NR 224 Fundamentals Skills Exam 2 Review | Oxygenation, Nutrition & Enteral Feeding | Study Guide & Verified Questions | Graded A+

Excel in your nursing fundamentals course with this detailed NR 224 Exam 2 Review study guide. This document provides a comprehensive analysis of core nursing skills, focusing heavily on Chapter 41: Oxygenation and Chapter 45: Nutrition. Students will find essential information on respiratory alterations such as hypoventilation, hyperventilation, and hypoxia, including their clinical signs and symptoms. The guide also covers critical enteral nutrition protocols, including NG tube placement verification via X-ray, managing gastric residual volume (GRV), and identifying signs of parenteral nutrition complications. Additional high-yield topics include incentive spirometry, tracheostomy suctioning, and the indications for CVC placement with high-dextrose infusions. Whether you are preparing for a mid-term or the final, this verified resource offers the clinical insights and safety protocols needed to succeed in your nursing skills competency exams. NR 224 Fundamentals Skills Exam 2 Review | Oxygenation, Nutrition & Enteral Feeding | Study Guide & Verified Questions Chapter 41: Oxygenation Know alterations in breathing pattern/ alterations in respiratory functioning. o The three primary alterations are hypoventilation, hyperventilation, and hypoxia. o Hypoventilation and hyperventilation are often determined by arterial blood gas analysis. o At rest, the NORMAL adult respiration rate is 12 to 20 regular breaths/min. o Hyperventilation: » rate and depth of respirations increase » hypocarbia sometimes occurs (also called hypocapnia, meaning reduced CO2 in the blood) » CAUSES OF HYPERVENTILATION: 1. severe anxiety, infection, drugs, or an acid-base imbalance induces hyperventilation 2. increased body temperature (fever) which causes increased metabolic rate 3. increased CO2 production results in patient’s rate and depth of respiration to increase 4. sometimes can be chemically induced » SIGNS & SYMPTOMS OF HYPERVENTILATION: 1. rapid respirations 2. sighing breaths 3. numbness 4. tingling of hands/feet 5. light-headedness 6. loss of consciousness o Hypoventilation: » respiratory rate is abnormally low, depth of ventilation is depressed » hypercarbia sometimes occurs (also called hypercapnia, means too much CO2 in the bloodstream) » occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide » can lead to respiratory acidosis and respiratory arrest » in patients with COPD, the administration of excessive oxygen results inhypoventilation» for patients with atelectasis, a collapse in the alveoli prevents the normal exchange between oxygen and carbon dioxide, which results in less of the lung being ventilated, and hypoventilation occurs » SIGNS & SYMPTOMS OF HYPOVENTILATION: 1. mental status changes 2. dysrhythmias 3. potential cardiac arrest 4. in untreated, patient’s status rapidly declines, leading to convulsions, unconsciousness, and death o Hypoxia: » is inadequate tissue oxygenation at the cellular level. » it results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. » Untreated it produces possibly fatal cardiac dysrhythmias. » CAUSES OF HYPOXIA: 1. a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood 2. a diminished concentration of inspired oxygen, which occurs at high altitudes 3. the inability of the tissues to extract oxygen from the blood, as with cyanide poisoning, 4. decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia, 5. poor tissue perfusion with oxygenated blood, as with shock 6. impaired ventilation, as with multiple rib fractures or chest trauma » SIGNS & SYMPTOMS OF HYPOXIA: 1. apprehension 2. restlessness 3. inability to concentrate 4. decreased level of consciousness 5. dizziness 6. behavioral changes 7. unable to lie flat and appears both fatigued and agitated 8. VITAL SIGN CHANGES INLCUDE: — an increased in pulse rate — increase rate and depth of respiration — in early stages, blood pressure is elevated unless caused by shock — when worsens, respiratory rate declines as a result of respiratory muscle fatigue9. in a late sign of hypoxia, cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries would be present 10. central cyanosis observed in the tongue, soft palate, and conjunctiva of the eye where blood flow is high o Hypoxemia: » refers to a decrease in the amount of arterial oxygen. o Bradypnea: » rate of breathing is regular and abnormally slow » less than 12 breaths/min o Tachypnea: » rate of breathing is regular but abnormally rapid » greater than 20 breaths/minute