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High gastric residual exceeds with tube feeding

Notify health care provider to determine if you need to hold feedings; Maintain patient in semi-Fowler's position (at least 30 degrees); Reassess residual volume 1 hour

complications with feeding tubes

The feeding tube becomes clogged; Patient develops nausea and vomiting; High gastric residual exceeds; hyperglycemia; Patient develops diarrhea three times or more in 24 hours; Aspiration of formula; Skin Irritation around tubing site

nasogastric tube

tube inserted through the nose into the stomach

impaction

unable to pass stool

Symptoms of lower UTI

urgency, burning, itching cloudy, foul smelling; in older adults: confusion

Sengstaken-Blakemore

used when tamponade is needed; do not aspirate or suction

Kidneys

remove waste from the blood to form urine

bladder

reservoir for urine until the urge to urinate develops

plan

set goals of care and desired outcomes and identify appropriate nursing actions

example of psychomotor

showing how they use insulin

Tap water enemas

stimulates evacuation, never repeated due to potential water toxicity

NG and NJ tubes upper digestion located in

stomach

esophagus

transports food to stomach

ileostomy

no colon; liquid stools; malnutrition and dehydration are likely

Decreasing drinking 2 hours before bedtime decreases risk of

nocturia

Pharynx

swallows

motivation to learn

the patient's desire or willingness to learn

Urethra

urine travels from the bladder and exits through the urethral meatus

A nurse is preparing to instill and enteral feeding to a client with a NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure?

verify the placement of the tube

when should teaching begin

on admission

stoma should be

red

Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care?

registered nurse

Descending Colostomy

right and left side of colon left; formed consistency stools

Ilius or bowel abstruction if you can hear on

right side but not left

ascending colostomy

right side of colon left; liquid stools

learning environment

safe environment that promotes learning

Normal saline enemas

safest due to equal osmotic pressure, volume stimulates peristalsis

If patient received an enema and then there is blood in their stool

this is emergent -> must bring to attention of physician

Orogastric

through the mouth and stomach

Nasointestinal

through the nose to intestine

ecoli

(from stool) most common form of UTI

Normal bowel sounds every

5-15 sec

Verifying Placement of Nasogastric Tubes

A pH between 0 to 4 is a good indication of gastric placement; chest xray

For a client with difficulty swallowing, the nurse should crush which medication?

Acetaminophen extra strength

Coping with impaired functions

Adaptive measures for patients with permanent health alterations

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include?

Administering water after the feeding is completed

urine: odor

Ammonia in nature; Smell can change on what you eat or medication you take

UTIs

Bacteria in urinary tract; Can result from catheterization or procedure (if from catheter it is called catheter associated UTI); CAUTI

Double-barrel colostomy

Bowel is surgically cut and both ends are brought through the abdomen

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what?

Cause the device to pull away from the skin.

How can a nurse best evaluate the effectiveness of communication with a client?

Client feedback

invasive urinary examinations

Endoscopy-cystoscopy; Arteriogram (angiogram)

symptoms of upper UTI

Fever, chills, diaphoresis, flank pain, potential hematuria

assess

Gather information about the patient's condition

A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. Which type of stool should the nurse expect?

Moist and formed

Which is an abnormal finding of the urinary system?

Pain in the flank region upon hitting

which ng tubes can suction

Salem-sump and Levin

Data Documentation

The last component of a complete assessment; Legal and professional responsibility; Requires accurate and approved terminology and abbreviations

role play

affective

examples of restoration of health

anatomy and physiology of body system, medications, nutrition, diagnostic examinations, surgery

digestion ends in the

anus after you expel fecal material

Loose and liquid stools are associated with a colostomy that involves the

ascending colon

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?

assessment

hematuria

blood in the urine

pre-renal

decreased blood flow to and through kidneys

parenteral feeding

delivery of nutrients directly to the bloodstream

examples of coping with impaired functions

home care, self-care, physical therapy, occupational therapy, speech therapy, prevention of complications, and environmental alterations

r/t

how did it become

Aeb

what we are observing

Hyperactive bowel sounds

when you hear your stomach grumbling aloud

care of patient with urinary diversions

Never put foley bag on floor; Foley bag should never be above the bladder; Inspect the client's stoma regularly, keep it clean and dry;

Soapsuds enemas

Pure castile soap in tap water or normal saline, acts as an irritant to promote peristalsis

PEG tube

percutaneous endoscopic gastrostomy tube - feeding tube

implement

perform the nursing actions identified in planning

A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes

psychomotor learning

large intestine

reabsorbs some water, vitamins, and ions; forms and stores feces; primary goal elimination of waste

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply.

