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systematic assessment RNS HOPE
- rest & activity
- nutrition, fluids,electrolytes
- safety & security
- hygiene & grooming
- oxygenation & circulation needs
- psychosocial & learning
head to toe assessment
- beginning of shift
- establishing priority care
gastrointestinal system (GI)
- digestive system
- composed of: mouth tongue teeth, pharynx, esophagus, stomach, small intestine, large intestine, anus.
- salivay glands
largest movable organ of the body.
- largest of the salivary glands
- location: both side of ear.
- location: upper left Q
- 20cm long
- moves food to stomach
- includes: duodenum, jejunum, ileum.
- 2.5cm 6m long
- cecum ascending colon, tranverse colon,descending colon, sigmoid colon, rectum, anus.
- reddish bown
- location: upper right Q
- pear shape sac
- attached to surface of liver by the cystic duct.
- flat elongated organ
- location: posterior abdominal wall.
breaks food down into particals with saliva
position food for swallowing
grasping, tearing, crushing,grinding food.
- breaks food down for taste.
- plays a role for chemical digestion of starches.
passage way for food to inter the esophagus thru swallowing.
- passage way for food to inter stomach.
absorption of fluid and electrolytes and elimination of waste products.
process of digestion is finished.
secretes bile into small intestine for digestion of fat.
stores and concentrates bile.
GI changes in age
- tooth loss
- decrease taste
- decrease gag reflex causing chocking and aspiration.
- decrease muscle tone @ sphincters
- decrease gastric secretions
- decrease peristalasis..constipation.
- temporary nutrition support.
- thru nose and esophagus into stomach.
- decompress stomach before/after surgy
- remove toxins
- give medication.
- confidence of patient is gained first.
- check air flow
- elevate 30-90 degrees(gravity)
- measure: tip of nose-tip of ear-to xiphoid(between lower breast)
- chill/warm tube
- slid toward ear
- head hyperextented
- swallow water/head forward
- if no stomach contents are obtained from syringe turn patient on left side & insert tube 1-2 in. test ph, 30ml
- gastic ph 1-4 intestinal/respiratory greater than 6.
- insert 10-20ml air listen xiphoid(not recommended)
- check tube placement prior to feeding and medication.
- flush 30-60ml saline
- record as intake
- NG short term nose
- PEG long term intestines.
- placement check: skin level to adapter. compare measurements on chart.
- greater it has moved outward.
soap water saline peroxide remove extremities.
- residual is greater than 150ml replace the withdrawn fluids and delay further feeds for 1-2 hrs.
- 30 degrees elavated
feeding tubes and pumps
- continuous can not tolerate large amounts of fluid.
- intermittent feed self or reintroducing.
- 10 mins flow
- 30ml water after feeding.
- 8-12 oz per feeding
- 2000 ml requirements
- 150-240ml per feeding
sugar in the blood
- peripherally inserted central catheter
- in vein for nutrient
- long term like burns.
- method of delivery total nutrition thru a catheter place in large central vein.
- main energy souse: carbs.
increased concentration of solutes w/i the fluid
- increased pulse
- respiratory distress
- crackles on auscultation of lungs
- imbalance of I/O
- every 4 hrs check tube
- pain respiratory nausea etc
nursing diagnoses for nutritional assistance
- risk for: deficient fluid volume diarrhea or excessive vomiting.
- imbalanced nutrition
- risk for injury related to aspiration, difficulty swallowing.
- less than 720ml/24hrs