EXAM 3 1430
Nursing Interventions For The Culturally Diverse
Primary Prevention - Maintain Antecedents Therapeutic Diets - Regular - Soft - Mechanical - Clear liquids - Full liquids Enteral Nutrition Parenteral Nutrition Primary Prevention - Disease Dietary Recommendations - No more than 35% of calories should be from fat - Unsaturated fats are more healthy than saturated fats The recommended daily calorie amount is age and activity dependent - Excessive calorie intake is converted to fat for storage Secondary Prevention Mini-Nutritional Assessment Tool Regular weight/BMI screening School-based screenings Food journaling Dietician referral Annual visit to PCP
Discuss patient teaching points for weight control.
Balanced Diet: Emphasize importance of a balanced diet that includes a variety of fruits, vegetables, whole grains, lean proteins, and healthy fats. Portion Control: Teach patients about appropriate portion sizes and the importance of mindful eating to prevent overeating. Reduce calorie intake by 500 calories/day. Regular Physical Activity: Encourage regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise per week, such as brisk walking, cycling, or swimming. Behavioral Changes: Discuss behavioral strategies such as keeping a food diary, setting realistic goals, and identifying triggers for overeating. Limit Sugary Beverages and Snacks: Advise reducing intake of sugary drinks and snacks, which contribute excess calories and can lead to weight gain. Meal Planning: Teach patients how to plan meals and snacks ahead of time to avoid impulsive food choices and overeating. Stress Management: Discuss the importance of stress management techniques such as relaxation exercises, mindfulness, or engaging in enjoyable activities to prevent emotional eating. Sleep Hygiene: Highlight the role of adequate sleep in weight management, as poor sleep quality can disrupt hunger hormones and lead to weight gain. Seeking Support: Encourage patients to seek support from healthcare professionals, registered dietitians, or support groups for guidance, accountability, and motivation.
Maturation/Remodeling Phase
Begins about 3 weeks after injury and may continue for months or years. Collagen is remodeled to strengthen the wound and make it more like adjacent tissue. Scar tissue forms, becoming a flat, thin line over time. Scar tissue is less elastic and weaker (70-80% strength) than normal tissue. Wounds healing by secondary intention take longer to remodel and form a scar smaller than the original wound. Scars over joints or body structures may limit movement and cause disability.
Identify risk factors for development of iron deficiency anemia.
Blood Loss Major causes - Inadequate iron intake - Chronic hemorrhage - Iron malabsorption - High iron demands Sociocultural factors - Diet intake of red meat, meat in general, beans and greens Availability of iron-fortified foods
Discuss medical/surgical management of patients with dysphagia.
Botox injections Thickening agents Diet adjustments - Mechanical soft PEG Tube placement
Discuss the pathophysiology of impetigo.
Common skin infection usually caused bystreptococcus orstaphylococcus bacteria - Most common in children - Occurs when a break in the skin allows bacteria to enter causing inflammation and infection - If untreated can cause glomerulonephritis
Describe the complications of iron deficiency anemia.
Limited activity/independence due to fatigue Heart failure Pregnancy complications Restless leg syndrome
MALNUTRITION
MALNUTRITION
Describe the complications of obesity.
Many associated conditions, few causally linked Social stigma - "Healthism" (the excessive preoccupation with personal health and the pursuit of a "perfect" or idealized state of health) Fatphobia and anti-fat bias in health care Disordered eating High cholesterol
Identify the risk factors for pressure ulcers.
Mobility and activity limitations are required conditions for pressure injury development. In the absence of mobility issues, the risk factors listed here should not result in the formation of a pressure injury. Inadequate nutrition and dehydration, skin moisture, altered mental status, and advanced age Additional: Poor skin hygiene Diabetes mellitus Diminished sensory perception (pain awareness) Fractures History of corticosteroid therapy General poor health Immobility secondary to paralysis or injury/illness Immunosuppression Incontinence—urinary or fecal Increased body temperature Microvascular dysfunction Multiple organ dysfunction syndrome (MODS) Previous pressure injuries Poor nutrition and hydration Sedation or coma Significant obesity or thinness Smoking Surgery Terminal illness/end-of-life/dying process
NUTRITION
NUTRITION
Identify changes in laboratory tests and diagnostic results in iron deficiency anemia.
The definitive method of establishing the diagnosis of iron deficiency anemia is bone marrow aspiration - Aspirate is stained to detect iron, which is at a low level or even absent. - After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls - As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases - Low serum iron level and an elevated TIBC - Elevated ferritin level Hemoglobin, hematocrit Mean corpuscular volume Mean corpuscular hemoglobin concentration RBC indices Serum ferritin Serum transferrin
Subcutaneous Tissue
The innermost layer of the skin, located beneath the dermis. Composed of adipose (fat) tissue and connective tissue. Functions as an insulator, helping to regulate body temperature. Provides cushioning and protection to underlying structures like muscles and bones. Contains larger blood vessels and nerves that supply the skin and underlying tissues.
Dermis
The middle layer of the skin, located beneath the epidermis. Made up of connective tissue, including collagen and elastin fibers, fibroblasts, blood vessels, nerves, sweat glands, and hair follicles. Provides structural support and elasticity to the skin. Contains sensory receptors for touch, pressure, pain, and temperature. Responsible for regulating temperature and blood flow to the skin.
