What are the basic nutrients required by the body?
Carbohydrates
Fats
Proteins
Vitamins
Minerals
Water
What nutrient provides most of the body's energy and fiber?
Carbohydrates
What nutrient is used for energy and to provide vitamins for the body?
Fats
What nutrient should be no more than 30% of the daily caloric intake?
Fats
What nutrients need to be consumed daily and are necessary for metabolism?
Vitamins
What nutrients are needed by the body to complete essential biochemical reactions in the body?
Minerals
What nutrient is needed to replace fluids lost through perspiration, elimination and respiration?
Water
What practices may guide a client's food preparation or choices?
Religious practices
How do finances affect nutrition?
May prevent clients from buying foods that are higher in protein or vitamins and minerals
What are some reasons appetite may decrease?
Illness
Medications
Pain
Depression
Unpleasant environmental stimuli
How might a client's preferences for nutrition and hydration be influenced?
Bad experiences with certain foods
Familiarity of foods that the client has tried and liked before
What can impact the functional ability of the client to prepare and eat food?
Disease/illness
How can medications affect the nutritional status of a client?
Can alter taste and appetite
Can interfere in the absorption of certain nutrients
What factors can affect nutrition?
Age
Religious practices
Appetite
Preferences
Disease/illness
Medications
What are the nutritional requirements for infants (birth to 1 year)?
Breast milk is preferred or formula
Needs to provide 108 kcal/kg of weight the first 6 months and 98 kcal/kg of weight the second 6 months
What age should solid foods be introduced?
4 to 6 months
What are the nutritional requirements for toddlers and preschoolers?
Fewer calories per kg of weight than infants
Increased protein from sources other than milk
What are the nutritional requirements for school-age children?
Adequate protein and vitamins C and A
Need to be monitored because they tend to eat too many foods high in carbohydrates, fats and salt
What are the nutritional requirements for adolescents?
High metabolic demands which require more energy
Protein, calcium, iron, iodine, folic acid and B vitamin needs are high
1/4 of dietary intake comes from snacks
Increased water consumption for active adolescents
What are the nutritional requirements for young and middle adults?
Decreased need for most nutrients (except during pregnancy)
Calcium and iron consumption are important for women
What are the nutritional requirements for older adults?
Slower metabolic rate requires fewer calories
Need the same amount of vitamins and minerals as younger adults
What are three main types of eating disorders?
Anorexia nervosa
Bulimia
Obesity
What are the clinical/psychological presentations of anorexia nervosa?
Body weight less than 85% of ideal
Fear of being fat
Feeling fat
In female clients - no menses for at least 3 consecutive months
What is bulimia?
Cycle of binge eating followed by purging
What are some methods of purging used by bulimic individuals?
Vomiting
Using diuretics or laxatives
Exercise
Fasting
What BMI is considered obese?
30 or higher
How is BMI determined?
Dividing weight (in kg) by height (in meters2)
What should the dietary history include?
Number of meals per day
Fluid intake
Food preferences and amounts
Food preparation/purchasing practices, access to food
Hx of indigestion, heartburn and/or gas
Allergies
Taste
Chewing and swallowing
Appetite
Elimination patterns
Use of any medications
What clinical measures and labs need to be acquired during a nutrition assessment?
Height and weight for BMI and ideal body weight (IBW) calculations
Lab values of cholesterol, triglycerides, hemoglobin, electrolytes, and albumin levels
Which clients require I&O monitoring?
Any client with fluid or electrolyte alterations
When should weights be taken and what should the client be wearing?
Each day at the same time after the client voids and while wearing the same type of clothes
If you are using a bed scale to weigh the client, what needs to be done?
Use the same amount of linen each day and zero out the scale if possible
What does clinical assessment of poor nutrition include?
Muscle tone flaccidity
Mental status changes
Loss of appetite
Change in bowel pattern
Spleen or liver enlargement
Dry, brittle hair
Loss of subcutaneous fat
Dry, scaly skin
Inflammation and bleeding of gums
Poor dental health
Dry, dull eyes
Enlarged thyroid
Prominent protrusions over bony areas
What are some nursing diagnoses for nutritional status?
Constipation
Deficient/excess fluid volume
Imbalanced nutrition: less/more than body requirements
Feeding self-care deficit
What are some nursing interventions for nutritional status of clients?
Assisting the client in advancing diet as disease allows
Education
Promoting appetite
Feeding assistance
Prevent aspiration
Therapeutic diets
Assessing and monitoring enteral/parental feedings
Maintaining fluid balance
What are some interventions to promote appetite?