"I should drink at least six glasses of water every day."; "I can include bran muffins in my breakfast daily."; "I will walk every day as part of my exercise regimen."

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse "why the water is necessary." Which of the following is an appropriate response by the nurse?

"Water helps clear the tube so it doesn't get clogged."

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?

"Wear cotton underpants."

The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen?

"With the enclosed towelettes, wipe your labia from front to back before collecting the specimen."

concept mapping

A visual representation that allows nurses to graphically illustrate the connections between a patient's health problems; Allows nurses to obtain a holistic perspective of health care needs

Factors that influence Bowel Elimination

Age; Diet; Fluid intake; Physical activity; Psychological; pregnancy; Surgery and anesthesia; medications

Continuous tube feeding

Allow formula to be admin at lower rates, usually 1.5 ml/min over a longer time usually 12-24 hours. delivered by gravity flow system or an electronic feeding pump; patients bed at 30-35 degrees so they dont aspirate

urinary retention

An accumulation of urine due to the inability of the bladder to empty; Bladder scan to check PVR- Less than 50cc is normal in adults

Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed?

Aspirate for a residual volume

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?

Aspiration pneumonia

Care of Ostomies

Assessing the ostomy; An ostomy requires a pouch to collect fecal material; Maintenance of skin integrity; Nutritional considerations; Fluid intake; Psychological Considerations

A nurse is caring for a client in a long term care facility who is receiving enteral feedings via an NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding?

Auscultate bowel sounds; Assist the client to an upright position; Test the pH of the gastric aspirate

Medication Administration in a feeding tube

Begin and end with a 30 mL tap water flush; Flush -> Med -> Flush; Administer one medication at a time and flush in between each medication

A client has a surgically created colostomy. What is the most effective nursing intervention initially to help the client accept the colostomy?

Begin to teach self-care of the colostomy by introducing equipment.

Noninvasive urinary examinations

Bladder scanner; Abdominal x-ray (KUB); CT scan abdomen; IVP (intravenous pyelogram); Renal US

Guaiac Fecal Occult Blood tests

Checking for blood in stool bcuz it may be indicative of a GI bleed; if it turns blue its positive; if test is positive Xray or CT if they don't show anything then colonoscopy and relay to physician immediately

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

Checking for residual stomach contents

affective

Deals with expression of feelings and acceptance of attitudes, opinions, or values

Specific diseases that affect urination

Diabetes mellitus, multiple sclerosis, BPH, Alzheimer's disease, Parkinson's disease, and degenerative joint disease.

urinary diversions

Diversion of urine to external source

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus (gas) from the stoma. What is the nurses initial action?

Document assessment

A client has surgery for an abdominal cholecystectomy and returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first?

Ensure that all tubes are attached to collection devices

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention?

Evaluating the client's ability to care for the ileostomy

A client recently had surgery to create and ileostomy. The nurse assesses the client 3 days post-operative for which most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

Fresh Fruit and whole wheat toast

restoration of health

Helping injured or ill patients regain their previous level of functioning - Teaching of family

A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings?

Hypotension; Fever; Poor skin turgor

diagnose

Identify the patient's problems

cognitive

Includes all intellectual behaviors and requires thinking

bedside commode

Needs to be clean tub, these are for collection

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?

Institute measures to prevent constipation.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error?

Interpreting

urinary incontinence

Involuntary leakage of urine; Cognitive or behavioral decline; Kegel exercise to help fix it; women more likely; likely when pregnant; in men BPH can cause this; mobility, stroke, and medications may cause this; not a normal part of aging

psychomotor

Involves acquiring skills that require integration of mental and muscular activity

pyelonephritis

Kidney infection; UTI going long periods of time without being treated

Which nursing action is a part of the evaluation phase of the critical thinking process?

Looking at all the situations objectively; Using several criteria to determine the effectiveness of a nursing intervention

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?

