Fundamentals Exam 2 PDF

Hygiene & Tissue Integrity 1. Functional Ability Assessment measures the client's ability to complete the tasks and activities associated with daily living ○ Measure the impact of an illness on the person’s ability to care for themselves​. ○ Determine the scope of...

Hygiene & Tissue Integrity 1. Functional Ability Assessment measures the client's ability to complete the tasks and activities associated with daily living ○ Measure the impact of an illness on the person’s ability to care for themselves​. ○ Determine the scope of assistance required by an individual. ○ Monitor changes in the functional ability of a client living with a chronic alteration in health​. Types of Assessments: ○ Social ○ Economic ○ Mental health ○ Physical health ○ Self-care capacity An individual's functional ability often decreases due to alterations in health caused by an illness or accident ○ It is the nurse's responsibility to work with the client to determine their level of functional ability and plan interventions that promote the client's independence while assuring they receive the assistance they need Tools to Assess Funtional Ability: ○ Katz Index of Independence in Activities of Daily Living: assess client’s ability to do bathing, dressing, toileting, transferring (mobility), continence, and feeding. Client is given one point for being able to perform these tasks independently and no points if the client needs assistance. higher the score, the more independent the client is lower the score, the more dependent the individual will be on others for performing these basic ADLs. ○ Lawton Instrumental Activities of Daily Living Scale: assesses the client’s ability to complete more complex daily activities including using a telephone, shopping, preparing food, keeping a home, doing laundry, getting from place to place, managing their medications, and handling their finances. higher the score, the more independent the client is lower the score, the more dependent the individual will be on others for performing these basic ADLs. Braden Scale: measures risk for pressure wounds ○ Based on 6 Factors: Sensory perception: The ability to respond meaningfully to pressure-related discomfort.​ Moisture: The degree to which skin is exposed to moisture.​ Activity: The client’s level of physical activity.​ Mobility: The client’s ability to change and control body position.​ Nutrition: The ability of the client to take in enough food and liquids. ​ Friction and Shear: The effects of moving while all or part of the body is in contact with surfaces that rub against the skin.​ ○ Individuals with a total score of 16 or less are considered at risk. ​ 15–16 = low risk​ 13–14 = moderate risk​ 12 or less = high risk​ 2. Hygiene Bathing Order ○ 1. Eyes Wearing clean gloves, assess the internal and external appearance of the eye for discharge, bruising, or inflammation. ​ Using a clean, damp washcloth, gently wipe the upper lid from the medial canthus (by the nose) outward. Change to a different portion of the washcloth and repeat for the other eye. ○ 2. Face The washcloth used to cleanse the eyes can be used for the face if not soiled or the client does not have an eye infection.​ Use a wet washcloth and mild or no soap, depending on needs.​ Wash the external ears gently, without entering the ear canal.​ Finish with the neck. ○ 3. Arms Cleanse both arms first, then the chest and underarms, finishing with the hands and nails. ○ 4. Chest ○ 5. Abdomen Change washcloths, if not done previously due to soiling. ​ Wash the abdomen and legs, avoiding the perineum. ○ 6. Legs ○ 7. CHANGE WATER ○ 9. Perineum Using mild soap and warm water, cleanse the perineum.​ Change the washcloth after the perinium is clean. ○ 10. Buttocks Clean the buttocks first.​ Inform the client before washing their anus. ○ 11. CHANGE WATER ○ 12. Back Starting with a clean washcloth, use long, slow, gliding strokes to relax the client. Foot Care for Clients w/ Decreased Circulation ○ Inspect the feet each time they are washed.​ ○ Wash the feet in warm (not hot) water.​ ○ Dry the feet thoroughly, including between the toes.​ ○ Apply lotion to the foot surfaces, but not between the toes.​ ○ Put on shoes (preferred) or slippers when the client is out of bed.​ ○ If the nails need to be trimmed, contact the healthcare provider.​ Although policies may vary by facility, nurses should not cut a client’s toenails.​ ○ Report any wounds or abnormalities to the healthcare provider.​ Providing Eye Care ○ 1. Assemble equipment, including clean, warm water, washcloth, and towel. ○ 2. Introduce yourself and state the purpose of being in the room. ○ 3. Identify the client using two identifiers. ○ 4. Position the client sitting comfortably with the head tilted back. ○ 5. Perform hand hygiene. ○ 6. Assess the external and internal eye for discharge, bruising, or inflammation.  ○ 7. Moisten a washcloth with warm water and gently clean the upper eyelid from the medial canthus outward. ○ 8. Using a clean portion of the washcloth, repeat the same process on the other eye. ○ 9. Remove gloves and perform hand hygiene. ○ 10. Return the client to a position of comfort. Providing Oral Care ○ 1. Assemble equipment, including clean water, toothbrush, oral swabs, toothpaste, emesis basin, dental floss, mouthwash, and towel. ○ 2. Introduce yourself and state the purpose of being in the room. ○ 3. Identify the client using two identifiers. ○ 4. Position the client sitting comfortably with the head tilted back. ○ 5. Perform hand hygiene and don clean gloves. ○ 6. Assess the integrity of the lips, teeth, oral mucosa, gums, palate, and tongue. ○ 7. Assess gag reflex and ability to swallow. ○ 8. Remove gloves, perform hand hygiene, and apply clean gloves. ○ 9. If using a toothbrush and toothpaste, apply toothpaste to the length of the toothbrush. ○ 10. Perform oral care in this order: Clean chewing surfaces and inner teeth on top and bottom. Clean outer surfaces of teeth. Use an oral swab soaked in water or mouthwash to clean the roof of the mouth, gums, and internal cheeks. Gently brush the tongue, being careful to avoid stimulating the gag reflex. ○ 11. Ask the client to rinse with mouthwash, discarding rinse in an emesis basin. ○ 12. Return the client to a position of comfort. 3. Bed Making & Bed Bath Types of Bathing ○ Complete Bed Bath: Bath is given to totally dependent clients in bed. sedated clients, quadriplegic ​clients, clients with cerebral palsy​ ○ Partial Bed Bath: bathing only body parts that would cause discomfort if left unbathed, such as hands, face, axilla, and perineal area. paraplegic clients in traction​, clients with extensive pain, hospice clients​ ○ Sponge Bath at Sink: It involves bathing from a bath basin or sink, with the client sitting in a chair. The client can perform a portion of the bath independently. The nurse helps with hard-to-reach areas.​ clients who tire easily, clients with lung issues​, clients have muscle weakness​, clients who have devices that cannot be removed (casts, ECG equipment, etc.)​ ○ Tub Bath: It involves immersion in a tub of water that allows more thorough washing and rinsing than a bed bath. Clients require the nurse's assistance. Some facilities have lifting devices that help with positioning clients in the tub. clients who have been hospitalized for long periods of time and aren’t able to shower, ​clients for whom the cleansing process​can provide pain relief ○ Shower: The client sits or stands under a continuous stream of water. A shower provides more thorough cleaning than a bed bath but can be tiring. independent clients ○ Disposable Bed Bath: The bag contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleaner and emollient. The bag bath offers an alternative because of the ease of use, reduced bathing time, and increased client comfort. clients with specific bacteria and infections with multidrug-resistant organisms  Bed Making ○ Gather Necessary supplies: clean linens, a tight bottom sheet to prevent wrinkles that might cause skin irritation, and upper bed clothing that does not weigh on the client’s body or restrict movements, but still covers their shoulders.​ ○ A hospital corner (also called a mitered corner): the way one folds a flat sheet in order to make it lay flat and tight against the mattress.​ ○ A pull sheet or pad: used for extra absorbency around the pelvic area. In addition, these pads, if strong enough, can be used as pull sheets to help with the upward movement of the client in bed.​ ○ A “trapeze” setup: If a client has good upper body mobility, this is available for the most common types of hospital beds. This allows assistance with repositioning.​ ○ Use good body mechanics in bed making: keeping a wide stance with knees bent when reaching over the bed. Always getting help when lifting or pulling a client is necessary. Avoid reaching too far over the bed as this can lead to back strain and injury.​ Bed Making Tips ○ Change the linen when it is soiled or wet​ Prevents skin breakdown​ ○ Inspect the bed after meals​ Check for crumbs. Keeps the bed linen clean.​ ○ Never shake linen and pillowcases​ Prevents aerosol particles from contaminating the uniform and surrounding areas​ ○ Do not place dirty linen on the floor​ Prevents cross contamination​ ○ Always get new linen if clean linen touches the floor ​ Prevents contamination​ ○ Organize bed making by proper planning and proper preparation​ Saves time and prevents client discomfort. Prepare the client for the need to roll over linens. Identify which client is the priority.