Understanding Macronutrients

Macronutrients

• Carbohydrates supply 4 kcal/g of energy, making up 45-65% of daily caloric intake
• Simple carbohydrates are sugars found in fruits, milk, and sweeteners
• Complex carbohydrates are starches and fibers from whole grains, legumes, and vegetables
• Fiber is vital for digestion and bowel regularity, found in whole grains, fruits, and vegetables
• Proteins are essential for tissue repair, immune function, and enzymatic reactions, providing 4 kcal/g
• Complete proteins contain all essential amino acids, examples include meat, fish, dairy, and eggs
• Incomplete proteins lack one or more essential amino acids, examples include beans, nuts, and grains
• The recommended daily intake of protein is 0.8 g/kg of body weight
• Fats provide 9 kcal/g, important for energy storage, cell membrane integrity, and hormone production
• Saturated fats are found in animal products, with excessive intake leading to heart disease
• Unsaturated fats are beneficial for heart health, found in plant-based oils, avocados, and nuts
• Trans fats are artificially produced and increase LDL cholesterol while lowering HDL cholesterol

Micronutrients

• Vitamins are essential for metabolism, immune function, and cellular processes
• Fat-soluble vitamins include A (vision), D (calcium absorption), E (antioxidant), and K (blood clotting)
• Water-soluble vitamins include B-complex (energy metabolism, nerve function) and C (collagen synthesis, immunity)
• Minerals are necessary for enzymatic reactions and bodily functions
• Major minerals include Calcium (bone health), Potassium (muscle contraction), Sodium (fluid balance), and Magnesium (nerve function)
• Trace minerals include Iron (oxygen transport), Zinc (immune function), and Iodine (thyroid function)

Dietary Guidelines & Nutrition Assessment

• MyPlate promotes a balanced intake of protein, grains, fruits, vegetables, and dairy
• Nutritional screening tools include 24-hour recall, food frequency questionnaires, and BMI calculation
• Signs of malnutrition are weight loss, muscle wasting, delayed healing, weakness, dry skin, and brittle hair
• Nutritional deficiency disorders include Scurvy, Rickets, Iron-Deficiency Anemia, Kwashiorkor and Marasmus
• Scurvy (Vitamin C deficiency) presents with bleeding gums and weakness
• Rickets (Vitamin D deficiency) results in soft bones and skeletal deformities
• Iron-Deficiency Anemia leads to fatigue and pale skin
• Kwashiorkor (Protein Deficiency) causes a swollen belly and stunted growth
• Marasmus (Severe Malnutrition) causes extreme weight loss and muscle wasting

Special Diets

• NPO (Nothing by Mouth) is used pre-surgery or for patients at risk of aspiration
• A Clear Liquid Diet includes broth, gelatin, and clear juices, often used postoperatively
• A Full Liquid Diet includes dairy, pudding, and soups, for patients with difficulty swallowing
• A Soft Diet includes mashed potatoes, scrambled eggs, and soft fruits, for patients with chewing/swallowing difficulties
• A Diabetic Diet involves controlled carbohydrates, high fiber, and low sugar
• A Cardiac Diet includes low sodium, low fat, and high fiber to manage heart conditions

Urinary System

• Normal urination for adults is at least 30 mL/hr of urine
• Urinary retention is the inability to fully empty the bladder, resulting from medications, neurological conditions, or blockages
• UTIs (Urinary Tract Infections) occur when bacteria enter the urinary tract, causing symptoms like burning sensation, urgency, cloudy urine, and fever
• Stress incontinence is leakage with exertion, such as coughing or sneezing
• Urge incontinence involves a sudden, intense need to void due to an overactive bladder
• Overflow incontinence occurs when the bladder overfills and leaks due to weak detrusor muscle or obstruction
• Functional incontinence is the inability to reach the toilet in time due to mobility issues or cognitive impairment

Bowel Elimination

• Normal bowel patterns vary, ranging from 1-3 times per day to a few times per week
• Constipation causes hard, dry stools, infrequent bowel movements due to low fiber, dehydration or medications
• Diarrhea is frequent, watery stools, leading to dehydration and electrolyte imbalances
• Fecal impaction is hard stool lodged in the rectum, potentially needing digital removal
• Flatulence is gas accumulation in the GI tract, relieved with movement and dietary changes