Good oral hygiene
Favorite foods
Decreasing environmental odors
How does a nurse assess for and assist with preventing aspiration when eating?
Position client in Fowler's or in a chair
Support the upper back, neck and head
Have client tuck chin when swallowing
Observe for aspiration and/or pocketing of food in the cheeks or other areas of the mouth
Maintain client in semi-Fowler's position for at least 1 hour after meals
Provide oral hygiene after meals/snacks
Match the diet with its liquids/foods:
1. clear liquid
2. full liquid
3. pureed
4. mechanical soft
5. soft/low-residue
6. High-fiber
7. Low sodium
8. Low cholesterol
9. Diabetic
10. Dysphagia
11. Regular
A. clear and full liquids, plus pureed meats and fruits, and scrambled eggs
B. pureed food and thickened liquids
C. leave little residue (clear fruit juices, gelatin broth)
D. clear and full liquids, plus foods that are diced or ground
E. clear liquids, plus liquid dairy products, all juice, pureed vegetables
F. no restrictions
G. balanced intake of protein, fats, and carbohydrates with a total caloric intake of about 1800 calories
H. whole grains, raw and dried fruits
I. no added salt or 1 to 2 g of sodium
J. foods that are low in fiber and easy to digest
K. no more than 300 mg/day of dietary cholesterol
1 - C
2 - E
3 - A
4 - D
5 - J
6 - H
7 - I
8 - K
9 - G
10 - B
11 - F
What types of nutrients are given parenterally?
Lipids
Electrolytes
Minerals
Vitamins
Dextrose
Amino acids
How is placement confirmed for parenteral nutrition?
X-ray
How is the rate of parenteral nutrition infusion determined?
Gradually increasing the rate until the desired rate is achieved
How often are parenteral nutrition tubes supposed to be changed?
Lipids - every 24 hours
Other solutions - every 48 hours
How is fluid balance maintained?
Administering IV fluids
Restricting oral fluid intake
Encouraging oral intake of fluid
(it all depends on the client)
What are ways in which restricting oral fluid intake can be implemented?
Removing the water pitcher from the bedside
Communicating with the dietary staff about the amount of fluid to be served with each meal tray
Communicating with each shift about the amount of fluid the client is allowed besides what is served with each meal
How can you encourage your client in increase their oral intake of fluids?
Provide fresh drinking water
Ask the client about beverage preferences
When conducting a nursing assessment on a family with a low income, the nurse discovers that the family is deficient in protein. Which of the following would be the best choice for increasing protein intake for this family?
B. beans and rice
A client is diagnosed as being high risk for aspiration. Which of the following is an appropriate nursing intervention?
B. instruct the client to tuck chin when swallowing
Which nutrient is the body's preferred energy source?
B. carbohydrates
Which of the following is most appropriate for a client on a low-reside diet?
B. dairy products
School-age children tend to have a dietary deficiency in which of the following if their diet is not adequately supervised?
D. vitamins
What are the stages of wound healing?
Inflammatory
Proliferative
Maturation or remodeling
When and how long is the inflammatory stage of healing?
First 3 days after the initial trauma
What is happening during the inflammatory stage of healing?
The body attempts to control bleeding with clot formation and attempts to deliver oxygen, white blood cells and nutrition to the area via the blood supply
How long does the proliferative stage last?
3 to 24 days
What happens to the wound during the proliferative stage?
Lost tissue is replaced with connective or granulated tissue
Contracting of the wound
Resurfacing of new epithelial cells
What happens during the maturation or remodeling stage of wound healing?
Strengthening of the collagen scar and the resumption of a more normal appearance
How long does the maturation/remodeling stage of wound healing last?
It can take more than 1 year to complete - depends on the original wound
What are the three types of healing?
Primary intention
Secondary intention
Tertiary intention
Which type of healing occurs in a wound with little or no tissue loss, with edges that are approximated?
Primary intention
Which type of healing of a wound will heal rapidly, has a low risk of infection, and will have no or minimal scarring?
Primary intention
Which type of healing occurs in a wound with loss of tissue, and with wound edges that are widely separated?
Secondary intention
Which type of healing of a wound will have a longer healing time, increased risk of infection and scarring?
Secondary intention
Which type of healing occurs in a wound that is widely separated, deep, may be a spontaneous opening of a previously closed wound, and has a possible presence of infection?
Tertiary intention
Which type of healing occurs in a wound likely to have extensive drainage and tissue debris, will be closed later and has a long healing time?
Tertiary intention
What are the 11 factors that affect wound healing?