​ ○ If making an occupied bed, provide privacy. Pull the curtain and keep the client covered.​ Ensures privacy and promotes comfort and safety​ ○ After making an occupied bed, return the bed to the lowest position​ Ensures client safety​ Perineal Care ○ performed after a client uses the bedpan, becomes incontinent, and as a part of daily bathing. ○ If the client has a vagina, use a downward motion over the top of the labia majora to just above the anus.​ ○ If the client has a penis, have them hold the penis and wash and rinse the tip. Cleanse from the urinary meatus outwards in a circular motion. If the penis is not circumcised, pull back the foreskin and wash, rinse, and dry the area underneath. Return the foreskin to its natural position. Request the client to assist with holding and moving the foreskin as needed.​ ○ Use a different part of the washcloth for each wipe so you prevent spreading germs and contaminating the urethral opening.​ ○ Teach the client to spread their legs and wash. They can then rinse and dry the area (and scrotum if testicles are present). It's important that they clean between the skin folds in this area and under the perineal area thoroughly. ​  ○ Teach the client to wash, rinse, and dry the anal area, moving front to back. Be sure to use a different part of the washcloth for each wipe. Dry the area thoroughly as moisture between skin folds may cause skin breakdown. ​ Unlicensed Assistive Personnel’s (UAP’s) Scope of Practice ○ activities of daily living (ADLs) Bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions) ○ positioning ○ bed making ○ specimen collection ○ lntake and output (I&O) ○ vital signs (for stable clients) 4. Wound Assessment Assessment ○ Should be performed when the nurse initiates care and once per shift, at a minimum. More frequent assessment may be needed for clients who have neurological impairment, are critically ill, or those with impaired mobility. ○ Sensation​ Do you have any tingling or decreased/absent feeling in any extremity?​ Can you feel pressure when sitting or lying down?​ Is your skin sensitive to heat or cold?​ ○ Mobility​ Do you have any physical limitations, injury, or paralysis that limits your ability to move on your own?​ Can you change your position by yourself easily?​ Tell me about any pain you have when walking, sitting, or moving about your home.​ ○ Nutrition​ Have you had any appetite changes?​ Do you have access to groceries or food delivery services?​ Does someone prepare your meals or are you able to prepare your meals?​ ○ Continence​ Do you have problems leaking urine or stool?​ What help do you need when using the toilet?​ How often do you use the toilet?​ Inspection ○ skin should be examined systematically for any signs of breakdown and/or injury in a warm, well-lit room with natural light for any signs of breakdown and/or injury ○ If a wound is present, the nurse will assess:​​ location and size, including depth​ stage of healing (redness, appearance of wound edges)​​ discharge (color, quantity, odor)​ wound care devices in use​ ○ If a wound is present, the nurse will ask:​ What caused your wound?​ When did the wound occur?​ What has changed with the wound since it occurred?​ What have you done to treat the wound that helped healing? Slowed healing?​ Do you have any pain, itching, or other symptoms with the wound?​  Who helps you care for the wound? Palpation ○ provides clinical information about the texture and temperature of the skin, the surface characteristics, and the type of lesions.​​ ○ Temperature changes: Is the wound warmer or cooler than the surrounding skin?​​ ○ Swelling: Increased edema around the wound edges?​​ ○ Turgor: Good elasticity (normal)? Or poor/decreased elasticity and tenting of skin?​ Drainage ○ Sanguineous: Indicates active bleeding ○ Purulent: Indicates possible infection ○ Serosanguineous: Consists of blood and blood serum Pressure Injury ○ Risk Factors: impaired mobility (e.g., spinal cord injuries, fractured hip, acute illness)​ impaired sensory perception (e.g., spinal cord injuries)​ fecal or urinary incontinence​ poor nutrition (e.g., diabetes mellitus)​ altered level of consciousness (e.g., comatose, confused, or disoriented) ​ shear, friction, and moisture Necrotic Tissue ○ Necrotic tissue encourages bacterial growth, which may lead to infection. It must be debrided before the injury can be assessed and staged. ​ ○ There are two main types of necrotic tissue present in wounds: ​ Eschar presents as dry, thick, leathery tissue that is often tan, brown, or black. ​ Slough is characterized as being yellow, tan, green, or brown in color and may be moist, loose, and stringy in appearance. ○ A pressure injury can not be staged if necrotic tissue is present Medical Related Injuries ○ Medical Device-related Pressure Injury: occurs when the skin or underlying tissues are subjected to pressure or shear from a medical device or piece of equipment used for diagnostic or therapeutic purposes. Critically ill clients are at most at risk for this type of injury. Because these injuries form quickly, proactive assessment and prevention measures are essential. ​ Most common areas of concern: face and head region, and the ears specifically. Most common devices causing injury: oxygen tubing, nasal cannulas, masks, cervical collars, endotracheal tubes, and pulse oximetry devices.  ○ Medical Adhesive-related Skin Injury: occurs when erythema or other manifestations of subcutaneous abnormality are present 30 minutes or more after removal of a device or adhesive securing the device. This injury occurs when attachment between the skin and an adhesive is stronger than the skin cells, causing the epidermis to detach from the underlying layers. ​ The nurse should carefully remove adhesives and perform a comprehensive assessment of the exposed skin following removal. 5. Wound Care Level of Wound Healing: describes the onset and duration of the healing process and enables the nurse to understand the risks associated with a wound and implications for healing Healing Type of Injury Effects of Healing Primary Intention The wound is closed. Closed surgical incision - Healing occurs by Edges are with staples, sutures, or epithelization. The approximated. liquid glue to seal the wound heals quickly laceration. with minimal scarring. - Low risk for infection. Secondary Intention Wound edges are not - Pressure injury left - Healing occurs by closed or open to heal granulation tissue approximated. - Surgical wounds that formation, wound have tissue loss or contraction, and contamination epithelialization. - Longer healing time - Increased risk for infection and scarring Tertiary Intention The wound is deep and The abdominal wound - Closure of wound is left open for several is initially left open until delayed until the risk of days, then the edges infection is resolved, infection is resolved. are approximated. then closed. - Healing involves extensive drainage and tissue debris. - Longer healing time - Scarring is likely. Wound Dressing ○ Purpose: protecting the wound from contamination​ aiding in hemostasis​ promoting healing by maintaining adequate wound moisture​ promoting healing by absorbing drainage and debriding a wound​ supporting or splinting a wound site​ promoting thermal insulation of a wound surface​ ○ Type depends on stage of healing A wound healing by primary intention with minimal drainage forms a fibrin seal that eliminates the need for a dressing.​  A wound healing by secondary intention needs the support of a moist wound environment. ​ An open wound with extensive tissue loss always needs a dressing. ○ Considerations: The wound and area surrounding the wound must be cleaned with each dressing change. ​ The dressing should keep the skin surrounding the wound dry while keeping the wound bed moist. ​ The type of dressing used may change over time as the wound heals or deteriorates. ​ The dressing should control exudate without completely drying out the wound bed. Documentation ○ After wound care is performed, it is important to document the interventions: Describe the location and characteristics of the wound. Document the client's response and pain level Report any deterioration in wound appearance.  