How to assess if patient needs assistance with feeding?

Special needs, glasses, dentures, special utensils, blind, thickner.

How do you prepare the patient for eating?

Correct position/pt. Wash hands nurse/pt. Right tray/diet

Safety factors in feeding?

Temperature, consistency, bite size.

How to evaluate food intake?

Use percentages, count fluid actually consumed (30cc = 1oz). When counting calories: list food and count percentage.

Common Hospital Diets?

Regular, light, soft, mechanical soft, full liquid, clear liquid, special therapeutic.

Omit fried, gas forming, raw, fatty or rich foods.

similar to soft, foods more cooked.

juices, cream soup, milk, ice cream, gelatin, cooked cereal.

water, clear broth, clear juice, plain gelatin, tea.

Special adaptive devices you can use with clients with special needs?

Large handles, high ridge plates, straw, grip mats under plates.

Nursing responsibilities when serving food?

Ordering/canceling diet, serving/collecting meal trays, helping clients eat, record percentages of food eaten.

Steps to prepare the client to eat?

Correct patient/position, wash hand, tray, right diet, allergies, special needs.

Methods of serving food which will encourage safety and appetite?

Temperature, culture, make foods appealing, cutting up food, encourage independence.

Emotion and safety factors involved with feeding a client who is unable to feed oneself?

frustration, encourage independence and choices.

Factors that influence nutritional needs?

Food preferences, meal patterns, attitudes, knowledge, income, time, eating habits, religious beliefs.

Three facts the nurse must know about a client's diet?

type of diet, purpose of diet, characteristics of the diet.

Three unique aspects of nutrition that apply to older adults?

Age related physical changes, underlying medical condition, adverse effects of medication therapy, functional impairments.

Practices that promote health through personal cleanliness.

5 hygiene practices that most people preform regularly?

bathing, shaving, oral hygiene, hair care, nail care.

2 reasons a partial bath is more appropriate than a daily bath for older adults?

they do not perspire as much, and soap tends to dry their skin.

3 advantages of towel or bag baths?

add lubrication to skin, avoid friction to preserve skin integrity, reduce transmission of microorganisms from one part of the body to the other, saves times.

Name four visual and hearing devices?

eye glasses, contact lenses, artificial eye, hearing aid.

2 alternatives for clients who cannot insert or care for their own contact lenses?

eye glasses, magnifying lens, doing without while ill.

4 reasons for sound disturbances experienced by people who wear hearing aids trouble shooting procedures.

dead weak batteries, batteries not making full contact, corroded batteries, mal position within the ear.

Different types of hearing aid devices?

External, internal, behind ear, body aid, infrared.

external hearing device?

small self contained, fits just outside the ear.

internal hearing device?

small self contained, fits entirely in the ear.

behind ear hearing device?

larger, self contained, fits behind ear with connector. Has a sound amplifier.

body aid hearing device?

external, uses electrical components enclosed within a case carried on the body. delivers sound via a wire connected to an ear mold receiver.

infared hearing device?

convert sound to infared light then light to sound through a receiver worn in a headset with ear phones.

Components of early AM care?

knock, initiate, conversation, provide a pleasant environment, wash hand/face, give oral care, position for breakfast, do not communicate disapproval, respect patient.

Nurses role in assisting clients with self care.

encourage independence, assist when needed.

Assess the need for teaching for patients in different stages in their life cycle?

Children: learn while growing up, family practices may dictate hygiene rituals. Feeling about body/nudity. Elderly: need less bathing. Teenagers: longer hot showers, increased body awareness.

How to toilet a patient?

bathroom, commode, bed pan, urinal.

components of a healthy mouth?

NO: sores, coated tongue, cracked lips, broken/cracked teeth.

Benefits of good oral hygiene?

prevent bacteria build up that causes bleeding gums and inflammation.

differences in providing oral care to dependent VS unconscious clients?

position the head of an unconscious client to the side.

care and special needs for the clients with dental appliances?

massage gums, look for sores, check pt. for cleaning preference, remove at night.

3 items recommended for oral hygiene?

tooth brush, floss, toothpaste/mouthwash.

dried crusts containing mucous, microorganisms, and epithelial cells shed from mucous membranes.

Chief hazard in providing oral hygiene to the unconscious client?

aspiration of liquid into the lungs.

Ways to prevent aspiration in an unconscious pt.

Position client on side with head lower than the body. Use oral suction equipment.