o Hyperpnea: » respirations are labored, increased in depth, and increased in rate » greater than 20 breaths/min; occurs normally during exercise o Apnea: » absence of respiration lasting for 15 seconds or longer » respirations cease for several seconds » persistent cessation results in respiratory arrest o Dyspnea: » associated with hypoxia » it is the subjective sensation of difficult or uncomfortable breathing » shortness of breath usually associated with exercise or excitement » CAUSES OF DYSPNEA: 1. smoking, 2. pollution, 3. cold air o Orthopnea: » is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated » the number of pillows used usually helps to quantify the orthopnea (e.g., two- or three-pillow orthopnea). Also ask if the patient must sleep in a recliner chair to breathe easier. o Cheyne-Stokes Respiration: » occurs when there is a decrease blood flow or injury to the brainstem » respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilationThe nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia. » respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth » the pattern reverses; breathing slows and becomes shallow, concluding as apnea before respiration resumes o Kussmaul’s Respiration: » respirations are abnormally deep, regular, and increased in rate » greater than 35 breaths/min o Biot’s Respiration: » respirations are abnormally shallow for two to three breaths, followed by irregular period of apnea Know the different types of masks and how much oxygen you can get from those masks. o The nasal cannula and oxygen masks are the most common devices to deliver oxygen to patients. o A nasal cannula is a simple, comfortable device used for precise oxygen delivery. The two nasal prongs are slightly curved and inserted in a patient’s nostrils. o An oxygen mask is a plastic device that fits snugly over the mouth and nose and is secured in place with a strap. It delivers oxygen as the patient breathes through either themouth or nose by way of a plastic tubing at the base of the mask that is attached to an oxygen source. TABLE 41-7 Oxygen Delivery Systems Delivery System FiO2Delivered Advantages Disadvantages Low-Flow Delivery Devices Nasal cannula 1-6 L/min: 24%- 44% Safe and simple Easily tolerated Effective for low concentrations Does not impede eating or talking Inexpensive, disposable Unable to use with nasal obstruction Drying to mucous membranes Can dislodge easily May cause skin irritation or breakdown around ears or nares Patient's breathing pattern (mouth or nasal) affects exact FiO2 Simple face mask 6-12 L/min: 35%- 50% Useful for short periods such as patient transportation Contraindicated for patients who retain CO2 May induce feelings of claustrophobia Therapy interrupted with eating and drinking Increased risk of aspiration Partial and nonrebreather masks 10-15 L/min : 60%- 90% Useful for short periods Delivers increased FiO2 Hot and confining; may irritate skin; tight seal necessary Interferes with eating and talkingDelivery System FiO2Delivered Advantages Disadvantages Easily humidifies O2 Does not dry mucous membranes Bag may twist or kink; should not totally deflate Oxygen-conserving cannula (Oxymizer ) 8 L/min: up to 30%- 50% Indicated for long-term O2 use in the home Allows increased O2concentration and lower flow Cannula cannot be cleaned More expensive than standard cannula High-Flow Delivery Devices Venturi mask 24%-50% Provides specific amount of oxygen with humidity added Administers low, constant O2 Mask and added humidity may irritate skin Therapy interrupted with eating and drinking Specific flow rate must be followed CO2, Carbon dioxide; FiO2, fraction of inspired oxygen concentration. Regarding chest tube, should we ever separate the drainage system from the tube itself? o NO, unless we clamp it. Unless we have an order to clamp it, then do not remove a tubing from the drainage system to avoid pneumothorax or hemothorax. o Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Air pressure builds in the pleural space, collapsing the lung and creating a life-threatening event.o A chest tube is only clamped when replacing the chest drainage system, assessing for an air leak, or during removal Know interventions for a patient with pulmonary secretions. o we want to increase fluids to allow secretions to become thinner o turning, coughing, deep breath every 2 hours o suctioning o positioning o Oxygen Therapy: » reduces dyspnea associated with exercise and hypoxemia o Hydration: » for airway maintenance, to prevent thick, tenacious secretions o Humidification: » is the process of adding