106 Final Exam Study Guide PDF

Test 1 Ch. 21 Managing Patient Care Transformative leadership: focused on change and innovation through the team development, serves as a mentor for staff, and develops and supports the moral agency of nurses. Shares...

Test 1 Ch. 21 Managing Patient Care Transformative leadership: focused on change and innovation through the team development, serves as a mentor for staff, and develops and supports the moral agency of nurses. Shares ideas, empowers staff, appreciates, etc. Servant leadership: Choose to serve others before they decide to become leaders. Their priority is to pit the needs of others first and to promote personal growth & autonomy by ensuring their individual employees’ highest priority needs are met. Humble, calm, practices humility Nursing Care Delivery Models: designed to help your pts achieve desirable outcomes. Contain the common components of nurse-patient relationship, clinical decision making, methods for pt assignments & work allocation interprofessional communication, and management of the environment care. 2 Types: 1) Team Nursing: care is provided by a group of people lead by an RN 2) Primary Nursing: One RN assumes the responsibility for a caseload of pts from admission to discharge. The same nurse provides care for the same pt throughout their hospitalization Total Patient Care: involves an RN being responsible for all aspects of care for one or more patients. o Total patient care is found primarily in critical care areas Case Management: Coordinates and links health care services across all levels of care for pts and their families while streamlining costs and maintaining quality -Focused on achieving pt outcomes withing effective timeframes and with available resources -Case managers are often APRNs -Case managers do not provide direct care, but collab with direct-care providers to actively coordinate pt discharge planning, ensuring necessary services and resources are available and making cost-effective decisions. Ex. case manager coordinates a patient’s acute care in the hospital and follows up with the patient after discharge, either to home, rehabilitation, or a long-term care setting. Shared governance: the typical decentralized structure used within health care agencies today. This structure creates an environment in which managers and staff become more actively involved in making decisions to shape the identity and determine the success of a health care agency. -Managers move decision making down to the lowest possible level. Autonomy: the freedom of choice and responsibility for the choices. Autonomy consistent with the scope of professional nursing practice maximizes a nurse’s effectiveness Authority: refers to the legal ability to perform a task. It provides the power for a nurse to make final decisions and give instructions related to the decisions. You use authority to determine whether collaboration was successful. Ex. while managing the care of a patient, you discover that the registered dietitian did not follow through on a discharge teaching plan. You have the authority to consult with the registered dietitian to understand why the recommendations on the plan of care were not implemented and to review the established plan to ensure that recommended patient teaching is completed. Accountability: refers to individuals being answerable for their actions. It involves follow-up and a reflective analysis of decisions and an evaluation of their effectiveness. It means that as a nurse you take responsibility to provide excellent patient care by following standards of practice and agency policies and procedures. You assume responsibility for the outcomes of the actions, clinical judgments, and omissions in providing patient care. While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient’s health care provider. Which of the following is the nurse exercising? 1. Authority 2. Responsibility 3. Accountability 4. Decision making Ans: 3 Delegation Delegation: process of assigning part of responsibility to another qualified person in a specific situation. Provides job enrichment by showing trust. Use the 5 rights of delegation to ensure you stay within an RNs legal scope of practice. 1) Right task: The right tasks to delegate are ones that are included in the delegatee’s job description or are included in the health care agency’s policies and procedures. Policies and procedures need to describe expectations, limits, and required competency training for the activity. 2) Right circumstance: Consider the patient’s status. The patient needs to be stable for you to delegate tasks. The delegatee must report changes in patient condition to the licensed nurse. The licensed nurse must reassess and evaluate the situation and appropriateness of delegation when a patient’s condition changes. 3) Right person: The licensed nurse, employer, and delegatee are all responsible for ensuring the delegatee has the knowledge and skills required to perform the activity. 4) Right directions and communication: Give a clear, concise description of a task, including its objective, limits, and expectations. Communication needs to be ongoing between the licensed nurse and delegatee. The delegatee is responsible for asking questions to clarify information. 5) Right supervision and evaluation: Provide appropriate monitoring, evaluation, intervention as needed, and feedback. The licensed nurse must follow up with the delegatee at the end of the activity to evaluate patient outcomes, be available and ready to intervene when appropriate, and ensure appropriate documentation. *Cannot delegate clinical reasoning, nursing judgment (ADPIE), patient teaching, & clinical decision* SBAR as a Communication Tool Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO to a patient 30 minutes ago for postsurgical pain. You return to the patient’s room to evaluate the effectiveness of the medication 30 minutes later. The patient rates his pain as an 8 on a scale of 0–10. You use SBAR to contact the patient’s health care provider. Situation: The patient is rating his pain as an 8 on a scale of 0–10. He had his pain medication 30 minutes ago. Background: The patient had a knee replacement and returned from the postanesthesia care unit 6 hours ago. He has 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO ordered every 6 hours. This is the first pain medication he has taken since being admitted to the unit. Assessment: His current medication order is not sufficiently managing the patient’s pain. He does not want to sit up or move because of the pain he is experiencing. Recommendation: It might be helpful to change the pain medication order for the patient. TeamSTEPPS Principles  Team Structure: Identify the complex parts of the health care system that work together effectively to promote patient safety.  Communication: Use structured processes to exchange information clearly and accurately among members of the health care team.  Leadership: Ensure that all members of the health care team understand the team’s actions, receive information about changes, and have the resources needed to perform their jobs.  Situation Monitoring: Actively assess any situation to gather information, improve your understanding, or maintain awareness to support the functioning of the team.  Mutual Support: Understand the responsibilities and workload of all team members so that you can anticipate and support their needs.  Ch. 38 Activity and Exercise Physical activity o Elevates mood and attitude. o Helps in the management of stress. o Enables physical fitness. o Promotes a better quality of sleep. o Helps one to quit smoking and stay o Improves self-image and self- tobacco-free. confidence. o Boosts energy levels. Body mechanics: is a term that describes the coordinated efforts of the musculoskeletal and nervous systems. Knowing how patients initiate movement and understanding your own movements require a basic grasp of the physics surrounding body mechanics. Body alignment: Body alignment means that an individual’s center of gravity is stable. o Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy. Without balance control the center of gravity is displaced. o “posture” refers to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Gravity & Friction: Unsteady patients fall if their center of gravity becomes unbalanced. o Friction is a force that occurs in a direction to oppose movement. Shear: the force exerted against the skin while the skin remains stationary o If patient is in bed about 60 degrees, gravity will pull skin downwards while skin is intact o Can use a drawsheet to reposition patient Deconditioning: loss of muscle mass, strength, and oxidative capacity that occurs when muscles are inactive. Physical activity (PA): is any movement produced by skeletal muscles that results in energy expenditure (e.g., occupational, sports, conditioning, and household activities) Physical exercise: a subset of PA that is planned, structured, and repetitive and has a final or an intermediate objective, such as the improvement or maintenance of physical fitness Activity tolerance: the type and amount of exercise or work that a person is able to perform without undue exertion or injury. Observe patients after ambulation, self-bathing, or sitting in a chair for several hours and assess their verbal report of fatigue and weakness. Factors influencing Activity Intolerance: o Skeletal abnormalities o Decreased endurance o Muscular impairments o Impaired physical stability o Endocrine or metabolic illnesses (e.g., o Pain diabetes mellitus, thyroid disease) o Sleep pattern disturbance o Hypoxemia o Prior exercise patterns o Decreased cardiac function o Infectious processes and fever Isotonic exercises: cause muscle contraction and change in muscle length (isotonic contraction). Isotonic exercises enhance circulatory and respiratory functioning; increase muscle mass, tone, and strength; and promote osteoblastic activity that combats osteoporosis. o Ex. walking, swimming, jogging, and bicycling Isometric exercise: involve tightening/tensing muscles without moving body parts, is ideal for patients who are immobilized in bed. o Benefits are increased muscle mass, tone, and strength, increased circulation to the involved body part; and increased osteoblastic activity. o Ex. planks, wall sits, or squat hold Resistive isometric exercises: those in which an individual contracts the muscle while pushing against a stationary object or resisting the movement of an object. Promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity. Ex. push-ups and hip lifting, in which a patient in a sitting position pushes with the hands against a surface such as a chair seat and raises the hips.  