Bowel Diversions

• A colostomy is a surgical opening in the colon to divert stool, consistency varies by stoma location
• An ileostomy is a surgical opening in the ileum, producing liquid stool and requiring increased fluid intake

Fluids & Electrolytes

• Intake & Output (I&O) should be roughly equal, monitored in hospitalized patients for fluid imbalances
• Fluid Volume Deficit (Dehydration) presents with dry mucous membranes, low BP, tachycardia, and sunken eyes
• Fluid Volume Excess (Overload) includes edema, high BP, crackles in lungs, and weight gain
• Pitting edema leaves an indentation when pressed
• Non-pitting edema has tight and shiny skin without indentation

Electrolytes & Imbalances

• Sodium (Na+) controls fluid balance and nerve function, normal range is 135-145 mEq/L
  • Hyponatremia (low sodium) causes confusion and seizures
  • Hypernatremia (high sodium) causes thirst and confusion
• Potassium (K+) assists muscle function and heart rhythm, normal range is 3.5-5.0 mEq/L
  • Hypokalemia (low potassium) causes muscle weakness and arrhythmias
  • Hyperkalemia (high potassium) causes cardiac arrest
• Calcium (Ca2+) is important for bone health and muscle contraction, normal range is 8.5-10.5 mg/dL
  • Hypocalcemia (low calcium) causes tetany and cramps
  • Hypercalcemia (high calcium) causes kidney stones
• Magnesium (Mg2+) assists enzymatic reactions and muscle function, normal range is 1.5-2.5 mEq/L
  • Hypomagnesemia (low magnesium) causes tremors and seizures
  • Hypermagnesemia (high magnesium) causes hypotension

Respiratory System Basics

• Ventilation moves air in and out of the lungs
• Diffusion involves gas exchange between alveoli and blood
• Perfusion transports oxygen to tissues

Respiratory Assessment

• A normal breathing pattern is 12-20 breaths per minute (eupnea)
• Abnormal breathing patterns consist of:
  • Bradypnea: slow breathing (<12 breaths/min)
  • Tachypnea: rapid breathing (>20 breaths/min)
  • Dyspnea: difficulty breathing
  • Apnea: absence of breathing
  • Cheyne-Stokes: periods of deep breathing followed by apnea

Oxygen Therapy

• A Nasal Cannula delivers 1-6 L/min (24-44% oxygen)
• A Simple Mask delivers 6-12 L/min (35-50% oxygen)
• A Non-Rebreather Mask delivers up to 100% oxygen

ABGs (Arterial Blood Gases)

• Normal ABG Values:
  • pH: 7.35-7.45
  • PaCO₂: 35-45 mmHg
  • HCO₃: 22-26 mEq/L
  • PaO₂: 80-100 mmHg
  • SaO₂: 95-100%

Acid-Base Imbalances

• Respiratory Acidosis results from hypoventilation, leading to high CO₂ and low pH
• Respiratory Alkalosis comes from hyperventilation, leading to low CO₂ and high pH
• Metabolic Acidosis is caused by low HCO₃ and low pH (e.g., DKA, kidney failure)
• Metabolic Alkalosis results from high HCO₃ and high pH (e.g., vomiting, diuretics)

Surgical

• The Preoperative Checklist includes informed consent, patient education, NPO status, lab values, and medication review
• Informed consent signifies that the patient signed off before surgery, explaining the risks and benefits
• A sterile field prevents infections, and includes scrubbing, gowning, and gloving

Anesthesia Types

• General: Loss of consciousness
• Local: Numbs a specific area
• Regional: Blocks sensation in an entire region such as an epidural

Postoperative Care

• PACU monitoring includes airway patency, vital signs, and pain management
• Complications includes
  • Atelectasis: Alveolar collapse which is prevented via deep breathing and coughing
  • DVT (Deep Vein Thrombosis) which is prevented via mobility, anticoagulants
  • Infection Prevention ensured through hand hygiene and aseptic technique, wound care

Pain Management

• Acute pain is sudden and resolves with healing, example includes post-surgical pain
• Chronic pain lasts greater than 3 months, the pain is persistent, example includes arthritis and neuropathy
• Referred pain is felt in an area different from the injury source