water to gas. » is necessary for patients receiving oxygen therapy greater than 4 L/min. » it might be necessary to add humidification at lower oxygen concentrations if the environment is dry and arid » bubbling oxygen through water adds humidity to the oxygen delivered to the upper airways » humidification of air will help keep the mucous membranes moist and will make secretions easier to expel o Coughing and Deep-breathing Techniques: » proper coughing techniques remove secretions and keep the airway open » coughing is effective for maintaining a patent airway » directed coughing is a deliberate maneuver that is effective when spontaneous coughing is not adequate. » Cascade Cough: the patient takes a slow, deep breath and holds it for two seconds while contracting expiratory muscles. Then the patient opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. » Huff Cough: stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice the patient inhales more air and is able to progress to the cascade cough. » Quad Cough: is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort,the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. » Diaphragmatic Breathing/Belly Breathing: is a technique that encourages deep breathing to increase air to the lower lungs o For managing alterations in airway clearance: » Chest Physiotherapy (CPT): is a group pf therapies used to mobilize pulmonary secretions you will want to work collaboratively with respiratory therapists when using these techniques these include: — postural drainage: is a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration; it improves secretion clearance and oxygenation; For example, patients with left lower lobe atelectasis require postural drainage of only the affected region, whereas a child with cystic fibrosis often requires postural drainage of all lung segments. — chest percussion: involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration; he procedure should produce a hollow sound and should not be painful; Percussion is contraindicated in patients with bleeding disorders, osteoporosis, or fractured ribs. Avoid percussion over burns, open wounds, or skin infections of the thorax. Take caution to percuss the lung fields under the ribs and not over the spine, breastbone, stomach, or lower back or trauma can occur to the spleen, liver, or kidneys — vibration: is a gentle, shaking pressure applied to the chest wall to shake secretions into larger airways. This technique increases the velocity and turbulence of exhaled air, facilitating secretion removal. Vibration increases the exhalation of trapped air, shakes mucus loose, and induces a cough ▪ Suctioning Techniques: is necessary when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures — Oropharyngeal and Nasopharyngeal Suctioning: used when the patient can cough effectively but is not able to clear secretions — Orotracheal and Nasotracheal Suctioning: used when the patient is unable to manage secretions by coughing and does not have an artificial airway — Tracheal Suctioning: used with an artificial airway ▪ Nebulization:The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient’s care plan. Which sleep condition caused the nurse to assign this nursing diagnosis? a. Insomnia b. Narcolepsy c. Sleep deprivation d. Obstructive sleep apnea adds moisture or medications to inspired air by mixing particles of varying sizes with the air the moisture added through nebulization improves clearance of pulmonary secretions nebulization delivers bronchodilators and mucolytic agents Know obstructive sleep apnea and what kind of masks these patients wear. o Obstructive Sleep Apnea: — airways collapse causing shallow or absent breathing — any air moving past the obstruction results in loud snoring — one of the greatest concerns after general anesthesia is airway obstruction, especially in patients with obstructive sleep apnea — a drop in oxygen saturation by pulse oximetry is a sign of airway obstruction in patients with obstructive sleep apnea — masks needed: CPAP and BiPAP (bilevel positive airway pressure (BiPAP) o Continuous Positive Airway Pressure (CPAP): — treats patients with obstructive sleep apnea, patients with heart failure, and preterm infants with underdeveloped lungs — equipment includes a mask that fits over the nose or both nose and mouth and a CPAP machine that delivers air to the mask — the smallest mask with the proper fit is the most effective. Because straps hold the mask in place, it is important to assess for excess pressure on the patient's face or nose that could cause skin breakdown or necrosisA nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV) Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). The purpose of CPAP and BiPAP is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. AC, PSV, and SIMV are invasive mechanical ventilation and are not routinely used on patients with sleep apnea. AC delivers a set tidal volume (VT) with each breath, regardless of whether the breath was triggered by the patient or the ventilator. Synchronized intermittent mandatory ventilation like AC delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient’s respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths is determined by the patient’s strength, effort, and lung mechanics. PSV mode is often combined with SIMV mode: inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient’s spontaneous breaths. Know visual signs and symptoms for patients with poor oxygenation. o clubbing o wheezing o cyanosis Obstructive sleep apnea (OSA) occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.o confusion o presence of a cough, shortness of breath, dyspnea, wheezing, pain, environmental exposures, frequency of respiratory tract infections, pulmonary risk factors, past respiratory problems, current medication use, and smoking history or secondhand smoke exposure If a patient has difficulty breathing when they’re lying flat in bed, what is the ideal position or interventions for them? o reposition o Semi-Fowler position Normal SPO2 level is 95 or higher. Anything below SPO2 is NOT normal. CO = SV x HR Chapter 46: Urinary Elimination If a patient has less than expected in a standard amount of time, we can see decreased urinary output… what can we relate that to? o Urinary Incontinence: What interventions or patient teaching we need to do for urinary incontinence? TABLE 46-1 Urinary Incontinence Definition Characteristics Selected Nursing Interventions Transient Incontinence Incontinence caused by medical conditions that in many cases are treatable and reversible Common reversible causes include: • Delirium and/or acute confusion. With new-onset or increased incontinence look for reversible causes. Notify health care provider of anyDefinition Characteristics Selected Nursing Interventions • Inflammation (e.g., urinary tract infection [UTI], urethritis). • Medications (e.g., diuretics) ( • Excessive urine output (e.g., hyperglycemia, congestive heart failure). • Mobility impairment from any cause. • Fecal impaction. • Depression. • Acute urinary retention. suspected reversible causes. Functional Incontinence Loss of continence because of causes outside the urinary tract Usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, poor motivation, or environmental barriers Direct result of caregivers not responding in a timely manner to requests for help with toileting Toilet access restricted by: • Sensory impairments (e.g., vision). • Cognitive impairments (e.g., delirium, dementia, severe retardation). • Altered mobility (e.g., hip fracture, arthritis, chronic pain, spastic paralysis associated with multiple sclerosis, slow movements associated with Parkinson's disease, hemiparesis). • Altered manual dexterity (e.g., arthritis, upper extremity fracture) • Environmental barriers (e.g., caregiver not available to help with transfers, pathway to bathroom not maneuverable with a walker, tight clothing that is difficult to remove, incontinence briefs). Adequate lighting in the bathroom Individualized toileting program designed for the degree of cognitive impairment: habit training program, scheduled toileting program, prompted voiding program Mobility aides (e.g., raised toilet seats, toilet grab bars) Toilet area cleared to allow access for a walker or wheelchair Elastic-waist pants without buttons or zippers Call bell always within reach Use of incontinence containment product patient can easily remove such as a pull-up–type pant or a pad that can be moved aside easily for voiding Urinary Incontinence Associated with Chronic Retention of Urine (Overflow Urinary Incontinence) Involuntary loss of urine caused by an overdistended bladder often related to bladder outlet obstruction or poor bladder emptying because of weak or absent bladder contractions Distended bladder on palpation High postvoid residual Frequency Involuntary leakage of small volumes of urine Nocturia Interventions are individualized related to the severity of the urinary retention, ability of bladder to contract, existing kidney damage. Mild retention with some bladder function: • Timed voiding • Double voiding • Monitor postvoid residual per healthDefinition Characteristics