N330 Exam 2

nutrition nursing interventions

-teaching nutritional info -monitoring nutritional status -stimulating appetite -assisting with eating -providing oral nutrition -providing long-term nutritional support

spinal cord injury (SCI)

damage to spinal cord, vertebral column, supporting soft tissue, or intervertebral discs as result of trauma; spinal cord can be bruised or completely severed

right sided stroke

paralyzed left side, spatial or perceptual deficits, quick and impulsive behavioral style, performance memory deficits

left sided stroke

paralyzed right side, speech/language deficits, behavioral style; slow and cautious, language memory deficits

sensory loss from chronic ischemic stroke

paresthesia, impairment of sensation to touch, loss of proprioception, agnosia

dehiscence

partial or total separation of wound layers

major causes of death due to SCI

pneumonia, pulmonary embolism, and sepsis

MNT strategies for type 2 diabetes

portion control, meal planning, diabetes plate method

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

gerontological motor alterations

decreased strength, decreased agility, increased reaction time, decreased balance, slower gait, risk for falls

gerontological sensory alterations

decreased tactile sensation, increased sensitivity to glare, decreased peripheral vision, hearing lass, decreased smell and taste temp regulation, pain perception

awake EEG

hour

central cord syndrome

loss of function in upper extremities caused by injury to the middle portion of the spinal cord; impaired sensation below injury

Anterior cord syndrome

loss of most function below the site of injury to the anterior portion of the spinal cord

DKA management

lower blood sugar with insulin, replace fluid, correct electrolyte imbalance, correct acidosis, frequent blood sugar monitoring

nursing implications for hemorrhagic stroke

lower stimulation, HOB 30 degrees, bed rest, seizure precautions, monitor for hypernatremia, prevent constipation, DVT prevention, pt/fam education, anxiety reductions

why are SCI at risk for pneumonia?

lowered mobility, shallow breathing and no coughing causing buildup of bacteria in the lungs

vitamin A

maintains healthy skin, bones, teeth, and hair; aids vision in dim light

creatinine

measures effectiveness of renal function

causes of constipation

medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise

causes of pruritis

medications: aspirin, antibiotics, hormones, opioids; soaps and chemicals, radiation therapy, prickly heat; psychological factors

serosanguineous drainage

mixture of serum and red blood cells

Colostomy stool characteristics

moist and formed stool; closer to normal stool consistency

nursing assessment of SCI

monitor respirations and breathing pattern, assess lung sounds and cough, monitor for motor and sensory deficits, monitor of bowel/bladder dysfunction, monitor temp, skin and pain assessment

lability of mood

mood swings

diverticulosis

multiple diverticula without inflammation

proliferative diabetic retinopathy

new blood vessels formed which cause vitreous hemorrhage or retinal detachment

parenteral nutrition

nourishment provided via IV therapy

presenting symptoms of ischemic stroke

numbness or weakness of the face; especially one side

Areas susceptible to pressure ulcers

occiput, ear, scapula, elbow, sacrum, greater trochanter, ischial tuberosities, medial condyle of tibia, fibular head, medial malleolus, lateral malleolus, heel

secondary spinal injuries

occur after the initial insult but can cause the same and even more harm

hemorrhagic stroke

occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed

treatment of diabetic retinopathy

pan retinal photo-coagulation or intravitreous injections

hemiplegia

paralysis of one side of the body

geriatric ostomy considerations

-skin care issues -difficulty managing care b/c of decreased vision, impaired hearing, difficulty with fine motor coordination

causes of urinary retention

- Adults 60 years and older may have 50 to 100 mL of residual urine remaining in the bladder after voiding - Postoperative spasms - Diabetes, prostatic enlargement, urethral pathology, trauma, pregnancy, neurologic disorder - Medications

nursing care of pt with IBD

- assess health history to identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and fam history -discuss dietary patterns, alcohol, caffeine, and nicotine use -assess bowel elimination patterns and stool -abdominal assessment

psoriasis

- chronic, autoimmune, inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate - may be aggravated by stress, trauma, seasonal and hormonal changes - treatment= baths to remove scales and meds; baby tooth brush to remove scales

tinea cruris

- jock itch - fungal infection of groin and scrotal areas; mainly affects men - aggravated by increased perspiration, and tight-fitting shorts/pants/undergarments

considerations to prevent contamination of tube feed

- milk based formulas not being hung more than 4 hours -refrigeration of some feeds - tubing changed every 24 hours

Bolus Gastrostomy Feeding by Gravity

- natural and easier to tolerate - gravity prevents dumping syndrome and abdominal distention is pushing through tube

Toxic Epidural Necrolysis (TEN) and Stevens-Johnson Syndrome

- potentially fatal -widespread erythema and macule formation with blistering -epidermal detachment or sloughing and erosion formation -triggered by a reaction to medications (antibiotics, anticonvulsants, NSAIDs, allopurinol)

chronic kidney disease

- screening: urinary albumin with a spot urinary albumin to creatinine ration and estimated GFR -treatment: BP and glucose control -lifestyle: lower sodium and protein