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Fundamentals Quiz #3

Bates Fundamentals Quiz #3

Question	Answer
How to assess if patient needs assistance with feeding?	Special needs, glasses, dentures, special utensils, blind, thickner.
How do you prepare the patient for eating?	Correct position/pt. Wash hands nurse/pt. Right tray/diet
Safety factors in feeding?	Temperature, consistency, bite size.
How to evaluate food intake?	Use percentages, count fluid actually consumed (30cc = 1oz). When counting calories: list food and count percentage.
Forms of communication used during feeding?	Clock plate
Common Hospital Diets?	Regular, light, soft, mechanical soft, full liquid, clear liquid, special therapeutic.
Regular Diet?	Normal, no restrictions.
Light Diet?	Omit fried, gas forming, raw, fatty or rich foods.
Soft Diet?	Low in residue.
Mechanical Soft?	similar to soft, foods more cooked.
Full Liquid?	juices, cream soup, milk, ice cream, gelatin, cooked cereal.
Clear Liquid Diet?	water, clear broth, clear juice, plain gelatin, tea.
Special Therapeutic Diet?	Low sodium/fat/fiber.
Special adaptive devices you can use with clients with special needs?	Large handles, high ridge plates, straw, grip mats under plates.
Nursing responsibilities when serving food?	Ordering/canceling diet, serving/collecting meal trays, helping clients eat, record percentages of food eaten.
Steps to prepare the client to eat?	Correct patient/position, wash hand, tray, right diet, allergies, special needs.
Methods of serving food which will encourage safety and appetite?	Temperature, culture, make foods appealing, cutting up food, encourage independence.
Emotion and safety factors involved with feeding a client who is unable to feed oneself?	frustration, encourage independence and choices.
Factors that influence nutritional needs?	Food preferences, meal patterns, attitudes, knowledge, income, time, eating habits, religious beliefs.
Three facts the nurse must know about a client's diet?	type of diet, purpose of diet, characteristics of the diet.
Three unique aspects of nutrition that apply to older adults?	Age related physical changes, underlying medical condition, adverse effects of medication therapy, functional impairments.
Hygiene?	Practices that promote health through personal cleanliness.
5 hygiene practices that most people preform regularly?	bathing, shaving, oral hygiene, hair care, nail care.
2 reasons a partial bath is more appropriate than a daily bath for older adults?	they do not perspire as much, and soap tends to dry their skin.
3 advantages of towel or bag baths?	add lubrication to skin, avoid friction to preserve skin integrity, reduce transmission of microorganisms from one part of the body to the other, saves times.
Name four visual and hearing devices?	eye glasses, contact lenses, artificial eye, hearing aid.
2 alternatives for clients who cannot insert or care for their own contact lenses?	eye glasses, magnifying lens, doing without while ill.
4 reasons for sound disturbances experienced by people who wear hearing aids trouble shooting procedures.	dead weak batteries, batteries not making full contact, corroded batteries, mal position within the ear.
Different types of hearing aid devices?	External, internal, behind ear, body aid, infrared.
external hearing device?	small self contained, fits just outside the ear.
internal hearing device?	small self contained, fits entirely in the ear.
behind ear hearing device?	larger, self contained, fits behind ear with connector. Has a sound amplifier.
body aid hearing device?	external, uses electrical components enclosed within a case carried on the body. delivers sound via a wire connected to an ear mold receiver.
infared hearing device?	convert sound to infared light then light to sound through a receiver worn in a headset with ear phones.
Components of early AM care?	knock, initiate, conversation, provide a pleasant environment, wash hand/face, give oral care, position for breakfast, do not communicate disapproval, respect patient.
ADL?	activities of daily living.
Nurses role in assisting clients with self care.	encourage independence, assist when needed.
Assess the need for teaching for patients in different stages in their life cycle?	Children: learn while growing up, family practices may dictate hygiene rituals. Feeling about body/nudity. Elderly: need less bathing. Teenagers: longer hot showers, increased body awareness.
Universal precautions for hands?	gloves
How to toilet a patient?	bathroom, commode, bed pan, urinal.
Steps to maintain privacy while toileting a patient?	close door, pull curtain.
Proper handling and disposing of wastes and equipment?	gloves, dispose in toilet.
components of a healthy mouth?	NO: sores, coated tongue, cracked lips, broken/cracked teeth.
Oral mucosa's job?	first line of defense.
Benefits of good oral hygiene?	prevent bacteria build up that causes bleeding gums and inflammation.
differences in providing oral care to dependent VS unconscious clients?	position the head of an unconscious client to the side.