Discuss potential complications associated with decubitus ulcers.
Pain, Fluid and Electrolyte Imbalance, Psychological Effects Signs of Infection: - Wound is swollen - Wound is deep red in color - Wound feels hot on palpation - Drainage is increased and possibly purulent - Foul odor may be noted - Wound edges may be separated, with dehiscence present Type of Infection: - Soft tissue - Osteomyelitis
Stage 2 Pressure Injury
Partial-Thickness Skin Loss With Exposed Dermis Characteristics: Loss of the epidermis and possibly part of the dermis, creating a shallow open ulcer or blister. May present as an abrasion, blister, or shallow crater. Wound bed is pink or red and moist; may be painful.
Discuss age-related changes in tissue integrity.
Pediatric: Infants have thin, weak skin Geriatric: Skin becomes more fragile Delayed wound healing Decrease in vitamin D production Susceptible to dry skin Decrease in sensory perception Greater risk of hypothermia or hyperthemia Elasticity decreases Decreased perspiration
Deep Tissue Pressure Injury
Persistent Nonblanchable Deep Red, Maroon, or Purple Discoloration Characteristics: Discoloration may be intact or may progress to ulceration over time. Typically occurs over a bony prominence. May involve underlying tissue damage, such as necrosis or hematoma formation, without initially breaking the skin. Discoloration may be accompanied by pain, firmness, or temperature difference compared to surrounding tissue.
Discuss local conditions that increase risk for impaired tissue integrity.
Pressure Desiccation (dehydration) Maceration (overhydration) Trauma Edema Infection Excessive bleeding Necrosis (death of tissue) Presence of biofilm (thick grouping of microorganisms)
Identify essential teaching points for treating and preventing the spread of impetigo.
Prevent the spread of the infection to other family members/contacts - Hand washing - Do not share personal care items like towels, wash clothes Keep skin clean and dry Clean minor cuts and scrapes with soap and water
Parenteral Nutrition
Description: Parenteral nutrition involves delivering nutrients intravenously, bypassing the gastrointestinal tract. Therapeutic Use: Indicated for patients who cannot tolerate enteral feeding or have non-functioning gastrointestinal tracts, such as those with severe malabsorption, intestinal obstruction, or critical illness. It provides essential nutrients and fluids to sustain life and promote healing. Amino acid solutions Dextrose solutions Lipid emulsions Multivitamin and mineral additives
Describe the attributes of functional tissue integrity.
Integument - Structurally Intact and Functioning Normal Healing Process
Iron Deficiency Anemia
Iron Deficiency Anemia
Diagnostic Tests To Assess Nutritional Status
KUB (Kidneys, Ureters, Bladder) X-ray: Radiographic examination of the urinary system. Used to detect stones, tumors, or abnormalities. Abdominal Ultrasound: Diagnostic imaging using sound waves. Assesses liver, gallbladder, pancreas, kidneys, and abdominal structures. Swallow Study (Videofluoroscopic Swallow Study/Modified Barium Swallow Study): Evaluates swallowing function in real-time using barium-coated foods and liquids. Tracks movement through mouth and throat with X-rays. EGD (Esophagogastroduodenoscopy): Flexible endoscope examines esophagus, stomach, and duodenum. Diagnoses and treats ulcers, inflammation, tumors, etc. ERCP (Endoscopic Retrograde Cholangiopancreatography): Specialized endoscopic procedure for bile ducts, pancreatic duct, gallbladder. Injects contrast dye for imaging. Diagnoses and treats gallstones, obstructions, tumors.
Laboratory Tests To Assess Nutritional Status
Laboratory Tests Hemoglobin (12-18 g/dL) Hematocrit (40-50%) Albumin (3.5-5.5 g/dL) Prealbumin (23-43 mg/dL) Transferrin (240-480 mg/dL) Blood urea nitrogen (17-18mg/dL) Creatinine (0.4-1.5 mg/dL) Stool studies Urinalysis
Describe the signs and symptoms of malnutrition.
Lack of appetite or interest in food or drink Tiredness and irritability Inability to concentrate Always feeling cold Loss of fat, muscle mass, and body tissue Higher risk of getting sick and taking longer to heal Longer healing time for wounds
Inflammatory Phase
Lasts about 2 to 3 days following hemostasis. White blood cells, including leukocytes and macrophages, migrate to the wound to remove debris and fight infection. Macrophages release growth factors essential for tissue regeneration and attract fibroblasts. Increased capillary permeability leads to exudate formation and acute inflammation. Systemic response includes mild fever, leukocytosis, and malaise.
Proliferation/Repair Phase
Lasts several weeks and involves tissue regeneration. Fibroblasts synthesize collagen, form fibrin, and promote blood vessel formation. Granulation tissue forms, providing a foundation for scar tissue. Epidermal cells seal the wound, and collagen synthesis peaks in 5 to 7 days. Wound gradually lightens in color as inflammation subsides. Adequate nutrition, oxygenation, and prevention of strain are crucial considerations.
Epidermis
The outermost layer of the skin. Composed of stratified squamous epithelium. Contains several layers: the basal layer (where new cells are produced), the spinous layer, the granular layer, and the outermost layer, the stratum corneum (composed of dead cells). Provides a protective barrier against environmental factors, pathogens, and water loss. Also contains melanocytes, which produce melanin, the pigment responsible for skin color.