Increased age
Overall client wellness
Immune function
Medications
Nutrition
Tissue perfusion
Obesity
Chronic diseases
Chronic stress
Smoking
Wound stress
Why does increased age affect wound healing?
Loss of skin turgor
Skin fragility
Decreased peripheral circulation and oxygenation
Slower tissue regeneration
Decreased absorption of nutrients
Decreased collagen
Impaired function of the immune system
Why is nutrition important in wound healing?
Provides elements required for wound healing and energy requirements
Why is adequate tissue perfusion important in wound healing?
Provides circulation needed to deliver the required elements for tissue repair and infection control
How does obesity effect wound healing?
Fatty tissue lacks blood supply
How does smoking impair wound healing?
Impairs oxygenation and clotting
How would vomiting or coughing disrupt the wound healing process?
Stresses the suture line
What is a wound?
Disruption of the skin
A localized protective response brought on by injury or destruction of tissue
Inflammation
How can wounds become infected?
By the invasion of a pathogenic microorganism
What are the principles of wound care?
Assessment
Cleansing
Protection
What nursing responsibility has a high impact on wound healing?
Wound care
When collecting assessment data on the appearance of a wound, what should the nurse be looking for?
The color of open wounds
Skin edges of closed wounds should be well-approximated
What does the color red indicate in an open wound?
Healthy regeneration of tissue
What does the color yellow indicate in an open wound?
Presence of purulent drainage and slough
What does the color black indicate in an open wound?
Presence of eschar that hinders healing and must be removed
When does drainage, a normal result of the healing process, occur?
During the inflammatory and proliferative phases
What things are important to note about drainage?
The amount of drainage from a drain or on a dressing
Skin around the drain - irritation and breakdown
Character of the drainage (serous, sanguinous, etc...)
Wound closure
Pain
Match the drainage type with its description
1. serous
2. sanguinous
3. serosanguinous
4. purulent
A. drainage contains both serum and blood; watery and appears blood-streaked or blood tinged
B. watery and clear or slightly yellow in appearance
C. result of infection; composed of white blood cells, tissue debris and bacteria; may have a foul odor, is thick and appears colored by the specific type of organism present
D. contains serum and red blood cells; thick and appears reddish
1 - B
2 - D
3 - A
4 - C
What are some nursing diagnoses for wounds?
Pain
Risk for infection
Impaired skin integrity
Impaired tissue integrity
Disturbed body image
Imbalanced nutrition
How much fluid should a client with a wound be encouraged to drink?
2,000 to 3,000 mL of water/day if not contraindicated
What dietary education should be given to a client with a wound?
Education on high sources of protein
What are some foods with high protein content?
Meat
Fish
Poultry
Eggs
Dairy products
Beans
Nuts
Whole grains
What serum ablumin level indicates a need for increased protein intake?
<3.5 g/dL
Cleanse a wound in a direction from ______ contaminated to ______ contaminated
least; most
What amount of friction is used when cleansing or applying solutions to the skin when performing wound cleansing?
Gentle friction
Why is it important only use gentle friction when cleansing a wound?
To avoid bleeding or further injury to the wound
What type of solution (hypotonic, isotonic, or hypertonic) is the preferred cleansing agent for wounds?
Isotonic
True or false: Use the same gauze to clean across an incision or wound, until the gauze pad is completely soiled
False - never us the same gauze more than once
How high above the wound should a solution-filled irrigation syringe be?
1 inch
Match the wound dressing with its description
1. woven gauge (sponge)
2. nonadherent
3. self adhesive, transparent film
4. hydrocolloid
5. hydrogel (Aquasorb)
A. occlusive dressing that swells in the presence of exudate
B. does not adhere to the wound bed
C. may be used on infected, deep wounds and it provides a moist wound bed
D. temporary second skin that is ideal for small, superficial wounds
E. absorbs exudate from the wound
1 - E
2 - B
3 - D
4 - A
5 - C
Which type of wound dressing is used to maintain a granulating wound bed and may be left in place up to 5 days?
Hydrocolloid
What is done to remove dead wound tissue that prevents wound healing?
Debridement
What are common forms of debridement?
Wet-to-dry dressing
Surgical intervention
Proteolytic enzyme
How does a wound VAC work?
Uses negative pressure to remove drainage from a wound
True or false: staples/sutures may be removed without a doctor's order
False
What needs to be documented about a wound?
