Card Set Information
fun test 3#
systematic assessment RNS HOPE
rest & activity
safety & security
hygiene & grooming
oxygenation & circulation needs
psychosocial & learning
head to toe assessment
beginning of shift
establishing priority care
gastrointestinal system (GI)
: mouth tongue teeth, pharynx, esophagus, stomach, small intestine, large intestine, anus.
largest movable organ of the body.
largest of the salivary glands
: both side of ear.
: upper left Q
moves food to stomach
: duodenum, jejunum, ileum.
2.5cm 6m long
cecum ascending colon, tranverse colon,descending colon, sigmoid colon, rectum, anus.
: upper right Q
pear shape sac
attached to surface of liver by the cystic duct.
flat elongated organ
: 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
decrease gag reflex causing chocking and aspiration.
decrease muscle tone @ sphincters
decrease gastric secretions
temporary nutrition support.
thru nose and esophagus into stomach.
decompress stomach before/after surgy
confidence of patient is gained first.
check air flow
elevate 30-90 degrees(gravity)
: tip of nose-tip of ear-to xiphoid(between lower breast)
slid toward ear
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.
: 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residual is greater than 150ml replace the withdrawn fluids and delay further feeds for 1-2 hrs.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
crackles on auscultation of lungs
imbalance of I/O
every 4 hrs check tube
pain respiratory nausea etc
nursing diagnoses for nutritional assistance
: deficient fluid volume diarrhea or excessive vomiting.
risk for injury related to aspiration, difficulty swallowing.
less than 720ml/24hrs