Identify the risk factors for development or exacerbation of psoriasis.
Triggered by stress, trauma, infections Genetics: - Family history of psoriasis increases risk. Immune System Dysfunction: - Autoimmune response targets healthy skin cells. Environmental Triggers: - Stress, infections, skin trauma, medications, smoking, and alcohol can trigger or exacerbate psoriasis. Obesity: - Strong association with psoriasis, linked to inflammation and metabolic syndrome. Endocrine Factors: - Hormonal changes during puberty, pregnancy, or menopause can influence symptoms. Lifestyle Factors: - Unhealthy habits like poor diet, lack of exercise, and inadequate sleep may worsen psoriasis. Comorbidities: - Associated with conditions like psoriatic arthritis, cardiovascular disease, metabolic syndrome, and inflammatory bowel disease. Multidisciplinary approach needed to manage psoriasis effectively and address associated risk factors.
Explain the pathophysiology of obesity.
Types Hypertrophic: adipose cells increased in SIZE Hypercellular: adipose cells increased in NUMBER Adipose tissue is active in hormonal regulation and inflammation processes. Highly complex, multifactorial - Hereditary component - Co-occurring with other conditions (Hormonal imbalance, eating disorders)
Explain the pathophysiology of malnutrition.
A lack of intake of nutrients due to - Inadequate calorie consumption - Inadequate intake of vitamins minerals Root cause may be - Problems with digestion, absorption, or distribution of nutrients in body - Chronic illness - Eating disorder Results in weight loss and muscle wasting Starvation (marasmus) versus protein deprivation (kwashiorkor)
Explain the definition of Body Mass Index (BMI) and the parameters for underweight, normal weight, overweight, and obese.
A measure used to assess an individual's body weight in relation to their height. Divide a person's weight in kilograms by the square of their height in meters (BMI = weight in kg / height in m^2). Underweight: BMI less than 18.5 - May indicate insufficient body weight relative to height - Could be associated with nutritional deficiencies, weakened immune function, and osteoporosis. Normal Weight: BMI 18.5 to 24.9 - Associated with the lowest risk of weight-related health problems - Indicative of a healthy weight status. Overweight: BMI 25 to 29.9 - May indicate excess body weight relative to height - Can increase the risk of developing heart disease, type 2 diabetes, and hypertension. Obese: BMI 30 or greater - Associated with an increased risk of numerous health problems - Heart disease, stroke, type 2 diabetes, certain types of cancer, and musculoskeletal disorders.
Where do pressure ulcers most commonly occur?
A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device Can present as intact skin or an open ulcer and may be painful
Discuss medical/surgical management of patients with malnutrition.
Address underlying cause Intake - Dietician, Case Manager Indigestion - Pharmacologic treatment Malabsorption - Digestive enzymes Eating disorders - Psychiatric treatment
Identify the attributes of optimal nutrition.
Adequate Intake for: Development-Energy- Growth-Tissue Repair Ideal Ht-Wt-BMI—(MAC) (MAMM) Muscle Tone-Strength-Agility-Reflex Response Cognitive & Mood Response Albumin WNL Hemoglobin & Hematocrit WNL Electrolytes WNL
Define the three layers of the skin.
1. Epidermis 2. Dermis 3. Subcutaneous Tissue
Optimal Conditions for Wound Healing
Adequate blood supply to deliver oxygen and nutrients. Maintain a moist wound environment to accelerate healing. Ensure proper nutrition with adequate protein, vitamins, and minerals. Provide sufficient oxygenation to support cellular metabolism. Control infections through proper wound care and antimicrobial treatments. Minimize tension and pressure on the wound site. Promote a healthy lifestyle with no smoking and management of chronic conditions. Use appropriate wound care practices, including cleaning and dressing.
Discuss systemic conditions that increase risk for impaired tissue integrity.
Age Circulation and oxygenation Nutritional status (Albumin Level) Wound etiology Health status Immunosuppression Medication use Adherence to treatment plan
Primary Lesions
Arise from previously normal skin and represent the initial appearance of a skin condition. They are typically characteristic of the specific disease or condition and may include: Macules: Flat, discolored spots (e.g., freckles). Papules: Small, raised bumps (e.g., pimples). Plaques: Raised, flat-topped areas (e.g., psoriasis plaques). Nodules: Firm, elevated masses (e.g., dermatofibroma). Vesicles: Small fluid-filled blisters (e.g., herpes simplex). Bullae: Large fluid-filled blisters (e.g., bullous pemphigoid). Wheals: Raised, red welts (e.g., hives). Pustules: Small pus-filled lesions (e.g., acne pustules).
Describe the complications of dysphagia, including malnutrition.
Aspiration Choking Coughing Respiratory Distress Low oxygen Aspiration Pneumonia Malnutrition Oral infections/candida
Discuss the pathophysiology of psoriasis.
Autoimmune lifelong skin condition - May run in family Median onset 28 years old Epidermal hyperplasia
Identify the essential teaching points for a patient with psoriasis.
Avoid any trauma to the skin - Sunburn, cuts, abrasions Avoid stress Avoid extreme temperatures Avoid scratching plaques Wash skin regularly but notdaily and keep moisturized Support for psychosocialeffects of disease
DIETS
DIETS
Identify risk factors for development of dysphagia.