Exanthematous rash

-small, raised or flat lesions on reddened skin; may blister and fill with pus

BGM vs CGM

-BGM measures capillary glucose; CGM measures interstitial glucose -BGM requires individual sample for each reading; CGM uses one device for several days to obtain continuous sampling -real time CGM provide warning of blood sugar drops; BGM and intermittent scanning CGM need patient initiation

chronic complications of diabetes

-CVA -cardiovascular disease -diabetic nephropathy -diabetic neuropathy -PVD -foot damage -periodontal disease -diabetic retinopathy, glaucoma, cataracts

Purposes of Gastrointestinal Intubation

-Decompress the stomach -Lavage the stomach (flush with water or other fluids) -Diagnose GI disorders -Administer medications and feeding -To compress a bleeding site -To aspirate gastric contents for analysis

constipation

-Hard, slow stools that are difficult to eliminate; often a result of too little fiber in the diet -defined as fewer than 3 BMs weekly or bowel movements that are hard, dry, small, or difficult to pass

indications for parenteral nutrition

-Intake is insufficient to maintain anabolic state. -Ability to ingest food orally or by tube is impaired. -Patient is not interested or is unwilling to ingest adequate nutrients. -The underlying medical condition precludes oral or tube feeding. -Preoperative and postoperative nutritional needs are prolonged.

MRI nursing implications

-ask if they ever had or have now any metal in there body -implants, pacemakers, bullets, shrapnel, internal drug infusion pumps, eye prothesis, bone growth stimulators -remove: medical patches, monitoring patches, IV pumps, suction machines, PCA pumps, oxygen, jewelry, wallets, purses, hearing aids. glasses, keys, air clips - continual monitoring for sedated patients

tinea pedis

-athlete's foot - fungal infection of foot; spread by direct contact with contaminated surfaces - most commonly develops in warm, moist area between toes

tinea corporis

-ringworm - fungal infection of smooth skin on arms, legs, and body - red, ring-shaped with pale center

types of debridement

-autolytic= uses own digestive enzymes to break down necrotic tissue - enzymatic products= mimic body's natural enzyme, increase process of necrotic tissue involvement - surgical=immediate removal of necrotic tissue

hypoglycemia prevention

-avoid fasting or skipping meals, alcohol, intense exercise, lack of sleep -monitor blood glucose level

impetigo

-bacterial skin infection characterized by isolated pustules that become crusted and rupture - bathe at least once daily with bactericidal with soap

contact dermatitis

-caused by an allergen or substance that irritates the skin - redness, itching, macules, papules, fissures, blisters, swelling, or tenderness to touch -keep clean and well moisturized -avoid allergen or irritant

pt education with urinary diversion

-changing appliance -controlling odor -reliving pain -managing/cleaning the appliance -potential long-term complications -maintaining skin integrity -body image

hidradenitis suppurativa

-chronic suppurative folliculitis of the perianal, axillary, and genital areas or under the breast; produces abscesses or sinuses with scarring -education to use warm compresses and wear loose-fitting clothes over the nodules or lesions

diverticular disease

-condition in which bulging pouches (diverticula) in the gastrointestinal (GI) tract push the mucosal lining through the surrounding muscle -may occur anywhere but most common in the sigmoid colon -diagnosis usually by colonoscopy -increases with age and associated with low-fiber diet

Geriatric GI changes

-decreased filtration rate -diminished tubular function with less efficiency in reabsorbing and concentrating the urine -slower restoration of acid-base balance in response to stress -male: benign prostatic hyperplasia -female: relaxed perineal muscles, detrusor instability (urge incontinence), urethral dysfunction (stress incontinence)

geriatric gastrointestinal changes

-decreased sense of thirst, smell, and taste -decreased salivation -difficulty chewing and swallowing food -delayed esophageal, gastric emptying -diminished secretion of gastric acid and pepsin -reduced gastrointestinal motility

risk factors for CVD in pt with diabetes

-elevated total to HDl cholesterol ratio -hypertension -hypertriglyceridemia -elevated plasma fibrinogen -obesity -hyperglycemia -hyperinsulinemia -insulin resistance

Anorectal conditions nursing interventions

-encourage intake of 2L of water a day -high-fiber foods -bulk laxatives, stool softeners, and topical medications -promote urinary elimination -hygiene and sitz baths -monitor for complications -educate on self-care

pt education diabetic physical activity

-exercise at least 3 times a week -be consistent -proper equipment -check feet after exercise -stress test prior to routine -avoid exercising with ketones or glucose over 250 (stress response) -15g of carbs prior to exercise

autonomic neuropathy symptoms

-gastroparesis: delayed emptying, nausea, vomiting -sexual dysfunction -urinary retention -hypoglycemic unawareness

eczema

-general inflammatory response of skin to injuries from irritants, allergens, or trauma -erythema, pruritus, and skin lesions

sensory neuropathy symptoms

-generally distal -painful numbness, burning, tingling -leading cause of nontraumatic amputation in US -leads to ulcerations and foot deformaties

diarrhea

-increased frequency of bowel movements (more than 3 per day) with altered consistency of stool -usually associated with urgency, perianal discomfort, incontinence, or a combo -may be acute, persistent, or chronic

scabies

-infestation of the skin by the itch mite Sarcoptes scabei -increased itching during the evening hours; patient should wear clean clothing and sleep in freshly clean linens -> washed in hot water - each person in household gets treated and repeat treatment after 7-10 days

functional or paralytic intestinal obstruction

-intestinal musculature cannot propel the contents along the bowel -blockage also can be temporary and the result of the manipulation of the bowel during surgery