Selected Nursing Interventions care provider's direction • Intermittent catheterization Severe retention, no bladder function: • Intermittent catheterization • Indwelling catheterization Stress Urinary Incontinence Involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter (e.g., weak pelvic floor muscles, trauma after childbirth, radical prostatectomy) Result of weakness or injury to the urinary sphincter or pelvic floor muscles Underlying result: urethra cannot stay closed as pressure increases in the bladder as a result of increased abdominal pressure (e.g., a sneeze or cough) Small-volume loss of urine with coughing, laughing, exercise, walking, getting up from a chair Usually does not leak urine at night when sleeping As directed by the health care provider, instruct patient in pelvic muscle exercises. Urge or Urgency Urinary Incontinence Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction In many cases bladder overactivity is idiopathic; cause is not known Caused by involuntary contractions of the bladder associated with an urge to void that causes leakage of urine May experience one or all of the following symptoms: • Urgency • Frequency • Nocturia • Difficulty or unable to hold urine once the urge to void occurs • Leaks on the way to the bathroom • Leaks larger volumes of urine, sometimes enough to wet outer clothing • Dribbles small amounts on the way to the bathroom • Strong urge/leaks when one hears water running, washes hands, drinks fluids Ask patient about symptoms of a UTI Avoid bladder irritants (e.g., caffeine, artificial sweeteners, alcohol). As directed by the health care provider, instruct patient in pelvic muscle exercises, in urge-inhibition exercises, and/or in bladder training. If ordered by the health care provider, monitor patient symptoms and for the presence of side effects of antimuscarinic medications.Definition Characteristics Selected Nursing Interventions Reflex Urinary Incontinence Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2 Diminished or absent awareness of bladder filling and the urge to void Leakage of urine without awareness May not completely empty the bladder because of dyssynergia of the urinary sphincter; inappropriate contraction of the sphincter when the bladder contracts, causing obstruction to urine flow CAUTION: At risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis Follow the prescribed schedule for emptying the bladder either through voiding or by intermittent catheterization. Supply urine-containment products: condom catheter, undergarments, pads, briefs. Monitor for signs and symptoms of urinary retention and UTI. Monitor for autonomic dysreflexia; this is a medical emergency requiring immediate intervention. Notify the health care provider immediately. What is stress urinary incontinence? (Table 46-1) (page 1104) o STRESS URINARY INCONTINENCE: — involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter (e.g., weak pelvic floor muscles, trauma after childbirth, radical prostatectomy) — result of weakness or injury to the urinary sphincter or pelvic floor muscles — underlying result: urethra cannot stay closed as pressure increases in the bladder as a result of increased abdominal pressure (e.g., a sneeze or cough) o CHARACTERISTICS: — small-volume loss of urine with coughing, laughing, exercise, walking, getting up from a chair; — usually does not leak urine at night when sleeping o NURSING INTERVENTIONS: — as directed by the health care provider, instruct patient in pelvic muscle exercises called Kegel exercises.Know common symptoms of urinary alterations (Table 46-2) (page 1110) o URGENCY: an immediate and strong desire to void that is not easily differed — COMMON CAUSES: 1. full bladder 2. urinary tract infection, 3. inflammation or irritation of the bladder 4. overactive bladder o DYSURIA: pain or discomfort associated with voiding — COMMON CAUSES: 1. urinary tract infection 2. inflammation of the prostate 3. urethritis 4. trauma to the lower urinary tract 5. urinary tract tumors o FREQUENCY: voiding more than 8 times during waking hours and/or at decreased intervals such as less than every 2 hours. — COMMON CAUSES: 1. high volumes of fluid intake 2. bladder irritants (ex. caffeine) 3. urinary tract infection 4. increased pressure on bladder (ex. pregnancy) 5. bladder outlet obstruction (ex. prostate enlargement, pelvic organ prolapse) 6. overactive bladder o HESITANCY: delay in start of urinary stream when voiding — COMMON CAUSES: 1. anxiety (ex. voiding in public restroom) 2. bladder outlet obstruction (ex. prostate enlargement, urethral