Lower the enema fluid container bcuz it will more slowly go in; Stop it if cramping doesn't get better after lowering the enema fluid container

Hyperglycemia with tube feeding

Measure finger-stick glucose every 6 hours, until maximum administration rate is attained and tolerated for 24 hours

insertion of nasogastric tube

Measure from tip of nose to ear and then down to xyphoid process document in cm

different types of enteral feeding

Orogastric; Nasogastric; Nasointestinal; Gastrostomy; Jejunostomy

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus

A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report?

Projectile vomiting

Skin Irritation around tubing site with tube feeding

Provide a skin barrier for any drainage at the site; Monitor the tube's placement

health promotion and illness prevention

Providing information to allow patients access to healthier lifestyle

End colostomy

Proximal end forms stoma and distal end is removed or sewn closed; Patient can have it reversed if there is enough intestine left

A healthcare provider prescribes intermittent nasogastric tube feedings to supplement a client's oral nutritional intake. Which hazard associated with a nasogastric tube feeding will be reduced if the nurse administers this feeding over 30 to 60 minutes?

Regurgitation

After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube to negative pressure. What does the nurse explain is the purpose of this tube?

Removing fluids and gas from the upper gastrointestinal tract

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?

Rise of formula in the tube

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?

Sequence of steps used to meet the client's needs

A nurse is caring for a client who is receiving continuous tube feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feedings?

Stop the feeding

Can hinder bowel movements

Surgery; Stress; immobility

Loop colostomy

Temporary in the transverse colon; To give body a break; Not enough bowel

During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which reply by the nurse is best?

To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours."

urine: clarity

Transparent unless pathology is present

Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter?

Tubing luer-lok port

most common health care-acquired infections

UTI

Indications for Use of Bladder Scanner

Urinary frequency; Absent or decreased urine output; Bladder distention; Inability to void; Establishing intermittent catheterization schedule

The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care?

Urinary tract infection

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen?

Urinate small amount, stop flow, fill half of cup

Intermittent urethral catheters

Used to drain the bladder for shorter periods (5 to 10 minutes)

indwelling urethral catheter

Used when a catheter is to remain in place for continuous drainage; Designed using an inflated balloon so that it does not slip out of the bladder; Should not stay longer than necessary

Bowel Assessment

Usual elimination pattern; Description of stool; Changes in appetite; Diet hx; Intake; Hx of surgeries; Medication hx

removal of an indwelling catheter

Want to remove catheter ASAP - Nurse sensitive indicator; Removal of the catheter should not cause any patient discomfort; Increase fluid intake; Monitor voiding

Fleet

a commercially prepared hypertonic enema

Jejunostomy

a tube that is placed surgically or by laparoscopy through the abdominal wall into the jejunum for long-term nutritional support; long term

Problem-oriented approach

honing into the problem

Pancreas

hormones regulate blood glucose levels; bicarbonate neutralize stomach acid

Which step in the nursing process would involve promoting a safe environment for the client?

implementation

Dobhoff

is mostly used for enteral feedings in patients who are at increased risk for aspiration, such as those with absent or diminished gag reflex or severe gastroesophageal reflux disease (GERD); do not aspirate or suction

Post-void residual (PVR)

is the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization

Hypoactive bowel sounds

longer than 15 sec

Hypertonic solutions enemas

low volume, good for clients that cannot tolerate high-volume enemas; Good for smaller patients

Oil retention enemas

lubricates the rectum and colon for easier passage of stool

Transverse Colostomy

middle of colon missing; liquid stool

digestion begins in the

mouth with breakdown of food

levin

must be connected to suction to low suction to prevent gastric irritation; also drains fluid and gas from stomach; can suction

24 hour urine collection

must be kept on ice or in frig

If you can't hear bowel sounds

must notify physician

Salem-Sump

nasogastric small vent tube within a large suction tube for decompressing the stomach; most common; can suction

sodium affects

nervous system

sputum

not spit, more hearty than spit

Indications for Enteral feeding

Critical illness/trauma; Neurological and muscular disorders; GI disorders; Muscular disorders; Cancer that affects head, neck, or GI tract; Inadequate oral intake

demonstration

psychomotor

Patient develops diarrhea three times or more in 24 hours: indicates possible intolerance with tube feeding

notify health care provider; one of the biggest side effects of tube feeding

anus

opening for elimination of feces

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

planning

different types of ng tubes

salem-sump, duo, dobhoff, levin, Sengstaken-Blakemore

salivary glands

saliva moistens and lubricates food, amylase digests carbohydrates

stomach

stores and churns food; HCl activates enzymes, breaks up food, kills germs; mucus protects stomach wall; limited absorption