Causes of hemorrhagic stroke

-intracerebral hemorrhage -subarachnoid hemorrhage -cerebral aneurysm -arteriovenous malformation

nursing goals for pt with intestinal obstruction

-maintaining the function of the NG tube -assessing and measuring the NG output - assessing for fluid and electrolyte imbalances -monitoring nutritional status -assessing for manifestations consistent with resolution

pt education with IBS

-medication management - complimentary medicine (meditation, stress management) - dietary changes -food diary -adequate fluid intake -avoid alcohol and smoking -relaxation techniques

appendicitis

-most frequent cause of acute abdominal pain - appendix becomes inflamed and edematous as a result of becoming kinked, resulting in an infection - inflammatory process increased intraluminal pressure, causing edema and obstruction of the orifice - appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs

nursing care of pt with gastrostomy or jejunostomy

-patient knowledge and ability to learn -self-care ability and support -skin condition -nutrition and fluid status -inspection of the tube

risk factors for diabetic foot ulcer

-poorly glycemic control -peripheral neuropathy -smoking -foot deformities -preulcerative callous -PAD -history of foot ulcer, amputation -visual impairment -CKD

pt education with diarrhea

-recognition of need for medical treatment -rest -diet and fluid intake - avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods -perianal skin care -medications -may need to avoid milk, fat, whole grains, fresh fruit, and vegetables -lactose intolerance

nursing goals for pt with appendicitis

-relieving pain -preventing fluid volume deficit -reducing anxiety -preventing or treating surgical site infection -maintaining skin integrity - preventing atelectasis -attaining optimal nutrition

assessment of enteral feeding pt

-tube placement -pt ability to tolerate formula and amount (residual feed) - clinical response -signs of dehydration - elevated blood glucose, decreased urine output, sudden weight gain, and periorbital or dependent edema -infection control - I&O, weekly weights, dietician consult

pt education for urinary incontience

-urinary incontinence is not inevitable and is treatable -management takes time -develop and use of voiding log or diary -behavioral interventions -medication education related to pharmacologic therapy -strategies for promoting contience

hives

-urticaria - red, swollen, raised wheals on the skin caused by an allergic reaction to something specific -can itch or sting, last less than 24 hours -usually OTC antihistamine used for treatment

normal creatinine level

0.6-1.2 mg/dL

Prediabetes fasting blood glucose

100-125 mg/dL

Prediabetes glucose levels

100-125 mg/dL

asleep EEG

12 hours

treatment of hypoglycemia

15 grams of rapid acting sugar, glucagon emergency kit, 50% dextrose solution, intranasal glucagon

recommended fiber for MNT diabetes

25 grams a day

medication (TPA) can be administered to stroke patients up to what time

4 1/2 hours

Braden Scale for Predicting Pressure Sore Risk

6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear

A1C goal for diabetic

7%

normal BUN level

7-18 mg/dL; pts greater than 60 -> 8-20 mg/dL

normal glucose range

70-120 mg/dL

Diabetes fasting plasma glucose

>126 mg/dL

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? A. Place objects within the visual field. B. Teach passive range of motion exercises. C. Instill artificial teardrops into the affected eye. D. Reduce time client is positioned on the left side.

A

Which potential complication may occur early in the recovery period when providing care for a client with paraplegia secondary to a spinal cord injury? A. Impairment of bladder control B. Inadequacy of nutritional intake C. Unskillful use of aids for ambulation D. Insufficient quadriceps setting

A

oliguria

Decreased urine output

fiber

A tough complex carbohydrate that the body cannot digest; important for bowel elimination by adding bulk to the stool and stimulation of peristalsis to ease elimination

cholesterol

A type of fat made by the body from saturated fat; a minor part of fat in foods; found only in foods that come from animals such as butter, eggs, and meats

fat-soluble vitamins

A, D, E, K

symptoms of ulcerative colitis

Abdominal pain/cramping (LLQ) Anorexia Weight loss Fever Diarrhea Abdominal distention Abdominal tenderness & firmness High pitched bowel sounds Rectal bleeding/ blood in stool

flatulence

Accumulation of gas in the intestines causing the walls to stretch

EEG (electroencephalogram)

An amplified recording of the waves of electrical activity that sweep across the brain's surface. These waves are measured by electrodes placed on the scalp. used for pts with seizures; identify areas of the brain causing problems that may be alleviated by surgical removal of those areas; pt may be triggered during for monitoring

The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis? A. high transferrin levels B. low serum albumin levels C. high lymphocyte count D. high serum albumin levels

B

Which goal would the nurse add to the plan of care for a forgetful, disoriented client who has dementia? A. Restrict gross motor activity to prevent injury. B. Redirect the client's energies to more appropriate behaviors. C. Prevent further deterioration in the client's condition. D. Maintain scheduled activities through behavior modification.