care and special needs for the clients with dental appliances?	massage gums, look for sores, check pt. for cleaning preference, remove at night.
3 items recommended for oral hygiene?	tooth brush, floss, toothpaste/mouthwash.
Sordes?	dried crusts containing mucous, microorganisms, and epithelial cells shed from mucous membranes.
Chief hazard in providing oral hygiene to the unconscious client?	aspiration of liquid into the lungs.
Ways to prevent aspiration in an unconscious pt.	Position client on side with head lower than the body. Use oral suction equipment.
How to prevent damage to dentures?	nurse hold dentures over a plastic or towel lined contained and uses cold/tepid water.
Types of razors?	electric or safety.
Safety precautions in shaving?	discard in sharps container.
How to effectively shave a male patient?	wash skin, lather, shave in direction of hair growth, pull skin taut, rinse, dry.
Two situations in which shaving with a safety razor is contraindicated?	clients with clotting disorders, those receiving anticoagulants and thrombolytics, and those who are depressed or suicidal.
Principals of hair care?	clients preference, brush slowly/carefully using a wide tooth comb starting at the ends. Avoid hair pins and clips.
What to do for a client with oily hair?	use oil, castor oil, olive oil, and mineral oil.
Methods of removing hair tangles?	apply conditioner or alcohol.
Pediculosis?	lice (head lice)
Treatment of pediculosis?	OTC medication, wash linen, vacuum, clean all hair and body items.
Dandruff?	itching and flaking of the scalp.
Scabies?	burrows under skin, leaves tracks.
Ticks?	blood sucking parasite, burrows head in under the skin.
How to care for pt. nails?	clean under nails, cut straight across.
How to care for the diabetics nails?	use a file.
How to care for pt. eyes?	note secretions, moisten crusts, cleanse inner to outer.
how to care for pt. nose?	check kardex for special treatment, not drainage color, consistency, amount, odor. Note any skin breakage.
What is a healthy nose?	should be pink, moist, free of obvious drainage. Air should move freely and fairly quietly.
Nose is used for?	Medications, tubing, respirations, oxygen.
Nose drainage is caused by?	Infection, allergy, injury, illness.
How to blow nose?	both nostrils open to avoid transporting bacteria to other areas.
How to care for a hearing aid?	Pt. preference. Avoid water exposure & chemicals and cleanse with cloth.
When to change hearing aid battery?	Q100-200h
How to care for pt. eyeglasses?	Pt preference. Tepid water/mild soap. Hold by nose/ear brace and dry with soft cloth.
How to care for pt contact lenses?	Pt preference. Rinse and put in proper container.
How to care for an artificial eye?	pt preference. Slide eye free, irrigate eye and cleanse artificial eye as ordered. Check for damage or irregularities.
Functions of the skin?	Protect inner body structures, regulate temperature, maintain fluid/chemical balance. Provides sensory information pain/temperature/touch/pressure.
Sitz bath characteristics?	Immersion of buttox and perineum in a small basin of continuously circulating water. Removes blood, serum, stool, urine, reduces swelling.
Whirlpool bath characteristics?	Warm water continuously agitated within a tub/tank. Improves circulation, relieves discomfort, removes dead tissue.
Tub bath/ Shower characteristics?	Independent bathing.
Partial Bath characteristics?	washing body areas subject to greatest soiling or that are sources of body odor. Face, hands, axillae, perineal area.
Towel bath characteristics?	nurse uses a single wide towel to cover and wash the client.
Temperature of baths?	105-110 degrees.
Primary purpose of the bath?	eliminate body odor, reduce infection potential, stimulate circulation, provide a refreshed feeling, improve self image.
Primary purpose of a back rub?	Relaxation, improves circulation.
Primary purpose of skin care?	To keep skin clean and intact.
Reasons a person would need a bed bath?	Client cannot take a tub bath or shower independently.
How do you provide for safety during a bed bath?	The use of side rails.
How do you provide comfort during a bed bath?	The moist towel or cloths are used so quickly they are warmer when applied. A bath blanket to keep warm.
How do you provide privacy during a bed bath?	Draping techniques, exposing only one body part at a time, using a bath blanket.
Components of nail and foot care?	Check kardex, keep nails cleaned and trimmed.
Patient conditions that the nurse would approach nail and foot care with extreme caution?	Diabetics, vascular disease, fungal infection, circulation problems.
Reasons for giving perineal care?	vaginal delivery, rectal surgery, soiled.
Types of patients you would assist with peri care?	Infants, incapable/coma, vaginal delivery, gynecologic/rectal surgery.
Acne?	inflammatory disease with skin eruptions due to infection of the oil glands and hair follicles of the skin. Characterized by papules and pustules.
Alopecia?	absence or loss of hair, especially on the head.
Furncle?	usually caused by staph or strep. Also called a boil.