Location
Type of wound/incision
Status of wound
Type of drainage
Type of dressings and materials used
Client teaching provided
How the client tolerated the procedure
The partial or total rupture of a sutured wound usually with separation of underlying skin layers
Dehiscence
A type of dehiscence that involves the protrusion of visceral organs through the surgical incision
Evisceration
What typically causes an evisceration?
Increased flow of serosanguineous fluid occurring approximately 3-11 days post-op
What are the following signs and symptoms of?
- Appreciable increase in the flow of serosanguineous fluid on the wound dressings
- Immediate history of sudden straining
- Client stats "something just happened to my stomach"
- Visualization of visceral organs
Dehiscence
What are the risk factors for dehiscence?
Chronic disease
Advanced age
Obesity
Invasive abdominal cancer
Vomiting
Dehydration/malnutrition
Ineffective suturing
Abdominal surgery
What should be done when evisceration is found?
Call for help
Stay with the client
Cover the wound and any protruding organs with sterile towels or dressing that have been soaked in saline solution
Position the client supine with hips and knees bent
Observe the client for signs of shock
Maintain a calm environment
True or false: Do not attempt to reinsert eviscerated organs
True
What are the risk factors for infection?
Extremes in age
Impaired circulation and oxygenation
Wound condition/nature
Impaired/suppressed immune system
Malnutrition
Alcoholism
Chronic disease
Poor wound care
what are the signs and symptoms of infection pertaining to wounds?
Purulent drainage
Pain
Redness and edema - in and around wound
Fever
Chills
Increased pulse and respiratory rate
Increase in white blood cell count
When do signs and symptoms of infection typically present after injury/surgery?
2 to 7 days
How can infection of wounds be prevented?
Using appropriate aseptic technique when performing dressing changes
Promoting good nutrition
Providing for adequate rest to promote healing
How can infections of wounds be treated?
Antibiotic therapy per physician's orders
Good nutrition
Adequate rest
Aseptic technique
Scenario: An adolescent client with diabetes is recovering from an appendectomy. This is the third post-op day. The client has been ordered a regular diet and is tolerating it well. He has ambulated successfully around the unit with the help of his parents and is requesting pain medication every 6 to 8 hours while reporting pain at a 2 on a scale of 0 to 10 after medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing.
1. What type of healing process would the nurse expect this wound to be undergoing?
2. Which of the following risk factors does this client possess? (select all that apply)
- Extremes in age
- Impaired circulation
- Impaired/suppressed immune system
- Malnutrition
- Poor wound care such as breaches in sterile technique
3. What is the single most important nursing intervention to protect this client from developing a post-op infection?
1. Primary intention
2. Impaired circulation and impaired/suppressed immune system
3. Proper wound care
An entry in a client's chart states the wound drainage is "sanguineous." That means it is
B. bright red
Which of the following is an example of a wound or injury healing by secondary intention?
C. an open burn area
Scenario: An older adult woman has undergone surgery for a bowel obstruction 6 days ago. Prior to surgery, she experienced nausea and vomiting for 3 days. During the last 24 hours, she has reported nausea, and she has vomited small amounts of clear liquid three times in the last 8 hours. Her vital signs are stable. The client weighs 81.6 kg and is 5 ft 2 in tall and smokes two packs of cigarettes a day. Currently, her incision is well approximated and free of redness, tenderness, or swelling.
1. What assessment findings would indicate development of a wound infection?
2. What risk factors for poor healing does this client exhibit?
3. Later that day, the client becomes confused and pulls of her surgical dressing. The nurse enters the room and finds the client with an extensive dehiscence. Which of the following nursing interventions are appropriate? (select all that apply)
- repack the wound
- call for help
- assist the client to a chair
- cover the wound with a sterile dressing moistened with normal saline
- stay with the client
4. What placed this client at risk for a wound dehiscence/evisceration?
What stage would this ulcer be in?
Epidermal involvement only
Lightly pigmented skin = redness; darker skin tones = red, blue or purple in tone
Reversible if pressure is relieved
Skin intact
Stage 1
What stage would this ulcer be in?
Partial-thickness skin loss involving the epidermis and/or dermis
Lesion presenting as an abrasion, shallow crater or blister
May appear swollen and may be painful
Takes several weeks to heal when pressure is relieved
Superficial
Stage II
What stage would this ulcer be in?
Full-thickness skin loss, including sub-q tissue and underlying fascia
Lesion presenting as a deep crater with or without undermining of adjacent tissue
May have foul-smelling, purulent drainage if locally infected
Yellow slough and/or necrotic tissue in wound bed
May require months to heal after pressure is relieved
Shallow to deep
Stage III
What stage would this ulcer be in?