stricture) o POLYURIA: voiding excessive amounts of urine — COMMON CAUSES: 1. high volumes of fluid intake 2. uncontrolled diabetes mellitus 3. diabetes insipidus 4. diuretic therapyo OLIGURIA: diminished urinary output in relation to fluid intake — COMMON CAUSES: 1. fluid and electrolyte imbalance (ex. dehydration) 2. kidney dysfunction or failure 3. increased secretion of antidiuretic hormone (ADH) 4. urinary tract obstruction o NOCTURIA: awakened from sleep because of the urge to void — COMMON CAUSES: 1. excess intake of fluids (especially coffee or alcohol before bedtime) 2. bladder outlet obstruction (ex. prostate enlargement) 3. overactive bladder 4. medications (ex. diuretic taken in the evening) 5. cardiovascular disease (ex. hypertension) o DRIBBLING: leakage of small amounts of urine despite voluntary control of micturition — COMMON CAUSES: 1. bladder outlet obstruction (prostatic enlargement) 2. incomplete bladder emptying 3. stress incontinence o HEMATURIA: presence of blood in urine — Gross hematuria: blood is easily seen in the urine — Microscopic hematuria: blood not visualized but measured on urinalysis — COMMON CAUSES: 1. tumors (ex. kidney, bladder) 2. infection (ex. glomerular nephritis, cystitis) 3. urinary tract calculi 4. trauma to the urinary tract o RETENTION: — Acute Retention: suddenly unable to void when bladder is adequately full or overfull — Chronic Retention: bladder does not empty completely during voiding, and urine is retained in the bladder — COMMON CAUSES:1. bladder outlet obstruction (prostatic enlargement, urethral obstruction) 2. absent or weak bladder contractility (ex. neurological dysfunction such as caused by diabetes, multiple sclerosis, lower spinal cord injury) 3. side effects of certain medications (ex. anesthesia, anticholinergics, antispasmodics, antidepressants) Know proper routine catheter care. o Patients with indwelling catheters require regular perineal hygiene, especially after a bowel movement, to reduce the risk for catheter-associated UTI (CAUTI). o In many institutions, patients receive catheter care every 8 hours as the minimal standard of care. o Empty drainage bags when ½ full. o An overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra and/or urinary meatus, and increase risk for CAUTI. o Expect continuous drainage of urine into the drainage bag. o In the presence of no urine drainage, first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter. Preventing Catheter-Associated Infection: o A critical part of routine catheter care is reducing the risk for CAUTI). o A key intervention to prevent infection is maintaining a closed urinary drainage system. o Portals for entry of bacteria into the system are illustrated in Figure 46-14. o Another key intervention is prevention of urine backflow from the tubing and bag into the bladder. o Many urine drainage systems are equipped with an antireflux valve, but the nurse should monitor the system to prevent pooling of urine within the tubing and to keep the drainage bag below the level of the bladder. o Prevention of CAUTI often requires use of an evidence based “bundle” to perform all elements of care at one time along with completion of a checklist to ensure that each element is included in that care. — Know the policies of your institution to determine which components are in a care bundle. — Patients in acute care hospital should have urinary catheters inserted using aseptic technique with sterile equipment. — Secure indwelling catheters to prevent movement and pulling on the catheter. — Maintain a closed urinary drainage system. — Maintain an unobstructed flow of urine through the catheter, drainage tubing, and drainage bag. — Keep the urinary drainage bag below the level of the bladder at all times. — Avoid dependent loops in urinary drainage tubing.— Prevent the urinary drainage bag from touching or dragging on the floor. — When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. — Before transfers or activity, drain all urine from the tubing into bag and empty the drainage bag. — Empty the drainage bag when full. — Perform routine perineal hygiene daily and after soiling using antiseptic wipes. — Be sure to use a wipe to clean the length of the exposed catheter. — Obtain urine samples using the sampling port. Cleanse the port with disinfectant. Use a sterile syringe/cannula. — Quality improvement programs should be in place that alert providers that a catheter is in place and include regular educational programming about catheter care. Chapter 48: Skin Integrity and Wound Care Know the different types of wound