Nutrition & Bowel Elimination 1. Nutrition - Promoting Wound Healing Certain foods and food groups help promote wound healing. For enhanced wound healing, the client should increase calories, protein, zinc, and vitamins A and C. ○ Protein: Meats, beans, eggs, milk and yogurt (particularly Greek yogurt), tofu, soy nuts, and soy protein products ○ Vitamin C: Citrus fruits and juices, strawberries, tomatoes, tomato juice, peppers, baked potatoes, spinach, broccoli, cauliflower, Brussels sprouts, and cabbage ○ Vitamin A: Dark green, leafy vegetables; orange or yellow vegetables; cantaloupe; fortified dairy products; liver; and fortified cereals ○ Zinc: Fortified cereals, red meats, and seafood - Nutrition Across the Lifespan Infants Through School Age ○ Rapid growth and high protein, vitamin, mineral, and energy requirements mark the developmental stage of infancy. Commercial formulas and human breast milk both provide 20 kcal/ounce. A healthy infant needs approximately 100 kcal/kilogram of body weight each day. ​ The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life and breastfeeding with the addition of complementary foods from 6 to 12 months (Eidelman et al., 2012). ​ ○ The growth rate slows during toddlerhood, so the toddler needs fewer calories but an increased amount of protein in relation to body weight. Their appetite decreases around the age of 18 months. Toddlers exhibit strong food preferences and are picky eaters. ​ Milk consumption should be limited to 24 ounces daily to avoid iron-deficiency anemia. Toddlers need to drink whole milk until age 2 years, then switch to low-fat milk products. ​ Foods that pose a choking hazard should be avoided, such as hot dogs, hard candy, nuts, grapes, raw vegetables, and popcorn. ​ ○ Preschoolers have similar dietary requirements as toddlers. They consume slightly more food and nutrient density is more important than the quantity of food consumed. ​ ○ School-aged children grow at a slower and steadier rate, with a gradual decline in energy requirements per unit of body weight. The diet should be rich in vitamins A and C and contain adequate protein. Avoid foods high in sugar, fat, and salt. Adolescents ○ Physiological age is a better guide to nutrition needs than chronological age. Energy needs increase to meet the metabolic demands of growth. Adequate amounts of protein, iron, and calcium are essential. Iodine supports increased thyroid activity and B-complex vitamins support increased metabolic activity. ​ ○ Concerns about body image and appearance, a desire for independence, eating fast food, peer pressure, and fad diets are common. The onset of eating disorders, such as anorexia nervosa and bulimia nervosa, often begins in adolescence. Recognition is essential for early intervention. Pregnancy ○ Energy and protein needs increase during pregnancy. ​ ○ Adequate calcium intake is essential. ​  ○ Iron supplements are often necessary to support increased blood volume, fetal blood storage, and blood loss during delivery. ​ ○ Folic acid intake is important for DNA synthesis and the growth of red blood cells. The need for folic acid increases during pregnancy. Lactation ○ Women who are lactating need 500 extra kcal/day to support the production of milk. ​ ○ Protein requirements are even higher than in pregnancy. Adequate intake of calcium and vitamins A, B, and C is essential. ​ ○ Fluid intake needs to be adequate but not excessive. ​ ○ Lactating women should avoid caffeine, alcohol, and drugs that will remain present in breastmilk. Older Adults ○ Older adults have a decreased need for food energy because their metabolic rate slows with age. However, vitamin and mineral requirements remain unchanged from middle adulthood. ​ ○ Age-related changes in taste, smell, and digestion affect nutrition. ​ ○ Multiple factors may contribute to food insecurity. ​ ○ Declining oral health may contribute to malnutrition and dehydration. - Nutrition Screening & Assessment Nutritional Screening ○ quick way to identify malnutrition or the risk of malnutrition. ○ Screening tools gather objective data, such as height, weight (BMI), weight change, primary diagnosis, and the presence of other comorbidities. ○ Subjective data is collected related to nutrition to screen for potential problems. Risk factors, such as unintentional weight loss, presence of a modified diet, or presence of gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea, and constipation) require nutritional consultation. ​ ○ Standardized nutritional screening tools include the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment (MNA) used for older adults. Laboratory & Biochemical Test ○ Multiple laboratory and biochemical tests are used to diagnose nutrition disorders. ○ most common tests measure plasma proteins, such as albumin, transferrin, prealbumin, retinol-binding protein, total iron-binding capacity, and hemoglobin. ​ ○ Albumin level is a better indicator of malnutrition in clients with long-term chronic illness, whereas a prealbumin level is preferred for short-term changes in acute conditions. Diet History ○ dietary intake and food preferences​, unpleasant symptoms​, allergies​, taste, chewing, and swallowing​, appetite and weight​, use of medications Common Signs of Malnutrition ○ General appearance: Easily fatigued, no energy, falls asleep easily; looks tired; apathetic; cachectic ​ ○ Weight: Overweight, obese, or underweight (special concern for underweight); unplanned weight loss over a period of time ​ ○ Posture: Poor posture, sagging shoulders, sunken chest, humped back ​ ○ Muscles: Flaccid, weak, poor tone, tender; “wasted” appearance, impaired mobility ​ ○ Mental status: Inattentive, irritable, confused ​  ○ Neurological function: Burning and tingling of hands and feet (paresthesia), loss of position and vibratory sense, decrease or loss of ankle and knee reflexes ​ ○ Gastrointestinal function: Anorexia, indigestion, constipation or diarrhea, symptoms of malabsorption, liver or spleen enlargement, abdominal distension ​ ○ Cardiovascular function: Tachycardia, abnormal rhythm, elevated blood pressure ​ ○ Hair: Stringy, dull, brittle, dry, thin, and sparse, depigmented ​ ○ Skin (general): Rough, dry, scaly, pale, pigmented, irritated, bruises, petechiae ​ ○ Face and neck: Swollen, skin dark over cheeks and under eyes ​ ○ Lips: Dry, scaly, swollen; redness and swelling at the corners of the mouth (cheilosis); angular lesions at corners of the mouth, fissures, or scars (stomatitis) ​ ○ Mouth and oral mucous membranes: Swollen, deep red oral mucous membranes; oral lesions ​ ○ Gums: Spongy, bleed easily, inflamed, receding ​ ○ Tongue: Swelling, scarlet and raw, magenta color, beefy (glossitis) ​ ○ Teeth: Missing teeth, broken teeth ​ ○ Eyes: Eye membranes pale (pale conjunctivae), redness of membrane (conjunctival injection), dryness or infection ​ ○ Nails: Spoon-shaped (koilonychia), brittle, ridged ​ ○ Legs and feet: Edema, tender calf, tingling, weakness, lesions ​ ○ Skeleton: Bowlegs, knock-knees, chest deformity at diaphragm, beaded ribs, prominent scapulas ​ - Body Mass Index (BMI) BMI= Weight(kg) / Height(m) x Height(m) ○ Underweight: 40 - Religious & Cultural Dietary Practices Muslim dietary practices include the avoidance of pork, alcohol, and caffeine. ○ Muslims fast from sunrise to sunset for one month during Ramadan. Muslims may eat certain types of meat if proper practices are followed in the slaughter of the animal. ​ Some Christian faiths, such as Baptists, limit or abstain from alcohol. ○ Some meatless days may be observed during the calendar year, commonly during Lent. Hindu dietary practices include abstaining from all meats and alcohol, and sometimes fish or shellfish. Judaism dietary practices include abstaining from pork, predatory fowl, shellfish (eating only fish with scales), rare meats, blood (e.g., blood sausage), and the mixing of milk or dairy products with meat dishes. Food preparation must adhere to kosher food preparation methods. The Jewish people practice 24-hour fasting on Yom Kippur, a day of atonement, and eat no leavened bread during Passover (8 days). There is no cooking on the Sabbath from sundown Friday to sundown Saturday.​ Mormon dietary practices include the avoidance of various substances, like alcohol and tobacco. A Seventh-Day Adventist diet discourages pork, shellfish, fish, alcohol, and caffeine. Vegetarian or ovolactovegetarian diets are encouraged. 2. Aspiration Precautions - Aspirations & Dysphagia Aspirations: occurs when food, liquid, and other material enter the airway and eventually the lungs by accident Dysphagia: difficulty swallowing ○ Increases risk of aspirations ○ can lead to inadequate food intake, resulting in malnutrition Warning Signs: coughing during eating, changes in voice quality or tone after swallowing, abnormal mouth, tongue, or lip movements, and slow, weak, or uncoordinated speech, abnormal gagging, delayed swallowing, incomplete oral clearance (pocketing), regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently Causes of Dysphagia: ○ Myogenic (issue with muscular tissue): myasthenia gravis, aging, muscular dystrophy, Polymyositis ○ Neurogenic (issues with nervous system): Stroke, cerebral palsy, Guillain-Barré syndrome, multiple sclerosis, amyotrophic lateral sclerosis (Lou Gehrig’s disease), diabetic neuropathy, Parkinson’s disease ○ Obstruction: benign peptic stricture, lower esophageal ring, candidiasis, head and neck cancer, inflammatory masses, trauma/surgical resection, anterior mediastinal masses, cervical spondylosis ○ Other: gastrointestinal or esophageal resection, rheumatological disorders, connective tissue disorders, vagotomy (vagus nerve removal) - Screening for Dysphasia Bedside Swallowing Assessment to screen for dysphagia prior to administering any oral intake in at-risk clients. ○ If problems are identified, a referral to a speech-language pathologist (SLP) is needed for further screening and diagnosis. ​ Bedside Screen: ○ Can the client be positioned upright and remain awake and alert for at least 15 minutes? If not, contact the healthcare provider and recommend SLP evaluation. Maintain nothing by mouth (NPO) status until evaluations are performed. ​ ○ Is the client’s mouth clean of food or debris? If not, perform oral hygiene and continue with the screen.