Pain Assessment Tools

• Numeric Rating Scale (NRS) ranged from 0-10 scale
• Faces Pain Scale is used for pediatric or non-verbal patients
• PQRST includes:
  • Provocation/Palliation (P)
  • Quality (sharp, dull, burning) (Q)
  • Region/Radiation (R)
  • Severity (S)
  • Timing (T)

Pain Management Strategies

• Pharmacological options include NSAIDs, opioids, muscle relaxants
• Non-pharmacological options include heat/cold therapy, relaxation techniques, and acupuncture

NG Tubes & Enteral Feedings

• Placement checked via X-ray (gold standard), pH testing, auscultation
• Feeding precautions involve head of bed at 30-45°, checking residual volume, and assessing bowel sounds
• Complications are aspiration, clogged tube, and diarrhea

Total Parenteral Nutrition (TPN)

• TPN is given via a central line, not a peripheral IV
• Blood sugar is to be monitored, it can cause hyperglycemia
• Complications are infection by improper sterile technique, electrolyte imbalances

Electrolytes & Side Effects

• Hyponatremia leads to confusion, seizures; hypernatremia leads to thirst, edema
• Hypokalemia can cause arrhythmias, muscle weakness; hyperkalemia can cause cardiac arrest
• Hypocalcemia can cause tetany, Chvostek's sign; hypercalcemia can cause kidney stones and constipation
• Hypomagnesemia can cause tremors, seizures; hypermagnesemia can cause low BP and respiratory depression

Blood Transfusions

• Verify patient ID & blood type with another RN
• If signs appear, monitor for reaction and STOP transfusion
  • Febrile reaction includes fever and chills
  • Hemolytic reaction includes back pain, hypotension, and tachycardia
  • Allergic reaction includes hives and itching

Fluid Balance

• Deficit (Dehydration) presents with low BP, tachycardia, and dry mucosa
• Overload presents with edema, crackles in lungs, and high BP
• IV Fluids are used in therapy
  • Isotonic (NS, LR) stay in the bloodstream for dehydration
  • Hypotonic (½ NS) moves fluid into cells for DKA
  • Hypertonic (3% NS) pulls fluid into vessels for cerebral edema

Oxygen Therapy & Devices

• Nasal Cannula delivers 1-6 L/min, which is 24-44% oxygen. It is used for stable patients
• Simple Mask delivers 6-12 L/min, which is 35-50% oxygen. It is used if moderate O2 is needed
• Non-Rebreather delivers up to 15 L/min, which is 100% oxygen. It is used for critical patients
• Venturi Mask is for precise O2 control and used for COPD patients

Tracheostomy Care

• Suction if needed, PRN, not on routine
• Use sterile technique
• Keep obturator at bedside in case of emergency replacement

Acid-Base Balance

• Respiratory Acidosis is caused by hypoventilation, ABG values are low pH with high CO2, example of why it happens is COPD or sedation
• Respiratory Alkalosis is caused by hyperventilation, ABG values are high pH with low CO2, example of why it happens is anxiety or pain
• Metabolic Acidosis is caused by low HCO3, ABG values are low pH with low HCO3, example of why it happens is DKA or diarrhea
• Metabolic Alkalosis is caused by high HCO3, ABG values are high pH with high HCO3, example of why it happens is vomiting or diuretics

Urinary Elimination

• UTIs causes dysuria, urgency, cloudy urine
• Urinary catheters should be sterile insertion and keep below bladder level
• Diet for urinary health should include increase fluids, cranberry juice, avoid caffeine

Bowel Elimination

• Ostomies require skin care, bag should be emptied when ⅓ full, diet modification is low fiber at first
• Enemas require left side position, warm solution, insert 3-4 inches
• Constipation therapy involves increasing fiber, fluids and exercise

Surgical Client: Pre-op Checklist

• NPO status must be confirmed
• Informed consent must be signed
• Jewelry, dentures and contacts must be removed

Post-op Complications

• Atelectasis: encourage deep breathing, incentive spirometry
• DVT: ambulate early, compression devices
• Infection: hand hygiene, sterile technique

Pain Assessment (PQRST)

• Provocation

• Quality

• Radiation

• Severity

• Timing

• Cold therapy reduces swelling, do not use with poor circulation