Deconditioning of muscles Neurological disorders Neurological damage Pharyngoesophageal diverticulum (Zenker's diverticulum) Cancer Complications of Aging Dental issues
Explain the pathophysiology of iron deficiency anemia.
Decreased Iron Stores: Depletion of iron stores in the body, primarily in the form of ferritin and hemosiderin. - Often asymptomatic and may precede the development of anemia. Impaired Hemoglobin Synthesis: As iron stores become depleted, the synthesis of hemoglobin is impaired. Microcytic, Hypochromic Red Blood Cells: Without sufficient iron, red blood cells are produced with: - Smaller size (microcytic) - Lower hemoglobin content (hypochromic). - Smaller and paler red blood cells Reduced Oxygen-Carrying Capacity: As hemoglobin levels decrease, the blood's ability to carry oxygen to tissues is impaired. - Can lead to symptoms of anemia, such as fatigue, weakness, shortness of breath, and pallor. Compensatory Mechanisms: In response to decreased oxygen-carrying capacity, compensatory mechanisms may be activated - Increased cardiac output and heart rate, in an attempt to maintain tissue oxygenation.
Regular Diet
Description: A balanced diet with no specific dietary restrictions. Therapeutic Use: Prescribed for patients with no specific medical conditions or dietary restrictions, suitable for general nutrition. Lean meats, poultry, fish Fruits and vegetables Whole grains Dairy products Healthy fats
Clear Liquid Diet
Description: Comprises transparent liquids that are easy to digest and leave minimal residue in the gastrointestinal tract. Therapeutic Use: Used as a transitional diet for patients recovering from surgery, experiencing gastrointestinal upset, or preparing for medical procedures. Broth Clear fruit juices without pulp Gelatin Clear sports drinks Popsicles without fruit pieces
Soft Diet
Description: Consists of foods that are soft, tender, and easy to chew. Therapeutic Use: Recommended for patients with chewing difficulties, dental problems, or recovering from oral surgery. Cooked vegetables without skins or seeds Tender meats, poultry, and fish Soft fruits and cooked fruits without skins or seeds Soft bread and grains Dairy products like yogurt and pudding
Enteral Nutrition
Description: Enteral nutrition involves providing nutrition directly into the gastrointestinal tract via a feeding tube. Therapeutic Use: Used when patients cannot consume adequate nutrition orally, such as those with dysphagia, impaired consciousness, or gastrointestinal disorders. It provides essential nutrients and hydration to maintain or improve nutritional status. Standard polymeric formulas High-protein formulas Elemental or semi-elemental formulas for patients with malabsorption issues
Mechanical Soft Diet
Description: Includes foods that are soft, moist, and easily chewed or mashed. Therapeutic Use: Prescribed for patients with difficulty chewing or swallowing, such as those with dysphagia or recovering from head and neck surgery. Mashed potatoes Pureed vegetables and fruits Soft cooked eggs Ground or finely chopped meats Creamy soups and stews
Full Liquid Diet
Description: Includes liquids and foods that are liquid at room temperature or can be converted to liquid form. Therapeutic Use: Prescribed for patients who cannot tolerate solid foods or have difficulty swallowing, providing hydration and nutrients in liquid form. Milk and milk-based beverages Strained creamy soups Pureed vegetables and fruits Plain ice cream or sherbet
Evaluation of Nutritional Status
Dietary assessment provides information about macronutrient and micronutrient intake. Anthropometric measurements, such as weight, height, and BMI, assess nutritional status and body composition. Biochemical markers, including serum albumin, prealbumin, and vitamins/minerals levels, indicate nutrient status. Clinical assessment evaluates signs of malnutrition, such as muscle wasting or poor wound healing. Functional assessment assesses the individual's ability to perform daily activities.
Explain dietary recommendations for a patient who suffers from iron deficiency anemia.
Dietary interventions - Increase intake of iron rich foods - Administer iron supplements with vitamin C or orange juice Iron-Rich Foods: Encourage consumption of foods high in heme iron, which is more readily absorbed by the body. These include: - Red meat (beef, lamb, pork) - Poultry (chicken, turkey) - Fish (especially shellfish such as oysters, clams, and shrimp) - Organ meats (liver) Non-heme iron sources can be included: - Beans and lentils - Tofu and tempeh - Dark leafy greens (spinach, kale, swiss chard) - Fortified cereals and grains - Nuts and seeds (especially pumpkin seeds, sesame seeds) - Dried fruits (apricots, raisins) Enhancing Iron Absorption: Pairing iron-rich foods with sources of vitamin C can enhance iron absorption. Encourage consuming vitamin C-rich foods such as citrus fruits (oranges, grapefruits), berries, tomatoes, bell peppers, and broccoli alongside iron-containing meals. Avoiding Inhibitors of Iron Absorption: Certain substances can inhibit iron absorption and should be limited or avoided. These include: - Calcium-rich foods (dairy products) when consumed with iron-rich foods - Tannins found in tea and coffee - Phytates in whole grains and legumes - Encourage spacing out consumption of these foods from iron-rich meals.
Discuss medical/surgical management of patients with obesity.
Diets have not been shown to be effective in long term weight loss - Refer to dietician - Refer to social work/case manager for assistance accessing healthy food options Bariatric surgery is last option if other options failed
Explain the pathophysiology of dysphagia.
