Exam #3 Study Guide Realll PDF

Exam #3 STuddy guide: 1.Actions nurses take to promote Skin integrity - Sherpath Actions for risk for impaired skin integrity or risk for pressure ulcer injury: Actions: ​ -Clean the contaminated skin immediately with a cl...

Exam #3 STuddy guide: 1.Actions nurses take to promote Skin integrity - Sherpath Actions for risk for impaired skin integrity or risk for pressure ulcer injury: Actions: ​ -Clean the contaminated skin immediately with a cleanser for perineal care. ​ -Do not use antibacterial soap and avoid hot water because they cause drying. ​ -Use warm water and a mild pH-neutral soap. ​ Apply a moister-barrier ointment to skin at risk for exposure to urine or stool. Actions for turning and repositioning patients -Turn patient at least every 2 hours. After that, skin begins to settle, and decomposition begins. A turning schedule can be used to ensure turning within this time frame. -Elevate head of bed no more than 30 degrees to decrease shear effects. -Position patient’s head of bed at 30 degrees or less, not 90 degrees, to prevent shear. -Position patient laterally 30 degrees when side-lying to avoid direct pressure on bony prominences. -Place folded blankets or pillows or towels between knees to prevent pressure against knees when the patient is side-lying. -Position legs with pillows so that heels “float” off the mattress (see image) to remove pressure. Heels are at an especially high risk for development of pressure injuries. -Limit chair use to 2 hours or less. -Frequent position changes also apply to seated patients. -Patients who are unable to change positions independently or sense the need to change positions while seated in chairs need assistance changing positions to relieve pressure every hour; pressure-redistribution cushions can be beneficial. -Provide adequate calories, protein, and vitamin C for healing of skin and Change wet/soiled gowns and sheets frequently. Acions for pressure-reducing mattresses -Support surfaces: -Diminish pressure by redistributing the body’s weight over a greater surface area made of foam, gels, fluids, or air -Include overlays, replacement mattresses, and specialty beds; made for chairs, operating room tables, and stretchers -Accommodate all types of patients: children, adults, and the obese Actions for Patients with skin integrity: -Keep skin dry from urine, stool, wound drainage, and moisture (pat dry thoroughly). -Apply skin barrier as needed. -Turn patient every 2 hours. -Position patient at 30 degrees laterally when side-lying. -Keep head of bed 30 degrees or less. -Transfer to chair (remember to have patient move, or if patient is unable, reposition patient as needed). -Use pressure-reducing devices as needed. -Chair pads, Mattresses, Special beds -Offer healthy diet. *Offer foods high in protein (all types of meat, milk, eggs, cheese, beans, nuts, seeds). *Offer foods high in vitamins C and A. *Vitamin C: oranges, citrus fruit, strawberries, kiwi, broccoli, peppers, tomatoes *Vitamin A: carrots, apricots, sweet potatoes or dark yellow or orange vegetables; dark green leafy vegetables *Offer food high in zinc and copper. *Zinc: found in high-protein foods *Copper: found in high-protein foods, molasses -Offer fluids to increase intake. -Ask patient for input on favorite foods and for completion of diet requests. -Consult dietitian/nutritionist as needed. -Monitor albumin and prealbumin levels. -Use Braden Scale or Norton Scale for pressure injuries. -Do not massage pressure injuries because this exacerbates the damage. -What Action will the nurse take for a patient with hyposthessis of Impaired skin integrity? -Suggest fluid intake Heat and Cold Therapy Actions: -Moist Compress Actions: *Soak sterile gauze or linen in a sterile solution. *Place over the wound/injury. *Cover with towels or a waterproof pad to maintain warmth or cold for the time prescribed -Moist Soak Actions: *Place extremity completely in solution (may be medicated). *Maintain temperature of the solution by covering container and extremity. *Keep the solution warm or cold, as needed, by changing solution or adding to it, as needed (about every 10 minutes). *Dry the extremity completely. -Size Bath actions: *Soak perineum/pelvic area for 20 minutes. (The patient must be able to sit up to use this form of therapy.) *Adjust temperature, following facility protocol. *Use a chair, tub, or toilet attachment (usually has hose attached that sprays water on pelvic area and drains into basin. Also, Monitor the sensitive perineal area for any complications Aquathermia Actions: -Obtain pad and control unit, which regulates temperature and water flow (can only use distilled water) through the pad channels. -Place pad around extremity (some facilities may require a towel wrapped around the extremity before applying pad). -Turn control unit on. Hot and Cold Pack Actions: -For commercial hot/cold packs, follow manufacturer’s directions. -For noncommercial ice bags, fill with water or only two-thirds full, if using crushed ice. -Remove air before closing. -Do not place heat or cold pack directly on skin; place a small washcloth between the skin and pack. Wrapping a wound/injury Actions: -Keep limb elevated for 15 to 30 minutes before wrapping. -Begin at the distal end of the limb. -Perform two circular wraps to secure bandage. -Wrap from distal to proximal. -Wrap according to injured limb: *Extremities: spiral or reverse spiral *Joints: figure 8 *Head or amputation: recurrent -For each wrap, cover half of previous wrap. -Check circulation. -Keep extremity elevated Wound cleansing and irrigation Actions: -Use a cleaning agent that provides a balance between cleaning and trauma to the wound bed. -Avoid Dakin’s solution, povidone-iodine, acetic acid, and hydrogen peroxide because although they kill bacteria, they damage cells needed for healing and delay wound healing. -Use normal saline 0.9% because it is readily available and adequate for wound cleaning. Wound Drain Actions: -Clean drain in a circular motion. -Note that each movement requires a new cleansing gauze. -Clean from close to the drain, outward. -Place specially prepared 4” × 4” dressing around drain. -Apply abdominal (ABD) pads and tape. Patients with negative pressure injuries, burn