B

Components of Nutritional Assessment

BMI, waist circumference, biochemical measurements, clinical findings, dietary data

assessment and diagnostic findings of gastrointestinal diseases

CBC, serum chemistries, urinalysis, stool examination, endoscopy or barium enema

therapeutic diets

Clear liquid Full liquid soft diet renal diet sodium restricted diet carb-consistent diet cardiac diet

infection

Contamination or invasion of body tissue by pathogenic organisms; 2nd most common nosocomial disease

advantages of enteral nutrition

Cost-effective Reduced length of hospital stay Reduced need for surgical interventions Reduced incidence of infectious complications Improved wound healing Maintenance of GI function

Dementia vs Delirium

Dementia -Onset is slow, over months to years. -Impaired memory, judgment, calculations, attention span, abstract thinking; agnosia -LOC not altered -Activity level not altered; behaviors may worsen in evening (sundown syndrome) -Emotional state is flat; delusions present -Speech and language incoherent, slow (sometimes due to effort to find the right word), inappropriate, rambling, repetitious -Non reversible & progressive Delirium -Onset is sudden, over hours to days -Impaired memory, judgment, calculations, attention span; can fluctuate throughout the day -LOC altered -Activity level can be increased or reduced, restlessness; sleep-wake cycle may be reversed -can be fearful, anxious, suspicious, aggressive, have hallucinations and/or delusions -Speech and language rapid, inappropriate, incoherent, rambling -Reversible with proper and timely treatment

mneumonic for DELIRIUM causes

Drugs Emotional factors Low arterial oxygen level Infections Retention of urine Ictal or postictal state Undernutrition Metabolic conditions Subdural hematoma

BUN/Creatinine Ratio

Evaluates hydration status. An elevated ratio is seen in hypovolemia; a normal ratio with an elevated BUN and creatinine is seen with intrinsic renal disease

hemorrhage

Excessive or profuse bleeding; risk is greatest first 24-48 hours post injury or surgery

meds for ASCVD risk

GLP-1RA and SGLT2i

types of dressings

Gauze -passive= Transparent film, tegaderm -interactive= Hydrocolloid, Hydrogel - active= skin graft

NIHSS Stroke Scale

Grade severity of stroke 0 No stroke symptoms 1-4 Minor stroke 5-15 Moderate stroke 16-20 Moderate to severe stroke 21-42 Severe stroke Factors: Level of Consciousness, LOC Responsiveness, LOC Questions, LOC Commands, Horizontal Eye Movement, Visual field test, Facial Palsy, Motor, Arm, Motor Leg, Limb Ataxia, Sensory, Language, Speech, Extinction and Inattention If <5 then excludes tPA therapy Higher the score for each category, the worse the symptoms

Brown-Sequard Syndrome

Hemi-section of the cord - ipsilateral (same side) spastic paralysis and loss of position sense - contralateral (opposite side) loss of pain and thermal sense

incontinence

Inability to control passage of feces and gas to the anus

continent urinary diversion

Indiana pouch, Kock pouch, uretherosigmoidostomy

cellulitis

Infection of skin cells

Which conditions can cause delirium?

Infection, dehydration, urine retention, medications

causes of ischemic stroke

Large artery thrombosis • Small penetrating artery thrombosis • Cardiogenic embolic • Cryptogenic (no known cause) • Other

mechanical intestinal obstruction

Intraluminal obstruction or mural obstruction from pressure on the intestinal wall

diabetic sick day rules

Keep taking insulin, monitor glucose more frequently, watch for signs of hyperglycemia; drink 4-6oz every 30 min; check blood sugar every 3-4 hours; check ketones every 3-4 hours (type 1)

physical assessment of urinary functioning

Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment. Urinary bladder: Palpate and percuss the bladder or use a bedside scanner. Urethral orifice: Inspect for signs of infection, discharge, or odor. Skin: Assess for color, texture, turgor, and excretion of wastes. Urine: Assess for color, odor, clarity, and sediment.

position for a sigmoidoscopy

Knee-chest

Signs of increased ICP

LOC changes, eyes/pupils, HA and vomiting, increased BP, bradycardia and RR, seizures

Posterior Cord Syndrome

Loss of dorsal columns bilaterally, bilateral loss of proprioception, vibration, pressure, stereognosis, 2 point discrimination; preservation of motor function, pain and light touch; very rare!