Difficulty swallowing. Difficulty moving food bolus from mouth into esophagus due to epiglottis not covering entrance totrachea sufficiently.
IMPETIGO
IMPETIGO
Dysphagia
Dysphagia
Identify potential barriers to health care and achieving a normal BMI for a patient with obesity.
Financial Barriers: - Lack of health insurance coverage or limited coverage - High out-of-pocket costs for obesity treatments Limited Access to Healthcare Services: - Geographic barriers in rural or underserved areas. - Long wait times for appointments with specialists like endocrinologists or bariatric surgeons. Stigma and Discrimination: - Fear of stigma or discrimination from healthcare providers - Negative attitudes within the healthcare system leading to suboptimal care Psychosocial Factors: - Mental health issues like depression or anxiety affecting motivation for weight loss. - Socioeconomic stressors such as job insecurity hindering healthy lifestyle changes. Environmental Factors: - Limited availability of healthy food options in low-income neighborhoods or food deserts. - Lack of safe and accessible spaces for physical activity. Medical Complexity: - Presence of obesity-related comorbidities complicating weight management efforts.
Other assessment methods nurses use to assess a pressure ulcer.
Full Assessment: Risk assessment Mobility Nutritional status Moisture and incontinence Appearance of existing pressure injury Pain assessment Push Assessment: Measures three parameters that are considered most indicative of healing: - Wound size - Exudate amount - Tissue type
Stage 3 Pressure Injury
Full-Thickness Skin Loss Characteristics: Extends into the dermis and deeper tissue layers, creating a deeper ulcer with visible subcutaneous fat. May present as a deep crater with or without undermining. May involve necrotic tissue and tunneling. Does not extend through the fascia to involve muscle or bone.
Stage 4 Pressure Injury
Full-Thickness Skin and Tissue Loss Characteristics: Extends through all skin layers and into underlying muscle, bone, or supporting structures (e.g., tendon or joint capsule). May present as a deep ulcer with extensive tissue loss, exposing muscle, tendon, or bone. May have eschar or slough, with the potential for undermining and tunneling. May be extensive and require surgical intervention.
Describe the complications of malnutrition.
Impaired Immune Function Muscle Wasting and Weakness Delayed Wound Healing Nutrient Deficiencies Gastrointestinal Issues Cognitive Impairment Cardiovascular Complications Electrolyte Imbalance Endocrine Dysfunction Increased Risk of Infections Impaired Growth and Development Organ Damage
Risk factors For Impaired Nutrition (Book)
Genetic defects impacting metabolism or absorption of nutrients: Inherited metabolic disorders, phenylketonuria (PKU) and Tay-Sachs disease, result from genetic defects in enzyme activity Malformation or damage to the gastrointestinal mucosa: Conditions such as malabsorptive syndromes or inflammatory conditions Inadequate or excessive dietary intake of required nutrients: Undernutrition: Inadequate calorie consumption or insufficient intake of essential vitamins and minerals. Overnutrition: Excessive consumption of nutrients, leading to obesity and related health issues. Excessive nutrient losses: Vomiting, diarrhea, or laxative use Hypermetabolic states: Hyperthyroidism, cancer, burns, fever, or severe infection exert excessive metabolic demands, increasing nutrient requirements Age-related changes: Older adults at increased risk due to factors such as poor appetite, alterations in taste, swallowing difficulties, limited income, inadequate social support, and mobility limitations. Malabsorption: Conditions affecting the absorption of nutrients, pancreatic dysfunction, enzyme deficiencies, inflammatory conditions, or gastrointestinal atrophy Food allergies: Not causing nutritional deficiencies directly, but can lead to dietary modifications and avoidance of certain foods Protein energy malnutrition: Deprivation of food leading to starvation or inadequate protein intake, conditions like marasmus or kwashiorkor, affecting muscle mass, organ function, and overall health. Lysosomal storage diseases: Tay-Sachs disease, characterized by defects in lipid metabolism, lead to neurologic impairment, impact nutrient absorption and utilization.
Identify risk factors for development of obesity.
Genetics: - Estimated to be responsible for about one third of the individual's body mass index. - Number and size of adipose cells, distribution of body fat, and resting metabolic rate are genetically influenced; more than 200 genes are involved in obesity. Lifestyle factors: - Consumption of a diet with excessive calories combined with a sedentary lifestyle Neurologic mechanisms and hormones: - Act on the hypothalamus, stimulating and suppressing hunger and satiety. Leptin: - Hormone secreted by adipocytes - Major role in body weight regulation. - Signals satiety to the hypothalamus, reduces food intake and lipid storage, and promotes energy expenditure. - In obesity, individuals have high levels of leptin but are resistant to this hormone. Estrogen: - Hormone that stimulates lipid movement into adipocytes in the hip and upper thigh regions and restricts movement into the abdominal region, explains the shape of many women who have adequate estrogen levels. Thyroid hormone: - Active in metabolic processes. Insulin - Secreted by the pancreas - Acts on the CNS to inhibit food intake and is involved in the synthesis and storage of lipids. Melanocortin hormone: - Acts on melanocortin receptors and modifies appetite. Ghrelin hormone - Secreted from the stomach, is a major hunger hormone. Enzymes: - Mediate metabolic processes and movement of dietary lipids into the adipocyte - Lipoprotein lipases promote lipid storage. Hormones: - Mediate movement of dietary lipids from the blood, across the capillary wall, and into the adipocyte.