Skeletal System Skeletal System: provides attachments for muscles and ligaments and the leverage necessary for mobility, thus, supporting the framework of the body and is made up of four types of bones: long, short, flat, and irregular. Disuse Atrophy: a type of muscle atrophy that occurs when muscles are not used enough, causing them to decrease in size and strength Hypertrophy: Active use of muscles during exercise can increase muscle size Joints: The region where two or more bones attach is referred to as a joint. Each joint is classified according to its structure and degree of mobility. three classifications of joints: fibrous, cartilaginous, and synovial. 1. Fibrous joints: fit closely together and are fixed a. permits little if any movement, such as the syndesmosis between the tibia and fibula. (fig. 38.1) 2. Cartilaginous joints: joints where bones are connected by cartilage, a tough but flexible connective tissue. When bone growth is complete, the joints ossify. (fig. 38.1) 3. Synovial joints aka true joints: such as the hinge type at the elbow, are freely movable and the most mobile, numerous, and anatomically complex body joints Ligaments: A ligament is one type of collagenous fiber that intertwines in irregular, swirling arrangements to form thick connective tissue. o connect bones to cartilage. o Ligaments are predominantly elastic fibers and are thus somewhat elastic in nature. Some ligaments serve a protective function Ex. ligaments between the vertebral bodies and the ligamentum flavum prevent damage to the spinal cord during movement of the back. Tendons: are glistening white fibrous bands of tissue that occur in various lengths and thicknesses. o Tendons connect muscle to bone o strong, flexible, and inelastic. The Achilles tendon is the thickest and strongest tendon in the body. Cartilage: nonvascular, supportive connective tissue o located chiefly in the joints and the thorax, trachea, larynx, nose, and ear. It has the flexibility of a firm, plastic material. o sustains weight and serves as a shock absorber between articulating bones. Permanent cartilage: is unossified (not hardened), except in advanced age and diseases such as osteoarthritis, which impairs mobility. Term Movement Example Prime mover Muscle that directly performs a specific movement. Brachialis is a prime mover when flexing the elbow. Muscle that directly when contracting opposes The triceps brachii is an extensor Antagonist prime mover or agonist. Relaxes while prime mover that relaxes when brachialis contracts. Provides precision and control during contracts. contraction of prime mover. Muscle that contracts at same time as prime mover. The deltoid contracts when Synergists Facilitates prime mover actions to produce more brachialis contracts. effective movement. Muscles that stabilize joints, act as type of synergist. The deltoid maintains balance of Fixators Serve to maintain posture and balance. arm when brachialis contracts. Proprioception: is a muscle sense that makes us aware of the position of the body and its parts, including body movement, orientation in space, and muscle stretch. Stretch receptors associated with muscles, joint capsules, and tendons are classified as proprioceptors. Located within muscle spindles. Nervous System: regulates movement and posture. The precentral gyrus, or motor strip, is the major voluntary motor area and is in the cerebral cortex. A majority of motor fibers descend from the motor strip and cross at the level of the medulla. Transmission of impulses from the nervous system to the musculoskeletal system is an electrochemical event and requires a neurotransmitter. o controls balance specifically through the inner ear, the cerebellum, and vision.  Pathological influences on body alignment, mobility, and activity o Using the principles of balance and o Disorders of bones, joints, and alignment aids in safe patient transfer muscles and positioning during routine care o Central nervous system damage activities o Musculoskeletal trauma o Congenital defects o Obesity Principles of Safe Patient Transfer and Positioning o Dividing balanced activity between arms and o Use mechanical lifts and lift teams when legs reduces the risk of back injury. patients are unable to assist. o Leverage, rolling, turning, or pivoting requires o The wider the base of support, the greater the less work than lifting. stability of the nurse. o When friction is reduced between the object to o The lower the center of gravity, the greater the be moved and the surface on which it is stability of the nurse. moved, less force is required to move it. o The equilibrium of an object is maintained if o Patients are more likely to incorporate an the line of gravity passes through its base of exercise program if those around them are support. supportive o Facing the direction of movement prevents abnormal twisting of the spine.  Factors Influencing Activity and Exercise o Infants through school-age children: spine is flexed and lacks the anteroposterior curves of an adult. As growth and stability increase, the thoracic spine straightens, and the lumbar spinal curve appears, which allows sitting and standing o Adolescence: Adolescent growth is often sporadic and uneven. As a result, the adolescent appears awkward and uncoordinated. Adolescent girls usually grow and develop earlier than boys. Hips widen, and fat deposits in the upper arms, thighs, and buttocks. The adolescent boy’s changes in shape are usually a result of long-bone growth and increased muscle mass. o Young to middle-aged adults: normally have full musculoskeletal function. A healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs and physical exercise. However, for people 45 to 64 years of age, the percentage of adults with two or more common chronic conditions increases. o Older adults: ▪ Arthritis ▪ Depression ▪ Cancer ▪ Chronic kidney disease ▪ Chronic lung disease ▪ Heart disease ▪ Dementia ▪ Hypertension ▪ Diabetes ▪ Stroke Helping a patient walk o Assess patient’s ability to walk safely o Evaluate environment for safety o Assist patient to sitting position, dangle patient’s legs over the side of the bed 1 to 2 minutes before standing o Provide support at the waist so the patient’s center of gravity remains midline (gait belt) o Restorative and continuing care Tripod Stance o Implement strategies to assist patient with ADLs Crutch Gait: basic crutch stance is the tripod position, formed when the crutches are placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot o four-point alternating gait ▪ gives stability to the patient but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times o three-point alternating ▪ requires the patient to bear all of the weight on one foot. In a three-point gait the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence o two-point gait ▪ requires at least partial weight bearing on each foot. The patient moves a crutch at the same time as the opposing leg, so the crutch movements are similar to arm motion during normal walking. ▪ Best for bilateral knee replacements o swing-through gait ▪ Individuals with paraplegia who wear weight- supporting braces on their legs frequently use the swing-through gait 4 Point Alt 3 Point Alt 2 Point Alt  Ch. 39 Immobility Mobility: refers to a person’s ability to move about freely, and immobility refers to the inability to do so Systemic effects: body systems work more efficiently with some form of movement. When there is an alteration in mobility, each body system is at risk for impairment. The severity of the impairment depends on a patient’s overall health, degree and length of immobility, and age. Metabolic changes Musculoskeletal o Endocrine metabolism changes o Calcium resorption Urinary elimination o Gastrointestinal (GI) system functions changes Respiratory changes o Kidney stones o Atelectasis: lung collapses, resulting in reduced or absent Integumentary changes gas exchange o Pressure injuries o Hypostatic