​ ○ Is the client able to cough voluntarily and swallow their own secretions? If not, stop the screen and contact the healthcare provider to recommend SLP evaluation. Maintain NPO status until evaluations are performed. ​ ○ Observe the client drinking 3 ounces of water without a straw. Are any of these signs present: absent swallowing, coughing, delayed coughing, or altered voice quality (gurgling or wet)? Ask the client to speak, to assess voice quality. If symptoms are present, notify the healthcare provider and recommend SLP evaluation. Maintain NPO status until evaluations are performed. ​ Dysphagia is diagnosed with a modified barium swallow test - Aspiration Techniques can be delegated to unlicensed assistive personnel (UAP) ○ nurse is responsible for ongoing assessment, determination of correct position, special feeding techniques, and following the prescribed diet. ○ Nursing assessment should include the client’s mental status to ensure that they are alert, oriented, and able to open the mouth and stick out the tongue. Aspiration Precautions: ○ Position the client upright (45–90 degrees) during and after feeding and while taking oral medications. ​ ○ Apply a continuous oxygen saturation monitor and obtain a baseline reading as any decrease may indicate aspiration. ​ ○ Provide the prescribed dysphagia diet. Encourage the client to feed themselves. ​ ○ Do not use a straw for drinking. ​ ○ Advise the client to assume a chin-down position while eating and drinking. Do not tilt the head backwards. ​ ○ Feed slowly and provide small bites that are easy to swallow. ​ ○ Maintain an upright position for at least 30–60 minutes after eating. ​ ○ Monitor for coughing, gagging, a wet voice, or pocketing food. Throat clearing, respiratory distress, and drooling may indicate a need for airway suctioning. ​ ○ If signs of aspiration are noted, stop the feeding, place the client on nothing by mouth (NPO) status, and notify the healthcare provider. ​ ○ If feeding is without incident, continue to monitor intake and output as well as daily weight to ensure that interventions are preventing malnutrition and dehydration. ​ - Dysphasia Diets Levels 0–4 are for liquids​. ○ Level 0: Thin Liquids​ Liquid is thin and flows fast like water. Can be consumed through a cup or straw as appropriate for age and skills. Ex. water ○ Level 1: Slightly Thick Liquids​ Liquid is thicker than water and requires more effort to drink. Flows at a slightly slower rate than water. Can be consumed through a straw or syringe. Used when thin liquids flow too fast. Example: milk​ ○ Level 2: Mildly Thick Liquids​ Liquid is sippable and pours quickly from a spoon but slower than thin liquids. Mild effort is required to drink this thickness through a standard straw. Flows at a slightly slower rate than water. Used when thin or slightly thick liquids flow too fast. Example: nectar-thick liquids such as a thick orange juice​ Levels 3–7 are for foods​. ○ Level 3: Liquidised Food and Moderately Thick Liquids​ Can be consumed from a cup or with a spoon. Moderate effort is required to consume through a standard straw. Cannot be layered or molded on a plate because it will not retain its shape. Cannot be eaten with a fork because it will drip through the prongs. No oral processing or chewing is required. Smooth texture with no lumps, fibers, husks, or gristle. Allows more time for oral control and requires some tongue propulsion effort. Example: honey-thick liquids such as a milkshake​  ○ Level 4: Pureed Food and Extremely Thick Liquids​ Usually eaten with a spoon; fork may be possible. Cannot be consumed from a cup or through a straw. Does not require chewing. Can be layered or molded because it retains its shape. Shows slow movement under gravity but cannot be poured. Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate. No lumps; not sticky. Used if client has missing teeth, poorly fitting dentures, or significantly reduced tongue control. Example: pudding-thick liquids such as custard or yogurt; pureed food such as cooked cereals or smooth mashed potato ○ Level 5: Minced & Moist Food​ Can be eaten with a fork or spoon. Can be scooped and shaped on a plate. Food is soft and moist. Small lumps visible within the food but are easily squashed with tongue. Biting is not required. Minimal chewing is needed. Used if client has missing teeth or poorly fitting dentures. Example: soft breads, soft rice, oatmeal​ ○ Level 6: Soft & Bite-Sized Food​ Can be eaten with a fork or spoon. Can be mashed/broken down with pressure from a utensil. A knife is not required to cut this food but may be used to help load a fork or spoon. Soft, tender, and moist throughout. Chewing is required before swallowing. Biting is not required. Tongue force and control is required to move food. Used if client has missing teeth or poorly fitting dentures. Example: steamed or boiled vegetables​ ○ Level 7: Easy to Chew Food​ Includes normal, everyday foods that are soft and tender. Any method can be used to eat these foods. Foods are not hard, tough, chewy, fibrous, stringy, crunchy, or crumbly with seeds, husks, or bones. Requires the ability to bite, chew, and swallow food. Does not necessarily require teeth. Example: baked potato without skin, pancakes with syrup, noodles​ - Extra other strategies to consider when feeding a client with dysphagia:​ ○ If the client is unable to feed themselves, place ½ to 1 teaspoon of food on the unaffected side of the mouth, allowing the utensil to touch the mouth or tongue. ​ ○ Provide verbal coaching by reminding the client to chew and think about swallowing. ​ ○ Avoid mixing foods of different textures in the same mouthful. ​ ○ During the meal, take time to teach the client and caregiver about the techniques used to promote safe swallowing. ​ ○ Minimize distractions and do not rush the client while they are eating. 3. Therapeutic Diets - Prescribed Diets Clear Liquid​: ○ A clear liquid diet means that foods are liquid at room temperature and primarily consist of water and carbohydrates with minimal digestion needed. This diet is common for a short period of time after a major surgical procedure. This diet should not be used for an extended period as it is not nutritionally complete. Examples include water, tea, coffee, clear broth, carbonated clear beverages, clear fruit juices without pulp, gelatin, and popsicles. Full Liquid:​  ○ A full liquid diet is liquid at room temperature but with more variety and nutritional support than a clear liquid diet. If prescribed for more than 3 days, add additional protein and calories to support nutritional needs. Examples include clear liquids, smooth-textured dairy products such as ice cream, strained or blended cream soups, custards, refined cooked cereals, vegetable juice, puréed vegetables, all fruit juices, sherbets, puddings, and frozen yogurt. Blenderized (Pureed) Liquid: ○ A blenderized or pureed diet means that all foods are pureed to a liquid form in a blender. It is important to puree foods separately to preserve the flavor. Can be nutritionally adequate when offering all food groups. Examples of foods that are often pureed include ground meats, canned fruits, and softly cooked vegetables. Mechanical Soft​: ○ A mechanical soft diet means that a regular diet is modified in texture and includes foods that require minimal chewing before swallowing. Examples include all foods included in clear liquid, full liquid, and blenderized liquid diets, plus all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried).​ Low Fiber (Residue)​: ○ A low fiber (residue) diet reduces foods that contain fiber and is nutritionally inadequate for long-term use. The client may not eat raw fruits and vegetables or whole-grain breads and cereals. Examples include soft fruits and thoroughly cooked vegetables without peels or skins, moist tender meats. High Fiber: ○ A high fiber diet is used in the prevention or treatment of many gastrointestinal, cardiovascular, and metabolic diseases. Increased fiber should come from a variety of sources including fruits, legumes, vegetables, whole-grain breads, oatmeal, and cereals. Low Sodium: ○ No added salt (regular diet with no salt packets on the tray), low sodium diet (1 or 2 gram), or sodium restriction diet (500 mg).​ Low Cholesterol: ○ Follows American Heart Association guidelines of 300 mg/day. Examples include fruits, vegetables, oats, barley, whole grains, legumes, and nuts. Avoid foods that are high in saturated fats. - Medical Nutritional Therapy Gastrointestinal Diseases: ○ Peptic ulcers are managed by eating regular, smaller meals during the day and taking prescribed medications. should avoid alcohol, caffeine, tobacco, excessive milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper), which increase stomach acidity and pain.​  ○ Inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis, are managed with a low-fiber, high-protein, high-calorie, and low-fat diet. must identify and avoid trigger foods, such as alcohol, caffeine, tobacco, carbonated beverages, pepper, nuts, corn, and dried fruits. Lactose-containing foods should be consumed in moderation or may need to be avoided completely. ​ ○ Celiac disease is an autoimmune illness that affects the small intestine. The client must eat a gluten-free diet, which means avoiding any foods that contain wheat, rye, or barley Nutritional deficiencies must be corrected with vitamin and mineral supplements. Lactose-containing foods should be consumed in moderation or may need to be avoided completely. The diet should be low in fat but high in protein and calories containing fruits and vegetables. ​ ○ Diverticulitis is inflammation of the diverticula in the colon. It is treated with a low-fiber (residue) diet until the inflammation resolves. Diabetes Mellitus: ○ Consistent carbohydrate consumption at each meal is necessary to maintain normal blood glucose levels. Complex carbohydrates are more beneficial than simple carbohydrates for consistent glucose levels. Carbohydrates should comprise 45-54% of total caloric intake. At least 25 grams of fiber daily is recommended. ​ ○ Saturated fat intake is limited to less than 7% of the total caloric intake. ○ Cholesterol intake is limited to less than 200-300 mg/day​. ○ Protein intake should comprise 15-20% of total caloric intake. ○ Sodium should be limited to 2300 mg/day. ○ Alcohol consumption should be limited. Artificial sweeteners are acceptable for use. Cardiovascular Diseases: ○ Eat foods that are low in fat. Saturated fat intake is limited to less than 7% of the total caloric intake. Cholesterol intake is limited to less than 200-300 mg/day​. Decrease overall consumption of red meat. ​ Increase fiber and omega-3 fatty acid consumption. ○ Consume adequate amounts of folate and vitamins B6 and B12. ○ Limit sodium intake to 2300 mg/day.