Describe the antecedents of functional tissue integrity.
Good Nutrition Lack of External Trauma Adequate Perfusion Limited Pressure on Site Affected by Life Cycle (Birth to Death)
Discuss important teaching points to promote optimal nutrition.
Healthy Dietary Pattern Across Life Stages: Infancy: Exclusive breastfeeding for about 6 months, then continue with human milk or iron-fortified formula. Toddlerhood: Introduce nutrient-dense complementary foods, including allergenic foods. Childhood and Beyond: Encourage variety from all food groups to meet nutrient needs and reduce chronic disease risk. Customization and Enjoyment: Tailor food choices to personal preferences, cultural traditions, and budget. Dietary Guidelines are adaptable to individual needs and diverse cultural foodways in the United States. Focus on Nutrient-Dense Foods: Prioritize nutrient-dense foods and beverages across all food groups within calorie limits. Core elements of a healthy dietary pattern include vegetables, fruits, whole grains, dairy, protein foods, and oils. Limit Added Sugars, Saturated Fat, Sodium, and Alcohol: Keep added sugars and saturated fat below 10% of daily calories starting at age 2. Limit sodium intake to less than 2,300 milligrams per day, even less for children. Alcohol consumption should be moderate, with limits set for men and women, and avoided by certain groups such as pregnant women.
Describe the phases of normal wound healing
Hemostasis Inflammatory Proliferation Maturation
Stage 1 Pressure Injury
Nonblanchable Erythema of Intact Skin Characteristics: Skin appears red, usually over a bony prominence. Skin Integrity: Skin is intact, but the area may be tender, firm, soft, or warmer or cooler compared to surrounding tissue. May indicate tissue damage has started but has not yet progressed to an open wound.
Identify appropriate accommodations for patients with obesity.
Nonjudgment Screen for eating disorders Provide same quality care that is provided to all patients Provide appropriate accommodations for patient - Different size hospital bed, wheelchair Assist patient in interventions they choose
Identify the antecedents of nutrition and their role in optimal nutrition.
Normal Alimentary Tract and Associated Organs - Intake, Digestion, Absorption, Storage Adequate Ingestion of Nutrients and Water - Water (dissolves, maintains fluid balance, transports nutrients and waste, lubricates, maintains body temperature) - Macronutrients (protein, lipids, carbohydrates) Normal Temperature (98.6) Normal ph (7.35-7.45)
OBESITY
OBESITY
Unstageable Pressure Injury
Obscured Full-Thickness Skin and Tissue Loss Characteristics: Wound covered by eschar or slough, making it difficult to assess the depth of tissue involvement. Requires debridement or removal of the necrotic tissue to determine the true depth and stage of the ulcer.
Hemostasis
Occurs immediately after injury to stop bleeding and activate white blood cells. Blood vessels constrict, and platelet activation leads to clot formation. Clot dissolves over time, releasing substances that initiate subsequent healing phases.
Describe the signs and symptoms of iron deficiency anemia.
Often asymptomatic Symptoms of anemia Pallor of the skin and mucous membranes Fatigue, weakness, lightheadedness, syncope, headache Breathlessness, palpitations, tachycardia Brittle hair and nails, mouth sores Pica Glossitis
Discuss signs and symptoms of impetigo.
One or many blisters that itch Filled with yellow to honey colored fluid Blisters ooze and crust over Spread by direct contact with fluid in blisters Can spread on the patient by patient scratching and then touching another part of body
Describe the function of the skin in maintaining physiological homeostasis.
Protection - Acts as a barrier to water, microorganisms, and damaging ultraviolet rays of the sun - Protects against infection - Protects against injury to underlying tissues and organs - Prevents loss of moisture from the surface and underlying structures Body temperature regulation - Draws heat from the skin as perspiration occurs and evaporates - Dissipates heat as blood vessels in the skin dilate - Compensates for cold conditions with the constriction of blood vessels in the skin to diminish heat loss - Compensates for cold through the contraction of pilomotor muscles that cause the hair to stand on end, forming a layer of air on the body for insulation (gooseflesh or goose bumps) Psychosocial - Contributes to the external appearance and is a major contributor to self-esteem - Plays an important role in identification and communication Sensation - Provides the sense of touch, pain, pressure, and temperature through millions of nerve endings - Allows the body to adjust to the environment through sensory impulses, in conjunction with the brain and spinal cord Vitamin D production - Activated by ultraviolet rays from the sun to produce vitamin D Immunologic - Triggers immunologic responses when broken Absorption - Absorbs substances, such as medications, for local and systemic effects Elimination - Excretes small amounts of water, electrolytes, and nitrogenous wastes in sweat
Role of Nutrition in Tissue Healing
Protein is crucial for tissue repair, providing amino acids for collagen synthesis and cellular proliferation. Vitamins (e.g., vitamin C, vitamin A) and minerals (e.g., zinc) support various aspects of wound healing, such as collagen synthesis and immune function. Adequate energy intake fuels cellular metabolism and supports tissue regeneration and immune responses. Proper hydration facilitates nutrient transport and metabolic processes involved in wound healing.