diabetic retinopathy symptoms

Macular edema (blurred vision) Proliferative DR: ocular hemorrhages, floaters, blurred vision, flashes of light - traction, vision loss - retinal detachment

potential complications of parenteral nutrition

Pneumothorax - caused by improper catheter placement puncturing pluera - tx: semi fowlers, monitor VS, prepare for thoracentisis Air Embolism - caused by disconnecting tubing, cap missing from port or blocked segment of vascular system - tx: replace tubing, notify MD, turn patient on left side Clotted or Displaced Catheter - caused by infrequent flushes of lines - tx: flush with thrombolytic agent with the okay from the MD Sepsis - caused by separated dressings, infection at insertion sites, contaminated solutions - tx: notify MD/pharmacists and monitor VS Hyperglycemia - caused by glucose intolerance - tx: notify MD, may add insulin to PN solution Rebound Hypoglycemia - caused by feedings stopped too abruptly - tx: monitor for s/s (weakness, tremors, headache, hunger) and notify MD Fluid Overload - fluid infused too rapidly - tx: decrease rate, monitor VS, notify MD and tx resp distress by sitting up and O2 as needed

anorectal conditions

Proctitis Anorectal abscess Anal fistula Anal fissure Hemorrhoids Pilonidal sinus or cyst

upper UTI

Pyelonephritis: acute and chronic Interstitial nephritis Renal abscess and perirenal abscess

Dumping syndrome

Rapid emptying of gastric contents (hyperosmolar) into small intestines. Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia.

normal stoma appearance

Red, round, moist you want the stoma to stick out

Mini Nutritional Assessment (MNA)

Screening tool which evaluates 1. Independence 2. Medications 3. Number of full meals consumed 4. Protein intake 5. F & V 6. Fluid 7. Mode of feeding In individuals >/=65 YO

pressure injury stages

Stage 1: non-blanchable erythma of intact skin Stage 2: partial thickness skin loss with exposed dermis. wound bed is pink and moist Stage 3: full thickness skin loss in which adipose and granulation tissue is visible Stage 4: full thickness and tissue loss with exposed palpable fascia, muscle, tendon, or bone. slough and eshcar may be visible

what potential complication of severe preeclampsia may result from severe hypertension?

Stroke Hemorrhage Precipitous labor= rapid labor Disseminated intravascular coagulation

herpes varicella

highly contagious disease usually seen in childhood, commonly called chickenpox; transmitted via respiratory secretions or vesicular fluid

expressive aphasia

The inability to produce language ( despite being able to understand language)

continuous glucose monitoring (CGM)

Wearable technology that measures blood glucose automatically; may be linked to an insulin pump

Crohn's disease

a chronic autoimmune disorder that can occur anywhere in the digestive tract; however, it is most often found in the ileum and in the colon - inflammation anywhere in the GI tract -patches of inflammation -pain typically in lower right abdomen -ulcers penetrate the entire thickness of the abdominal lining -bleeding uncommon in BM

nodule

a circular, elevated, solid bump of greater than 0.5cm

vegetarian diet

a diet in which vegetables are the foundation and meat, fish, and poultry are restricted or eliminated

clear liquid diet

a diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello

vesicle

a fluid-filled blister less than 0.5cm in size

Hyperosmolar Hyperglycemic Syndrome (HHS)

a life threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.

macule

a non-palpable, flat lesion that is different in color, and less than 0.5cm in size

vegan diet

a plant-based diet that eliminates all animal products

CT scan

a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body; high sensitivity for detecting lesions; IV contrast

perceived constipation

a subjective problem in which the person's elimination pattern is not consistent with what he or she believes is normal

gastrostomy tube

a surgically placed feeding tube from the exterior of the body into the stomach

MRI

a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain; more sensitive for cerebral abnormalities; painless; no radiation; with or without contrast

ischemic stroke

a type of stroke that occurs when the flow of blood to the brain is blocked

clean catch specimen

a urine specimen that does not include the first and last urine that is voided; also called mid-stream

PET scan (positron emission tomography)

a visual display of brain activity that detects where a radioactive form of glucose goes while the brain performs a given task nuclear imaging; radioactive substance to see blood flow, tissue composition, and metabolism; useful to see metabolic changes in Alzheimer's

Symptoms of Crohn's disease

abdominal pain (RLQ), diarrhea, pain, and fever, skin rashes, arthritis and inflammation of eye; found anywhere in the GI tract

urinary retention

abnormal accumulation of urine in the bladder because of an inability to urinate

UTI in males

absence of urinary catheter is complicated b/c usually associated with renal stones, strictures, or enlarged prostate

anuria

absence of urine

effects of bedrest on nutrition

accelerates loss of muscle mass, function, glucose tolerance; needs leucine rich foods; skin integrity issues

BEFAST

acronym to remember sudden signs that stroke is occurring - Balance - loss of balance; Eyes - blurred vision; Face - one side of face is drooping; Arms - arm (or leg) weakness; Speech - speech difficulty; Time - time to call 911 (or notify nurse if the resident is in a health care facility)

nursing management of ischemic stroke

adequate oxygenation, elevation of HOB, antihypertensive treatment, monitor blood glucose, frequent NIHSS/neuro assessments

signs to monitor for with hemorrhagic stroke

altered LOC, sluggish pupillary reaction, motor and sensory dysfunction, cranial nerve deficits, speech difficulties, visual disturbance, headache and nuchal rigidity

lower UTI

cystitis, prostatitis, urethritis

risk factors for spinal cord injuries

younger age, male gender, and alcohol and drug use

nursing complications with ischemic stroke

alternate communication and speak clearly, place objects in field of vision, use assistive devices when ambulating, encourage use of eyeglasses, provide active or passive ROM to affected side reoritent patient, repeat instructions, verbal cues, educate pt and family about potential for emotional lability

dermatomes

an area of the skin supplied by nerves from a single spinal root

papule

an elevated solid lesion, up to 0.5cm in size, circumscribes and firm, appears in various colors

