NR 224Exam 3 study guide

NR224: Fundamentals: Skills Study Guide for Exam 3 70 questions total including 5 math conversions  Nursing Diagnosis o PES / 1, 2, 3 Directly address the PES. Such as: wound healing: looking for PES that related ...

NR224: Fundamentals: Skills Study Guide for Exam 3 70 questions total including 5 math conversions  Nursing Diagnosis o PES / 1, 2, 3 Directly address the PES. Such as: wound healing: looking for PES that related wound healing. Not select other thing else. EX: PT stage 3 and non-healing ulcer which fowling statement best support PES……..NOT looking for related infection. P: impair skin integrant. E: left side weakness. S/S: secondary life style, incontinent. o Validation o Problem / NANDA o Etiology / Causative factors o Defining characteristics / signs and symptoms o Expected outcomes / patient goals o Nursing interventions o Education interventions  Nutrition BMR requirements: is the energy needed to maintain life-sustaining activities (breathing, circulation, heart rate, and temperature) for specific period of time at rest. The amount of energy or number of calories burned to maintain life sustain activities at rest. Weight can effect by calories intake. Reduce my calories intake my weight will reduce Eat too many calories intake my weight gain weight If I eat the same calories then I will maintain my weight EX: If PT BMR is imbalance, we want to the PT eat 5 or 6 small high calories meals to meet body requirement, Monitor PT calories intake by keep them dietary log, Then RN review the dietary log to make recommendation to the PT increase the calories intake. Also review the Lab albumen and monitors their weight. BMR imbalance caused factors: decease nutritional intake, abortion in the GI track o Assessment for wound healing NR224: Fundamentals: Skills Study Guide for Exam 3 Intake and hydration in the food. Hydration: skin turgor Intake: 24 recall. (The % of amount intake) what percent did the PT eat. o Diet types Maintain protein is created positive nitrogen base that help the deposition and granulation tissue grows. Need energy and vitamin: A, C and zinc. Low fat diet: all old people (cardiac disease PT has least 10% fat diet. Risk of low fat diet: interfered absorption of soluble fat vitamins. Depression, colon and breasts cancer. Related food. o 3 part Nursing diagnosis Ex: imbalance nutrition: less than body requirements related to decrease ability to ingest food as a result of depression. Diagnosis Risk for aspiration Diarrhea Deficient knowledge Imbalance nutrition less/more than body required Impaired swallowing  Expected outcomes Mrs Cooper will progressively gain weight. Will gain 1 or 2 pounds per month until goal of 130 pounds is reached. Will ingest 1900 kcal/day, including 50g of protein per day.  Teaching:  Interventions: coordinate plan of care with health care provider, PT and dietitian. Mini test: 12-14 normal 8-11 at risk 0-7 malnourished  Enteral tubes o How to insert an NGT: measure for nose to ear and to stomach Gags keep going Cough pulling out. o Verification of placement 1. Measurement: Ph 1-4 2. Chest X –ray 3. NGT to suction by after the x –ray. o Small bore vs. large bore tubes NR224: Fundamentals: Skills Study Guide for Exam 3 Large bore NG to decompression the small bowel. Can get medication Small bore is enteral feeding and give medication. (Dobudff) Both one medication at one time follow each time and 15 ML fluid flashed each time after each follow the administration (Discounted) Medication cannot crush enter costed any time Intervention for medication: PT has no time, so we can call the doctor get new order (Liquid). Change to liquid formed meds. o Aspiration risks and nursing interventions  Dysphagia: difficulty swallowing  Different diet used  Chopped diet  Thinking water and juice.  High position  Not lower than 30 degree. o Formula temperature for tubes  Consequences of temperature  Need to room temperature otherwise PT get abdominal cramping.  Too fast gets abdominal cramping o Complications of tubes  Clogging the tube: Dislodging or Migrated can go to lungs, remeasure the gastro tube but need to get X ray first. For intermittently fed patients, test placement immediately before feeding (usually a period of at least 4 hours has elapsed since previous feeding). More frequent checking has been associated with increased clogging of small-bore tubes. To avoid clogging, flush tube with 30 mL water after aspirating for the gastric residual volume o Assessment of gastric residual NG- PT get (intermittent or continuous feeding) check the GRV (stomach contain the volume) 60 cc and undo the feeding. Drown back to see the volume. If the volume is greater 250 Ml, feeding is too fast for PT to digest then call doctor. Alter the feeding. If measure 500 ml just once that is problem even though PT has high fyler position 90 degree. Put respiration issue. Normal is 40-45 Ml per hour  Urinary NR224: Fundamentals: Skills Study Guide for Exam 3 Cultural issue: people have difficulty to talk with GI or UI problems Intervention: find someone who has the same culture. o Oliguria: decease urine volume  Nursing interventions: increase fluid intake, less contraindicated.  Treat: monitor Intake and output. Assesse for skin turgor. Check for UA Low specific gravity solute in urine then sign of dehydration. High specific gravity solute in urine then sign of hydration. o Anuria: lack of urine volume, Kidney dises and renal disease. Diabetes: lose weight o Incontinence types