Psoriasis
Psoriasis
Healthy Eating
Recommended daily allowances (RDAs) Caloric (kcal/kg): based on: - Age - Gender - Activity level - Current weight - Pregnancy/lactation Macronutrients (μg or mg per day) Macronutrients (%) - Carbs: 45% to 65% - Protein: 10% to 35% - Fats: 20% to 35%
Macronutrients
Required by the body in relatively large amounts to provide energy and support growth and development. Types: Carbohydrates (sugar): Primary source of energy for the body. (Grains, fruits, vegetables, and legumes). Proteins (amino acids): Essential for building and repairing tissues, producing enzymes and hormones, and supporting the immune system. (Meat, poultry, fish, eggs, dairy products, legumes, and nuts). Fats (Lipids): Important for energy storage, insulation, and hormone production. Healthy fat sources include oils, nuts, seeds, avocados, and fatty fish. Dietary Sources: Carbohydrates: Bread, pasta, rice, fruits, vegetables, legumes. Proteins: Meat, poultry, fish, eggs, dairy products, legumes, nuts, seeds. Fats: Oils, butter, avocados, nuts, seeds, fatty fish. Purpose in the Body: Carbohydrates: Provide energy for various bodily functions, including metabolism and physical activity. Proteins: Build and repair tissues, produce enzymes and hormones, support immune function. Fats: Provide a concentrated source of energy, support cell structure, help absorb fat-soluble vitamins, and provide insulation.
Micronutrients
Required by the body in smaller amounts to support various physiological functions. Types: Vitamins: Organic compounds that regulate various bodily processes, such as metabolism, immune function, and cell growth. - Fat soluble (A, D, E, K) - Water soluble (B1, B2, B6, B12, C) Minerals: Inorganic substances that are essential for building bones and teeth, transmitting nerve impulses, and maintaining fluid balance. - Macrominerals (Sodium, potassium, calcium, phosphorus, magnesium, sulfur) - Microminerals (Iron, zinc, fluoride, copper) Dietary Sources: Vitamins: Wide variety of foods, including fruits, vegetables, dairy products, and fortified cereals. Minerals: Dairy products, leafy greens, whole grains, nuts, seeds, and meats. Purpose in the Body: Vitamins: Support various physiological processes, including enzyme reactions, immune function, and cell growth. - Aid in metabolism of macronutrients - Help develop genetic materials, hormones, collagen, nervous system tissue Minerals: Essential for building and maintaining bone health, transmitting nerve impulses, maintaining fluid balance, and supporting overall health and well-being. - Constitute bone, hemoglobin, enzymes, hormones, chemical mediators - Mediate impulses, maintain fluid and acid-base balance
Cultural Considerations
Respect cultural beliefs and practices related to food and nutrition. Understand and accommodate cultural food preferences and dietary habits. Emphasize the importance of traditional foods and recipes in cultural identity. Cultivate cultural competence among healthcare providers. Use culturally and linguistically appropriate communication methods. Consider family and community dynamics in nutrition interventions. Acknowledge religious and spiritual considerations impacting dietary practices. Address socioeconomic factors affecting access to nutritious foods. Advocate for culturally diverse food options in the community. Collaborate with community organizations and cultural leaders for culturally tailored interventions.
Discuss medical/surgical management of patients with iron deficiency anemia.
Reverse the cause Increase iron intake through diet and/or supplements Oral Iron Supplementation: Primary mode of treatment. Various preparations available: ferrous sulfate, ferrous gluconate, ferrous fumarate. Ferric maltol approved for those with inflammatory bowel disease. Hemoglobin increase within weeks; anemia correction within months. Continuation for 6 to 12 months to replenish iron stores. Intravenous (IV) Iron: Considered if oral iron poorly absorbed or tolerated, or if large amounts needed. Given in repeated doses. Ferric maltol may be an alternative to parenteral iron, particularly for those who cannot tolerate other oral preparations or prefer not to have parenteral iron. Efficacy of ferric maltol compared to parenteral iron not yet fully established.
Secondary Lesions
Secondary lesions result from changes that occur to primary lesions or from external manipulation, such as scratching or infection. They may evolve from primary lesions or develop as a consequence of ongoing disease processes. Examples include: Scales: Flakes or plates of dead skin (e.g., psoriasis scales). Crusts: Dried serum, blood, or pus on the skin surface (e.g., impetigo crusts). Erosions: Superficial loss of skin (e.g., abrasions). Ulcers: Deeper loss of skin that may extend into the dermis (e.g., pressure ulcers). Fissures: Linear cracks in the skin (e.g., athlete's foot). Scars: Fibrous tissue that replaces normal skin after injury or surgery. Atrophy: Thinning or depression of the skin (e.g., striae).
Identify changes in laboratory tests and diagnostic results in malnutrition.
Serum albumin decreased - Prolonged protein depletion - Malabsorption Prealbumin decreased - Protein depletion - Malnutrition Complete blood count Sedimentation rate Serum electrolytes Urinalysis and urine culture Measurement of height, weight, BMI
Discuss the signs and symptoms of psoriasis.
Silvery plaques on knees, elbows, trunk - Itchy - Scaly - Red - Inflamed - Warm - Painful Joint pain and limited ROM
Discuss how the nurse should assess a pressure ulcer.