​ ○ Limit alcohol intake. ○ Maintain a healthy weight through dietary management and regular exercise. ○ Stop smoking. Cancer: ○ Radiation therapy may cause stomatitis, severe diarrhea, and strictures of the intestine. ○ Radiation therapy of the head and neck region causes taste and smell disturbances, decreased salivation, and dysphagia. ​ ○ client must increase calories and protein consumption. Consider liquid protein supplements in between meals. Consume smaller, frequent meals consisting of cool or room-temperature foods. Eat more food in the morning when energy is higher. ​ ○ For taste alterations, avoid metallic utensils, add sauces and seasonings for increased flavor, and eat tart foods. ​ ○ For stomatitis, avoid acidic, spicy, dry, and coarse foods. Cut food into small bites. Use straws when drinking liquids and moisten foods with gravy or broth.  HIV: ○ client must increase calories and protein consumption while taking vitamin and mineral supplements. Foods chosen for consumption should be nutrient dense. Consume smaller, frequent meals and liberal fluid intake. ​ ○ Because the client is immunocompromised, avoid food bacteria. Do not eat raw fruits or vegetables, undercooked meats, or eggs. 4. Feeding - Assisting with Oral Feeding Prior to Feeding: ○ Safety is the priority​! Assess aspiration risk and follow and take aspiration precautions​if prescribed. ​ ○ Respect the client’s dignity and need for independence by allowing the client to choose the food items (if possible) and to direct the order in which food is eaten. ○ Visual impairments may impact a client’s ability to self-feed. Provide assistance or adaptive devices as needed. ​ ○ Ensure that the meal tray delivered to the client’s room contains the prescribed diet prior to feeding. ​ ○ Provide at least 30 minutes of rest prior to eating. When the meal arrives, position the client with the head of the bed elevated at least 60–90 degrees. Instruct the client to swallow with the chin in a downward position During Feeding: ○ The client should empty the mouth completely after chewing each bite before taking another ​bite of food.​ ○ If the client is experiencing weakness on one side of the body, encourage the client to use the strong side of the body to eat by placing food on the strong side of the mouth. ​ ○ Remember, thicker fluids are usually easier to swallow​.​ ○ If the client is coughing or gagging with food or fluid intake, discontinue the meal immediately and place the client on NPO status until further evaluation is completed.​​ - Enteral Nutrition provides nutrients directly into the gastrointestinal (GI) tract. preferred method to meet nutritional needs when a client is unable to chew or swallow but has a functioning GI tract. ​ can be administered via the nasoenteral route (nasogastric, nasoduodenal, or nasojejunal) or through gastric tubes inserted into the stomach (gastrostomy) or jejunum (jejunostomy) ○ route selected depends on the client’s clinical status or condition. ○ Clients with a high risk of gastric reflux, which leads to aspiration, should receive jejunal feedings. ○ Once a route is selected and the tube inserted, placement must be confirmed before administering enteral feedings. ​ preferred over parenteral nutrition as it has fewer complications Enteral Formula: ○ Polymeric formula (1 kcal/mL) is a milk-based, blenderized food prepared by hospital dietary staff or in the client’s home. It also comes as a commercially prepared whole-nutrient formula. The GI tract must be able to absorb whole nutrients.​ ○ Modular formula (3.8 kcal/mL) contains a single macronutrient and is not nutritionally complete. Other foods must be added to meet nutritional needs.​  ○ Elemental formula (1–3 kcal/mL) contains predigested nutrients that are easier for a partially dysfunctional GI tract to absorb. This is a higher calorie with less water content formula. ○ Specialty formulas (1–2 kcal/mL) are designed to meet the specific nutritional needs of certain illnesses.​ Delivery: ○ Continuous infusion over 24 hours ensures a consistent flow rate. The tube is flushed with 20–50 mL of warm water every 4 hours to maintain tube patency and provide hydration. This type of feeding is used for critically ill clients.​ ○ Intermittent feedings are when formula is administered every 4–6 hours in 250–400 mL portions, typically over 30–60 minutes. Flush the tube with 15–30 mL of warm water before and after intermittent feedings.​ ○ Bolus feedings are administered with a large syringe attached to the feeding tube and must be delivered directly into the stomach to avoid dumping syndrome, which can occur if administered into the small intestine. Flush the tube with 15–30 mL of warm water before and after bolus feedings.​ ○ Cyclic feedings infuse over 8–20 hours. The formula is administered at a continuous rate, usually overnight.​ Packaging: ○ Formula can be packaged in prefilled bags or cans. Cans are used to add formula to a generic bag for infusion or for feeding directly from a syringe. Administering Enteral Nutrition ○ Nursing Assessment: Before instilling enteral formula, tube placement must be verified by x-ray. Once per shift, and prior to feeding, the tube placement must be verified to ensure migration has not occurred. Aspiration of gastrointestinal (GI) contents and measuring pH levels are used to verify ongoing placement.​ Injecting air into the tube while auscultating the stomach is not an effective method for verifying tube placement. Stomach content pH should be less than 5.0. Small intestine content pH should be less than 6.0. Pleural fluid will have a pH greater than 7.0.​ Always verify the presence of bowel sounds before instilling the formula.​ Assess gastric residuals every 4–6 hours during a continuous feeding and before every intermittent feeding. Per facility policy, return gastric contents back to the stomach after withdrawal. If there is more than 250–500 mL of gastric residual on two consecutive measurements, notify the healthcare provider for intervention. When enteral nutrition is prescribed, the nurse should weigh the client daily and monitor intake and output closely. The tube site should be assessed for skin breakdown and infection. Monitor the character and frequency of bowel movements. ○ Nursing Actions: Enteral feeding formula should always be at room temperature when administered.​ Elevate the head of the bed at least 30 degrees during feedings and for 30–60 minutes after feedings to reduce the risk of aspiration. Start full-strength feedings slowly, then increase as prescribed if no intolerance develops. ​ Provide meticulous oral care regularly.​  During the feeding, closely monitor for signs of aspiration, including coughing, dyspnea, tachypnea, decreasing oxygen saturation, hoarseness, and adventitious lung sounds.​ Formula bags and administration tubing must be discarded and replaced every 24 hours. Enteral Complications: ○ Pulmonary Aspiration: Continuously monitor the client receiving enteral nutrition for signs of aspiration and/or respiratory distress (severe coughing, dyspnea, cyanosis, crackles, or wheezing). If aspiration is suspected, stop the feeding immediately and notify the healthcare provider. Suction as appropriate. ​ Elevate the head of the bed at least 30 degrees during feedings and for 30–60 minutes after feedings to reduce the risk of aspiration. ​ Delayed gastric emptying increases the risk of aspiration. Medications to increase peristalsis may be prescribed. ○ Gastrointestinal Complications: Treatment for GI symptoms may include adjusting the rate of formula administration, changing the formula type, and promoting peristalsis.​ Elevating the head of the bed during feedings and administering formula at room temperature help to prevent some symptoms. Formula should never be warmed in the microwave. Remove the formula from the refrigerator and set it on the counter to allow it to warm up or run it under warm water in the sink. ​ Formula bags and administration tubing must be discarded and replaced every 24 hours to prevent bacterial contamination.