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NURS202 ExamII Pt2

Need for Nutrition and Elimination, NG tube,endoscopy,colostomy,enemas

What would assessment concerns be for a patient with a nursing diagnosis of "imbalanced nutrition: less than body requirements"? baseline data- weight, lab values, muscle tone of muscle required for swallowing and mastication, GI, oral, GU(abnormal or absent menses), nutritional history, etiology factors, patients attitude towards eating/food
What baseline data would you need to get a patient's overall nutritional status? dietary data, medical and socioeconomic data, anthropometric data, BMI and waist circumference, clinical data, biochemical data
What does the acronym DETERMINE mean and how is it used? Disease, Eating poorly, Tooth loss/mouth pain, Economic hardship, Reduced social contact, Multiple medicines, Involuntary weight loss/gain, Needs assistance in self-care, Elder >80 yrs,it is dietary data used to detect signs of poor or malnutrition
What should be assessed regarding bowel elimination? recent changes in bowel elimination, usual patterns of bowel elimination, problems with bowel elimination, aids to elimination, presence of artificial orifices (ostomy sites)
What should be assessed regarding nutrition? BMI,meds,hydration,disease/metabolic processes(stress),medical Hx,diagnostic procedures,illnesses,therapies,treatments,vitamins,signs of malnutrition,I&O,allergies,GI hx,alcohol/caffeine use,intolerances/avoidances,oral/dental,economics,exercise
How is nutrition related to wound healing? adequate proteins,carbs,fats,vits and minerals are required. calories and proteins:rebuild cells and tissue, vit A & C:regrowth of epithelial tissue and collagen synthesis, zinc:production of cells, fluids:optimal functionality of cells
What ways can correct NG tube placement be verified? x-ray(best), assess aspirate visually and for pH level(>7), insufflation and ascultation, measure length of exposed tubing to compare with initial placement measurement, verify mark made on tube at time of initial placement
What nursing interventions are involved with placement of an NG tube? explain to patient purpose/procedure/expected sensations, inserting tube, confirm placement, monitor patient and maintain tube function, provide oral/nasal hygiene/care, monitor for potential complications, remove tube
How is the length of the NG tube determined? measuring distance from tip of nose to earlobe and from earlobe to xiphoid process; add 6 in for NG placement
If a patient with an NG tube has poor or no drainage what does this indicate and what should be done? possibly blocked or malpositioned tube. check suction equipment for proper function, verify no anastomoses nearby, attempt to reposition the tube, irrigate tube, air check the patency
What are nursing interventions for a patient undergoing an endoscopy? NPO for 8hrs pre-exam,admin of local anesthetic,possible admin of sedative,anticholinergic or glucagon,patient in L lateral position,post-exam assessments:LOC,VS,oxygen saturation,pain,signs of perforation,need someone to take home/receive discharge info
What would you educate a patient about who just had a colostomy procedure? skin care and it's importance,how to apply/remove drainage pouch,empty/change pouch when 1/3 to 1/4 full,irrigation,encourage patient to express any concerns,know when to call physician/which complications need prompt attention,nutrition and impact,meds
What is the correct positioning for an enema? L side, semi-prone, L leg extended, R leg flexed, L arm along back, chest forward (Sim's position)
What diagnostic tests/studies are associated with the GI system? stool collection,endoscopy,radiography,UGI and small bowel series,barium enema,abdominal ultrasound,MRI,abdominal CT scan
Created by: kgrabo99