wound, malignant wound, surgical wound, or traumatic wound Actions: -Clean and pat dry wound and surrounding skin. -Apply skin barrier protectant. -Cut the foam to fit the wound and place in wound. -Apply a transparent occlusive dressing over foam and extend 2 inches out. -If there is not a precut center hole in the dressing, cut one. -Place suction tubing in the center hole without the tubing touching wound bed. -Apply another transparent dressing over both the tubing and the first dressing. -Apply the suction tubing to the canister. -Discard gloves and wash hands. -Turn on unit (should cause the dressing to shrink). -Document wound assessment, characteristics of drainage, type of dressing, pressure setting, and patient response to NPWT Malignant wound, Traumatic wound, Ssurgical Wound Actions: -Keep dressing dry and intact. -Assess dressings and change as needed, or in accordance with health care provider’s instructions or facility policies. -Assess and measure wound: *Inspect skin for abrasions, edema, discoloration, or exposed wound edges prior to applying bandages or binders. -Assess drainage characteristics. -Provide meticulous wound care, including dressing changes, wound cleansing, and wound irrigation as required. -Monitor and clean drains, as needed. -Offer foods high in protein, zinc, copper, and vitamins A and C. -Provide pain medication as needed. -Monitor prealbumin and albumin levels. -Monitor white blood cell count. -Administer antibiotics, if needed. -Consult with dietitian/nutritionist, social worker, and WOCN, as needed. -Use binders or wraps as needed: *Cover exposed wounds or open abrasions with sterile dressings before applying wraps or binders. -Monitor vital signs, especially temperature. -Use NPWT, if prescribed. -Assist with debridement if prescribed. Patient Education Actions: -Educate patient and family on the following: *Treatment purpose *How to change dressing and when *How to tell if the wound is infected *How to dispose of old dressings *How to promote wound healing *When to notify the health care provider *When next follow-up visit is -Have the patient and/or family member perform a return demonstration before discharge. -Provide written instructions as well. -Use videos and images as required. -Determine patient’s acceptance and coping abilities with wound/injury. -Use active listening and therapeutic communication techniques. -Consult with social worker and WOCN, as needed. 2.The purpose of dressings: A dressing serves several purposes: Protects a wound from microorganism contamination Aids in hemostasis Promotes healing by maintaining wound moisture Promotes healing by absorbing drainage and debriding a wound Supports or splints a wound site Promotes thermal insulation of a wound surface When the skin is broken, a dressing helps reduce exposure to microorganisms. However, when drainage is minimal, the healing process by primary intention forms a natural fibrin seal that eliminates the need for a dressing. A wound that is healing by secondary intention needs the support of a moist wound environment. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible. Wounds with extensive tissue loss always need a dressing. The functions of a dressing on a healing wound are to provide protection, deliver medication, and absorb drainage. These dressings can be dry or moist. Gauze dressings come in various types, including gauze sponges, used to pack wounds with depth and drainage; gauze placed over a shallow healing wound as a topper dressing; or gauze placed over a wound to wick the wound drainage. A problem occurs if wound drainage dries, causing the dressing to stick to the suture line. Improperly removing a dressing disrupts the healing epidermal surface. If a gauze dressing sticks to a surgical incision, lightly moisten it with saline solution before removal. This saturates the dressing and loosens it from the incisional area, thus preventing trauma to the incisional area during removal. The dressing choice and technique vary, depending on the outcome of the treatment plan for a wound. For example, if the expected outcome is to maintain a moist environment to promote wound healing, a saline-moistened gauze dressing must remain moist and not become dry and stick to the wound. This is in direct contrast to the moist-to-dry dressing technique that mechanically debrides a wound. When wounds such as a necrotic wound require debriding, a moist-to-dry dressing technique or dressings can be considered. Also, foam and alginate dressings are used for wounds with large amounts of exudate and are designed to absorb drainage. Pressure dressings promote hemostasis for bleeding wounds. Applied with elastic bandages, a pressure dressing exerts localized downward pressure over an actual or potential bleeding site. It eliminates dead space in underlying tissues so that wound healing progresses normally. Check pressure dressings to be sure that they do not interfere with circulation to a body part by assessing skin color, pulses in distal extremities, the patient’s comfort, and changes in sensation. Pressure dressings are not removed routinely. Dressings applied to a draining wound require frequent changing to prevent microorganism growth and skin breakdown. Bacteria grow readily in the dark, warm, moist environment under a dressing. The periwound area can become macerated and irritated. Minimize periwound skin breakdown by keeping the skin clean and dry and reducing the use of tape. The inner layer of an absorbent dressing serves as a reservoir for secretions. The wicking action of woven gauze dressings pulls excess drainage into the dressing and away from the wound. The final outer layer of the dressing (usually an ABD pad that has an outer layer that prevents strike-through) helps prevent bacteria and other external contaminants from reaching the wound surface. Apply adhesives to this layer to secure the dressings. The more extensive a wound, the larger the dressing required. For example, a bulky dressing applied with pressure minimizes movement of underlying tissues and helps immobilize the entire body part. A bandage or cloth wrapped around a penetrating object should immobilize it adequately. Alternative dressings are available to cover and protect certain types