The best indicator if whether or not a patient is tolerating tube feeding is

the amount of residual

Fecal Incontinence

the inability to control the passage of feces and gas through the anus; if someone is super sick or cognitive deficient

Palpate bowel sounds

right lower, right upper, left upper, left lower

steps for collecting urine culture from indwelling catheter

1.Kink off tubing that goes into bag 2.After you see urine is backed up you wipe port with alcohol wipe 3.Empty 10cc of urine into collection typically you need 30cc 4.Rewipe the port with alcohol wipe

If patient is suspected to have TB you need to

collect 3 samples of sputum

small intestine

completes digestion; mucus protects gut wall; absorbs nutrients, most water; Primary location of nutrients and water absorbtion

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client?

Electrolyte imbalances

enemas

Never do enemas more than once; Need order for enemas; patients should lie on side

Which features distinguish nursing diagnoses from medical diagnoses?

Nursing diagnoses involve the client when possible; nursing diagnoses involve the sorting of health problems within the nursing domain; Nursing diagnoses involve clinical judgment about the client's response to health problems.

enteral feeding

Nutrients supplied to the gastrointestinal tract orally or by feeding tube.

A client has a nasogastric feeding tube inserted, and the healthcare provider prescribes the feeding to be instituted immediately. What should the nurse do first?

Obtain an x-ray to verify that the tube is in the stomach.

A nurse obtains daily stool specimens for a client with chronic bowel inflammation. What does the nurse determine is the reason these stool examinations were prescribed?

Occult blood

Aspiration of formula - into lungs instead of stomach with tube feeding

Stop the feeding; Turn client to the side; Suction the airway; Provide O2 if indicated; Monitor for elevated temp; Monitor for decreased O2 or increased respiratory rate; Auscultate breath sounds; Notify the provider; Obtain a chest x-ray

Bowel Diversions

Temporary or permanent artificial opening in the abdominal wall

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools.

who are at the greatest risk for low health literacy

The elderly, minorities, immigrants, persons of low income, and people with chronic mental and/or physical health conditions

A school nurse is asked to develop a program for teachers about infection control, especially focusing on hand washing technique. What is the most effective way for the nurse to evaluate what the teachers have learned?

Watch the teachers demonstrate infection control techniques.

A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client?

Weight gain

if a Patient develops nausea and vomiting on a feeding tube

Withhold tube feeding, and notify physician or health care provider

liver

breaks down and builds up many biological molecules; stores vitamins and iron; destroys old blood cells; destroys poisons; produces bile to aid digestion

mouth

breaks up food particles, assists in producing spoken language

Ileostomy or colonoscopy

can possibly be reversed

other enemas

carminative and Kayexalate (can also be used if patients have higher levels of potassium)

clean catch

clean self start to urinate and then catch it in the middle bcuz women have short urethras so more bacteria will be in the beginning so the midstream will come from the bladder

discussion

cognitive

ability to learn

depends on physical and cognitive abilities, developmental level, physical wellness, thought processes

evaluate

determine if goals and expected outcomes are achieved

Gastrostomy

directly into the stomach

renal

disease condition of the renal tissue

duo ng tube

do not aspirate or suction

examples of Maintenance and promotion of health and illness prevention

first aid, smoking/alcohol/substance abuse, stress management, nutrition, exercise, health screenings

sigmoid colostomy

formed stool; full colon besides rectum

If patient leaves sample of urine on back of toilet and its been sitting their for more than 30 min

get rid of it and get a new sample

Common Bowel Elimination Problems

constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids

intermittent or bolus feeding

gradual instillation of liquid nourishment four to six times a day

post-renal

obstruction in the lower urinary tract that prevents urine flow from the kidneys

gallbladder

stores and concentrates bile

rectum

stores and expels feces

Hemorrhoids

swollen, twisted, varicose veins in the rectal region; usually larger people or women who just gave birth

if stoma is blue or purple

that is emergent; call physician immediately

if patient has a urinary catheter

they must void before being discharged

nasogastric

through the nose to the stomach

Ureters

transport urine from the kidneys to the bladder

Never collect urine from

urinary catheter unless it is a new bag

Common urinary problems

urinary retention, UTIs, urinary incontinence, urinary diversions, hematuria, pyelonephritis

Nursing dx

what is diagnosed


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