Carbuncle?	involves deeper tissue and terminates in sloughing and suppuration. Usually caused by staph, diabetics are susceptible.
Calluses?	a thickening of the outer layer of the skin.
Corn?	caused by friction or pressure from ill-fitting shoes.
Pediculosis?	Lice
Decubitus ulcer?	bedsore, pressure sore.
Psoriasis?	common, chronic disease of the skin. Usually seen on scalp, knees and elbows.
Pruritus?	Severe itching caused by disease or allergic response.
Ringworm?	superficial fungus infection. Small, spreading papules on the scalp and other parts of the body.
Scabies?	Caused by an arachnid (itch mite) highly communicable, burrows under skin.
Impetigo?	a highly contagious superficial skin infection. Forms isolated pustules with sticky yellow crusts that rupture and spread.
Sebaceous cyst?	cyst filled with sebum from a distended duct of a sebaceous gland.
Papule?	solid elevated lesion less than 1cm.
Tinea Pedis?	Athlete's foot. fungus infection of the foot where skin between the toes becomes scaly, cracked, red and sore.
Vesicle?	blister containing serous fluid.
Pustule?	elevated lesion containing purulent fluid.
Wheal?	hives, fleeting skin elevation with a white center surrounded by a red periphery.
Exoriation?	damage or abrasion to the skin.
Desquamation?	shedding of the epidermis.
Keloid?	hypertrophic scar.
Uticaris?	sames as hives.
Keratosis?	brownish, raised, scaly spots, normal for skin of older adults.
Melanoma?	pigmented mole or tumor that may or may not be malignant.
eczema?	acute or chronic cutaneous inflammation with erythema, papules, vesicles, scales, and/or crusts.
Macule?	small, discolored area that is usually flat.
Dermatitis?	many varieties of dermatitis, treatment involves finding the underlying cause and removing it.
Induration?	area of hardened tissue.
Erythema?	redness caused by dilation of superficial capillaries.
Cellulitis?	inflammation of cellular or connective tissue.
shearing?	force applied parallel to the planes of an object, but opposite in the direction to whatever force was present.
Turgor?	normal tension or resistance of the skin to deformation. This change can occur with dehydration or aging.
Debride?	getting rid of dead tissue by mechanical, surgical, or chemical means.
Escar?	slough of dead matter or necrosed tissue.
Exudate?	fluid, usually containing pus, bacteria, and dead cells.
Functions of the skin?	first line of protection, skin provides the way in which we communicate in and with environment.
Types of baths?	partial, complete, medicated, soothing, therapeutic, sitz, self-help, cleansing, towel, tub.
Reasons for a bed bath?	promotes relaxation and cleanliness, while still meeting patient's need for rest.
axillae?	under arm/armpit.
Immobility?	inability to move all or part of the body.
infltration?	seepage of fluid into the skin tissue causing edema.
Pace?	distance covered in 1 steps, or number of steps per minute.
Rehabilitation?	the process of restoring to a good condition or improvement in the state of one's efficiency or health.
Unconscious?	unresponsive.
Atrophy?	muscles decrease in size.
Endurance?	the ability to tolerate exercise.
Posture?	position of the body, or the way in which it is held.
Muscle spasms?	sudden, forceful, involuntary muscle contractions.
Neutral position?	position of a limb that is turned neither toward or away from the body's midline.
Anatomic position?	frontal and back views with arms at sides and palms forward.
Functional position?	position in which an activity is preformed properly and normally.
Alignment?	parts of an object being in the proper relationship to one another.
Line of gravity?	vertical line that passes through the center of gravity.
Center of gravity?	point at which a mass of an object is centered.
Base of support?	area on which an object rests.
Swing phase?	opposite arm and foot move to maintain balance.
Body mechanics?	efficient use of the musculoskeletal system.
Repetitive strain injuries?	disorders that result from cumulative trauma to musculoskeletal structures.
Functional mobility?	alignment that maintains the potential for movement and ambulation.
Supine position?	on back.
Foot drop?	permanent dysfunctional position caused by shortening of the calf muscle and lengthening of the opposing muscle on the anterior leg.
Lateral position?	side laying.
Lateral oblique position?	side laying where top let is placed at 30 degrees of hip flexion and 35 degrees knee flexion.
Sim's position?	semi-prone position on left side with right knee drawn towards chest.
Fowler's position?	semi-sitting position.
Bed board?	rigid structure placed under mattress.
Contractures?	permanently shortened muscles that resist stretching.
Transfer?	moving a client from place to place.
Ischemia?	decreased blood supply.
Osteoporosis?	brittle bones.
Double stance?	both feet on ground and slightly apart, gives good balance.
Single stance?	body weight shifted to one foot.
Good standing posture characteristics?	head up, shoulders back, spine straight, , buttox tucked, abdomen pulled in, knees slightly flexed.