pneumonia: fluid builds up in the bottom of Psychosocial effects the lungs o Depression Cardiovascular changes o loneliness o Thrombosis Postural Disorders Abnormality Description Cause Lordosis Exaggeration of anterior convex curve of Congenital condition; temporary condition (e.g., lumbar spine pregnancy) Kyphosis Increased convexity in curvature of thoracic Congenital condition; rickets, osteoporosis; spine tuberculosis of spine Scoliosis Lateral S- or C-shaped spinal column with Sometimes a consequence of numerous vertebral rotation, unequal heights of hips congenital, idiopathic, and neuromuscular and shoulders disorders Decorticate Upper extremities flexed at the elbows and Caused by damage between the brain and posture held close to the body; lower extremities spinal cord; brainstem is no longer inhibited by (hemiplegic externally rotated and extended the cerebral cortex motor area; seen in cases of posture) cerebral vascular accident Decerebrate Increased tone in extensor muscles and Caused by severe injury to the brain and posture trunk muscles, with active tonic neck brainstem, resulting in overstimulation of reflexes postural righting and vestibular reflexes Dystonia Maintenance of an abnormal posture Seen in basal ganglia abnormalities; exact through muscular contractions may last pathological cause unknown several seconds to weeks; long term, can cause permanent, fixed contractures Basal Stooped, hyperflexed posture with a narrow- Common in Parkinson disease (see Fig. 39.1); ganglion based, short-stepped gait; due to loss of person loses stability and cannot make postural posture normal postural reflexes adjustment to tilting or loss of balance, and falls instead Developmental changes Infants, toddlers, and preschoolers o musculoskeletal development permits support of weight for standing and walking. Posture is awkward because the head and upper trunk are carried forward. Because body weight is not distributed evenly along a line of gravity, posture is normally off balance, and falls occur often. When an infant, toddler, or preschooler becomes immobilized, it is usually because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization delays progression of a child’s gross-motor skills, intellectual development, and musculoskeletal development.  Adolescents o The adolescent stage usually begins with a tremendous increase in growth. When the activity level is reduced because of trauma, illness, or surgery, the adolescent is often behind peers in gaining independence and accomplishing certain skills, such as obtaining a driver’s license. Social isolation is a concern for this age-group when immobilization occurs. Illnesses or injuries causes immobility usually Adults o The healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs. When periods of prolonged immobility occur, all physiological systems are at risk. In addition, the role of the adult often changes regarding the family or social structure. Some adults lose their jobs, which affects their self-concept. All systems are at risk when immobile Older Adults o A progressive loss of total bone mass in older adults results from decreased physical activity, hormonal changes, and bone resorption. The effect of bone loss is weaker bones. Older adults often walk more slowly, take smaller steps, and appear less coordinated. Prescribed medications often alter their sense of balance or affect their blood pressure when they change position too quickly, increasing their risk for falls and injuries. o Immobilization of some older adults results from degenerative diseases, neurological trauma, or chronic illness. In some it occurs gradually and progressively; in others, especially those who have had a stroke, it is sudden. When providing nursing care for an older adult, encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Implementation Acute Care: Patients in acute care settings who experience altered physical mobility are usually more debilitated than those in outpatient settings. These patients are often at risk for the hazards of immobility such as impaired respiratory status, orthostatic hypotension, DVT, and impaired skin integrity. Therefore, design nursing interventions to reduce the impact of immobility on body systems and prepare patients for the restorative phase of care. Metabolic system: Provide high-protein (the body needs protein to repair injured tissue and rebuild depleted protein stores), high-calorie diet with vitamin B (assists in energy metabolism) and C (needed for skin integrity and wound healing) supplements. Respiratory system: Cough and deep breathe every 1 to 2 hours. Provide chest physiotherapy. Patients need to frequently fully expand their lungs to maintain elastic recoil. Cardiovascular system: Reducing orthostatic hypotension (dangle feet), reducing cardiac workload, Preventing thrombus formation SCDs (compression devices), thromboembolic disease (TED), hose, and leg exercises Maintaining musculoskeletal function: Exercises to prevent excessive muscle atrophy and joint contractures help maintain musculoskeletal function. Active ROM should be encouraged for any patient at risk for reduced musculoskeletal strength or functionality by improving joint mobility. Positioning techniques o Supported Fowler’s position o Side-lying position o Supine position o Sims’ position o Prone position Restorative and continuing care: The goal of restorative care for the patient who is immobile is to maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance. The focus in restorative care is not only on ADLs that relate to physical self-care but also IADLs. Walking and exercise: Continuation of ROM exercises. hemiplegia (one-sided paralysis), hemiparesis (one-sided weakness) Psychotherapy: Therapists combine physical movement work and psychotherapy techniques to help patients gain greater awareness of their abilities and how to proceed toward recovery.  Diagnosis: o Risk for Disuse Syndrome o Impaired mobility When patient has some limitations but not completely immobile o Impaired Airway Clearance o Impaired Sleep o Risk for Impaired Skin Integrity o Risk for Constipation o Social Isolation o Through the patient’s eyes In the sagittal plane, movements are: flexion and extension (e.g., fingers and elbows) dorsiflexion and plantar flexion (feet) extension (e.g., hip) In the frontal plane, movements are: abduction and adduction (e.g., arms and legs) eversion and inversion (feet). In the transverse plane, movements are: pronation and supination (hands) internal and external rotation (hips)  Ch. 43 Sleep Sleep: is a cyclical physiological process that alternates with longer periods of wakefulness. The sleep-wake cycle influences and regulates physiological function and behavioral responses. Circadian Rhythm: Circadian rhythms influence the pattern of major biological and behavioral functions. The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24-hour circadian cycle. o The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus control the rhythm of the sleep- wake cycle and coordinate this cycle with other circadian rhythms. o Factors such as light, temperature, social activities, and work routines affect circadian rhythms and daily sleep-wake cycles. Two-process model of sleep regulation shows the time course of the: o homeostatic process (Process S) and the circadian process (Process C). o Process S rises during waking and declines during sleep. The intersection of Process S and Process C defines the time of wake-up. There are two sleep phases: nonrapid eye movement (NREM) sleep o 75% of night o In the classical definition of NREM sleep, people progress through four stages during a typical 90- minute sleep cycle. o The American Academy of Sleep Medicine defines three stages in NREM sleep, combining stages 3 and 4. o N1 (formerly stage 1) ❖ Stage of lightest level of sleep, lasting a few minutes. ❖ Decreased physiological activity begins with gradual fall in vital signs and metabolism. ❖ Sensory stimuli such as noise easily arouse sleeper. ❖ If awakened, person feels as though daydreaming has occurred. o N2 (formerly stage 2) ❖ Stage of sound sleep during which relaxation progresses. ❖ Arousal is still relatively easy. ❖ Brain and muscle activity continue to slow. o N3 (formerly stages 3 and 4) ❖ Called slow-wave sleep. ❖ Deepest stage of sleep. ❖ Sleeper is difficult to arouse and rarely moves. ❖ Brain and muscle activity are significantly decreased. ❖ Vital signs are lower than during waking hours. ❖ Hypothyroidism decreases this stage of sleep  Rapid Eye Movement (REM) sleep: REM sleep is the phase at the end of each 90-minute sleep cycle. During REM sleep there is increased brain activity associated with rapid eye movements and muscle atonia. o 25% of night o Vivid, full-color dreaming occurs. o Stage usually begins about 90 minutes after sleep has begun. o Stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure. o Loss of skeletal muscle tone occurs. o Gastric secretions increase. o It is very difficult to arouse sleeper. o Duration of REM sleep increases with each cycle and averages 20 minutes. Sleep cycle: o Sleep cycle begins with pre-sleep period. Lasts 10-30 minutes. o Once asleep, we progress through four to six complete sleep cycles (3 stages of NREM and 1 of REM) for about 90-110 minutes. o With each successive