​ ○ Mechanical complications: tube migration, leakage at the insertion site, irritation of the nasal mucosa, and tube occlusion. ​ Verifying placement prior to feeding and at least once per shift will help with the early identification of tube migration. ​ Proper securement of the tube can prevent leakage and irritation of mucosa. ​ If the feeding tube becomes clogged, administer 30–50 mL of warm water via a 60 mL syringe or use a commercial clot-buster solution per agency protocol. ○ Metabolic complications: dehydration, hyperglycemia, electrolyte imbalances, and fluid overload. ​ Adjusting the rate, dilution, and/or components of the feeding may be necessary. ​ Monitor laboratory results (electrolytes, BUN, creatinine, minerals, and CBC) for early identification of problems. ​ Refeeding syndrome may occur when a client who is in a state of starvation is started on enteral nutrition. Electrolyte shifts and altered glucose levels cause a potentially fatal complication. ​ - Parenteral Nutrition a form of specialized nutritional support provided intravenously to clients who are unable to digest or absorb enteral nutrition Two Types: ○ Total Parenteral Nutrition (TPN): Nutritionally Complete Indicated: High caloric needs  Long-term therapy is needed Solution contains more than 10% dextrose Only administered through a central line Common uses: cancer, bowel disorders, critical illness, trauma, burn victims ○ Peripheral Parenteral Nutrition (PPN): Nutritionally Incomplete Indicated: Administer up to 14 days Short-term therapy only Solution contains no more than 10% dextrose and 5% amino acids May use a peripheral IV line Common uses: nutritional replacement or supplement Components: ○ Carbohydrates (Dextrose)​: 2.5% to 10% (PPN)​ Up to 70% (TPN)​ ○ Electrolytes, Vitamins, and Trace Elements: Added based on the serum laboratory values​ ○ Protein (Amino Acids)​: 3%–20% concentrations​ The amount included is based on the client’s estimated requirements as well as liver and kidney function.​ ○ Lipids (Fats)​: 10%, 20%, and 30% concentrations​ Provides extra calories if dextrose must be reduced​ Contraindicated if severe hyperlipidemia, hepatic disease, or allergy to soybean, eggs, or safflower oil​ ○ Other Additives​: Insulin reduces the risk of hyperglycemia.​ Heparin prevents fibrin buildup on the catheter tip of the intravenous line​. Provide glutamine, antioxidants, prebiotics, or probiotics based on client needs. Administering ○ Before: The nurse must assess the client’s weight, calculate body mass index (BMI), and evaluate their nutritional status prior to administering parenteral nutrition. Review available laboratory studies, which may include complete blood count (CBC), comprehensive metabolic panel, lipid profile, blood urea nitrogen (BUN), prealbumin, albumin, creatinine, and liver function studies. Be sure to check for client allergies before administration begins. An electronic infusion device must be used to deliver parenteral nutrition. A micron filter is needed on the intravenous administration tubing for administering peripheral parenteral nutrition. If the solution appears oily on top (“cracked” solution), do not administer! Parenteral nutrition should be administered at room temperature. In most facilities, parenteral nutrition requires double nurse verification of the prescription, solution label, and client identification before administration can begin. ○ During:  The nurse must assess the client’s weight daily as well as closely monitor intake and output. Vital signs should be assessed regularly. The intravenous insertion site should be monitored for signs of infection. Laboratory values should be monitored regularly, particularly blood and urine glucose. Insulin may be needed to treat hyperglycemia. The nurse should monitor the solution flow rate. If administered too fast, the client may develop hyperglycemia, hyperosmolar diuresis, or fluid overload. If the solution runs out and another bag of parenteral nutrition solution is not yet available, administer dextrose 10% in water until the next bag of solution is available. The solution bag and administration tubing must be changed every 24 hours. If lipids are administered via a separate bag of solution, the bag and administration tubing must be changed every 12 hours. Use strict aseptic techniques when changing tubing and accessing the intravenous site. ○ Discontinuation: the infusion should slowly be stopped to avoid rebound hypoglycemia. Enteral or oral nutrition (clear liquids) should be provided during the transition. It may take time for the client’s appetite to return to normal. Blood glucose should be monitored closely. Complications: ○ Infection & Sepsis: Monitor for temperature and white blood cell (WBC) count elevation regularly. Prevention of infection involves proper catheter care. Monitor and maintain normal glucose levels. ○ Mechanical Complications: include catheter migration, embolus, thrombosis, catheter obstruction, or accidental bolus infusion. Use of an infusion pump can prevent accidental bolus infusion. Careful care and handling of intravenous catheters can prevent migration, embolus, thrombosis, and obstruction. ○ Metabolic Complications: include hyperglycemia or hypoglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration, and fluid overload. Adjusting the rate and/or components of the solution may be necessary. Monitor laboratory results (electrolytes, BUN, creatinine, minerals, CBC) for early identification of problems. Refeeding syndrome may occur when a client who is in a state of starvation is started on enteral nutrition. Electrolyte shifts and altered glucose levels cause a potentially fatal complication. 5. NG Tube: Insertion, Care, Use, Removal - Choosing a NG tube Small-Bore Feeding Tubes​: ○ used to deliver enteral nutrition because it is more comfortable for the client. ○ Adult clients typically need an 8-12 French tube that is 36-44 inches long. These tubes are designed for feeding and not gastric decompression. However, they can be prone to  clogging and dislodgement. Smaller bore tubes that are weighted on the tip may aid in the ease of insertion. ​ ○ Flexible feeding tubes come with a stylet, which makes the tube stiffer, and are used when the tube is inserted. The stylet is removed after the correct tube placement is confirmed and before feedings are started. ​ Never reinsert the stylet into the tube after it has been removed. ​ Large-Bore Nasogastric (NG) Tubes​: ○ When inserted for gastric decompression, choose a 14 or 16 French nasogastric tube, which can better remove thick secretions. ​ ○ Standard practice is to use enteral-only connectors (ENFit) designed specifically for enteral tubes. This is done to reduce medical tubing misconnections and improve client safety. ​ - Enteral Nutrition: Nasal Insertion: ○ A tube is inserted through the nose (nasogastric or nasointestinal) when EN will be used for less than 4 weeks. ○ These tubes can be inserted by a nurse. ○ Feeding tube insertion cannot be delegated to assistive personnel (AP) ○ the insertion, use, maintenance, and use of EN tubing require ongoing nursing assessment. ○ Before inserting an NG tube, the nurse should assess the patient’s medical history to determine if the NG tube is contraindicated. Some contraindications are a history of basilar skull fracture, nasal conditions, nosebleeds, facial trauma, nasal-facial surgery, or deviated septum. The nurse should also assess for the presence of a gag reflex. ○ During the insertion, pulse oximetry and/or capnography should remain on during the procedure to monitor for changes in baseline which may indicate tube misplacement in the lungs. If this occurs, the nurse should stop the procedure. ○ Once the tube is inserted, the nurse should verify its placement via x-ray. Surgical or Endoscopic Insertion: ○ This is insertion surgically (gastrostomy or jejunostomy) or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy) when EN therapy will be needed more than 6 weeks. ○ This method is more comfortable, reliable, and secure than the use of a nasal tube. ○ Some patients have conditions that require the tube to be placed beyond the stomach into the intestine, such as gastroparesis, esophageal reflux, or a history of aspiration pneumonia. ○ Percutaneous endoscopic gastrostomy tubes are commonly known as PEG tubes and jejunostomy tubes are commonly known as PEJ tubes. - Verifying NG Tube Placement: Tube placement much be verified by an X-ray before use once per shift and prior to feeding, tube placement must be verified to ensure migration has not occurred Aspiration of gastrointestinal (GI) contents and measuring pH levels are used to verify ongoing placement.  ○ Stomach contents pH should be less than 5.0. ○ Small intestine contents pH should be less than 6.0. ○ Pleural fluid will have a pH greater than 7.0. Ongoing Assessment ○ When used for gastric decompression, the nurse must observe the amount and character of contents draining from the nasogastric tube. ○ Evaluate for nausea and auscultate bowel sounds. Be sure to turn off suction while listening to bowel sounds. ○ Palpate the abdomen for distention, pain, and rigidity. ○ Inspect the condition of the client’s nares, nose, and skin surrounding the nasogastric tube. ○ Observe the position of the tube for misplacement. ○ It is normal for the client to experience throat irritation and soreness. ○ Monitor for signs of pulmonary aspiration, including fever, shortness of breath, and pulmonary congestion. - NG Tube for Gastric Decompression Once NG tube placement is confirmed it should be connected to a suction device ○ Suction is usually on a low setting to prevent gastric irritation If secretions are too thick the tube may not drain properly and irrigation may be required Irrigation: ○ Disconnect tube from suction ○ Verify tube placement ○ Draw 30 mL of normal saline into a syringe and insert the tip into the end of the nasogastric tube. ○ Hold the syringe with the tip pointed at the floor and inject the saline slowly and evenly. Do not force the solution!