drainage. TABLE 48-2 Types of Wound Drainage Type Appearance Serous Clear, watery plasma Purulent Thick, yellow, green, tan, or brownType Appearance Serosanguineous Pale, pink, watery; mixture of clear and red fluid Sanguineous Bright red; indicates active bleeding What is debridement? o DEBRIDEMENT: — is the removal of nonviable, necrotic tissue. — removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing — Plan to administer an ordered analgesic 30 minutes before debridement. — Methods of Debridement: o mechanical (wound irrigation & whirlpool treatments)o autolytic (transparent film & hydrocolloid dressings) o chemical (Dakin’s solution or sterile maggots) o sharp/surgical (scalpel, scissors) (quickest method) — If excessive wound exudate is present, evaluate the volume, consistency, and odor of the drainage to determine if an infection is present. Know patients who are at risk for development of pressure ulcers: o Older adults, those who have experienced trauma o Those with spinal-cord injuries (SCI) o Those who have sustained a fractured hip o Those in long-term homes or community care, the acutely ill o Individuals with diabetes o Patients in critical care settings o Risk Factors for Pressure Ulcer Development: — impaired sensory perception — impaired mobility — alteration in level of consciousness — shear — friction — moisture Know the different classification of pressure ulcers. o Stage I: Nonblanchable Redness: — discoloration of skin, warmth, edema, hardness, or pain may be present — may be difficult to detect in individuals with dark skin tone o Stage II: Partial-Thickness: — partial thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough — it presents as shiny or dry ulcer without slough or bruising o Stage III: Full-Thickness Skin Loss: — subcutaneous fat may be visible — bone, tendon, and muscle are NOT exposed — slough may be present but does not obscure the depth of tissue loss — may include undermining or tunneling o Stage IV: Full-Thickness Tissue Loss: — exposed bone, tendon, or muscle — subcutaneous fat may be visible— slough or eschar may be present — often included undermining or tunneling — exposed bone or muscle is directly palpable o Unstageable: Full-Thickness Skin or Tissue Loss- Depth Unknown: — actual depth of an ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed is unstageable — until enough slough or eschar is removed, we cannot determine depth of the wound — stable eschar should not be removed o Suspected Deep-Tissue Injury- Depth Unknown: — purple or maroon localized area of discolored intact skin or a blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear — the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue. Know the role of selected nutrients in wound healing. TABLE 48-4 Role of Selected Nutrients in Wound Healing Nutrient Role in Healing Recommendations Sources Calories Fuel for cell energy “Protein protection” 30-35 kcal/kg/day (Individuals who are underweight or have significant unintentional weight loss may need additional calories.) Protein Fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function 1.25-1.5 g protein/kg body weight Poultry, fish, eggs, beef Vitamin C (ascorbic acid) Collagen synthesis, capillary wall integrity, fibroblast function, immunological 1000 mg/day Citrus fruits, tomatoes, potatoes, fortified fruit juicesNutrient Role in Healing Recommendations Sources function, antioxidant Vitamin A Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation retinol equivalents per day Green leafy vegetables (spinach), broccoli, carrots, sweet potatoes, liver Can reverse steroid effects on skin and delayed healing Zinc Collagen formation, protein synthesis, cell membrane and host defenses 15-30 mg Correct deficiencies No improvement in wound healing with supplementation unless zinc deficient Use with caution—large doses can be toxic May inhibit copper metabolism and impair immune function Vegetables, meats, legumes Fluid Essential fluid environment for all cell function 30-35 mL/kg/day Use noncaffeinated, nonalcoholic fluids without sugar Water is best—6-8 glasses/day Adapted from Stotts NA: Nutritional assessment and support. In Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 5, St Louis, 2016a, Elsevier. Know about sacral ulcer.o On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? a. 1. Category/stage II b. 2. Category/stage IV c. 3. Unstageable d. 4. Suspected deep-tissue damage Best way to prevent pressure ulcer. o repositioning every 2 hours! o Use of Braden Scale Know what Braden Scale is and what is it used for? o The Braden Scale is