test #3

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Anonymous
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203104
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test #3
Updated:
2013-02-25 02:58:00
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test
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fun test 3#
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  1. systematic assessment RNS HOPE
    • rest & activity
    • nutrition, fluids,electrolytes
    • safety & security
    • hygiene & grooming
    • oxygenation & circulation needs
    • psychosocial & learning
    • elimination
  2. head to toe assessment
    • beginning of shift
    • establishing priority care
  3. gastrointestinal system (GI)
    • digestive system
    • composed of: mouth tongue  teeth, pharynx, esophagus, stomach, small intestine, large intestine, anus.
  4. accessory organs
    • salivay glands
    • liver
    • gallbladder 
    • pancrease
  5. tongue
    largest movable organ of the body.
  6. parotid glands
    • largest of the salivary glands
    • location: both side of ear.
    • anterior/inferior.
  7. stomach
    • location: upper left Q
    • 1.5L
  8. esophagus
    • 20cm long
    • moves food to stomach
  9. small intestine
    • includes: duodenum, jejunum, ileum.
    • 2.5cm 6m long
  10. large intestine
    • cecum ascending colon, tranverse colon,descending colon, sigmoid colon, rectum, anus.
    • 1.5m
  11. liver
    • reddish bown
    • location: upper right Q
  12. gallbladder
    • pear shape sac
    • attached to surface of liver by the cystic duct.
  13. pancrease
    • flat elongated organ
    • location: posterior abdominal wall.
  14. mouth
    breaks food down into particals with saliva
  15. tongue
    position food for swallowing
  16. teeth
    grasping, tearing, crushing,grinding food.
  17. salivary glands
    • breaks food down for taste.
    • plays a role for chemical digestion of starches.
  18. pharynx
    passage way for food to inter the esophagus thru swallowing.
  19. esophagus
    • passage way for food to inter stomach.
    • lubricates.
  20. large intestine
    absorption of fluid and electrolytes and elimination of waste products.
  21. small intestine
    process of digestion is finished.
  22. liver
    secretes bile into small intestine for digestion of fat.
  23. gallbladder
    stores and concentrates bile.
  24. 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.
  25. NG tube
    • temporary nutrition support.
    • thru nose and esophagus into stomach.
    • uses:
    • decompress stomach before/after surgy
    • remove toxins
    • give medication.
  26. NG sucess
    • 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
  27. NG irragation
    • 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)
  28. NG
    • check tube placement prior to feeding and medication.
    • flush 30-60ml saline
    • record as intake
  29. TUBES
    • NG short term nose
    • PEG long term intestines.
  30. PEG
    • placement check: skin level to adapter. compare measurements on chart.
    • greater it has moved outward.
  31. cleaning PEGS
    soap water saline peroxide remove extremities.
  32. irragation PEG
    • residual is greater than 150ml replace the withdrawn fluids and delay further feeds for 1-2 hrs.
    • 30 degrees elavated
  33. feeding tubes and pumps
    • continuous can not tolerate large amounts of fluid.
    • intermittent feed self or reintroducing.
    • 10 mins flow
    • 30ml water after feeding.
  34. feeding
    • 8-12 oz per feeding
    • 2000 ml requirements
    • 150-240ml per feeding
  35. glycosuria
    sugar in the blood
  36. picc
    • peripherally inserted central catheter
    • in vein for nutrient
    • long term like burns.
  37. TPN
    • method of delivery total nutrition thru a catheter place in large central vein.
    • main energy souse: carbs.
  38. hyperosmolality
    increased concentration of solutes w/i the fluid
  39. fluid overload
    • increased pulse
    • coughing
    • respiratory distress
    • crackles on auscultation of lungs
    • imbalance of I/O
  40. assessment
    • every 4 hrs check tube
    • pain respiratory nausea etc
  41. nursing diagnoses for nutritional assistance
    • risk for: deficient fluid volume diarrhea or excessive vomiting.
    • imbalanced nutrition
    • risk for injury related to aspiration, difficulty swallowing.
  42. urinary output
    • 1000-1500ml
    • less than 720ml/24hrs
    • 30ml/hrs

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