of wounds such as large wounds, wounds with drainage tubes or suction catheters in the wound, and wounds that need frequent changing because of excessive drainage. In the home setting a clean towel or diaper is often the best secondary dressing. Pouches or special wound collection systems cover wounds with excessive drainage and collect the drainage. Some of the collection systems have a plastic window on the front of the wound pouch, allowing you to change the packing without removing the pouch from the skin. For many surgical wounds, dressings are no longer used (see Chapter 50). However, when a surgical wound has a dressing, its purpose is to promote wound healing by primary intention. Thus it is common to remove surgical dressings as soon as drainage stops. In contrast, when dressing a wound healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or helping in debridement 3. Dehydration: Dehydration: The excessive loss of water from the body tissues accompanied by a disturbance of body electrolytes. -Excess loss of colonic fluid(through diharea) results in dehydration, with fluid and electrolyte or acid-base imbalances if the fluid is not replaced. Infants and older adults are particularly susceptible to associated complications. Because repeated passage of diarrhea stools exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage is necessary to prevent skin breakdown. Signs of dehydration in adults include: Thirst Less frequent urination than usual Dark-colored urine Dry skin Fatigue Dizziness Light-headedness Signs of dehydration in infants and young children include: Dry mouth and tongue No tears when crying No wet diapers for 3 hours or more  Sunken eyes or cheeks or soft spot in the skull High fever Listlessness or irritability -Symptoms of dehydration in older adults include confusion; weakness; hot, dry skin; furrowed tongue; rapid pulse; and high urinary sodium. -Patients with colostomies have no diet restrictions other than the diet discussed for normal healthy bowel function, with adequate fiber and fluid to keep the stool softly formed. Patients with ileostomies digest their food completely but lose both fluid and salt through their stoma and need to be sure to replace them to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they empty their pouch. This helps them remember that they have greater fluid needs than they did before having an ileostomy. 4. Function of Fats: Fats (lipids) are the most calorie-dense nutrient and produce the most energy, providing 9 kcal/g. Fats are composed of triglycerides and fatty acids. 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. Fatty acids can be saturated(usually comes from animal sources and are at solid room temperature and should not excess 10% of daily intake) in which each carbon in the chain has two attached hydrogen atoms, or unsaturated (usually comess from vegetables, nuts and seeds), in which an unequal number of hydrogen atoms are attached, and the carbon atoms attach to one another 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 also classified as essential or nonessential. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Linolenic acid and arachidonic acid, other types of unsaturated fatty acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. Deficiency occurs when fat intake falls below 10% of daily nutrition and should not exceed more then 20-35% of daily intake.. Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. People acquire vitamins primarily through dietary intake, although vitamin D also comes from the sun. The body has a high storage capacity for fat-soluble vitamins. As a result, toxicity is possible when a person takes large doses of them. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils. 5. Process of Digestion: Digestion of food is the mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food is reduced to its simplest form (Grodner et al., 2020). Each part of the GI system has an important digestive or absorptive function (Fig. 45.1). 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. Process of the digestive system is: Salivary glands: Saliva moistens and lubricates food; Amylase digests carbohydrates.  Mouth: Breaks up food particles; assists in producing spoken language. Pharynx: Swallows. Esophagus: Transports food. Gallbladder: Stores and concentrates bile. Liver: Breaks down and builds up many biological molecules Stores vitamins and iron. Destroys old blood cells. Destroys poisons. Produces bile to aid digestion. Stomach: Stores and churns food; HCI activates enzymes, breaks up food, kills germs. Mucus protects stomach wall; Limited absorption. Pancreas: Hormones regulate blood glucose levels; Bicarbonates neutralize stomach acid. Small intestine: Completes digestion; Mucus protects gut wall; Absorbs nutrients, most water. Large intestine: Reabsorbs some water, ions, and vitamins. Forms and stores feces Most enzymes have one specific function. Each enzyme works best at a specific pH. For example, the enzyme amylase in the saliva breaks down starches into sugars. The secretions of the GI tract have very different pH levels. Saliva is relatively neutral, gastric juice is highly acidic, and the secretions of the small intestine are alkaline. The mechanical, chemical, and hormonal activities of digestion are interdependent. Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action. 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. 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. The longer an individual chews food, the more starch digestion occurs in the mouth. Proteins and fats are broken down physically but remain unchanged chemically because enzymes in the mouth do not react with these nutrients. Chewing reduces food particles to a size suitable for swallowing, and saliva provides lubrication to ease swallowing of the food. The epiglottis is a flap of skin that closes over the trachea to prevent aspiration as a person swallows. 