing, roaring, humming in ears), dizziness, hears poorly in a noisy environment, speaks loudly, no otoscopic finding
What are some sensorineural hearing loss findings?
pH less than 7.35 and PaCo2 greater than 45.
- Shortness of breath, anxiety and confusion, fatigue, tremors, lethargy
What are some assessment findings with respiratory acidosis?