Extensive damage to underlying structures including tendons, muscles, and bones
Lesion appearing small on the surface but can have extensive tunneling out of sight beneath superficial tissue
Local infection easily spread, which can cause sepsis
May take months or years to heal after pressure is relieved
Deep
Stage IV
Why can some ulcers not be staged?
Because they are covered with eschar and the wound bed cannot be visualized
What are some nursing diagnoses related to pressure ulcers?
Pain
Impaired skin integrity
Impaired tissue integrity
Ineffective tissue perfusion
How are pressure ulcers prevented?
Maintaining clean, dry skin and wrinkle-free linens
Repositioning the client
Providing adequate hydration and meeting protein and caloric needs
How can a nurse maintain clean, dry skin and wrinkle-free linens?
Appropriately use pressure-reducing surfaces and pressure-relieving devices
Inspect skin frequently and document risk using a tool such as the Braden Scale
Clean and dry skin immediately following urinary or stool incontinence
Apply moisture barrier creams to the skin of clients who are incontinent
Use tepid water, minimal scrubbing and pat skin dry
How often should a client be repositioned in bed? In a chair?
every 2 hours; every 1 hour
Where should pillows be placed to relieve pressure?
Between bony surfaces
To relieve pressure on sacrum, buttocks and heels, what angle should the HOB be maintained at, if not contraindicated?
30 degrees or less
Why should the client be prevented from sliding down in bed?
To decrease shearing forces that pull tissue layers apart and cause damage
Why should you lift rather than pull a client up in bed or in a chair?
Because pulling creates friction that can damage the client's outer layer of skin
When should a client be ambulated?
As soon as possible and as often as possible
What should be implemented for immobile clients to prevent pressure ulcers?
Active/passive ROM exercises
True or false: Massaging bony prominences relieves pressure
False - do not massage bony prominences
What are interventions to treat stage I pressure ulcers?
Relieve pressure
Encourage frequent turning/repositioning
Use pressure-relieving devices
Implement pressure-reduction surfaces
Keep the client dry, clean, well-nourished and hydrated
What are interventions to treat stage II pressure ulcers?
Maintain a moist healing environment
Promote natural healing while preventing formation of scar tissue
Provide nutritional supplements as needed
Administer analgesics as needed
What are interventions to treat stage III pressure ulcers?
Clean and/or debride
Provide nutritional supplements as needed
Administer analgesics as needed
Administer antimicrobials
What are interventions to treat stage IV pressure ulcers?
Perform nonadherent dressing change every 12 hours
Treatment may require skin grafts
Provide nutritional supplements as needed
Administer analgesics as needed
Administer antimicrobials
What are some complications of pressure ulcers?
Deterioration to a higher stage ulceration and/or infection
Systemic infection
When deterioration of a pressure ulcer occurs, what does the nurse assess/monitor?
Frequently assess/monitor the ulcer and report increases in the size or depth of the lesion, changes in granulation tissues, and changes in exudates
Follow protocol for ulcer treatment
What should be assessed/monitored for in a systemic infection?
Signs of sepsis
What are signs of sepsis?
Changes in level of consciousness
Persistent recurrent fever
Tachycardia
Tachypnea
Hypotension
Oliguria
Increased WBC
Scenario: An older adult client with diabetes mellitus and Alzheimer's disease must now use a wheelchair after a CVA 2 years ago that affected her right side. She does not respond to verbal commands or pain on the right side of her body. Her fluid and food intake is good, but she does require help with eating. She is continent for stool but is frequently incontinent for urine.
1. What risk factors does this client have for developing pressure ulcers?
2. What usual risk factor(s) does this client NOT have?
3. What can the nurse do to prevent skin breakdown?
1. wheelchair confinement (immobile), right-side immobility, decreased sensations on right side, impaired mental status, incontinence of urine, advanced age
2. poor nutrition and dehydration
3. encourage repositioning, keep client clean and dry, perform thorough daily assessments, provide good, frequent skin care, implement pressure-reducing devices, encourage and facilitate good nutrition
Scenario: A client has developed a red area approximately 1 cm x 1 cm on his elbow. It does not blanch.
1. To which stage has the client's skin lesion progressed, and which layer(s) of the skin are most likely damaged?
2. The primary focus of prevention and treatment of pressure ulcers is ________, _________, and _________
1. Stage I; epidermal damage
2. relieving pressure, providing good nutrition, providing good hydration
Which of the following statements best describes a stage III pressure ulcer?
D. the ulcer extends past the subcutaneous tissue to the muscle