Non-proliferative diabetic retinopathy

aneurysms form in blood vessels

EEG nursing considerations

anticonvulsants or other meds sometimes withheld before; dietary limitations may be necessary (glucose and caffeine); pt must lie quietly; reassure that no sensation is felt

communication impairments from chronic ischemic stroke

aphasia, apraxia, dysarthia

assessment of pt with blistering disease

appearance of the skin, monitor VS frequently for signs of infection, pain, pruritis, discomfort, coping of the patient with condition, note impact of pt activities

nursing management of wounds

assessment of the wound and dressing, promote wound healing, prevention of further breakdown, proper and timely wound care, pain management during dressing changes, pt and fam education

vitamin K

assists in normal clotting of blood

bacturia

bacteria in the urine

reasons for urinary diversion

bladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic infection or intractable cystitis; used as a last resort for incontinence

intestinal obstruction

blockage prevents the normal flow of intestinal contents through the intestinal tract

sanguineous drainage

bloody drainage; abnormal in wounds

charcot joint

bone and joint destruction secondary to a neuropathy and loss of sensation

Transient Ischemic Attack (TIA)

brief episode of loss of blood flow to the brain, usually caused by a partial occlusion that results in temporary neurologic deficit (impairment); often precedes a CVA lasts 1-2 hrs

ecchymosis

bruising

major minerals

calcium, phosphorus, potassium, sulfur, sodium, chloride, magnesium

Why can urine retention cause delirium?

can lead to a UTI that can become systemic and cause delirium

MNT strategies for type 1 diabetes

carbohydrate counting (2-4 serving per meal) -meal timing -carb load -macronutrient balance -insulin to match carbs -considers impact of fat and proteins -considers physical activity

six types of nutrients

carbohydrates, proteins, fats, vitamins, minerals, water

irritable bowel syndrome (IBS)

chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation, or both

ulcerative colitis

chronic inflammation of the colon with presence of ulcers -limited to the large intestine/colon -inflamed areas are continuous with no patchiness -typically inflammation in lower left abdomen -ulcers penetrate the inner lining of the abdomen only -bleeding common during bowel movements

triggers of IBS

chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods

serous drainage

clear, watery plasma

herpes simplex type 1

cold sores, fever blisters

wound care COCA

color, odor, consistency, amount of drainage

components of neuro assessment

consciousness and cognition, cranial nerves, motor system, sensory, reflexes

liquid diet

consist of liquids ( a liquid is described as food that is fluid at room temperature or becomes liquid at room temperature; puddings, gelatins

Macrovascular complications of diabetes

coronary artery disease, peripheral vascular disease, cerebrovascular disease -> heart failure

nurse role in pressure injuries

determine the risk, examine the skin, ask about pain, intervene to reduce risk

high waist circumference risks

diabetes, dyslipidemia, hypertension, heart attack, stroke

dysarthria

difficulty forming words

hemorrhoids

dilated, engorged veins in the lining of the rectum

geriatric considerations for skin

diminished epidermal thickness and tissue elasticity, drier skin, decreased tissue perfusion, muscle atrophy, decreased sensory perception

diabetic retinopathy

disease of the retina in diabetics characterized by capillary leakage, bleeding, and new vessel formation (neovascularization) leading to scarring and loss of vision -screen with annual dilated retinal exam -first exam within 6 months of T2DM diagnosis -first exam within 5 years of T1DM diagnosis

celiac disease

disorder of malabsorption caused by an autoimmune response to consumption of products that contain the protein gluten

psuedobulbar affect

emotional lability, a distinct neuromuscular condition where patient has unpredictable and sudden emotional outbursts of laughing, crying and other emotional displays. associated with brain injury, can impact QOL for patient and family

three purposes of skin care emerge

enhancing comfort and well-being, keeping the skin intact and healthy, cleaning

polyuria

excessive production of urine

PET Scan Nursing Considerations

explaining test; educate pt about sensations with injection of radioactive substance

presenting symptoms of hemorrhagic stroke

exploding headache, decreased LOC

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma

pureed diet

foods have been blenderized to liquid form; consistency based on client's needs, nectar or honey thick, can be long term; for residents with chewing or swallowing problems

professional CGM

for diagnostic purposes for short duration

diabetic ketoacidosis symptoms

fruity breath, hyperglycemic, ketosis, metabolic acidosis. weight loss, nausea/vomiting, abdominal pain, dehydration with electrolyte loss, polyuria, polydipsia, fatigue, blurred vision, headache, hypotension, decreased level of consciousness, Kussmaul respirations

transection of the spinal cord

full severing which paralyzes below the level of the injury

herpes simplex type 2

genital herpes

neuropathy management

glycemic control, pain management, low fiber and fat diet, small meals, meds and BP management for ED

conductive hearing loss

hearing impairment caused by interference with sound or vibratory energy in the external canal, middle ear, or ossicles (cerumen blockage, ear infections)

sensorineural hearing loss

hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness (prolonged exposure to loud noises)

motor loss from chronic ischemic stroke

hemiplegia, hemiparesis, ataxia, dysphagia

autonomic dysreflexia symptoms

high BP, low HR, pale lower extremities

DASH diet

high protein, high fiber, reduces risk of heart disease; primarily whole grains, vegetables, fruits, low-fat dairy, lean protein