the most widely used risk-assessment tool for pressure ulcers and is a valid tool to use for pressure ulcer risk assessment. o The Braden Scale was developed on the basis of risk factors in a nursing home population and is widely used on general patient care units in hospitals. o The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. o The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. Chapter 45: Nutrition Know the difference between Basic Metabolic Rate (BMR) and Resting Energy Expenditure (REE). o BASIC METABOLIC RATE (BMR): — the energy needed at rest to maintain life-sustaining activities (breathing, circulation, heart rate, and temperature) for a specific amount of time. o RESTING ENERGY EXPENDITURE (REE): — also called resting metabolic rate — is the amount of energy you need to consume over a 24-hour period for your body to maintain all of its internal working activities while at rest Know Nitrogen Balance. — Achieving nitrogen balance means that the intake and output of nitrogen are equal.— When the intake of nitrogen is greater than the output, the body is in positive nitrogen balance. — Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. The body uses nitrogen to build, repair, and replace body tissues. — Negative nitrogen balance occurs when the body loses more nitrogen than it gains (e.g., with infection, burns, fever, starvation, head injury, and trauma). — The increased nitrogen loss is the result of body tissue destruction or loss of nitrogen-containing body fluids. — Nutrition during this period needs to provide nutrients to put patients into positive balance for healing. Know carbohydrates, proteins, fats, and water. o CARBOHYDRATES: — composed of carbon, hydrogen, and oxygen — main source of energy in the diet — each gram of carbohydrate produces 4 kcal/g o PROTEINS: — essential for growth, maintenance, repair of body tissues — provide a source of energy (4 kcal/g) o FATS: — also called lipids — the most calorie-dense nutrient providing 9 kcal/g — composed of triglycerides and fatty acids’ — animal fats: saturated fatty acids — vegetable fats: unsaturated fatty acids o WATER: — makes up to 60% to 70% of total body weight — infants have the greatest percentage of total body water Know about vitamins. o VITAMINS: — essential to normal metabolism — antioxidant vitamins: beta-carotene and vitamins A. C. and E — Fat Soluble: • Vitamins A, D, E, and K • produced in the body, except vitamin D — Water Soluble: • Vitamin C and the B complex (which is 8 vitamins) • not produced in the body • not stored but toxicity can still occur in the body Know where the majority of absorption occurs.o occurs in the small intestine Know dietary guidelines. o Dietary Reference Intakes (DRIs): — EAR — RDA — AI — UL Know the USDA and USDHHS. Know enteral tube feeding. o Enteral nutrition (EN) provides nutrients into the GI tract. o It is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally yet has a functioning GI tract. EN provides physiological, safe, and economical nutritional support. Patients with enteral feedings receive formula via nasogastric, jejunal, or gastric tubes. Patients with a low risk of gastric reflux receive gastric feedings; however, if there is a risk of gastric reflux, which leads to aspiration, jejunal feeding is preferred. Know how to check placement of the tube. o After insertion of an enteral tube, it is necessary to verify tube placement by x-ray film examination. Confirmation of placement is needed before a patient receives the first enteral feeding Know the signs and symptoms of dehydration. o increased heart rate o skin turgor o high sodium levels o decreased blood pressure o INTERVENTION: increase fluids Know what to check for between feedings for NG tube placement. o check for residual volume in the stomach o Check for gastric residual volume (GRV) before each feeding for bolus and intermittent feedings, every 4 hours in critically ill patients, and every 4 to 6 hours in non–critically ill patients for continuous feedings. Know the signs and symptoms of poor nutrition related to cardiac function.o rapid heart rate (above 100 beats/min) o enlarged heart o abnormal rhythm o elevated blood pressure Know the signs and symptoms of hypoglycemia. — diaphoresis — shakiness — confusion — loss of consciousness Know parenteral nutrition. What would we require when giving patient through IV with anything dextrose greater than 10%? o PN with greater than 10% dextrose requires a CVC that a health care provider places into a high-flow central vein such as the superior vena cava under sterile conditions