​ If resistance occurs, check for kinks in the tube and turn the client to the left side. Attempt to flush. If resistance continues, contact the healthcare provider. ○ immediately aspirate after injecting saline (pull back slowly) on the syringe to withdraw the fluid. If the amount aspirated is greater than the amount instilled, record the difference as output. ○ Repeat irrigation if the solution does not return.​ ○ Reconnect the nasogastric tube to the suction device and help the client to a position of comfort. ​ - Adminstiring Medication Thru NG Tube First, stop the feeding or suction device and flush the tube with 30 mL of water. ○ If medications must be administered on an empty stomach, wait at least 30 minutes after stopping enteral feeding before medication administration. ○ ​If medications are incompatible with the enteral feeding, wait an additional 30–60 minutes. Medications should be liquid preparations when possible. ○ If not liquid, crush the tablets or open capsules and dissolve each medication in water. Gel caps can be pierced with a sterile needle and the contents emptied into 30 mL of warm water. ​  Administer medications one at a time, flushing the tube with at least 15 mL–30 mL of water after each medication. ​ Flush the tube with 30 mL–60 mL of water one final time after administering the last medication. If the nasogastric tube becomes clogged, administer 30 mL–60 mL of warm water via a 60 mL syringe or use a commercial clot-buster solution per agency protocol. - NG Tube Removal After removal of the NG tube, document the following: ○ the type and size of the tube removed ○ if the tube was intact after removal ○ client tolerance of removal ○ final amount and character of drainage 6. Alterations in Bowel Functions - Factors Influencing Bowel Elimination Age: affects normal bowel function. ○ Young children lack the ability to control defecation. ○ With aging, peristalsis slows, which impairs intestinal absorption. Muscle tone in the perineal floor and anal sphincter weakens which may cause difficulty with defecation control. ​ Diet: impacts bowel function. ○ Fiber provides bulk to the fecal matter. As the bowel stretches, peristalsis increases initiating the defecation reflex. ○ Some foods, such as cabbage, broccoli, and beans, produce gas that distends the intestinal walls and increases colonic motility. Fluid Intake: adult males need 3.7 liters per day and adult females need 2.7 liters per day. ○ The character of feces is affected by lack of fluid. ○ Reduced fluid intake slows the passage of food through the intestine and results in hardened stools, causing constipation. Physical Activity: promotes peristalsis and immobility slows peristalsis. ○ Encourage early ambulation during illness and after surgery to promote normal bowel function. Psychological Stress: impairs the function of almost all body systems. ○ During stress, the digestive process is accelerated and peristalsis is increased, leading to diarrhea. Depression may slow peristalsis, leading to constipation. ​ Position During Defecation: can impact bowel elimination. ○ Squatting in a normal position while contracting the gluteal muscles and leaning forward exerts intraabdominal pressure to facilitate defection. ○ If a client must remain in bed, elevate the head of the bed to a sitting position. Always provide privacy to the client while defecating. ​ Pain and Pregnancy ○ Conditions such as hemorrhoids, rectal surgery, and anal fissures can make defecation painful causing the client to suppress the urge. ○ Pregnancy slows peristalsis and the growing fetus exerts pressure on the rectum impairing the passage of feces. Frequent straining may result in hemorrhoids. Anesthesia and Medications: slow or temporarily stop peristalsis. ○ opioid analgesics slow peristalsis causing constipation and antibiotics decrease intestinal bacterial flora resulting in diarrhea.  ○ Some medications promote defecation, such as laxatives, while stool softeners draw water into the stool to prevent constipation. - Constipation Hards stools form because peristalsis slows down and water absorption is low Bowel movement become less than 3x a week and stool is difficult to pass Possible causes: improper diet, reduced fluid intake, lack of exercise, and use of certain medications Neurological Causes: multiple sclerosis, spinal cord injury, and stroke - Fecal Impaction unresolved constipation and is unable to expel the hard, dry stool retained in the rectum Clients with dementia, confusion, and debilitating illness are most at risk for fecal impaction If the urge to defecate is present, but the client has not produced a stool in several days, fecal impaction should be suspected. ○ Another sign is continuous oozing of liquid stool, which is higher in the colon and leaking around the impacted mass. ​ Symptoms: anorexia, nausea, vomiting, abdominal distention, cramping, flatulence, and rectal pain - Flatulance accumulation and release of gas in the gastrointestinal tract. common cause of abdominal distention, pain, and cramping. As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends. Gas may escape from the mouth (belching) or the anus (passing of flatus). ​ - Diarrhea increase in the number of stools with the passage of liquid, unformed feces Intestinal contents pass through the small and large intestines too quickly to allow normal fluid and nutrient absorption Common causes: antibiotic therapy, foodborne pathogens, lower gastrointestinal tract surgeries, enteral nutrition, and food intolerances. ​ major complication: dehydration with fluid and electrolyte or acid-base imbalances. - Fecal Incontinence Inability to control passage of feces Common cause: C. Diff - Diagnostic Testing Fecal Occult Blood Test: measure microscopic amount of blood in feces, helps diagnose colon cancer ○ Two types: guaiac fecal occult blood test (gFOBT) and ecal immunochemical test (FIT) gFOBT must be repeated at least three times with three separate bowel movements. The client must avoid eating red meat, citrus fruits and drinking citrus juice for three days before testing.  Additionally, the client may need to stop taking aspirin, ibuprofen, naproxen, and other nonsteroidal anti-inflammatories for 3-7 days before testing due to the risk of bleeding.​ The FIT test requires no dietary preparation and is more sensitive but is expensive to perform - Enemas instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis fluid breaks up the fecal mass, stretches the rectal wall, and initiates the defecation reflex commonly used to relieve constipation or empty the bowel before diagnostic testing Tap Water Enema: hypotonic and escapes from the bowel into the interstitial spaces ○ stimulates defecation before the fluid leaves the bowel ○ Use caution if repeating a tap water enema due to water intoxication and circulatory overload Normal Saline Enema: safest solution to use because it exerts the same osmotic pressure as fluids in the interstitial spaces surrounding the bowel. ○ The volume infused stimulates peristalsis and reduces the danger of excess fluid absorption.​ Hypertonic Enema: infused into the bowel pull fluid out of the interstitial spaces and into the colon. ○ As the colon fills with fluid, the resulting distention promotes defecation. ○ If the client cannot tolerate a large volume enema, the hypertonic solution may be beneficial as it requires much less volume to be effective. ​ Soapsuds Enema: Adding soapsuds to tap water or normal saline creates intestinal irritation to stimulate peristalsis. Use only pure Castille soap. ​ - Administrating a Enema Assessment: The nurse should assess the client’s last bowel movement, normal versus most recent bowel pattern, presence of hemorrhoids, and presence of abdominal pain or cramping. ○ The client should be able to turn and position on the side to receive an enema. ○ Inspect the abdomen, auscultate for bowel sounds, and palpate for distention. ○ Determine the client’s knowledge and previous experience with enemas. ​ Planning: Perform hand hygiene, then prepare enema equipment at the bedside. Provide privacy for the client and ensure that a commode is readily accessible (bathroom toilet, bedpan, or bedside commode). Explain the procedure to the client. Prepare the solution and fill the tubing if administering an enema from a standard enema bag. ​ Implementation: ○ Position the client in a left side-lying position with the right knee flexed to allow the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. ○ Place a waterproof pad under the client’s hips and buttocks. ○ Separate the buttocks and insert the lubricated tip gently into the anal cavity toward the umbilicus. Do not force the tube. ​ ○ Prepackaged disposable enema: Squeeze and roll the plastic bottle from bottom to tip until all the solution has entered the rectum. ​  ○ Standard enema bag: Place container of solution at the appropriate height (12 inches above anus, 18 inches above mattress) and slowly infuse solution into the rectum. Instill all the solutions, then clamp the tubing. ​ ○ Gently remove the tube from the anus and instruct the client to retain the solution until an urge to defecate occurs, usually 2–5 minutes. ​ ○ If severe abdominal cramping, bleeding, or sudden abdominal pain occur, stop the enema and notify the healthcare provider. Evaluation: Inspect color, odor, consistency, and amount of stool passed. Perform abdominal assessment.  