Risk factors of ischemic stroke

hypertension, dyslipidemia, diabetes, smoking, obstructive sleep apnea, excessive alcohol consumption, migraine, obesity, sedentary lifestyle, carotid stenosis, A-fib; older age, men, some races

Causes of hemorrhagic stroke

hypertension, medications, vascular malformations, brain tumors, venous thrombosis, amyloid angiopathy

cutaneous urinary diversion

ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy

why SCI patients at increased risk for PE?

immobility and stagnant blood forming clots into the lungs

management of SCI in acute phase

immobilization, reduction of dislocations, stabilization of the vertebral column (c collar or traction)

right sided stoke symptoms

impaired judgment, spatial-perceptual deficits, and a tendency to deny or minimize problems

cognitive impairment and psych effects of chronic ischemic stroke

impaired learning/memory, limited attention span, difficulties in comprehension, forgetfulness, lack of motivation, depression, fatigue

apraxia

inability to perform particular purposive actions, as a result of brain damage.

receptive aphasia

inability to understand spoken or written words

lacto-ovo-vegetarian

includes dairy and eggs

DASH diet

increase fruit, vegetables, and low fat dairy; k, mg, ca to stop hypertension

geriatric skin changes

increased tendency of the skin to tear, decreased sweat response, poor skin turgor (loss of collagen), SQ fat decreases, temp regulation, wrinkling and sagging of skin, decreased nerve endings and sensation

diverticulitis

infection and inflammation of diverticula

urinary tract infection (UTI)

infection of the urinary system; can involve your urethra, kidneys, or bladder

causes of diarrhea

infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

cystitis

inflammation of the bladder

stomatitis

inflammation of the oral mucosa

pyelonephritis

inflammation of the renal pelvis and the kidney

urethritis

inflammation of the urethra

acne

inflammatory disease of the skin involving the sebaceous glands and hair follicles

pressure injuries

injuries or wounds that result from skin deterioration and shearing - localized, may be painful, commonly seen in patients with SCI, critically ill, hospice, or using medical devices

primary spinal injuries

injuries that occur immediately and as a result of direct force

Autonomic Dysreflexia

involves uncontrolled activation of autonomic neurons

trace minerals

iron, iodine, manganese, zinc, copper, and fluorine

mechanical soft diet

is recommended for people with difficulty in chewing

abnormal clotting of COVID-19 can cause

ischemic stroke

pruritis

itching

purpose of T tube

keep the common bile duct patent; prevents edema

nursing considerations with liquid diets

lacks calories and poor energy sources; short-term transitional diets

lacto-vegetarian diet

lacto-vegetarians eat milk, cheese, and dairy foods, but avoid meat, fish, poultry, and eggs

position for tap water enema

left lateral recumbent

symptoms of poorly controlled diabetes

leg ulcers, loss of visual acuity, thick yellow toenails, decreased sensations in the feet, decreased growth of body hair

good sources of water-soluble vitamins

lemons, oranges, limes, grapefruit, broccoli, collard greens, spinach, turnip greens, kale

lipid management

lifestyle modification -DASH or mediterranean diet -weight loss -exercise primary prevention secondary prevention

nursing implications for CT scan

prep for CT, IV contrast (shellfish allergy), intact IV, relaxation techniques for advocating for patients

hematuria

presence of blood in the urine

Which findings indicate that a client is at an increased risk for colorectal cancer?

presence of dark, tarry stools family history of polyposis 20 year history of ulcerative colitis unintentional 20lb weight loss change in bowel pattern for 3 months

proteinuria

presence of protein in urine

Antiplatelet therapy

primary- aspirin 81mg secondary- aspirin 81mg, dual therapy for 1 year after acute coronary syndrome, dual therapy long term for CHD with intervention and high ASCVD risk

nursing interventions for SCI

promote breathing and airway clearance, improved mobility, preventing injury due to sensory perceptual alterations, maintaining skin integrity, maintaining urinary elimination, improving bowel function, comfort, counseling on sexual expression, enhancing coping mechanisms

vitamin D

promotes absorption of phosphorus and calcium to build and maintain bones

vitamin E

protects red blood cells; stabilizes cell membranes

nursing care of pt with nasogastric, nasoenteric, gastrostomy, and jejunostomy tube