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 part, of the stomach. The chief cells in the stomach secrete pepsinogen, and the pyloric glands secrete gastrin, a hormone that triggers parietal cells to secrete hydrochloric acid (HCl). The parietal cells also secrete HCl and intrinsic factor (IF), which is necessary for absorption of vitamin B12 in the ileum. HCl turns pepsinogen into pepsin, a protein-splitting enzyme. The body produces gastric lipase and amylase to begin fat and starch digestion, respectively. A thick layer of mucus protects the lining of the stomach from autodigestion. Alcohol and aspirin are two substances directly absorbed through the lining of the stomach. The stomach acts as a reservoir where food remains for approximately 3 hours, with a range of 1 to 7 hours. Food leaves the antrum, or distal stomach, through the pyloric sphincter and enters the duodenum. Food is now an acidic, liquefied mass called chyme. Chyme flows into the duodenum and quickly mixes with bile, intestinal juices, and pancreatic secretions. The small intestine secretes the hormones secretin and cholecystokinin (CCK). Secretin activates release of bicarbonate from the pancreas, raising the pH of chyme. CCK inhibits further gastrin secretion and initiates release of additional digestive enzymes from the pancreas and gallbladder. Bile, manufactured in the liver, 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. Pancreatic secretions contain six enzymes: amylase to digest starch; lipase to break down emulsified fats; and trypsin, elastase, chymotrypsin, and carboxypeptidase to break down proteins. 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 part of digestion occurs in the small intestine, producing glucose, fructose, and galactose from carbohydrates; amino acids and dipeptides from proteins; and fatty acids, glycerides, and glycerol from lipids. Peristalsis usually takes approximately 5 hours to pass food through the small intestine. 6. Water Soluble Vitamins: The water-soluble vitamins are vitamin C and the B complex (which is eight vitamins). The body does not store water-soluble vitamins; therefore we need them provided in our daily food intake. Water-soluble vitamins are absorbed easily from the GI tract. Although they are not stored, toxicity can still occur. 7. Signs of inadequate fiber intake: Encourage Patients to regularly eat fiber to prevent constipation and enhancing diet. Signs of inadequate fiber in a patient's diet is, constipation, abdominal bloating, infrequent bowl movements, hard stools, and straining during bowl movements. Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber in the diet provides the bulk in the fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help remove the fats and waste products from the body with more efficiency. Some of these foods such as cabbage, broccoli, or beans may also produce gas, which distends the intestinal walls and increases colonic motility. The bowel walls stretch, creating peristalsis and initiating the defecation reflex. Nutrition is especially important in helping patients maintain normal elimination patterns in continuing and restorative care settings. In choosing a diet for promoting normal elimination, consider the frequency of defecation, characteristics of feces, and types of foods that impair or promote defecation. A well-balanced diet with whole grains, legumes, fresh fruits, and vegetables promotes normal elimination. Fiber adds bulk to the stool, eliminates excess fluids, and promotes more frequent and regular movements. It is important to teach patients to drink enough fluid (about 3.7 L per day for men; about 2.7 L per day for women) along with increasing their fiber. If fluid intake is inadequate, the stool becomes hard because less water is retained in the large intestine to soften it. The amount of fiber and fluids necessary for optimal bowel function varies among individuals. Consult with a registered dietitian if a patient has chronic problems with constipation. 8. BMI: Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships. Calculate BMI by dividing a patient’s weight in kilograms by height in meters squared: weight (kg) divided by height2 Underweight BMI - >18.5 Normal Weight BMI - 18.5-24.9 Overweight BMI- 25.0-29.9 Obese BMI - 30 or Greater A BMI greater then 25 defines the upper boundaries of health weight and indicates a higher risk for respiratory diseas, tuberculosis, digestive disease and some types of cancer. A BMI greater then 35 puts people at a higher risk for coronary heart disease, some typess of cancer, diabetess mellitus, and hypertension 9.Dysphagia: Dysphagia refers to difficulty swallowing. There are a variety of causes and complications of dysphagia. Complications include aspiration pneumonia, dehydration, decreased nutritional status, and weight loss. Dysphagia leads to disability or decreased functional status, increased length of stay and health care costs, increased likelihood of discharge to institutionalized care, and increased mortality. Causes of Dysphagia Myogenic Myasthenia gravis Aging Muscular dystrophy Polymyositis Neurogenic: Stroke Cerebral palsy Guillain-Barré syndrome Multiple sclerosis Amyotrophic lateral sclerosis (Lou Gehrig disease) Diabetic neuropathy Parkinson disease Obstructive: 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 Warning signs of dysphagia: Coughing during eating Change in voice tone or quality after swallowing Food pocketing Abnormal movements of the mouth, tongue, and lips Slow, weak, or imprecise speech Abnormal gag reflex Delayed or absent triggers of swallowing Inability to speak consistently "Dysphagia is a physical sign of alteration in nutritional status, and patients who suffer from dysphagia should be referred to a speech pathologist for evaluation and treatment." Be aware of warning signs for dysphagia. They include cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. Patients with dysphagia often do not show overt signs such as coughing when food enters the airway. Silent aspiration is aspiration that occurs in patients with neurological problems that leads to decreased sensation. It often occurs without a cough, and symptoms (e.g., adventitious breath sounds, slight fever) usually do not appear for 24 hours. Silent aspiration is common in patients with dysphagia following stroke. Dysphagia often leads to an inadequate amount of food intake, which results in malnutrition. Frequently patients with dysphagia become frustrated with eating and show changes in skinfold thickness and albumin. During the rehabilitation period