Urinary Elimination 1. Urinary Elimination - Factors affecting elimination Growth and Development ○ Children cannot control urination until 18-24 months​of age. ○ Nocturnal enuresis is common in children less than 6 years old​. ○ Incontinence can affect all ages, but is more common in older adults. Psychological, Sociocultural, and Personal Habits ○ Anxiety and stress can cause urinary urgency or retention.​ ○ Cultural and social expectations of privacy when voiding, use of public restrooms, and time used for elimination can affect urination. Positioning and Muscle Tone ○ Weak abdominal and pelvic floor muscles cause incontinence.​ ○ Indwelling catheters cause loss of bladder tone.​ ○ Urination may be improved or more difficult in different positions. Food and Fluids ○ Caffeine and alcohol are mild diuretics, while sodium causes fluid retention. Pathologic Conditions ○ Diabetes, multiple sclerosis, stroke, organ failure, and spinal cord injuries affect the production of urine, the act of urinating, and/or the ability to empty the bladder Medication and Surgery ○ Anesthetics and narcotics can cause the retention of urine.​ ○ Diuretics, like furosemide and hydrochlorothiazide, increase output. It is important to teach clients to take these by mid-day to avoid nocturia. Some medications, like phenazopyridine, change the color of urine. It turns the urine orange - Urinary Assessment Monitoring intake and output along with urine characteristics (color, odor, turbidity, volume, and specific gravity) are the two most common assessments when there are concerns about altered urinary patterns Abdominal Assessment ○ palpate the abdomen for any bladder distention and observe for overflow. ○ Bladder distention can be an indication of urinary retention or bladder dysfunction. Urinary Pattern ○ document if the client is experiencing urinary frequency, urgency, incontinence, burning, or nocturia Intake and Output ○ Intake: at least eight, eight-ounce glasses of fluids daily ○ Output: average volume urinated in a 24-hour period is normally 1,200-1,500 mL Urine Characteristics ○ color should be clear and the urine should be free from odor How the Client Eliminates ○ Every effort should be made to have clients eliminate as normally as possible - Urinary Incontinence Inability to control bladder sphincter Stress Incontinence ○ Leaking, dribbling with sneezing, coughing, or laughing ○ Interventions: Pelvic floor exercises (Kegels) to strengthen pelvic muscles Urge Incontinence ○ Incontinence after a strong sense of urgency, may be in small or large amounts ○ Interventions: Avoid bladder irritants. Try bladder training and/or pelvic floor exercises. Overflow Incontinence ○ Cannot completely empty the bladder, which leads to leaking. ○ Interventions: Timed or double voiding. Catheterization may be needed in severe cases. Functional Incontinence ○ Bladder functions normally but the client is unable to access the toilet due to a physical or cognitive condition. ○ Interventions: Provide assistance and/or mobility aids to help with toileting. Reflex Incontinence ○ Incontinence with no sense of urgency ○ Intervention: Empty the bladder at scheduled intervals. Transient Incontinence ○ Treatable or reversible incontinence ○ Intervention: Treat the cause. - Urinary Retention incomplete emptying of the bladder 10-50 mL of urine should remain in the bladder after urinating ○ More remain with urinary retention client may feel pain or discomfort from a distended bladder and it increases the risk of a urinary tract infection a post-void residual test with a bladder scanning device is used to evaluate the amount of remaining urine in the bladder Interventions: catheterization and medication - Urinary Tract Infection (UTI) external bacteria enter the sterile urethra and cause an inflammatory response can spread from the bladder to the kidneys, eventually leading to sepsis if untreated Classic signs and symptoms of UTI are: ​ ○ dysuria: pain with urination ○ urinary frequency and/or urgency​ ○ Incontinence​ ○ cloudy urine/odor​ ○ flank pain ​ ○ fever Women are more likely to get UTIs due to the shortened urethral length ○ reduce the occurrence by cleaning the perineum from front to back and wearing cotton underwear Client education: maintaining adequate hydration, voiding at regular intervals, allowing enough time to empty the bladder, voiding after sexual intercourse flushes the urethra of any potential bacteria - Catherization may be used to: ○ relieve urinary retention ○ obtain a sterile urine specimen ○ measure the amount of residual urine in the bladder ○ empty the bladder before and during surgery ○ prepare for certain diagnostic procedures 3 Types: ○ Indwelling Catheter urethral or suprapubic catheter inserted into the bladder via the urethra or abdomen & anchored by a balloon and drains by gravity to a drainage bag attached to a leg (leg bag) or bed. ○ External Catheter condom catheter placed outside the body on male clients and has a lower risk than indwelling catheters In infants and small children, a bag that sticks to the surrounding perineal area can be used in either gender. ○ Intermittent Catheter Straight Catheter A short-term catheter is used to empty the bladder No anchor is necessary. These catheters are used to quickly empty the bladder, then discontinued. 2. Urine Specimens - Urinalysis client voiding at least 10 mL into a urine collection container a clean procedure and does not require a sterile specimen container. can be used to diagnose multiple diseases and conditions, like urinary tract infections and kidney disorders 3 Parts: ○ Visual Examination: Urine Color Normal: Clear to Yellow Abnormal: Dark yellow may indicate dehydration; presence of blood. Other colors may be caused by food or medications Clarity Normal: Clear Abnoral: Cloudy can indicate infection Odor Abnoraml: Smell of acetone may indicate diabetes. Foul odor may be a sign of infection ○ Microscopic Examination: White blood cells Normal: 0-4 Abnormal: Presence may be a sign of an infection. Red blood cells  Normal: ≤ 2 Abnormal: Presence may be a sign of kidney disease, a blood abnormality, or other medical condition. Bacteria or yeasts Normal: Negative Abnormal: Presence may be a sign of an infection. Casts Normal: Negative Abnormal: Presence may be a sign of kidney disorders. Crystals Normal: Negative Abnormal: Presence may be a sign of diabetes. 3. Urinary Catheters Urinary catheters are generally necessary when someone cannot empty their bladder. If the bladder is not emptied, urine can build up and lead to pressure in the kidneys. Infection control is a priority when inserting a urinary catheter. A skills return demonstration form provides the specific steps that nurses must follow to reduce the chances of causing an infection. If sterile technique is broken, or if the catheter or collection bag is contaminated during the ongoing care, the client may be at risk for a catheter-associated urinary tract infection (CAUTI). - Indwelling Catheters (Urethral or Suprapublic) Benefits: Decreased risk of skin irritation or breakdown (prevents client from sitting in urine) Complications or Risk ○ discomfort with insertion ○ increased risk of urinary tract infections ○ leakage from around the catheter ○ catheter blockage can occur ○ urethral injury - External Catherters (Condom or Purwick) Benefits: These catheters are generally more comfortable and carry a lower risk of infection than indwelling catheters. Condom catheters usually need to be changed daily, but some brands are designed for longer use. They can cause less skin irritation than condom catheters that require daily removal and reapplication. Complication or Risk ○ The skin adhesive can irritate the skin. ○ Condom catheters are at increased risk of falling off due to penile retraction. ○ They are not always easy to secure and can fall off causing spillage of urine. - Intermittent Catheters (Straight Cath or Red Robin) Benefits: client autonomy, freedom from indwelling catheter and bags, unimpeded sexual relations Complication or Risk ○ Bladder infection, urethral trauma, urethral inflammation, and strictures are risks.Infection with insertion is a risk, especially with catheter reuse or client self-catheterization. - Catheter Associated Urinary Tract Infection symptoms of urinary tract infections: ○ cloudy urine ○ blood in the urine ○ strong urine odor ○ urine leakage around the catheter ○ pressure, pain, or discomfort in the lower back or stomach ○ Chills ○ Fever ○ unexplained fatigue ○ vomiting CAUTI can be difficult to diagnose in hospitalized clients because similar symptoms may be part of the original illness. In older adults, changes in mental status or confusion can be signs of CAUTI. NO CAUTI represents how to prevent a catheter-associated urinary tract infection ○ Need for catheter assessment – Refer to indications, scan bladder, consider alternative, document reason. ○ Obtain client consent and OFFER client education. ○ Competenct – Clinicians who insert catheters must have documented competency. ○ Asepsis – Maintain asepsis during insertion and while catheter is in place. ○ Unobstructed flow – No kinks or loops, catheter secured, bag below bladder level and off the floor. ○ Timely catheter removal and documentation – Nurse initiated (refer to guidelines). ○ Infection Risk – Collect urine specimen only when clinically indicated.