cycle, stage 3 shortens, and REM sleep lengthens. o Amount of time in each stage varies o Number of sleep cycles depends on the total amount of time the person spends sleeping. Functions of sleep: o Sleep serves as a restorative period, memory consolidation, and preparation for the next period of wakefulness. o During NREM sleep biological functions slow. o Heart rate lowers to preserve cardiac function. o BP, temp, respirations, and muscle tone decrease during sleep. o Basal metabolic rate (BMR) decreases, conserving energy. o Restores Biologic Function o Dreams (NREM & REM) Physical Illness: Illness that causes pain, physical discomfort, or mood issues often results in sleep problems. o Respiratory illness o Restless leg syndrome (caused by iron o Cardiovascular illness deficiency) and neuropathy o Hyperthyroidism and Hypothyroidism o GI Disorders o Nocturia Nocturia: or urination during the night, disrupts sleep and the sleep cycle, often leading to excessive daytime sleepiness or fatigue Factors that interfere with sleep o Physical illness o Diet o Current Life Events o Fatigue o Acute and Chronic Stress o Sleep Environment o Mental Illness o Medications Diet o Good eating habits are important for proper o Some food allergies cause insomnia. sleep. o A milk allergy sometimes causes nighttime o Eating a large, heavy, and/or spicy meal at waking and crying or colic in infants. night often results in indigestion that o Weight loss or gain influences sleep patterns. interferes with sleep. o Weight gain contributes to OSA because of o Caffeine, alcohol, and nicotine consumed in increased size of the soft tissue structures in the evening produce insomnia. the upper airway. o Coffee, tea, cola, and chocolate contain o Weight loss caused by semistarvation diets caffeine and xanthines, which cause can cause sleep disorders such as reduced sleeplessness. sleep and insomnia  Fatigue o Moderately fatigued people usually achieve restful sleep. o If sleep is the result of enjoyable work or exercise, restful sleep is usually achieved. o Exercising 2 hours or more before bed allows the body a cooling down period and maintains a state of fatigue that promotes relaxation o Excess fatigue resulting from exhausting or stressful work makes falling asleep difficult. Drugs and Their Effects on Sleep Hypnotics Interfere with reaching deeper sleep stages medications that induce sleep Provide only temporary (1-week) increase in quantity of sleep Eventually cause “hangover” during day; excess drowsiness, confusion, decreased energy Sometimes worsen sleep apnea in older adults Antidepressants and Stimulants Suppress REM sleep Decrease total sleep time Alcohol Speeds onset of sleep Reduces REM sleep Awakens person during night and causes difficulty returning to sleep Caffeine Prevents person from falling asleep Causes person to awaken during night Interferes with REM sleep Diuretics Nighttime awakenings caused by nocturia Beta-Adrenergic Blockers Cause nightmares Cause insomnia Cause awakening from sleep Benzodiazepines Alter REM sleep Increase sleep time Increase daytime sleepiness Nicotine Decreases total sleep time Decreases REM sleep time Causes awakening from sleep Causes difficulty staying asleep Opiates Suppress REM sleep Cause increased daytime drowsiness Anticonvulsants Decrease REM sleep time Cause daytime drowsiness Pharmacologic Approaches o Sedatives: medications that produce a calming or soothing effect o Trazodone: serotonin antagonist and reuptake inhibitor (SARI) antidepressant often used in patients with depression or anxiety and insomnia. The most common side effects are daytime grogginess and orthostatic hypotension. Low-dose trazodone is often used as an alternative to benzodiazepines, especially in older patients. o Melatonin: neurohormone produced in the brain that helps control circadian rhythms and promote sleep. It is a popular nutritional supplement that is found to be helpful in improving sleep efficiency and decreasing nighttime awakenings. Common side effects include diarrhea, drowsiness, tiredness and dizziness.  Common Sleep Disorders Insomnia: is a symptom that patients experience when they have: ❖ chronic difficulty in falling asleep ❖ frequent awakenings from sleep, and/or ❖ short periods of sleep or nonrestorative sleep o Patients with insomnia experience EDS and insufficient sleep quality and quality. o Insomnia often signals underlying physical or psychological disorders. o Transient, acute and chronic insomnia. o Often associated with poor sleep hygiene practices o Treatment Hypersomnolence: a neurological disorder that causes excessive sleepiness or the inability to stay awake during the day. It can be caused by many different things and can lead to distress and problems with functioning o Excessive daytime sleepiness lasting at least 3 months o Impairs social and vocational activities o Increased risk for accident or injury Sleep Apnea: is a disorder in which an individual is unable to breathe and sleep at the same time. There is a lack of airflow through the nose and mouth for periods from 10 seconds to 1 to 2 minutes in length. 3 types of Sleep Apnea: 1. Obstructive (most common): occurs when the upper airway collapses or partially collapses during sleep, causing breathing to be reduced or stopped 2. Central: occurs when the brain doesn't send proper signals to the muscles that control breathing 3. Mixed (has an obstructive and central component) o Excessive daytime sleepiness (EDS) o Risk Factors o Common Symptoms o Treatment o Lifestyle Changes Narcolepsy: dysfunction of the processes that regulate sleep and wake states. o During the day, a person suddenly feels an overwhelming wave of sleepiness and falls asleep; REM sleep occurs within 15 minutes of falling asleep. o A person with narcolepsy falls asleep uncontrollably at inappropriate times. o Typically, the symptoms first begin to appear in adolescence and are often confused with the EDS that commonly occurs in adolescence. o Cataplexy o Treatment Teach patient to exercise Avoid activities that can cause regularly injury should the patient fall Small meals high in protein asleep Avoid activities that increase Take naps when drowsy or sleepiness narcoleptic events are likely Stimulants Take prescribed stimulants Cataplexy: sudden muscle weakness during intense emotions such as anger, sadness, or laughter that occurs at any time during the day, is a symptom of narcolepsy type 1 Sleep Deprivation: o The benefits of sleep often go unnoticed until a person develops a problem resulting from sleep deprivation. o Sleep deprivation affects immune function, metabolism, nitrogen balance, and protein catabolism. o A loss of REM sleep often leads to confusion and suspicion.  o Prolonged sleep loss alters various body functions: mood, motor performance, memory, equilibrium o Individuals with sleep problems are also more likely to have chronic diseases such as hypertension, cardiovascular disease, diabetes mellitus, obesity, and depression GERD (acid reflux): a chronic condition that occurs when stomach contents flow back into the esophagus o Most patients with GERD experience an increase in the severity of symptoms, including heartburn, while sleeping or attempting to sleep. o When lying down, gravity no longer helps keep stomach acid down, making it easier for reflux to occur. o Decreased swallowing during sleep reduces an important force that pushes stomach acid downward. o Saliva can help neutralize stomach acid, but production of saliva is reduced during deeper stages of sleep. o Risk Factors ▪ chronic alcohol use, obesity, cigarette/cigar smoking, hiatal hernia, NSAIDS o Treatment ▪ lifestyle modifications, drug therapy, nutrition therapy, surgery o Positioning: Sleep with Head of Bead elevated  Ch. 49 Visual, Auditory, & Sensory Alterations Senses o sight (visual) o smell (olfactory) o hearing (auditory) o taste (gustatory) o touch (tactile) kinesthetic sense: enables a person to be aware of the position and movement of body parts w/o seeing them. Stereognosis: a sense that allows a person to recognize the size, shape, and texture of an object. Sensory Overload: When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli Hyperesthesia: Sensitivity to stimuli Normal Hearing and Vision Function Anatomy and Physiology Ear Two ears provide stereophonic hearing to judge sound direction. The external ear canal shelters the eardrum and maintains relatively constant temperature and humidity to maintain elasticity. Transmits to the brain a The middle ear is an air-containing space between the eardrum and oval window. It pattern of all sounds contains three small bones (ossicles). received from the The eardrum and ossicles transfer sound to the fluid-filled inner ear. environment, the relative Movement of the stapes in the oval window creates vibrations in the fluid that bathes intensity of these sounds, the membranous labyrinth, which contains the end organs of hearing and balance. and the direction from The union of the vestibular (balance) and cochlear (hearing) parts of the labyrinth which they originate explains the combination of hearing and balance symptoms that occur with inner ear disorders. Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval window transmit in perilymph within the inner ear to stimulate hair cells that send impulses along the eighth cranial nerve to the brain. Eye Transmits to the brain a Light rays enter the convex cornea and begin to converge. pattern of light that is An adjustment of light rays occurs as they pass through the pupil and lens. reflected from solid Change in the shape of the lens focuses light on the retina. objects in the environment The retina has a pigmented layer of cells to enhance visual acuity. and becomes transformed The sensory retina contains the rods and cones (i.e., photoreceptor cells sensitive to into color and hue stimulation from light). Photoreceptor cells send electrical potentials by way of the optic nerve to the brain. Normal Sensation o Reception: Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound o Perception: “awareness” of unique sensations depends on the receiving region of the cerebral cortex, where specialized neurons interpret the quality and nature of sensory stimuli. ❖ When a person becomes conscious of a stimulus and receives the information, perception takes place ❖ Perception includes integration and interpretation of stimuli based on a person’s experiences. o Reaction: A person usually reacts to stimuli that are most meaningful or significant at the time. After continued reception of the same stimulus, a person stops responding, and the sensory experience goes unnoticed. ▪ Ex. a person concentrating on reading a good book is not aware of background music  Visual Deficits: o Presbyopia: A gradual decline in the ability of the lens to accommodate or focus on close objects. Individual is unable to see near objects clearly. o Cataract: Cloudy or opaque areas in part of the lens or the entire lens that interfere with passage of light through the lens, causing problems with glare and blurred vision. Cataracts usually develop gradually, without pain, redness, or tearing in the eye. ▪ Most are age related ▪ May have decrease in vision, abnormal color perception, and glare ▪ Vision decline is gradual o Computer Vision Syndrome: Describes a group of eye and vision-related problems that result from prolonged computer, tablet, e-reader, and cell phone use. Most commonly causes eyestrain, headaches, blurred vision, and dry eyes. o Dry eyes: Result when tear glands produce too few tears, resulting in itching, burning, or even reduced vision. o Glaucoma: A slowly progressive increase in intraocular pressure that, if left untreated, causes progressive pressure against the optic nerve, resulting in peripheral visual loss, decreased visual acuity with difficulty adapting to darkness, and a halo effect around lights. ▪ Peripheral vision loss ▪ 2nd leading cause of blindless ▪ More prevalent in African Americans ▪ Characterized by increased Intraocular Pressure (IOP); results in optic nerve atrophy, and peripheral visual field loss. ▪ Many people with glaucoma are unaware of their condition; incidence of glaucoma increases with age. Genetic factors play a role in some types of glaucoma. ▪ Patient usually does not notice the gradual vision field loss until peripheral vision has been severely compromised. o Diabetic retinopathy: Pathological changes occur in the blood vessels of the retina, resulting in decreased vision or vision loss caused by hemorrhage and macular edema. o Macular degeneration: Condition in which the macula (specialized part of the retina responsible for central vision) loses its ability to function efficiently. First signs include blurring of reading matter, distortion or loss of central vision, and distortion of vertical lines. ▪ Leading cause of irreversible central vision loss; related to retinal aging. ▪ Blurred and darkened vision, scotomas (blind spots in the visual field), and metamorphopsia (vision distortion). Cataract Surgery o Preoperative phase ▪ drops before surgery. ▪ A mydriatic (α-adrenergic agonist) produces pupillary dilation (mydriasis) by contracting the iris dilator muscle. ▪ Cycloplegics, such as tropicamide (Mydriacyl), are anticholinergic agents. They block the effects of acetylcholine on the ciliary body and iris sphincter muscles. This produces mydriasis and paralysis of accommodation (cycloplegia). ▪ Nonsteroidal anti-inflammatory eyedrops reduce inflammation and edema. The patient may also receive antianxiety medication before surgery. o Intraoperative phase ▪ most common form of cataract surgery is phacoemulsification. A very small incision is made in the surface of the eye in or near the cornea. A thin ultrasound probe is inserted into the eye and ultrasonic vibrations are used to dissolve the clouded lens into fragments. These pieces are then suctioned out  through the same ultrasound probe. The small incisions are self-sealing and usually do not need sutures. ▪ Most patients have an IOL implanted at the time of cataract extraction surgery. o Postoperative phase ▪ Usually go home as soon as the effects of sedative agents have worn off. Postoperative medications: antibiotic drops to prevent infection and corticosteroid drops to decrease inflammation. The eyedrops are gradually reduced in frequency and then stopped when the eye has healed. ▪ Activity restrictions and nighttime eye shielding: patient avoid activities that increase the IOP. These include bending, stooping, coughing, and lifting. Retinopathy: Process of microvascular damage to the retina o Can lead to blurred vision and progressive vision loss; may develop slowly or rapidly. May result in severe loss in central vision. o It occurs most often in adults with diabetes or hypertension. Assessment Abnormalities Finding Description Possible Etiology & Significance Blurred vision Inability to see clearly Cataracts, Age-related Macular Degeneration Dryness Discomfort, sandy, irritation Decreased tear formation Pain Severe, deep, throbbing Acute glaucoma Cataract Opacification of lens (cloudy or white) Aging Central vision field defect Loss of central vision Macular disease Peripheral vision field defect Partial or complete loss of peripheral Glaucoma, stroke vision Hearing Deficits o Presbycusis: A common progressive hearing o Aminoglycoside antibiotics: gentamicin, disorder in older adults. metronidazole o Cerumen accumulation: Cerumen becomes o Loop diuretics: furosemide hard and collects in the canal and causes o NSAIDS: aspirin, ibuprofen conduction deafness, called conductive o Chemotherapeutic agents: cisplatin, hearing loss carboplatin o Ototoxic medications Misc. deficits o Balance Deficit ▪ Dizziness and disequilibrium: Common condition in older adulthood, usually resulting from vestibular dysfunction. Frequently a change in position of the head precipitates an episode of vertigo or disequilibrium. o Taste Deficit ▪ Xerostomia: Decrease in salivary production that leads to thicker mucus and a dry mouth. Often interferes with the ability to eat and leads to appetite and nutritional problems. o Neurological deficit ▪ Peripheral neuropathy: Disorder of the peripheral nervous system, characterized by symptoms that include numbness and tingling of the affected area and stumbling gait. ▪ Stroke (CVA): Creates altered proprioception with marked incoordination and imbalance. ▪ Loss of sensation and motor function in extremities controlled by the affected area of the brain also occurs.  ▪ A stroke affecting the left hemisphere of the brain results in symptoms on the right side, such as difficulty with speech. ▪ A stroke affecting the right hemisphere causes symptoms on the left side, which may include visual spatial alterations, like loss of half of a visual field or inattention and neglect, especially to the left side. Communication methods o Aphasia: inability to speak, interpret, or understand language o Expressive aphasia: motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. ❖ Ex. a patient understands a question but is unable to express an answer. o Receptive (sensory) aphasia: the inability to understand written or spoken language. A patient can express words but is unable to understand the questions or comments of others o Global aphasia: the inability to understand language or communicate orally. Sensory Deprivation: Reduced sensory input o Elimination of patterns or meanings from input o Restrictive environments that produce monotony and boredom Effects of Sensory Deprivation o Cognitive ❖ Reduced capacity to learn ❖ Inability to think or problem solve ❖ Poor task performance ❖ Disorientation/confusion ❖ Bizarre thinking ❖ Increased need for socialization, altered mechanisms of attention o Affective ❖ Boredom ❖ Restlessness Risk for Injury ❖ Increased anxiety ❖ Emotional lability Risk for Fall ❖ Depression ❖ Panic Nursing Impaired Verbal Communication ❖ Increased need for physical Diagnoses Impaired Socialization stimulation o Perceptual ❖ Changes in visual/motor Impaired Mobility coordination ❖ Reduced color perception ❖ Less tactile accuracy ❖ Changes in ability to perceive size and shape ❖ Changes in spatial and time judgment Factors Affecting Sensory Function o Age o Persons at risk—older adults o Meaningful stimuli ▪ Pets, music, TV, pictures of family members, calendar, clock o Amount of stimuli ▪ Frequent procedures, pain, mobility restrictions (cast, traction) o Environmental ▪ elevator, nurse station o Social interaction o Environmental factors o Cultural factors  Test 2 Chapter 45 Nutrition Nutrition: a basic component of health and is essential for normal growth and development, tissue maintenance and repair, cellular metabolism, and organ function. o Basic component of health and is essential for normal growth and development, tissue maintenance and repair, cellular metabolism, and organ function Food security: means that all household members have access to sufficient, safe, and nutritious food to maintain a healthy lifestyle. Medical nutrition therapy (MNT): the use of specific nutritional therapies to treat an illness, injury, or condition. It is necessary to help the body metabolize certain nutrients, correct nutritional deficiencies related to a disease, and eliminate foods that may exacerbate disease symptoms. It is most effective using a team approach that promotes collaboration between the health care team and an RD o Type 1 Diabetes or mild hypertension Healthy People 2030: Promote health and healthy behaviors and decrease chronic disease. Basal metabolic rate (BMR): Energy needed at rest to maintain life-sustaining activities for a specific amount of time (breathing, circulation, heart rate, temperature). Resting energy expenditure (REE): Amount of energy needed to consume over 24-hour period for the body to maintain internal working activities while at rest Nutrients: Energy necessary for the normal function of numerous body processes (carbs, proteins, fats, water, vitamins, and minerals). Factors affect energy requirements o age body mass o Illness o gender o Injury o Fever o Infection o Starvation o activity level o Menstruation o thyroid function Factors that affect metabolism o Illness o Lactation o Pregnancy o activity level Nutrient Density: refers to the proportion of essential nutrients to the number of kilocalories. o High–nutrient dense foods such as fruits and vegetables provide a large number of nutrients in relationship to kilocalories. o Low–nutrient-dense foods such as alcohol or sugar are high in kilocalories but nutrient poor. The Biochemical Units of Nutrition Carbohydrates: composed of carbon, hydrogen, and oxygen. main source of energy in the diet. o Each gram of carbohydrate produces 4 kcal/g and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. You obtain carbohydrates primarily from plant foods, except for lactose (milk sugar). Carbohydrate classification occurs according to their carbohydrate units, or saccharides. o Potatoes, whole grain bread, oats, rice, beans, pasta, beets, bananas, apples, oranges, blueberries o Monosaccharides such as glucose (dextrose) or fructose ▪ do not break down into a more basic carbohydrate unit. o Disaccharides such as sucrose, lactose, and maltose are composed of two monosaccharides and water. The classification of both monosaccharides and disaccharides is as simple carbohydrates; found primarily in sugars. o Polysaccharides (complex carbs) such as glycogen make up carbohydrate units too. They are insoluble in water and digested to varying degrees. The body is unable to digest some polysaccharides because we do not have enzymes capable of breaking them down.  ▪ Starches, rice, potatoes o Fiber, a polysaccharide, is the structural part of plants that is not broken down by our digestive enzymes. The inability to break down fiber means it does not contribute calories to the diet. Therefore, insoluble fibers are not digestible and include cellulose, hemicellulose, and lignin. Soluble fibers dissolve in water and include barley, cereal grains, cornmeal, and oats. Proteins: provide a source of energy (4 kcal/g), and they are essential for the growth, maintenance and repair of body tissue. ▪ Meat, quinoa, nuts, whole milk, cheese, eggs, Greek yogurt, tuna, salmon, broccoli/cauliflower o Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein. In addition, blood clotting, fluid regulation, and acid–base balance require proteins. Proteins transport nutrients and many drugs in the blood. Ingestion of proteins maintains nitrogen balance. o The simplest form of protein is the amino acid, consisting of hydrogen, oxygen, carbon, and nitrogen. Because the body does not synthesize indispensable amino acids, we need these to be provided in our diet. o The body synthesizes dispensable amino acids. o A complete protein, also called a high-quality protein, contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. o Incomplete proteins are missing one or more of the nine indispensable amino acids and include ▪ cereals, legumes (beans, peas), and vegetables. o Complementary proteins are pairs of incomplete proteins that, when combined, supply the total amount of protein provided by complete protein sources. o Protein provides energy but, because it’s essential role is to growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. When there is sufficient carbohydrate in the diet to meet the body’s energy needs, protein is spared as an energy source. Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. ▪ Fats are composed of triglycerides and fatty acids. ▪ Salmon, butter, olive oil, avocado, egg yolks, chia seeds, peanut butter ▪ Triglycerides circulate in the blood and are composed of three fatty acids attached to a glycerol. ▪ Fatty acids are composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other. 1. Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms; 2. Or unsaturated, in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond. ▪ Monounsaturated fatty acids have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds. The various types of fatty acids, referred to in the dietary guidelines have significance for health and the incidence of disease. ▪ Fatty acids are categorized as essential or nonessential. ▪ Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Linolenic acid and arachidonic acid, another type of unsaturated fatty acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. o Deficiency occurs when fat intake falls below 10% of daily nutrition. Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Water: All cell function depends on a fluid environment ▪ Veggies, fruit, Vitamins: Essential for metabolism, organic substance ▪ Water-soluble  ▪ Vitamins C, B ▪ fat-soluble ▪ A DEK of cards (Vitamins ADEK) Minerals: Inorganic materials, catalysts for enzymes ▪ Iron potassium, zinc, calcium magnesium, sodium ▪ Macrominerals (more than 100 mg); trace elements Digestion Digestion: Mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food reduces to its simplest form Enzymes are the protein like substances that act as catalysts to speed up chemical reactions. They are an essential part of the chemistry of digestion. o Most enzymes have one specific function. Each enzyme works best at a specific pH. Salivary amylase breaks down starch into sugar The mechanical, chemical, and hormonal activities of digestion are interdependent. o Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action. o Hormones regulate the flow of digestive secretions needed for enzyme supply. Physical, chemical, and hormonal factors regulate the secretion of digestive juices and the motility of the GI tract. o Nerve stimulation from the parasympathetic nervous system (e.g., the vagus nerve) increases GI tract action.  Digestion begins in the mouth, where chewing mechanically breaks down food. The food mixes with saliva, which contains ptyalin (salivary amylase), an enzyme that acts on cooked starch to begin its conversion to maltose. o Proteins and fats are broken down physically but remain unchanged chemically because enzymes in the mouth do not react with these nutrients. Epiglottis: a flap of skin that closes over the trachea as a person swallow to prevent aspiration. o Swallowed food enters the esophagus, and wavelike muscular contractions (peristalsis) move the food to the base of the esophagus, above the cardiac sphincter. Pressure from a bolus of food at the cardiac sphincter causes it to relax, allowing the food to enter the fundus, or uppermost portion, of the stomach. Food leaves the antrum, or distal stomach, through the pyloric sphincter and enters the duodenum. o Food is now an acidic, liquefied mass called chyme. Manufactured in the liver, bile is then concentrated and stored in the gallbladder. It acts as a detergent because it emulsifies fat to permit enzyme action while suspending fatty acids in solution. Peristalsis continues in the small intestine, mixing the secretions with chyme. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions. Epithelial cells in the small intestinal villi secrete enzymes (e.g., sucrase, lactase, maltase, lipase, and peptidase) to facilitate digestion. The major portion of digestion occurs in the small intestine. Peristalsis usually takes approximately 5 hours to pass food through the small intestine. Absorption: The small intestine is the primary absorption site for nutrients. lined with fingerlike projections called villi (increase the surface area available for absorption) o The body absorbs nutrients by means of passive diffusion, osmosis, active transport, and pinocytosis. o 85%-90% of water is absorbed through intestines Metabolism and Storage of Nutrients Metabolism: all biochemical reactions within the cells of the body. Through the chemical changes of metabolism, the body converts nutrients into a number of required substances. Metabolic processes are anabolic (building) or catabolic (breaking down). Anabolism ▪ Amino acids are anabolized into tissues, hormones, and enzymes. Normal metabolism and anabolism are physiologically possible when the body is in positive nitrogen balance. Catabolism o Starvation is an example of catabolism when wasting of body tissues occurs. Nutrients absorbed in the intestines, including water, transport through the circulatory system to the body tissues. The major form of body reserve energy is fat, stored as adipose tissue. Protein is stored in muscle mass. When the energy requirements of the body exceed the energy supplied by ingested nutrients, stored energy is used. Amino acids also converted to fat and stored or catabolized into energy through gluconeogenesis. Nutrient metabolism consists of three main processes: 1. Catabolism of glycogen into glucose, carbon dioxide, and water (glycogenolysis). 2. Anabolism of glucose into glycogen for storage (glycogenesis). 3. Catabolism of amino acids and glycerol into glucose for energy (gluconeogenesis). Elimination: Chyme moves by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces. Water absorbs in the mucosa as feces move toward the rectum. o The longer the material stays in the large intestine, the more water is absorbed, causing the feces to become firmer. o Exercise and fiber stimulate peristalsis, and water maintains consistency. Feces contain cellulose and similar indigestible substances, sloughed epithelial cells from the GI tract, digestive secretions, water, and microbes.  Dietary Guidelines Dietary reference intakes (DRIs): Acceptable range of quantities of vitamins and minerals for each gender and age group: 4 main groups: 1. Estimated average requirement (EAR)—amount of nutrient that appears sufficient to maintain a specific body function for 50% of population based on age and gender. 2. Recommended dietary allowance (RDA)—average needs of 98% of population, not exact needs of an individual. 3. Adequate intake (AI)—suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes used when not enough evidence to set RDA. 4. Tolerable upper intake level (UL)—highest level that poses no risk of adverse health events. o These guidelines are for Americans older than the age of 2 years. As a nurse, consider the food preferences of patients from different racial and ethnic groups, vegetarians, and others when planning diets Daily values: Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and potassium The Food and Drug Administration (FDA): created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act (NLEA). The FDA first established two sets of reference values. o referenced daily intakes (RDIs) are the first set, comprising protein, vitamins, and minerals based on the RDA. o daily reference values (DRVs) make up the second set and consist of nutrients such as total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium. o Combined, both sets make up the daily values used on food labels. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older. Factors influencing nutrition: Sociological, cultural, psychological, and emotional o Environmental factors ▪ beyond the control of individuals contribute to the development of obesity. Obesity is an epidemic in the United States. Presently 68.7% of Americans are overweight or obese. often associated with several factors, such as sedentary lifestyle, overeating, and genetics ▪ Overweight is defined as having a body mass index (BMI) of 25 to 29, and obesity is defined as a BMI of 30 or greater o Developmental needs ▪ Rapid growth and high protein, vitamin, mineral, and energy requirements mark the developmental stage of infancy. o Infants through school age ▪ Breastfeeding, formula, solid foods ▪ American Academy of Pediatrics (AAP) strongly supports breastfeeding for the first 6 months of life and breastfeeding with complementary foods from 6 to 12 months ▪ Formula: Protein in the formula is whey, soy, cow’s milk, casein hydrolysate, or elemental amino acids; infants should not have regular cow’s milk during the first year because it is too concentrated for the kidneys to handle and is a poor source of iron and vitamins C and E. ▪ Solid food: Introduce solid foods one at a time 4 to 7 days apart to identify allergies; keep in mind that the growth rate slows in toddlers; they exhibit strong food preferences. ▪ Toddlers: consume more than 24 ounces of milk daily in place of other foods; sometimes develop milk anemia because milk is a poor source of iron. ▪ School age (6-12 years): assess diets for adequate protein and vitamins A and C. ❖ grow at a slower and steadier rate, with a gradual decline in energy requirements per unit of body weight. o Adolescents ▪ Energy needs increase to meet greater metabolic demands of growth. ▪ Daily requirement of protein increases.  ▪ Calcium is essential for the rapid bone growth of adolescence, and girls need a continuous source of iron to replace menstrual losses. ▪ Physiological age is better than chronological age for estimating nutritional needs. ▪ Pregnancy occurring within 4 years of menarche places a mother and fetus at risk because of anatomical and physiological immaturity. ▪ Onset of eating disorders, such as anorexia nervosa or bulimia nervosa, often occurs during adolescence. o Young and middle adults ▪ energy requirements for maintenance and repair only as growth slows. ▪ Pregnancy and lactation become significant in considering energy needs and are related to mother’s body weight and activity. Lactation requires an additional 500 calories above usual allowance with greater than protein requirements in pregnancy. ▪ Folic acid intake is particularly important for deoxyribonucleic acid (DNA) synthesis and the growth of red blood cells. o Older adults ▪ decreased needs for energy due to slowing of their metabolic rate. ▪ Age-related changes in appetite, taste, smell, and the digestive system affect nutrition. ▪ Fixed incomes influence the ability to purchase food. ▪ The elderly often have difficulty chewing, missing teeth, or oral pain, causing difficulty in food consumption. ▪ Need food from all groups, and require a vitamin/mineral supplement Assessment The Subjective Global Assessment (SGA): uses the patient history, weight, and physical assessment data to evaluate nutritional status. The SGA is a simple, inexpensive technique that is able to predict nutrition-related complications. Mini Nutritional Assessment (MNA): screens older adults in home care programs, nursing homes, and hospitals. The tool has 18 items divided into screening and assessment. If a patient scores 11 or less on the screening part, the health care provider completes the assessment part. A total score of less than 17 indicates protein-energy malnutrition  Anthropometry: a systematic method of Nursing Diagnosis measuring the size and makeup of the body Risk for aspiration Diarrhea Deficient Dysphagia: difficulty swallowing knowledge Ideal Body Weight (IBW): provides an estimate of what a person should weigh. Readiness for Feeding self-care Impaired Body Mass Index (BMI): measures weight enhanced nutrition deficit swallowing corrected for Imbalanced nutrition: less than body requirements height and serves as an alternative to traditional height-weight relationships. o Calculate body mass index (BMI) by dividing the patient’s weight in kilograms by height in meters squared: weight (kg) divided by height2 (m2). o 2lbs gain in 24hr period means pt is retaining fluid. o 500ml/fluid = 1lb Cardiac CCF is a sign of this Laboratory and biochemical tests. o No single laboratory or biochemical test is diagnostic for malnutrition. o Factors that frequently alter test results include fluid balance, liver function, kidney function, and the presence of disease. o Nitrogen balance can be calculated to determine serum protein status. ▪ Calculate nitrogen balance by dividing 6.25 into the total grams of protein ingested in a day (24 hours). o Common laboratory tests used to study nutritional status include measures of plasma proteins such as albumin, transferrin, prealbumin, retinol binding protein, total iron-binding capacity, and hemoglobin. o Factors that affect serum albumin levels include hydration; hemorrhage; renal or hepatic disease; large amounts of drainage from wounds, drains, burns, or the GI tract; steroid administration; and exogenous albumin. Dietary and health history o Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-the-counter (OTC) drugs; and the patient’s general nutrition knowledge 1oz. = 30mL 8 oz. x 30mL = 250mL Expected Findings of Poor Nutrition Nausea, vomiting, diarrhea, constipation Inflammation, bleeding of gums Flaccid muscles Poor dental health Mental status changes Dry, dull eyes Loss of appetite Enlarged thyroid Change in bowel pattern Prominent protrusions over bony areas Spleen, liver enlargement Weakness, fatigue Dry, brittle hair and nails Change in weight Loss of subcutaneous fat Poor posture Dry, scaly skin Eating Disorders o Anorexia nervosa ▪ Significantly low body weight for gender, age, developmental level, and physical health. ▪ Fear of being fat ▪ Self-perception of being fat  ▪ Consistent restriction of food intake or repeated behavior that prevents weight gain o Bulimia nervosa: a cycle of binge eating followed by purging (vomiting, using diuretics or laxatives, exercise, fasting) ▪ Lack of control during binges ▪ Average at least one cycle of binge eating and purging per week for at least 3 months o Binge-eating disorder: repeated episodes of binge eating ▪ Feels a loss of control when binge eating, followed by an emotional response such as guilt, shame, or depression ▪ Does not use compensatory behaviors, such as purging ▪ Binge-eating episodes can range from 1 to more than 14 times per week ▪ Clients are often overweight or obese. o Obesity ▪ BMI: greater than 25 is overweight and over 30 is obese Implementation o Acute care ▪ Risk factors in acutely ill patient ❖ Patients with decreased immune function (e.g., from cancer, chemotherapy, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], or organ transplants) require special diets that decrease exposure to microorganisms and are higher in selected nutrients. ▪ Advancing diets = Gradual progression of dietary intake or therapeutic diet to manage illness ▪ Promoting appetite ▪ Assisting with oral feedings o Assist with preventing aspiration: ▪ Position in Fowler’s position or in a chair. ▪ Support the upper back, neck, and head. ▪ Have clients tuck their chin when swallowing to help propel food down the esophagus. ▪ Avoid the use of a straw. ▪ Observe for aspiration and pocketing of food in the cheeks or other areas of the mouth. ▪ Observe for indications of dysphagia, such as coughing, choking, gagging, and drooling of food. ▪ Keep clients in semi-Fowler’s position for at least 1 hour after meals. ▪ Provide oral hygiene after meals and snacks. Enteral Tube Feeding (EN): provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support. When oral feeding assistance is inadequate in providing appropriate nutrition, enteral or parental feeding is required. ▪ EN is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally, yet has a functioning GI tract. ▪ If EN therapy is for less than 4 weeks, total, nasogastric, or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding (more than 6 weeks) to reduce the discomfort of a nasal tube and provide a more secure, reliable access. o Nasogastric, jejunal, or gastric tubes ▪ Patients at low risk for gastric reflux receive gastric feedings; however, if risk of gastric reflux, which leads to aspiration, is present, jejunal feeding is preferred. o Surgical or endoscopic placement ▪ Nasointestinal ▪ PEG (percutaneous endoscopic ▪ Gastrostomy gastrostomy) ▪ Jejunostomy ▪ PEJ (percutaneous endoscopic jejunostomy) o Risk of aspiration Types of formulas include:  o Polymeric: milk-based, blenderized; the patient’s gastrointestinal tract needs to be able to absorb whole nutrients. o Modular: single-macronutrient (protein, glucose, polymers, or lipids) formulas are added to other foods to meet patients’ needs. o Elemental formulas: predigested nutrients, easier for partially dysfunctional gastrointestinal tract to absorb. o Specialty formulas: designed to meet specific nutritional needs in certain illnesses. Parenteral Nutrition (PN): a form of specialized nutrition support provided intravenously. o Patients unable to digest or absorb enteral o Peripheral or central line nutrition or are in highly stressed o Initiating parenteral nutrition physiological states o Preventing complications o Glucose will need to be monitored o A basic PN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Total PN (TPN), administered through a central line, is a 2-in-1 formula in which administration of fat emulsions occurs separately from the protein and dextrose solution. o PN therapy requires clinical and laboratory monitoring by a multidisciplinary team. Consistent reevaluation for the continuation of PN is required. The goal to move toward use of the GI tract is constant. Medical nutrition therapy (MNT) Restorative and Continuing Care: includes both immediate postsurgical care and routine medical care and therefore includes patients in the hospital and at home. o Medical nutrition therapy (MNT) o Specific nutritional therapy usage for treating illness, injury, or a certain condition o Necessary for ▪ Metabolizing certain nutrients ▪ Correcting nutritional deficiencies ▪ Eliminating foods that worsen disease states o Most effective with collaborative health care team and dietitian o Gastrointestinal diseases o Peptic ulcer etiology ▪ Helicobacter pylori: Marshall and Warren first identified Helicobacter pylori in 1984. H. pylori, a bacterium that causes up to 85% of peptic ulcers, is confirmed by laboratory tests or a biopsy during endoscopy. ▪ Stress ▪ Acid overproduction o Peptic ulcer treatments ▪ Avoid caffeine ▪ Avoid spicy foods ▪ Avoid aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) ▪ Consume small, frequent meals o Inflammatory bowel disease ▪ Crohn’s and idiopathic ulcerative colitis Elemental diets Fat reduction Parenteral nutrition Large meal avoidance Vitamins and iron Lactose and sorbitol supplements avoidance Fiber increase ❖ The treatment of malabsorption syndromes such as celiac disease includes a gluten-free diet. Gluten is present in wheat, rye, barley, and oats. Short-bowel syndrome results from extensive resection of bowel, after which patients suffer from malabsorption caused by lack of intestinal surface area. These patients require lifetime feeding with either elemental enteral formulas or PN. ❖ Diverticulitis: a condition that results from an inflammation of diverticula, which are abnormal but common pouch-like herniations that occur in the bowel lining. Nutritional treatment includes a moderate- or low-residue diet until the infection subsides. Afterward, prescribing a high-fiber diet for chronic diverticula problems ensues. Diabetes mellitus (DM): requires both insulin and dietary restrictions for optimal control, with treatment beginning at diagnosis Type 1: insulin and dietary restrictions Type 2: exercise and diet therapy initially: By contrast, patients often control type 2 DM initially with exercise and diet therapy. If these measures prove ineffective, it is common to add oral medications. Insulin injections often follow if type 2 DM worsens or fails to respond to these initial interventions. Individualized diet ▪ ADA Diet, low carbs Carbohydrate consistency and monitoring Monitoring carbohydrate consumption is a key strategy in achieving glycemic control. Saturated fat less than 7% Cholesterol intake less than 200 mg/dL Protein intake 15% to 20% of diet Goals Goal of MNT treatment is to have glycemic levels that are normal or as close to normal as safely possible Cardiovascular diseases o American Heart Association (AHA) dietary guidelines: goal to reduce risk factors for the development of hypertension and coronary artery disease. ▪ Need a low-sodium diet ▪ Balance caloric intake and exercise. ▪ Maintain a healthy body weight. ▪ Eat a diet rich in fruits, vegetables, and complex carbohydrates. ▪ Eat fish twice per week. ▪ Limit foods and beverages high in sugar and salt. ▪ Limit trans-saturated fat to less than 1%. Cancer and cancer treatment o Malignant cells compete with normal cells for nutrients. o Anorexia, nausea, vomiting, and taste distortions are common. o Malnutrition associated with cancer increases morbidity and mortality. o Radiation causes anorexia, stomatitis, severe diarrhea, intestinal strictures, and pain. o Nutrition management. Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) o Need small, frequent meals o Body wasting and severe weight loss o Severe diarrhea, GI malabsorption, altered nutrient metabolism o Hypermetabolism as a result of cytokine elevation Maximize kilocalories and nutrients Encourage small, frequent, nutrient-dense meals with fluid in between  Chapter 46 Urination 1. Kidneys- Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance o Glomerulus: Filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes. Large proteins and blood cells do not normally filter through the glomerulus. Suspect glomerular injury when protein (proteinuria) or blood (hematuria) is found in the urine. 2. Ureters- carries urinary waste from kidneys to the bladder. 3. Bladder- hollow, distensible, muscular organ that holds the urine 4. Urethra- urine travels from the bladder through the urethra and passes to the outside of the body through the urethra. o Pelvic floor stabilizes urethra, which helps with urine incontinence o Women are more prone to UTIs because they have a shorter urethra (3-4 cm) Act of Urination: Bladder emptying (aka urination, micturition, voiding) o A complex interaction among the bladder, urinary sphincter, and central nervous system. o As the bladder fill and stretches, bladder contractions are inhibited by sympathetic stimulation from the thoracic micturition center. o When the bladder fills to approximately 400-600 ml, most people experience a strong sensation of urgency o Appropriate place to void, the urinary sphincter relaxes, and bladder contracts then relaxes, then a release of urine. o bladder control: Thalamus, hypothalamus, brainstem Common Urinary Elimination Problems o Urinary Retention- inability to partially or completely empty the bladder o Urinary Tract Infections (UTI)- Escherichia coli most common cause. o Urinary incontinence- involuntary loss of urine ▪ Types: Transient Stress Functional Urgency Overflow Reflex  Urinary Incontinence Definition Characteristics Selected Nursing Interventions Transient Incontinence Incontinence caused by medical Common reversible causes With new-onset or increased conditio