Good sitting posture characteristics?	both feet on floor, knees bent and clear of chair edge.
Good lying down posture characteristics?	head/neck centered between shoulders, shoulders level, arms, hips, knees slightly flexed. Trunk straight, hips level, legs parallel, fat at right angle to legs.
Principals of body mechanics that should be maintained using various activities?	distribute gravity through the center of the body over a wide base of support. Push, pull, or roll objects rather than lifting them. Hold objects close to the body.
Ergonomics?	is a field of engineering science developed to promoting comfort, performance, and health in the workplace by improving the design of the work environment and equipment that is used.
Why body mechanics are important to the nurse?	increased muscle effectiveness, reduced fatigue, avoids repetitive strain injuries.
Most common physical injury to health care workers and why?	Musculoskeltal disorders because of ergonomic hazards.
Examples of ergonomic recommendations in the work place?	assistive devices to lift or transport heavy items or clients using alternative equipment for repetitive tasks.
Signs or symptoms associated with the disuse syndrome?	weakness, atony, poor alignment, contractures, foot drop, impaired circulation, atelectasis, UTI, anorexia, pressure sores.
common client positions?	supine, lateral, lateral oblique, prone, sim's, fowlers.
5 positioning devices?	adjustable bed, pillows, trochanter rolls, hand rolls, foot boards.
Adjustable beds?	allows the position of the head and knees to be changed.
pillows?	provide support and elevate body parts.
Trochanter rolls?	prevent legs from turning outward.
hand rolls?	maintains hand function and prevent contractures.
Foot boards?	keep the feet in normal walking positions.
Pressure relieving devices?	side rails, mattress overlays, cradle.
Side rails?	help clients change position.
Mattress overlays?	reduce pressure and restore skin integrity.
Cradle?	keep linen off client's feet/legs.
Types of transfer devices?	transfer handles, transfer belt, transfer board, mechanical lift.
Guidelines to follow when transferring clients?	know clients diagnosis, capabilities, weaknesses, activity level. Be realistic about how much you can safely lift transfer clients across the shortest distance possible, solicit the client's help, use smooth movements.
How does disuse syndrome effect the muscular system?	weakness, decreased muscle tone/strength, atrophy.
How does disuse syndrome effect the skeletal system?	poor posture, contractures, foot drop.
How does disuse syndrome effect the cardiovascular system?	impaired circulation, thrombus formation, dependent edema.
How does disuse syndrome effect the respiratory system?	pooling of secretions, shallow respirations, atelectasis.
How does disuse syndrome effect the urinary system?	oliguria, UTI, calculi formation, incontinence.
How does disuse syndrome effect the GI system?	anorexia, constipation, fecal impaction.
How does disuse syndrome effect the integumentary system?	pressure sores.
How does disuse syndrome effect the endocrine system?	decreased metabolic rate, decreased hormonal secretions.
How does disuse syndrome effect the central nervous system?	sleep pattern disturbances, psychosocial changes.
Benefits of regular exercise?	reducing blood pressure, blood glucose, blood lipid levels, tension and depression. Increased bone density.
Fitness refers to a person's?	capacity to preform physical activities.
Factors that interfere with fitness?	chronic inactivity, concurrent health problems, impaired musculoskeletal function, obesity, advancing age, smoking, high blood pressure.
Two methods of fitness testing?	stress electrocardiogram and a submaximal fitness test such as a step test.
How to calculate a person target heart rate?	Subtract their age from 220 then multiply that number by .6 to .9 based on person's fitness level.
Metabolic Energy Equivalent MET?	is the measure of energy and oxygen consumption that a persons cardiovascular system can support safely.
Fitness exercise?	physical activities that develop and maintain cardiorespiratory function, muscular strength, and endurance in healthy adults.
Therapeutic exercises?	involve physical activities designed to prevent health related complications from an established medical condition or its treatment to restore lost physical function.
Isotonic exercise?	involves movement and work. Example: aerobic exercise.
Isometric exercise?	refers to stationary activities preformed against a restrictive force. Example: weight lifting.
Active exercise?	preformed independently after proper instruction.
Passive exercise?	is preformed with the assistance of another person.
ROM exercise?	is a form of therapeutic exercise that move joints in the directions they normally permit. They can be active or passive.
Why are ROM exercises preformed?	to maintain joint mobility and flexibility.
suggestions a nurse can suggest to elderly to stay active?	mall walking, group activities like ball room dancing.

Created by: MichelleBall31

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