patients experience longer adjustment periods regarding new dietary restrictions. Furthermore, malnutrition significantly slows swallowing recovery and may increase mortality. Dysphagia screening quickly identifies problems with swallowing and helps you initiate referrals for more in-depth assessment by an RD or a speech-language pathologist (SLP). Early and ongoing assessment of patients with dysphagia using a valid dysphagia-screening tool increases quality of care and decreases incidence of aspiration pneumonia (Suiter et al., 2020). Dysphagia screening includes medical record review; observation of a patient at a meal for change in voice quality, posture, and head control; percentage of meal consumed; eating time; drooling or leakage of liquids and solids; cough during or after a swallow; facial or tongue weakness; palatal movement; difficulty with secretions; pocketing; choking; and a spontaneous dry cough. Several validated screening tools are available, such as the Bedside Swallowing Assessment, Burke Dysphagia Screening Test, Acute Stroke Dysphagia Screen, and Standardized Swallowing Assessment. The Acute Stroke Dysphagia Screen is an easily administered and reliable tool for health care professionals who are not SLPs. Screening for and treatment of dysphagia requires an interprofessional team approach of nurses, RDs, health care providers, and SLPs 10. Paralytic Ileus: paralytic ileus: Usually temporary paralysis of intestinal wall that may occur after abdominal surgery or peritoneal injury and that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction. Parenteral nutrition: -Nonfunctional GI tract Massive small bowel resection, GI surgery, or massive GI bleed Paralytic ileus  Paralytic ileus (i.e., loss of function of the intestine), which causes abdominal distention, is always possible after surgery. Auscultate bowel sounds in all four quadrants, noting faint or absent bowel sounds. Inspect the abdomen for distention caused by accumulation of gas. Ask whether a patient is passing flatus, an important sign indicating return of normal bowel function. The return of flatus is usually more indicative of normal bowel function return than the return of bowel sounds (Rothrock, 2019). If a nasogastric (NG) tube is in place for decompression, assess the patency of the tube and the color and amount of drainage 11.Supplement to reduce Birth Defects: Poor nutrition during pregnancy causes low birth weight in infants and decreases chances of survival. In general, meeting the needs of a fetus is at the expense of the mother. However, if nutrient sources are unavailable, both suffer. The nutritional status of the mother at the time of conception is important. Significant aspects of fetal growth and development often occur before the mother suspects the pregnancy. The energy requirements of pregnancy relate to the mother’s body weight and activity. The quality of nutrition during pregnancy is important, and food intake in the first trimester includes balanced parts of essential nutrients with emphasis on quality. Protein intake throughout pregnancy needs to increase to 60 g daily. Calcium intake is especially critical in the third trimester, when fetal bones mineralize. Providing iron supplements to meet the mother’s increased blood volume, fetal blood storage, and blood loss during delivery is important. Folic acid intake is particularly important for DNA synthesis and the growth of red blood cells. Inadequate intake can lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia (Grodner et al., 2020). Women of childbearing age need to consume 400 mcg of folic acid daily, increasing to 600 mcg daily during pregnancy. Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts. 12.Nutritional for infants through school-age children: -Increase the proportion of infants who are breastfed exclusively through 6 months of age -Increase the proportion of infants who are bbreasfed at 1 year -Increase the proportion of students participating in the school breakfast program Infancy (0-1 year) Breastfeeding is recommended for at least the first 6 months of life. Formula can be used as a supplement or alternative to breast milk. Cow's milk should not be given to infants under 1 year old. Toddlerhood (1-3 years) Solid foods should be introduced one at a time, 4-7 days apart, to identify allergies. Toddlers need a balanced diet that includes protein, vegetables, and whole grains. School Age (6-12 years) Assess diet for adequate protein, vitamin A, and vitamin C. Encourage a balanced diet that includes a variety of foods. -Rapid growth and high protein, vitamin, mineral, and energy requirements mark the developmental stage of infancy. A healthy infant from birth to 1 year needs an energy intake of approximately 100 kcal/kg of body weight per day, with neonates needing 100 to 135 kcal/kg per day. The nutritional needs of premature infants vary with gestational age and stage of growth, but typically these infants require higher amounts of energy to promote growth. Commercial formulas and human breast milk both provide approximately 20 kcal/oz. A full-term newborn can digest and absorb simple carbohydrates, proteins, and a moderate amount of emulsified fat. Infants need about 100 to 120 mL/kg/day of fluid because a large part of total body weight is water -The 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 -Infant formulas contain the approximate nutrient composition of human milk. Protein in the formula is typically whey, soy, cow’s milk base, casein hydrolysate, or elemental amino acids. Infants should not have regular cow’s milk during the first year of life. It is too concentrated for an infant’s kidneys to manage, increases the risk of milk-product allergies, and is a poor source of iron and vitamins C and E. Furthermore, children under 1 year of age should never ingest honey and corn syrup products because they are potential sources of the botulism toxin, which increases the risk of infant death. -Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine-motor skills of the hand and fingers parallels an infant’s interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein -The growth rate slows during toddler years (1–3 years). A toddler needs fewer kilocalories but an increased amount of protein