pt education and preparation, tube insertion, confirming placement, clearing tube obstructions, monitoring the patient, maintaining tube function, oral and nasal care, monitoring and preventing complications, tube removal

signs of peritonitis

rebound tenderness, diminished bowel sounds, rigid abdomen

nursing care for patients with pruritis

reinforce prescribed therapeutic regimen, educate of self care, use tepid water for bath, avoid rubbing with towel, lubricate skin after bathing, avoid situations that cause vasodilation

debridement

removal of foreign material and dead or damaged tissue from a wound

intermittently scanned CGM

require action to store data, consistently scans blood sugar

impaction

results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel

Sequence of vomiting

reverse peristalsis, contraction of abdominal muscles, gastric contents propelled into esophagus, upper esophageal sphincter relaxes, trachea closes to prevent aspiration

why should tube feeding and decompression of the stomach not use the same tubing?

risk of aspiration

diverticulum

sac-like herniation of the lining of the bowel that extends through a defect in the muscle layer

hemorrhaging

serious bleeding inside the body

biochemical assessment for nutrition

serum prealbumin and albumin (liver functioning; malnutrition); serum transferrin and retinol-binding protein; complete blood count (iron); electrolytes; urine tests

BUN

serves as an index of renal function

pustule

similar to a vesicle but filled with pus instead of fluid

soft diet

similar to regular diet, but foods must require little chewing and be easy to digest

autonomic dysreflexia interventions

sitting position, check bladder, exam for fecal mass, assess skin, assess for noxious stimuli, patient education

assessment of pt with toxic epidermal necrolysis or stevens-johnson syndrome

skin inspection, oral cavity inspection, vital signs, respiratory status, fatigue and pain levels, urine volume, specific gravity, signs of infection, daily weight, evaluate for anxiety and coping mechanisms

neuropathy screening

skin inspection, vascular assessment, inspect for deformities, pinprick and temperature, vibration, proprioception, monofilament

symptoms of left sided stroke

slow performance and cautious behaviors, impaired speech and language aphasias, and awareness of deficits with depression and anxiety

factors unique to delirium when distinguishing between delirium and dementia?

slurred speech lability of mood long-term memory loss visual or tactile hallucinations insidious deterioration of cognition fluctuating level of consciousness

urge incontinence

state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void

symptoms of dehydration

sunken eyes, dry mucus membranes, poor skin turgor, tachycardia, decreased blood pressure

symptoms of hypoglycemia

tachycardia, excessive sweating (diaphoresis), light-headedness, visual disturbances, fatigue, weakness, nervousness

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

iatrogenic incontinence

the involuntary loss of urine due to extrinsic medical factors, predominantly medications

functional incontinence

the person has bladder control but cannot use the toilet in time

ileostomy stool characteristics

thin and liquid stool

geriatric considerations of nutrition

total body protein decreases, food purchasing and prep difficulties, impaired acuity of taste and smell, living arrangements, loss of partner, polypharmacy, poverty, nerve disorder, dental health

nasogastric tube

tube inserted through the nose into the stomach

BMI ranges

underweight: <18.5 normal: 18.5-24.9 overweight: 25-29.9 obese: >30

residual urine

urine that remains in the bladder after urination

potential complications of SCI

venous thromboembolism, orthostatic hypotension, autonomic dysreflexia/hyperreflexia

HHS symptoms

very high glucose 600-1200, rapid pulse with hypotension, profound dehydration, CNS changes due to lack of fluid and electrolytes hallucination focal orthostatic, dry membranes skin seizures

herpes zoster

viral disease affecting the peripheral nerves, characterized by painful blisters that spread over the skin following the affected nerves, usually unilateral; also known as shingles

perceptual disturbances from chronic ischemic stroke

visual-perception dysfunction, visual-spatial dysfunction, loss of peripheral vision, diplopia

Acts as a solvent and aids digestion, absorption, circulation, and excretion

water

hemiparesis

weakness on one side of the body

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevates. Which is an important nursing intervention?

weight patient daily restrict oral fluid intake measure urine specific gravity observe the client for increasing confusion

foods to avoid with celiac disease

wheat, barley, rye, and other grains, malt, dextrin, and brewer's yeast

leucine rich foods

whey protein, milk, beef, chicken, yogurt, peanuts, and soy foods

Mediterranean diet

whole grains, fruits, vegetables, legumes, nuts, seeds, fish, and olive oil and limits meat, saturated fat, and full-fat dairy products.

evisceration

with total separation of wound layers (protrusion of visceral organs) through wound opening occurs

how to determine nasogastric tube placement

x-ray, pH testing for 1.5-3.5 for stomach, and auscultate stomach when pushing air through tubing

purulent

yellow, gray or green drainage due to infection of the wound

jaundice

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood

Reasons for Catheterization

•Relieving urinary retention •Prolonged patient immobilization •Obtaining a sterile urine specimen when patient is unable to void voluntarily •Accurate measurement of urinary output in critically ill patients •Assisting in healing open sacral or perineal wounds in incontinent patients •Emptying the bladder before, during, or after select surgical procedures and before certain diagnostic examinations. •Providing improved comfort for end-of-life care