Size, Shape - Length, width and depth - Use the clock method for description Color - Pink/Red - Yellow - Necrotic-Black Location Undermining Tunneling Drainage - Serous: Clear, thin, and watery fluid Composed mainly of serum, the fluid part of blood Typically seen in blisters or normal healing wounds - Serosanguinous: Contains both serum and blood Pink to light red in color, thin consistency Often observed in new wounds or surgical drains - Sanguineous: Bright red, indicating substantial presence of red blood cells Thick fluid, similar to fresh blood Common in fresh wounds or reopened wounds - Purulent: Thick, opaque, and can be yellow, green, or brown Contains pus, indicating infection Associated with bacterial infections and requires medical attention
Identify the physiological causes for pressure ulcers.
Skin and underlying soft tissueare compressed between abony prominence and anexternal surface Pressure causes ischemia Mechanical forces that create ulcers - Pressure - Friction - Shear
Identify risk factors for development of malnutrition.
Societal norms/fatphobia Socioeconomic factors Familial pressures War/famine
Risk Factors for Impaired Nutrition (Slide)
Structural/Environmental: - Religious and cultural practices - Financial issues - Neighborhood resources - Stress - Health literacy Individual - Appetite - Anorexia (eating disorder characterized by restriction of food, accompanied by intense fear of gaining weight and disturbed perception of body weight and image) - "Picky eater" - Disease and illness - Medications
Identify changes in laboratory tests and diagnostic results in dysphagia.
Swallow study shows aspiration Chest XR shows infiltrates in lungs
Swallowing Phases in relation to dysphagia
Swallowing process includes oral preparatory, oral, pharyngeal, and esophageal phases. Oral phase dysfunction may result from issues with chewing, tongue movement, or coordination. Pharyngeal phase dysfunction can lead to aspiration, penetration, or residue due to problems with closure of the airway, laryngeal movement, or peristalsis. Esophageal phase dysfunction may involve issues with peristalsis, lower esophageal sphincter function, or structural abnormalities.
TISSUE INTEGRITY
TISSUE INTEGRITY
Factors Affecting Skin Integrity
Unbroken and healthy skin and mucous membranes serve as the first lines of defense against harmful agents. Resistance to injury of the skin and mucous membranes varies among people. - Factors influencing resistance include the person's age, the amount of underlying tissues, and comorbidities. Adequately nourished and hydrated body cells are resistant to injury. - The better nourished the cell is, the better able it is to resist injury and disease. Adequate circulation is necessary to maintain cell life. - When circulation is impaired for any reason, cells receive inadequate nourishment and cannot remove wastes efficiently.
Describe the signs and symptoms of dysphagia.
Unclear voice Coughing after eating or drinking, especially liquids Adventitious lung sounds Low oxygen Slow eating Food left in mouth after swallowing Poor oral hygiene
Discuss patient teaching points for carbohydrate intake.
Understanding Carbohydrates: Explain the different types of carbohydrates (simple vs. complex) and their sources (e.g., fruits, vegetables, grains, sweets). Portion Control: Teach patients about carbohydrate portion sizes and how to balance carbohydrate intake with other macronutrients. Choose Whole Grains: Encourage choosing whole grain sources of carbohydrates such as whole wheat bread, brown rice, quinoa, and oats, which provide more fiber and nutrients. Fiber-Rich Foods: Emphasize the importance of fiber-rich foods like fruits, vegetables, legumes, and whole grains in promoting satiety and regulating blood sugar levels. Limit Sugary Foods: Advise limiting intake of sugary foods and beverages, including desserts, candies, sugary drinks, and processed snacks. Balancing Carbohydrates: Teach patients how to balance carbohydrates throughout the day, considering factors such as meal timing, physical activity level, and individual carbohydrate tolerance. Monitoring Blood Sugar: For patients with diabetes or insulin resistance, discuss the importance of monitoring blood sugar levels and adjusting carbohydrate intake accordingly. Healthy Cooking Methods: Encourage healthy cooking methods such as steaming, baking, or grilling, rather than frying, to reduce added fats and calories from carbohydrate-rich foods. Reading Food Labels: Teach patients how to read food labels to identify hidden sources of added sugars and refined carbohydrates in processed foods. Individualized Approach: Stress the importance of individualized carbohydrate intake based on factors such as age, weight, activity level, and medical conditions. Encourage patients to work with a registered dietitian for personalized guidance.
Discuss how the Braden Scale is implemented by nurses to evaluate risk for skin breakdown.
Utilized as a standardized tool for assessing risk of pressure ulcers. Evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6 to 23, with lower scores indicating higher risk. Patients categorized into high risk, moderate risk, at-risk, or no risk based on total score. Regular monitoring and reassessment conducted to identify changes in risk status.
Discuss how the skin assessment are implemented by nurses to evaluate risk for skin breakdown.
Visual inspection and palpation of the skin conducted during routine assessments. Focus on areas prone to pressure ulcers, such as bony prominences. Findings documented, including presence of wounds, pressure ulcers, or skin changes. Interventions tailored based on assessment findings, including repositioning and skin care. Collaboration with healthcare team members for multidisciplinary approach to prevention and treatment.
Discuss how the nurse should document the assessment of a pressure ulcer.
Wound type Stage/Thickness Size (Height, Width,Depth) Wound Bed Color Drainage Amount and Type