in relation to body weight; consequently appetite often decreases at 18 months of age. Toddlers exhibit strong food preferences and become picky eaters. Small, frequent meals consisting of breakfast, lunch, and dinner with three interspersed high–nutrient-dense snacks help improve nutritional intake (Hockenberry et al., 2019). Calcium and phosphorus are important for healthy bone growth. -Toddlers who 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. Toddlers need to drink whole milk until the age of 2 years to make sure that there is adequate intake of fatty acids necessary for brain and neurological development. Avoid certain foods such as hot dogs, hard candy, nuts, grapes, raw vegetables, and popcorn because they present a choking hazard. Dietary requirements for preschoolers (3–5 years) are similar to those for toddlers. They consume slightly more than toddlers, and nutrient density is more important than quantity. -School-age children, 6 to 12 years old, grow at a slower and steadier rate, with a gradual decline in energy requirements per unit of body weight. Despite better appetites and more varied food intake, you need to assess school-age children’s diets carefully for adequate protein and vitamins A and C. They often fail to eat a proper breakfast and have unsupervised intake at school. Diets high in fat, sugar, and salt result from too-liberal intake of snack foods. Physical activity level decreases consistently, and consumption of high-calorie, readily available food increases, leading to an increase in childhood obesity 13. Lipids and Lipoproteins: -Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Fats are composed of triglycerides and fatty acids. 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. Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms, or unsaturated, in which an unequal number of hydrogen atoms are attached, and the carbon atoms attach to one another 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 also classified as essential or nonessential. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Linolenic acid and arachidonic acid, other types of unsaturated fatty acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. 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. -Lipoproteins: molecules made up of lipids (fatss) and proteins, they transport fats like cholesterol and triglycerides through the blooddstream, since fats cant move freely in water based enviormentss like blood. Lipoproteins have different types like LDL(badd cholesterol) and HDL(good cholesterol), which plays roles in managing cholesterol and cardiovascular health. -The combination of a simple protein with a nonprotein substance produces a complex protein such as lipoprotein, formed by a combination of a lipid and a simple protein. 14.Nasogastric Tube: A nasogastric (NG) tube is a pliable hollow tube that is inserted through the patient’s nasopharynx into the stomach. NG intubation has several purposes. There are two main categories of NG tubes: fine- or small-bore tubes and large-bore tubes. Small-bore tubes are frequently used for medication administration and enteral feedings. Large-bore tubes, 12-Fr and above, are usually used for gastric decompression or removal of gastric secretions. The Levin and Salem sump tubes are the most common for stomach decompression. The Levin tube is a single-lumen tube with holes near the tip. It is connected to a drainage bag or an intermittent suction device to drain stomach secretions. Types of Nasogastric Tubes/Purpose/Description: -Purpose : Decompression - Description: Removal of secretions and gaseous substances from gastrointestinal (GI) tract; prevention or relief of abdominal distention Type Of tube: Salem sump, Levin, Miller-Abbott -Purpose: Enteral feedings - Description: Instillation of liquid nutritional supplements or feedings into stomach or small intestine for patients with impaired swallowing Type of tube: Duo, Dobhoff, Levin -Purpose: Compression - Description:Internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhagee. Type of tube: Sengstaken-Blakemore -Purpose: Lavage Description: Irrigation of stomach in cases of active bleeding, poisoning, or gastric dilation Types of tube: Levin, Ewald, Salem sump How to Insert Nasogastric Tube: ​ Radiographic confirmation is the only reliable method to confirm tube position for initial placement and ongoing verification. ​ Auscultation of an air bolus alone is not considered a reliable or safe method for verifying enteral feeding tube position. ​ Do not reposition the NG tube of a patient who has undergone gastric surgery because that could rupture the suture line. ​ When feasible, investigate alternatives to NG placement (e.g., endoscopic or intraoperative placement, orogastric placement) in patients with basilar skull fracture or craniofacial injuries. ​ Use only new enteral syringes (greater than or equal to 20 mL) to administer medication through an enteral access device (EAD) or use oral syringes until enteral syringes with the new connector are available. ​ Remember to route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet). 1. Verify the health care provider’s orders. 2. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids. 3. Gather the necessary equipment and supplies. 4. Provide for the patient’s privacy. 5. Introduce yourself to the patient and family, if present. 6. Identify the patient using two identifiers, such as name and birth date or name and account number. 7. Explain the procedure to the patient and ensure that he or she agrees to treatment. Assess the patient’s cough and gag reflexes. 8. Position the patient upright in the high Fowler’s position, unless contraindicated. If the patient is comatose, raise the head of the bed, as tolerated, into the semi-Fowler’s position. If necessary, have NAP help with the positioning of confused or comatose patients. If the patient must lie supine, place him or her in the reverse Trendelenburg position. 9. Apply the pulse oximeter, and measure the patient’s vital signs. 10. Assess the patency of each nare. 11. To determine the length of the tube to be inserted, measure the distance from the tip of the nose to the earlobe, and then from the earlobe to the xiphoid process of the sternum. a. Adults: Added correct additional length for adult or child to ensure gastric placement. Mark the required tube length with tape or indelible ink. b. Children: Add half the distance from the xiphoid process to the umbilicus to this measurement to place the tube more distally in the stomach. Mark the required tube length with tape or indelible ink. 12. If the tube has a surface lubricant, dip it into a glass of room-temperature water to activate it. For other tubes, apply a water-soluble lubricant, according to the manufacturer’s instructions. 13. Apply clean gloves. 14. Prepare the NG or nasoenteric tube for intubation: a. Using a 30-mL to 60-mL catheter-tip syringe, inject 10 mL of water into the tube. If you are using a stylet, make certain it is securely positioned within the tube. 15. Explain the procedure to the patient, and then gently insert the tube through one nostril to the back of the throat (posterior nasopharynx), aiming back and down toward the ear. The patient may gag. 16. As the tube passes the nasopharynx, have the patient bend his or her head toward the chest. 17. Advance the tube along the floor of the nasal passage, aiming down toward the patient’s ear. If resistance is felt, pull the tube tip back slightly, angle it more downward to find the opening to the nasopharynx, and then advance the tube. If resistance continues, try to rotate the tube and then advance it. If resistance persists, withdraw the tube, allow the patient to rest, bend the tube slightly so that it will angle down when inserted, then lubricate the tube again, and insert it into the other naris. 18. If drinking water is not contraindicated and the patient prefers, provide small sips of water along with encouragement to swallow as the tube is inserted and advanced. Advance the tube as the patient swallows. With or without water, emphasize that the patient needs to mouth breathe and swallow throughout the procedure. 19. When the tip of the tube is approximately 25 cm to 30 cm (10 inches to 12 inches), assess for air coming out of the tubing. If the tube entered the trachea instead of the esophagus, air exchange may be heard. If air is present, withdraw the tube and start again. If there is no air, continue to advance the tube to the distance marker. 20. Check the tube position at the back of the patient’s throat with a penlight and tongue blade. Ensure the tube is not coiled in the posterior pharynx. 21. Anchor the tube to the patient’s cheek with tape. 22. Verify placement of the nasogastric tube per the organization’s practice. See the video skill “Managing a Nasogastric Tube.” 23. Clamp the tube. 24. Once the placement of the NG tube has been verified, secure it to the patient’s face. Anchor the tube to the patient’s nose, avoiding pressure on the nares. Mark the exit site on the tube with tape or indelible ink. Select one of the following options for anchoring: a. Tape: i. Optional: Apply a tincture of benzoin or other skin adhesive to the tip of the patient’s nose. It should feel tacky. ii. Remove your gloves. Cut a piece of hypo-allergenic tape 10 cm (4 inches) long, or prepare a membrane dressing or other securing device. Make a horizontal slit down the middle of one end of the tape creating two split ends. Fold just the ends of the split sections back to create tabs. iii. Securely apply the other end of the tape to the nose, leaving split ends free. iv. Carefully wrap the two split ends of tape around the tube. v. Apply a second piece of tape across the bridge of the nose perpendicular to the first as reinforcement. b. Membrane dressing:  i. Optional: Apply a tincture of benzoin or another skin protectant to the patient’s cheek and to the area of the tube to be secured. ii. Place the tube against the patient’s cheek, and secure it with the membrane dressing, out of the patient’s line of vision. c. Tube fixation device: i. Optional: Apply the wide end of the patch to the bridge of the patient’s nose. ii. Slip the connector around the feeding tube where it exits the nose. 25. Label the tubing at a site close to the patient and at a site close to the source when there are different access sites or several bags. 26. Fasten the end of the NG tube to the patient’s gown using a clip or a piece of tape. Do not use safety pins to pin the tube to the gown. 27. Help the patient into a comfortable position. 28. Obtain a chest or abdominal x-ray to verify placement. 29. Apply clean gloves, and administer oral hygiene. Clean the tubing at the nostril with a washcloth dampened in mild soap and water. 30. Dispose of used supplies. 31. Remove and dispose of used gloves. Perform hand hygiene. 32. Help the patient into a comfortable position, and place toiletries and personal items within reach. 33. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 34. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. NG tubes are used for the removal of gastric contents or the delivery of nutrition, water, and medications. These tubes are frequently placed by nurses at the bedside without direct visualization (blindly) of the gastrointestinal (GI) tract. The most common types of tubes used for stomach decompression include the Levin tube and the Salem Sump tube. A Levin tube is a single-lumen tube with holes near the tip. The tube is connected to a drainage bag or an intermittent suction device to drain stomach secretions. A Salem Sump tube has two lumens: the main lumen for removal of gastric contents and the secondary lumen, which provides an air vent, preventing suctioning of gastric mucosa into holes at the distal tip of the tube. A blue pigtail is the air vent that connects with the second lumen. When the sump tube’s main lumen is connected to low constant suction, the air vent permits free drainage of secretions through the main lumen. The air vent should never be clamped, connected to suction, or used for irrigation. An NG tube is inserted using clean technique. For patient comfort, the nurse should select the tube with the smallest lumen that is effective for the intended use. When a patient is unable to take food safely by mouth, a Levin or Salem Sump NG tube may be used to initiate enteral feedings; however, the softer, small-bore feeding tube is generally preferred. In some cases, an NG tube is left in place for gastric decompression while a small-bore feeding tube is inserted to deliver enteral feeding into the small bowel. Supportive nursing care includes changing soiled tape or securement devices, ensuring that the tube has not become dislodged or changed position, making sure that the tube is functioning adequately, keeping the naris lubricated and clean, and providing frequent mouth care to minimize drying of the oral mucosa. If the patient has undergone gastric surgery, do not reposition the NG tube because that could rupture the suture line. The selection of the type of water is determined by the task and immunocompromised state of the patient. Distribution (tap) water may pose a risk to the patient depending on the degree of chemical or pathogenic contamination. Contaminated water has been associated with outbreaks of infections. Use purified or sterile water for flushing and medication preparation. Use sterile water for reconstituting powdered formula and for all procedures that involve immunocompromised patients.2 Each organization should establish practices regarding the type of water to use based on the status of their drinking water supply. 15. Assessment of Flatus: A patient reports bloating andd flatulence. Basedd on this repot what ssigns and symptoms would the nurse anticipate to find during the assessment? Abdominal tensenesss on palpation, Patient reporting excesss gas through rectum, Patient reporting a feeling of fullnesss. -Flatus/Flatulence: by-product of digestion; excessive gas is expelled through the rectum/anus -Causes:Action of bacteria on chyme passing through the large intestine or swallowing air -Contributing factors making patients at risk: *Certain foods, such as cabbage, cauliflower, beans, broccoli, bran, and onions *Abdominal surgery *Lactose intolerance Patient Observation Cues: *Passing gas *Abdominal distention, pressure, tenseness *Sharp abdominal pain, cramping, rectal pain *Bloating *Embarrassment As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends. Flatulence is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus). However, flatulence causes abdominal distention and severe, sharp pain if intestinal motility is reduced because of opiates, general anesthetics, abdominal surgery, or immobilization. Assessment for bowel elimination patterns and alterations in bowel elimination includes a nursing history, physical assessment of the abdomen, inspection of fecal characteristics, and review of relevant test results. In addition, determine a patient’s medical history, pattern and types of fluid and food intake, mobility, chewing ability, medications, recent illnesses and/or stressors, and environmental situation. 16. Subcutaneous Injections Subcutaneous (SQ or Sub-Q) injection means the injection is given in the fatty tissue, just under the skin. An SQ injection is the best way to give yourself certain medicines, including: Insulin, Blood-thinners and Fertility drugs. Subcutaneous injection - 45-90 degres. 3-5 ml syringe. Small doses 1-2 mL Injection sites: Upper arms. At least 3 inches (7.5 centimeters) below your shoulder and 3 inches (7.5 centimeters) above your elbow, on the side or back. Outer side of upper thighs. Belly area. Below your ribs and above your hip bones, at least 2 inches (5 centimeters) away from your belly button Subcutaneous injections involve depositing medication into the loose connective tissue underlying the dermis. Because subcutaneous tissue does not contain as many blood vessels as muscles, medications are absorbed more slowly than with intramuscular (IM) injections. Physical exercise or application of hot or cold compresses influences the rate of drug absorption by altering local blood flow to tissues. Any condition that impairs blood flow is a contraindication for subcutaneous injections. You give subcutaneous medications in small doses of less than 2 mL that are isotonic, nonirritating, nonviscous, and water soluble. It is suggested that volumes greater than 2 mL may be associated with increased pain at the site, leakage of the medication, or other adverse events at the site. Examples of subcutaneous medications include insulin, heparin, and some vaccinations. Because subcutaneous tissue contains pain receptors, the patient often experiences some discomfort. The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, the anterior aspects of the thighs, and the buttocks. These areas are easily accessible and are large enough to permit rotating of multiple injections..Subcutaneous injections involve depositing medication into the loose connective tissue underlying the dermis. Because subcutaneous tissue does not contain as many blood vessels as muscles, medications are absorbed more slowly than with intramuscular (IM) injections. Physical exercise or application of hot or cold compresses influences the rate of drug absorption by altering local blood flow to tissues. Any condition that impairs blood flow is a contraindication for subcutaneous injections. You give subcutaneous medications in small doses of less than 2 mL that are isotonic, nonirritating, nonviscous, and water soluble. It is suggested that volumes greater than 2 mL may be associated with increased pain at the site, leakage of the medication, or other adverse events at the site. Examples of subcutaneous medications include insulin, heparin, and some vaccinations. Because subcutaneous tissue contains pain receptors, the patient often experiences some discomfort. The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, the anterior aspects of the thighs, and the buttocks. These areas are easily accessible and are large enough to permit rotating of multiple injections Subcutaneous injection Syringe and Needle: The gauge of the needle may vary. Typically, a 22- to 25-G needle can be used. Children ages 3 to 18 years may require a smaller gauge and shorter needl. When using the no-pinch method, a 4- or 5-mm needle (less than ¼ inch) on an injection pen or a 6-mm needle on a syringe can help reduce the risk of needlestick injury. 17.Rapid Acting Insulin Rapid-acting insulin is a type of insulin that starts working quickly to lower blood glucose levels, usually taken before meals. Rapid Insulin: Types of Rapid Insulin and Brand Names: Humalog or Lispro - Onset: