Fundamentals Of Nursing Study Guide (2011-12 Ponce)

Study these flashcards
• 669
Doc. errors 

z        ““Patient’s medical history has been remarkably insignificant with only a 40# weight gain in the past 3 months.”


z        “Patient had waffles for breakfast and anorexia for lunch.”

Doc. errors 

z        “Skin somewhat pale but present.”


z        “She is numb from her toes down.”


z        “The patient was alert and unresponsive.”

Doc. errors

z        “The pelvic exam will be done later on the floor.”


z        “Examination of genitalia reveals patient is circus sized.”


z        “The nurse is to dress daily.”

Doc. errors

z        “The baby was discharged home after being given written and verbal instructions.”

Doc. errors 

z        “While in ER the patient was examined, X-rated and sent home”


z        “Occasional, constant, infrequent headaches.”

Doc. errors 

z        “ Stated she had been constipated most of her life until she got a divorce.”


z        “Both breasts are equal, reactive to light and accommodation.”

The Art of chart 

z        “ The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately.”

1800 nursing
Florence Nightingale 
Contributions to nursing (Florence Nightingale)

Nursing Education in old days 
Impact of World Wars 
ANA standards of professional performance 

ANA standards of Nursing practice 
National Student Nurses Association 
Specialty Nursing organizations
Areas of Expertise 
Aims of nursing 
Nursing Education
Educational preparation for nursing practice 
Registered Nurse Education
RN's are licensed by:
Graduate Nursing Education standard:
Continuing Education ANA standard 
In service Education

Nurse practice Act and Licensure 
State board of nursing does what exactly? 
Increasing autonomy nursing actions: 
American Nurses Association (ANA)
established standards of practice and represents  nurses through legislative actions, supports the National Student Nurses Association  (NSNA)
Comprehensive Drug Abuse & Control Act – 1970
Set strict controls on manufacture and distribution of controlled medicaction (possession of controlled substances unlawful without prescription), established gov programs to promote prevention and treatment of medication dependence, categorized drugs on basis of addiction potential
Food & Drug Administration Act - 1988
allowed new drugs and medical devices to be approved in a more efficient manner, while insuring product safety, allowed pharmacy compounding of drugs, allowed manufacturers to market "off-label" use of drugs to health care providers 

distinguished between prescription and nonprescription meds. according to the FDA, required prescription by a physician for drugs that cannot be used safely without medical supervision, up until the time, all meds could be purchased over the counter 
Biological product 
Drug sources 
Factors the nurse must consider before administering meds
Principles of Drug Actions
Properties of cell membrane 
Membrane permeability.
Variables affecting Absorption 
Explanations of variables affecting absorption 
Drug reactions 
Side effects ex: drowsy, blurred vision
Adverse effects ex:palpatations, fever

Common Drug responses 
Half life of a drug 
Synergistic effect 
Drug systems:

drugs for immune system 
Routes of drug administration; ORAL/SUBLINGUAL 
Routes of drug administration: TOPICAL 
  Routes of drug administration: PARENTERAL   
Oral route advantage 
Oral route disadvantage 
Sublingual route advantage 
Sublingual route disadvantage (same as Buccal) 
Rectal route advantage and disadvantages 

Vaginal route Ads and disads:

local therapeutic effect

has a limited use

Topical route Ads and disads:

-Messy, soil clothes

transdermal route ads and disads:
increases Systemic effect

Subcutaneous (SC) route Ads and disads: 

-Faster than oral

Intramuscular (IM) route ads and disads: 
-decreased Pain from irritating drugs

Intradermal route ads and disads 

-Absorption slow

-Dosage is too small

Intravenous route ads and disads:   

-Rapid effect

-Limited to increase soluble drugs

Inhalation routes ads and disads:

Planning for drug therapy ( Teaching plan)
IV therapy (fluids)
IV therapy (electrolytes)

IV therapy (parenteral) 
Implementation of drug therapy, teach about:
Special considerations for administration of medications to specific age-groups



patients with organ failure

“It must be very frustrating; all these tests and no conclusive results yet…”

Therapeutic- empathy

“Vacations are great, but tell me about the pain you had while skiing”
Values are shaped by:
Value System
Mode of Value transmission
Value Clarification
3 actions of value clarification 
Essential values of the professional nurse
concern for the welfare of others, 
human dignity 

Fairness and equality 
Ethics in Nursing 
Principles of health care ethics 
to tell the truth

The nurse as a patient advocate 
Code of ethics for nurses: Conduct and behavior 
International council of nurses code for nurses 

Professional Accountability is: 
Patients bill of rights 
Example of ethical dilemmas 
Types of Loss 
Actual, Perceived, Anticipatory 
Actual Loss
Can be identified by others 
Perceived Loss
ambiguous, cannot be verified by others
is experienced before it occurs 
Sources of Loss
Developmental Loss
Situational Loss
Coping with Loss
Complicated Bereavement 

Chronic, Delayed, Exaggerated, Masked

Mourning/Grief response 

epends on cause of death 

Accidental Death response 
Line of Duty death response 
Suicide Death response 
Clinical Symptoms of Grief 
Clinical Symptoms of Grief cont. 
Engel's stages of grief 1 and 2 
Engel's stages of grief 3,4,and 5 
Kubler-Ross's stages of grief 1-5
Factors that influence grief 
Advance Directives 
Five wishes 
Nursing responsibilities: Autopsy 
Once death occurs 
What is Pain?
What is pain according to Maccafery 
International Association for the study of Pain 
Gate control Theory 
Types of pain 
Types of pain explained:
Bodily sensation: Superficial organs 
Bodily sensation: deep organs 
Pain perception: could occur w/o bodily injury
Pain perception: Intensity of pain 
Ovarian Cancer 
Types of responses: Behavioral 

Types of responses: Affective 
Factors influencing pain response 
Pain Management 
Pain Management cont. 
Pain Assessment: PQRSTU 


Nursing Approach to Pain: Assessment and Management 
Nursing process: Implementation, indications for analgesics
Guidelines for individualized Pain therapy 
Nursing process: planning/implementation
implications of assessment for interventions
Nursing process: evaluation
sensory experience 
sensory reception
Sensory experience : Reception 
Sensory experience: Reaction 
Factors affecting sensory function
Sensory experience: alterations 
Alterations: sensory deficits 
Senile macular degeneration- natural changes that occur that cause us to lose vision

Alterations: sensory deficits 
Sensory deficits: neurological


        Expressive aphasia

        Receptive aphasia

Peripheral neuropathy-damage in the surface area that affects the ability to feel in the lower extremities


Aphasia- without speech

Expressive- difficulty articulating sounds

Receptive- not understanding what is said.

sensory alterations: deprivation
žReduced sensory input
žRestriction of environment
effects of sensory deprivation
-Reduces the capacity to learn
-Reduced attention span
Sensory overload
¤Multiple stimuli
¡Example ICU Psychosis
ototoxicity: medications


                    Cardiac drugs

                    Analgesics – NSAID’s

                    Antineoplastic agents

Communication: Hearing Impaired
žFace client
Implementation: visually impaired

Using the clock is the best way to to orient a blind patient

Avoid suddenly approachment.

Feeding- use the clock

Driving tips for the elderly
žFamiliar areas
žRush Hour
žDrive defensively
žDrive during day
žCar in good working condition…
Possible nursing diagnosis
žRisk for injury
žSelf-care deficit, bathing/hygiene
žAlterations in sensory/perceptual, auditory, tactile, gustatory, olfactory
žImpaired social interaction
žSocial isolation
žAltered thought process
Possible nursing diagnosis
Constipation r/t pain, discomfort associated with hemorrhoids, aeb no b.m. for 4 days.
Nursing diagnosis
Sleep Deprivation
May result from a decrease REM or NREM sleep
Signs/ Symptoms:
Impaired mental  abilities
Loss of concentration
Physical pain
Disintegration of personality
Nursing Diagnosis
Potential for aspiration
Body image disturbance
Fluid volume deficit
Self care deficit, feeding
Tissue Perfussion, altered: gastrointestinal
Altered nutrition:

    less than body requirements

    more than body requirements

    risk for more/less than body       


Planning: outcomes
the number one priorit yshould be the safety of the patient.
Medical and nursing management Planning
žPromote safety
¡Actual interventions will vary depending on the sensory impairment and it’s severity
implementation: therapeutic devices, adaptive devices
¡Hearing aids
implementation: therapeutic devices, adaptive services
¡Meals on Wheels
¡Senior bus
¡Elderly Day Care
ža condition characterized  by increased intraocular pressure (IOP)

  …leading cause of irreversible blindness in US

  …incidence higher among African Americans older than 40

Primary Open Angle Glaucoma
žAccounts for 90% cases
žEarly symptoms not noticeable
žDefinite hereditary link
žGenetically linked to Diabetes
žUsually bilateral
POAG: Pathophysiology
  Exact cause unknown
žAqueous fluid not adequately drained from the eye, leading to increased IOP which exerted on the optic nerve leads to destruction of nerve fibers in retina causing painless visual loss in affected areas.
POAG: Symptoms
žSymptom free until changes in visual acuity:

    * Changes in peripheral vision

    * “Bumping” into objects

POAG: Diagnosis
ž1. Elevated IOP
ž2. Visual field loss
ž3. Cupping of the optic disc
POAG: Management
žGoal of treatment: maintain IOP at a reduced level to  prevent further damage

    1. Medicalmiotic topical medications, topical adrenergic blocking agents

    2. Surgical – (laser therapy), trabeculectomy, trabeculotomy

constrict the iris
Primary Angle Closure Glaucoma (PACG)
žshallow, narrow angle, or congested glaucoma.
ž…the iris bulges forward against the cornea creating a mechanical blockage leading to elevated IOP
1 in 10 ppl have this type
PACG: Symptoms
žblurred  vision
ž…frontal headache
ž…eye pain
PACG: Management
žSurgery – peripheral iridectomy, laser iridotomy



Laser Iridotomy

Small hole is made in the iris

žan opacity of the crystalline lens.
ž25% of world population
žLeading cause of preventable blindness
Cataracts: etiology, symptoms, and management
ž-breakdown of metabolic processes in the lens as a result of aging.
žAlso caused by trauma…
ž-Painless progressive loss of vision to one or both eyes…
-medical treatment and surgery
Cataract surgery

Use of  high frequency vibrations to "break up" the eye's cloudy lens, suction out the lens.

Detached Retina
  a separation of the retina from the retinal pigment epithelium in the back of the eye.
žUsually results from a hole or tear in the retina as a result of:

    1. Trauma

    2. Internal changes in vitreous  chamber associated with aging

Detached Retina: signs, symptoms, and management

Floating spots

Flashing lights

Lateral shadow

Total blindness


Meniere's disease: pathophysiology

a chronic disease of the inner ear characterized by recurrent episodes of vertigo; progressive sensorineural hearing loss, tinnitus, which may be bilateral.

Inner ear, thefluid is not draining properly and this causes damages to the ear.

Meniere's Disease Symptoms
  Tinnitus- ringing in the ear
žSensorineural hearing loss
žSevere vertigo – accompanied  by nausea & vomiting
Meniere's disease: management
žMedical (acute phase): Valium, Benadryl, vasodilators, antiemetics
žMedical (remission): diuretics, antihistamines, vasodilators, Valium,

  low salt diet

žSurgery: Labyrinthectomy, Endolymphatic-sac decompression (shunting)
Purpose of patient education
Provide information that will empower patients and families to:
perform self-care
make informed decisions about their healthcare options

Patient education involves:
families, and
others who care for the patient
Nurse as a learner according to ANA
  Participates in ongoing educational activities related to clinical knowledge and professional issues
Seeks experiences to maintain clinical skills
Seeks knowledge and skills appropriate to the practice setting
nurse as an educator according to ANA
Patient education:
Health maintenance/Illness


Restoring health
Coping with impaired


ANA code of ethics for nurses
“Nurses are responsible for promoting and protecting health, safety, and rights of patients.”
ANA standards of practice
“The nurse employs strategies to promote health and a safe environment.”
Cognitive learning
Storing and recalling information in the brain

Includes lecture materials, readings, programmed instruction, and computer-assisted instruction.

Cognitive domain: six levels of behavior
Psychomotor Learning vs. Affective learning
learning a skill that requires both mental and physical activity
involves changes in feelings, beliefs, attitudes, and values.
Factors affecting patient learning

Motivation-How can we motivate learning? Create a warm environment, convey interest in the patient. Remember they are motivated to learn only if they believe health is important.

Readiness-physical and emotional ability to learn: not before treatments, tests, or while in pain.
Timing- present items that can be used immediately; need time to absorb and apply the information given.
Factors affecting patient learning
Active Involvement- learners retain 10% of what they read, but 90% of what they do.
Feedback- positive feedback encourages the learner to continue in the educational process. Sometimes they need encouragement. Never use anger, punishment, ridicule, etc.
Repetition-each time you repeat the information the learner retains more.
Factors affecting patient learning

-Environment-Private, quiet, physically, and psychologically comfortable.

Scheduling the session- plan for uninterrrupted time

Amount & Complexity of Content- the more complex and detailed the content the more difficult it is to learn and retain.

Factors affecting patient learning
Communication-Verbal and non-verbal. Several factors including culture, language barriers, and distraction play an important role.
Special Populations-. learning disabilities: plan accordingly
Developmental Stage-12 common in children. Assess their level of development
Factors affecting patient learning
Cultural Factors- be aware of values, social structure, etc. of culture you are teaching to.
Literacy- about 20% of adults in the US cannot read and write at a level considered necessary for functioning in everyday life.
Teaching and nursing process: Assessment
Collect data – physical, psychological, social, cultural, developmental & spiritual needs:

        Learning needs

        Motivation to learn

        Ability to learn

        Teaching environment

Teaching and Learning Activities and strategies
Lecture / discussion
Role play
Panel discussion
PC Assisted
Discharge Planning and Documentation

-centralized, coordinated, multidisciplinary

-teaching needs, plan, implementation, evaluation

Purpose of Urniary Elimination
-Remove waste products, toxins – should void a minimum of 30cc/hour

-Alterations in urinary elimination may affect all body systems
1.Desire to urinate
2.Presence of bacteria in the urine
Urinary retention
3.lack of ability to urinate (BPH)
Residual urine
4.Residual urine is urine left in the bladder after a person has urinated (breeding for uti)
5.sudden, compelling urge to urinate.
6.painful urination
7.Sepsis from obstruction of infected urine
8.means the presence of an excess of serum proteins in the urine
1.absent production of urine
3.Presence of blood in the urine
4.involuntary excretion of urine: urge, stress (cough, sneeze), overflow, functional (mobility), transient (UTI), reflex (no urge to void but bladder is full).
5.Decreased production of urine
6.condition characterized by the passage of large volumes of urine
7.need to get up during the night in order to urinate, thus interrupting sleep.
Urinary diversion
8.Surgical created opening for urinary elimination.
Urinary elim: Ileal Conduit

Most common. Small piece of ileum removed and brought out through the abdominal wall creating a stoma. Urine and mucus from the ileum drain continuously. Mucous membrane protects the kidneys from ascending infection.

Continent Urostomy

Kock pouch: variation of ileal conduit. Urine drains from the ureters into a surgically created pouch. Stoma that is created contains a nipple valve to keep urine from leaking. Patient inserts a catheter into the stoma to drain the urine.

Factors affecting urinary elimination
Growth & Development- Increase in bladder size
Sociocultural factors- Assistance from same gender
Psychological factors- Loss of dignity
Personal habits- Putting off voiding
Muscle tone-After having a baby
Factors affecting urinary elimination continued

Fluid intake- Increase intake = increase output, caffeine, alcohol. Physical activity

Pathological conditions- Renal calculi, hypertrophy, neurogenic bladder.
Surgical procedures- Reproductive or urinary tract surgeries
Medications- Diuretics
Diagnostic examinations- IVP, sonography, etc
Urinary Assessment: Characteristics of Urine
Intake & output
Urinary elim How to gather a specimen

Foley: sterile technique using syringe.

24 hour, clean catch.

Using a “hat”

Urinary elim Diagnostic studies: Cystoscopy
1.Cystoscopy is a test that allows your doctor to look at the inside of the bladder and the urethra using a thin, lighted instrument called a cystoscope
Urinary elim Diagnostic Studies: IVP
An intravenous pyelogram (IVP) is an X-ray test that provides pictures of the kidneys, the bladder, the ureters, and the urethra (urinary tract) During IVP, a dye called contrast material is injected into a vein in your arm. it travels through the blood stream and collects in the kidneys and urinary tract, turning these areas bright white. An IVP allows the radiologist to view and assess the anatomy and function of the kidneys and lower urinary tract.
Urinary elim Diagnostic Studies:  Retrograde Pyelography
  A retrograde pyelogram is a type of x-ray that allows visualization of the bladder, ureters, and renal pelvis. Generally, this test is performed during a procedure called cystoscopy - evaluation of the bladder with an endoscope (a long, flexible lighted tube). During a cystoscopy, contrast dye, which helps enhance the x-ray images, can be introduced into the ureters via a catheter.
Urinary elim Diagnostic Studies:  Ultrasonography
1.Pelvic ultrasound, bladder ultrasound, etc.
Urinary elim Lab Studies:
Routine urinalysis

Clean catch urine- Cleanse genitalia before voiding and collect the sample midstream so it will be free of organisms from the urethral meatus or distal urethra.

Sterile specimenindwelling catheter

24 hour urine collectionVoid record time, discard first voiding and collect all the urine for the next 24 hours. (post signs, ice, etc)

Kidney function studies- Blood tests: assess renal function and hydration.  Creatinine ,Creatinine clearance, BUN
Urinary elim Possible nursing diagnosis
Altered urinary elimination r/t frequency, urgency, aeb urinating in small amounts often, constant sensation of full bladder.
Urinary elim Planning Goals: Short term (example)
Patient will urinate 100-200ccs at a time within 48 hours.
Urinary elim. Planning Goals: Long term (Example)
Patient will return to usual voiding pattern without discomfort within one week.
Possible Implementations for Urinary elim.
Assess intake & output, record.
Assess urinary voiding pattern.
Assess discomfort during urination.
Assess for bladder distention, urinary retention.
Administer antibiotics as ordered.
Encourage increased fluid intake.
Strengthen muscle tone (Kegel exercises )
Purpose of G.I. tract
Prepare food products for use by the body’s cells,

Promote the absorption of fluid and nutrients,

Eliminate wastes.
the rhythmic contraction of smooth muscles to propel contents through the digestive tract.
presence of a mixture of gases produced during digestion
waste product from the digestive tract expelled through the anus
the Act or process by which organisms eliminate solid or semisolid waste material (feces) from the digestive tract via the anus.
Valsalva Maneuver
Increase the pressure to expel the feces by contracting the abdominal muscles while maintaining a closed airway.
Fecal impaction
a solid, immobile bulk of stool that can develop in the rectum as a result of chronic constipation
is the decreased sensation of appetite
is the process by which food is mashed and crushed by teeth.
Factors affecting Bowel elimination
Age- Meconium to toilet training and problems again in the elderly.-loss of tonus smooth muscle of colon
Diet- Eating at regular time promotes a regular pattern. High fiber, yogurt help while calcium and carbs may not.
Pregnancy- Increase progesterone slows peristalsis plus effect of growing uterus.
Fluid intake- Low intake slows peristalisi and leads to dry hard stools
Factors affecting Bowel elimination
Pain- From hemmorhoids
Medications- Iron antacids pain meds and antimotility drugs may cause constipatin while antibotics and laxatives will cause diarrhea. NSAID irritate the stomach.
Surgery or Anesthesia- Anesthesia slows motility. Bowel surgery may lead to paralytic ileus. Usually have NG tube inserted to suction secretions until peristalisis returns (decreases bloating and discomfort).
Factors affecting bowel elimination
Pathologic Conditions- food allergies, diverticulosis (saclike outpuchings of the mucosa through muscle layers. Diverticulitis when these outpouchings become infected.
Psychological Factors- Diet, work (avoiding using the bathroom)
Personal habits-
Activity- Decreased movement slows peristalsis.
Position- Privacy
Diagnostic tests: Colonoscopy
The doctor puts a thin tube that has a light through the rectum and into the colon. This allows the doctor to "see" the lining of the whole colon.
Diagnostic tests: Flexible sigmoidoscopy
The doctor puts a thin tube that has a light into the rectum. It allows the doctor to check the rectum and the lower part of the colon.
Diagnostic tests: Upper endoscopy
This is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor sprays the throat to numb it and then slides a thin, flexible plastic tube called an endoscope down the throat. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy.
Diagnostic tests: Barium Enema
The doctor injects fluid containing a substance called barium into the rectum. Barium allows the doctor to see the colon on an X-ray.
Diagnostic tests:
Alterations in Bowel elimination: cONSTIPATION
or irregularity, is a condition of the digestive system where a person (or animal) experiences hard feces that are difficult to pass.
Alterations in Bowel elimination: Fecal impaction
  a solid, immobile bulk of stool that can develop in the rectum as a result of chronic constipation.
Alterations in Bowel elimination: Diarrhea
1.a condition in which the sufferer has frequent watery, loose bowel movements
Alterations in Bowel elimination: Fecal Incontinence
is the loss of regular control of the bowels
Alterations in Bowel elimination: Flatulence
the presence of a mixture of gases known as flatus in the digestive tract of mammals expelled from the rectum.
Ben Franklin Quote
Early to bed and early to rise makes a man healthy, wealthy and wise.”
Alteration in bowel movements: Hemorrhoids and Bleeding
-are also called piles, are swollen and inflamed veins in your anus and rectum.
-Blood in stool, etc
Alteration in bowel movements: Bowel Diversions
1.Surgically created opening for elimination of digestive waste products.
condition in which the body is  in decreased state A of activity with the consequent feeling of being refreshed.
A state of altered consciousness throughout which varying degrees of stimuli preclude wakefulness, reducing the O2 need of cells.
Rest and Sleep
Physiology of Sleep
Reticular Activating System (RAS):
            Sleep and awakening
Purpose of Rest and Sleep
Restores physical well-being.
Relieves anxiety and stress.
Restores ability to cope and to concentrate on activities of daily living.
Bowel elim. Assessment:History
1.Normal pattern, apperance, change in habits, use of elimination aides.
Bowel elim. Assessment:  Physical Assessment
1.Bowel sounds, abdomen
Bowel elim. Assessment: Lab and diagnostics

  oscopies, X-rays, Guaiac – occult blood

1.Detects Peroxidase (enzyme present in hemoglobin) restrict 3 days before test: red meats, some vegetables and fruits, fish, ASA, iron, etc. 
Factors affecting sleep #1 (4 items)
Nor epinephrine and Acetylcholine
Circadian Rhythms
Factors affecting sleep (continued) (3 items)
Developmental  Considerations
Physical Activity
Psychological  Stress
Factors affecting sleep (continued 2) (3 items)
Desire to be awake and alert help overcome sleepiness
Cultural Implications
Bowel Elim. Planning: Short term
  patient will defecate, have relief of discomfort anal area within 24 hours.
Bowel Elim. Planning: Long term
patient will maintain regular bowel elimination for the next 4  weeks             
Bowel Elim. Possible implementations
Assess for bowel sounds, flatus and defecation
Administer laxatives as ordered
Administer analgesics prn
Encourage increased fluid intake
Have patient select high fiber foods
Encourage increased activity/exercise
Sleep Deprived
130 million american adults accumulate sleep debt…up to 330 lost hours of rest per year…
Americans today sleep 2 hours less than 40 years ago
Sleep Deprived and Outcomes
40% of fatal crashes involving commercial truck drivers
21% of aviation incidents
sleep deprivation can have some of the same hazardous effects as being drunk
100,000 crashes – 71,000 injuries, 1,500  fatalities
Sleep Deprivation Studies
Changes in immune response
Impaired glucose tolerance
Increased risk of cancer, heart attack, hypertension, obesity, depression, accidents -  NIH
Decreased reaction times
Difficulty concentrating
Typical Effectsd of Sleep Deprivation
missed work
social conflict
slurred speech
SStandordpless at Stanford          80 % dangerously sleep
Age related sleep needs( Adapted National foundation for sleep)
0-2 years  - 14 hours
2-4 years  - 12 hours  /night, 2 during day
4-6 years  -  11-13 hours, 2 of those may be during day
6-12 years  - 10-12 hours
12-15 years - 8-9 hours
Age related sleep needs( Adapted National foundation for sleep) Continued
15-18 years - 8 hours, more on weekends
18-39 years - 8 hours
39-death    -  varies with age, lifestyle, health
Interfering Factors
Alcohol (ETOH) Intake
CNS stimulant
The body’s response
  to alert you that you
  need sleep
Assesment sleep/rest patterns
Non-Rapid Eye Movement (NREM)
Control by the Parasympathetic Nervous  System
Consists of 2 stages
Light stages of the sleep cycle
Assesment sleep/rest patterns
Rapid Eye Movement (REM)
Control by the Parasympathetic Nervous  System
Deep sleep stages of cycle
Total sleep, deep sleep or delta sleep
  Important to recuperate the body and repair injured body tissue
Essential for learning, memorization and adaptation
Physical Assessment
Sleep walking
Sleep talking (somniloquence)
Enuresis (bedwetting)
Sleep Disorders
Difficulty falling/staying asleep
Hypersomnia- polysomnia
Excessive sleep
Uncontrollable desire to sleep, “sleep attacks”
Sleep Apnea
Periods of no breathing between intervals of snoring
Promotion Strategies Implementation
Promote Comfort
Environmental Control
Lights low
Soft music
Night light
Window - open or closed
Quiet time
Promotion Strategies Implementation(continued)
Bedtime Rituals
Bedtime snacks
Promotion Strategies Implementation(continued)2
  Rest/Sleep Patterns
Allow for adequate time for rest/sleep
Adhere to patient’s usual sleeping pattern
Coordinate care as not to interrupt sleep time
Give medications that induce sleep per physician order
Do not administer sleeping medications prior to 2200hr or later than 0200hr
a condition in which the human system responds to changes in it’s normal balance state.”
anything that causes a person to experience stress…
Anything that a person perceives
as challenging, threatening,
or demanding.
(positive or negative)
Types of stress
Positive and negative
Stressors (continued)
The impact a stressor may have is affected by the perception of the event…
Mondays Stress
1 (of 25) high risk indicators for catastrophic health events…
  21% of cases of irregular heart beats occur Monday am.
psychosomatic disorders
…real, physical illness/condition where physical alterations are thought to at least be partially caused by  psychological influences…
  * diarrhea
  * asthma
  * hypertension
Stress (cont) Adaptation
Adaptation – change that takes place as result of responses to stressors, an ongoing process as a person attempts to maintain balance in the internal and external environment.
Adaptation Results in
Optimal functioning
Normal growth & development
Normal reactions to physical & emotional stress
Ability to tolerate changing situations
Sources of Stress
#1 source of stress bad relationships
Social readjustment rating scale
A tool used by health practitioners for identifying persons at risk for developing health problems as a result of response to stress.
Psysiologic Responces to stress
Local Adaptation Syndrome  (LAS)
General Adaptation Syndrome  (GAS)
Local Adaptation Syndrome LAS
Reflex pain response
Inflammatory response:
    1. Vasoconstriction
    2. Exudate
    3. Repair
Psycho social responses to stress
Coping Mechanisms
Defense Mechanisms
A sense of impending doom, fretfulness, unease, apprehension, worry about something that has not happened, may never happen
Mild anxiety

sever anxietpanic

Goals of Health Care
  • Health promotion
  • Illness prevention
  • Diagnosis and treatment
  • Rehabilitation
Health Promotion
- the least costly
- has highest impact on health
eg. teaching dental health, exercise programs, stress reduction, and healthy diet
Illness Prevention
  • Control of the environment (eg. pollution, immunizations)
  • Workplace safety (OSHA)
  • Safety regulations (eg. seat belts and bike helmets)
Diagnosis and Treatment
The responsibility of the physician (diagnosis and treatment) and the nurse, carrying out nursing care (treatment).  
Health Care Delivery Systems
  • Hospitals
  • Doctor's offices
  • Extended care facilities
  • Rehabilitation facilities
  • Community health clinics
  • Out-patient facilities (eg. Ambulatory care centers, Adult day care centers, and Hospices)
Levels of Health Care
  • Primary
  • Secondary
  • Tertiary
Primary Health Care 
Focuses on those currently not experiencing health problems
Goal is to maintain, improve health and prevent illness
Eg. teaching, lifestyle modification for health purposes, and immunizations
Delivery Locations for Primary Care
  • Ambulatory care centers
  • Health care clinics
  • Emergency Room
  • Crisis center
  • US Public Health Service
Secondary Health Care
  • Intermediate level of care
  • Involves diagnosis and treatment of existing illness
  • Focuses on avoiding complications/worsening of existing condition
Delivery Location for Secondary Health Care
  • Hospitals (because of the requirement/need for specialized equipment) eg. Surgery, ICU, Med-Surg
  • Birthing centers
Tertiary Health Care
Highly specialized care
Focuses on minimizing the effects and permanent disability of chronic or irreversible condition (treatment, care, and teaching)
Goal is to adapt to limitations (if any)
Delivery Location of Tertiary Care
  • Hospices
  • Extended Care Facilities (ECF's)
  • Rehabilitation centers
  • ACLF (Adult Congregate Living Facility)/ALF (retirement homes)
  • Home Health Care
Health Insurance - Group Health Plans
Long-term care
Private insurance
Medicare (federal government)
Medicaid (state government w/federal monies)
coping mechanisms
Relieve stress by changing a
  person’s response
  to a stressor…
coping mechanisms without concious thought
Crying, laughing, sleeping, cursing
Physical activity
Smoking, drinking
Lack of eye contact, withdrawal
Limited relationships
Defense Mechanisms
to protect one’s self esteem, useful in mild to moderate anxiety…
defense mechanisms (cont)
  When used to extreme, the use of these may distort reality and cause problems with relationships.
  If this occurs they become maladaptive instead of adaptive.
Stress and basic Human needs
Safety & Security
Love & Belonging
Stress reduction/ A.D.L's
  1. Exercise
  2. Rest / Sleep
  3. Nutrition
Stress Reduction /Support Systems
Support Systems:
    1. Family / Friends
    2. Significant others
    3. Support Agencies           
    4. Support Groups
Stress management techniques
Relaxation-opposite “fight or flight”
Meditation-quiet, pass
Anticipatory Guidance
Guided Imagery- videos, audio cassettes
Attitude (smile):
1.Lower B/P
2.Boost immunity
3.Release endorphins
ive, position, mental image
Approaches to Relational Issues:
“#1 cause of stress, #1 solution to stress”
Forgiveness -others, self
Humility – unassuming, concern for others
A simple hello
Not as easy
Friendliness is rare
Boost productivity
Friendliest most ignored
Respect begets respect
Rural vs urban settings
A simple hello (continued)
Save a marriage
Universal health insurance:
    Lower blood pressure
    Boost immunity
    Release endorphins
    Sense of wellbeing
Crisis Intervention
Identify problem
List alternatives
Implement plan
Evaluate outcome
"Will we have to calculate BSA?"

"These are just examples"


Medical Asepsis
Clean Technique    All practices intended to confine a specific organism to a specific area, limiting the number, growth and transmission of microorganisms
Surgical Asepsis
  Sterile Technique

    Practices that keep an area or objects free of ALL microorganisms and spores by destroying these.

Purposes of Surgery
Ablative (curative)
Palliative- reduce symptoms of a condition ex. Colostomy, removal of necrotic tissue
Categories of surgery: Emergency
may be life threatening, immediate attention
Categories of surgery: Urgent
prompt attention
Categories of surgery: Required
need for surgery
Categories of surgery: elective
should have surgery
Categories of surgery: Optional
decision rests with patient
Peri-op Nursing: Assessment of Risk factors


Fluid balance

Infectious process



Chronic illness

Pre-Op diagnostic tests
Respiratory – chest x-ray, blood gases
Cardiac/circulatory – EKG, blood studies (CBC)
Renal – urine & blood studies (BUN, creatinine
Metabolic – blood and urine (sugar, acetone)
GI – nutrition (albumin)
Informed Consent
Competence established

  * Explanation of procedure and risks

  * Description of benefits and alternatives

  * Offer to answer questions

  * Instructions patient may withdraw consent

  * Statement if protocol differs from usual

Understandable language
Pre-Op nursing: Teaching
Pre-Op Nursing: Preparations
Intestinal preparation: enemas until clear, NPO
Gown, hair
Skin prep
Jewelry, prosthesis
Intra-operative nursing: Circulating Nurse
manages the operating room
Intra-Op Nursing: Scrub Nurse
Responsible for the surgical field
a state of narcosis, analgesia, relaxation, and reflex loss.

              * general anesthesia

              * regional anesthesia

              * epidural anesthesia

              * spinal anesthesia

Method of Administration for General Anesthesia

* inhalation

* intravenous

Local Anesthesia: Regional
anesthetic agent injected around  nerves
Local Anesthesia: Conduction blocks
epidural, brachial
Local Anesthesia: Paravertebral
chest, abdomen, extremities
Local Anesthesia: Caudal Block
Local Anesthesia: Conscious Sedation
PACU Assessment
  O2 saturation

  Pulse regularity, volume

  Respiration rate, depth

  Skin color

  LOC / response

  Operative site

  Tubes / drainage

  Loss sensation
Post op Assessment: Acute care
Post-Op pain
Pain relief – physiologic and psychological makeup of patient
Correlation between poor pain control and complications
Opioid analgesics – short term pain control
Pain prevention – PCA
Alternative methods
Post-Op Phases: After Discharge
Patient Education
Home Care
Post -Op complications: Shock ( Hypovolemic/Neurogenic)


  Cool, moist skin

  Rapid breathing

  Cyanosis of lips, gums, tongue

  Rapid, weak, thready pulse

  Low blood pressure

  Concentrated urine

Neurogenic Shock
Loss of vascular tone
Spinal cord injury
Spinal anesthesia
Post-Op Complications: Respiratory

    * Location of incision

    * Pre-operative respiratory problems

    * Age

    * Opioid analgesics

    * History of smoking

    * Sepsis

    * Obesity / prolonged bed rest

    * Malnutrition / dehydration

    * Immunosuppression

Pulmonary Embolism: Signs and symptoms

Dyspnea, tachypnea

    Sharp, stabbing chest pain



    Cough, diaphoresis


Pulmonary Embolism: Prevention

Prevent deep vein thrombosis!

    1. Active leg exercises

    2. Early ambulation

    3. A.E. hose - tight

    4. Sitting

Atelectasis: Assessment
Pleural pain
Decreased excursion
Decreased to absent breath sounds
Percussion: flat
Tactile fremitus: absent
Foreign body/plug
Splinting of chest
Respiratory depression from opioids
Abdominal distention
Sedatives & muscle relaxants
  Inflammation of the lungs caused by bacteria, viruses, chemical irritants.

    Hypostatic pneumonia

Get patient moving…





    Homan’s sign, edema, fever, chills




increased pulse and respirations, pale,cool,clammy skin,restlessness, apprehension
Nausea & vomiting
Fluid imbalance
naralytic ileus
nU.T.I. – prolonged bed rest, previous history, pelvic surgery, indwelling catheter
nUrinary retention
Water and Cellular Function
  • Medium for metabolic reactions
  • Transport nutrients and waste products
  • Lubrication
  • Insulation
  • Regulation/maintenance of body temperature
Body Fluids
Intracellular Fluids (ICF)
Extracellular Fluids (ECF)
  • Intravascular (plasma)
  • Transcellular (cavities)
  • Interstitial (lymph, pleural, cerebrospinal, synovial, biliary)
Elements or compounds able to carry an electric charge when dissolved or melted. These electrical charges are called IONS.
Types of Ions
Cations - positively charged ions
Anion - negatively charged ions

Milliequivalents - unit of measurement for ions
Major Cations in the Body
Sodium - Na+
Potassium - K+
Calcium - Ca+2
Magnesium - Mg+2
Major Anions in the Body
Chloride - Cl-
Bicarbonate - HCO3
Phosphorus/Phosphate - PO4
Movement of water through a membrane from an area of low concentration to high
Movement of water and ions across a membrane from an area of high concentration to low.  
The use of pressure to assist in the movement of water across a membrane from an area of low concentration to high
Active Transport
The movement of water and ions across a membrane from an area of low concentration to high concentration - and energy is required (in the form of ATP)
Hydrostatic pressure
Pressure exerted by fluids
Osmotic pressure
Stops osmotic flow
Oncotic Pressure
Pressure exerted by colloids
The measurement of concentration
Balanced tension/concentration
Isotonic Solution
Fluid has the same concentration as "regular" cells in the blood

0.9% NaCl
Hypotonic Solution
Fluid has lower concentration than "regular" cells in the blood

0.45% NaCl
Hypertonic Solution
Fluid has higher concentration than "regular" cells in the blood

3% NaCl
Salt Sucks
Water/fluid will move in the direction of the higher Na+ value (inside/outside the cell)
Higher Na+ level INSIDE the cell/lower OUTSIDE the cell
Fluid will enter the cell, cell swells (HEMOSYSED)
Higher Na+ level OUTSIDE the cell/lower INSIDE the cell
Fluid levels the cell, cell shrinks (CRENATION)

Serum Concentration
The number of dissolved particles per unit of fluid

Serum Osmolarity - 280-300mOsm/Kg

Decreases in hydrated conditions
Increases in dehydrated conditions
Percentage of RBC's to the blood volume in relation to plasma

Males - 40-54%
Females - 38-47%

Increases with dehydration
Decreases with hydration
Means of Regulating Fluid Balance
Kidneys *
Endocrine system
Cardiovascular system
GI system

*systems that will be our focus
Maintaining Homeostasis
  • exhalation (exchange of gases)
  • regulation of ECF by retention/excretion of fluids and electrolytes (Na+ and K+)
  • regulation of pH by retention/excretion of H+ ions
  • excretion of wastes
Heart and blood vessels
  • pumping action

Examples of Kidneys Acting to Maintain Homeostasis (all temporary)
Hypothalamus (sensing thirst/activated by increase in serum osmolarity ) releases ADH (anti-diruretic hormone) which acts on the kidneys (retain more water/go to the bathroom less)

Adrenal cortex (increase response to increase levels of K+) release Aldosterone, which acts on kidney tubules to recycle Na+ (which recoups H20)

Adrenal gland (in response to hypovolemia or low BP) releases RENIN, which in then converted into Angioteninogen then into Angiotensin I and then Angiotensin II which increases
Examples of Kidneys Acting to Maintain Homeostasis (all temporary) CONTINUED
Adrenal gland (in response to hypovolemia or low BP) releases RENIN, which is then converted into Angioteninogen then into Angiotensin I and the Angiotensin II which increase Na+ reabsorption (via Aldosterone), water retention by the kidneys, salt appepite/water intake, increased BP, and the release of ADH
Daily Fluid Gains
Metabolism - 250-300 ml
Oral fluids - 1100-1400 ml
Solid foods - 800-1000 ml
Fluid therapy (if applicable)
Daily Fluid Losses
Kidneys - 1500 ml
Skin - 500-600 ml
Lungs - 400 ml
GI Tract - 100-200 ml (3-6 l are reabsorbed)
Additional loses - wounds, external bleeding, third space loss

Insensible Fluid Loss
Evaporation - just losing H2)
Sensible Fluid Loss
The loss of both water and electrolytes
Disorders of Fluid Balance
  • depletion of ECF volume, abnormally low circulating blood volume
  • caused by abnormal skin, GI, renal losses, bleeding, decreased intake, movement of fluid to third space
  • signs/symptoms - weakness, fatigue, syncope, confusion, oliguria, low BP, weight loss, tachycardia, sunken eyeballs
Disorder of Fluid Balance
expansion of the ECF volume, increase amount of intravascular fluid
cases are chronic stimulus of kidneys or abnormal kidney function to conserve Na+ and water, excessive IV fluids, interstitial to plasma fluid shift
signs/symptoms - edema, weight gain, increased BP, bounding pulses, SOB, rales, tachypnea, distended neck, veins, ascites
Fluid Volume Deficits
Fluids and electrolytes lost in proportion
(ratio of H2O/electrolytes remains the same)

Causes are fistulas, GI suctioning, Third Space shifts, Anorexia, inability to obtain fluids
Excessive, repaid loss of H2O from body tissues
Results in disturbance of Na+, K+, and Cl- balance

Causes - prolonged fever, diarrhea, vomitting
Arterial pH
Indirect measurement of hydrogen ion (H+) concentration

Normal values - range between 7.35 - 7.45

Below 7.35 - Acidosis
Above 7.45 - Alkalosis

Maintaining pH
pH is maintained by utilization of a buffer

Buffer - a substance that can absorb or release H+ to correct an acid/base imbalance

examples: HCO-3 (bicarbonate), Phosphate (PO3), Ammonium, Protein, CO2
Acid Base Balance
Acid base balance is based upon H+ concentration

Increased H+ --> decreased pH/Acidosis
Decreased H+ --> increased pH/Alkalosis
Lungs/Kidneys - Buffer Systems
Lungs - eliminate/retain CO2 in direct relation to arterial pH

Kidneys - increase/decrease HCO-3 concentration in body fluids

Acid Base Imbalances/ABG's (just the ones we need to know)
pH - 7.35-7.45

PaCO2 - 35-45mm

HCO-3 - 22-26 mEq/L
Arterial Blood Gases/Lab Values
If pH is outside the parameter of 7.35-7.45, then ABC is labeled UNCOMPENSATED

If pH is within the parameter of 7.35-7.45 (and other values are outside the range), then the ABG is labeled as COMPENSATED

If all parameters are within their specified range, the ABG is labeled as NORMAL
Uncompensated ABG
Value is OUTSIDE the range
Lower than 7.35 = Acidosis
Higher than 7.45 = Alkalosis
Respiratory Acidosis
Increased PaCO2
Decreased pH (increased H+)
Respiratory depression leads to hypoxemia (COPD)
Respiratory Alkalosis
Decreased PaCO2
Increased pH (decreased H+)
Seen in anxiety with hyperventilation and initial phase of asthma attack
Metabolic Acidosis
High acid blood content leading to loss of NaHCO-3 (alkaline buffer)
Seen in diabetic ketoacidosis, diarrhea
Metabolic Alkalosis
Heavy loss of acid from the body or from increased levels of bicarbonate

Common causes are vomiting, NG suctioning
Low levels of Na+
Serum level < 135 mEq/l
S/S - muscle twitching, seizure, muscle cramps, lethargy, confusion, coma
High levels of Na+
Serum level > 145 mEq/l
S/S - thirst, dry mouth
Severe hypernatremia - hallucinations, disorientation, irritable, focal or grand mal seizures
Low levels of K+
Serum level < 3.5 mEq/l
S/S - cardiac arrhythmias, increased sensitivities, of Digoxin, fatigue
High levels of K+
Serum level > 5.0 mEq/l
S/S - EKG changes, vague muscle weakness (usually the first sign)
Low levels of Ca+
Serum level < 8.5 mg/dl
S/S - Chvostek's sign (abnormal reaction of the facial nerve) and Trousseau's sign (hand and forearm contract in response to having blood occluded), confusion, altered mood or memory, abdominal spasms
High levels of Ca+
Serum level > 10.5 mg/dl
S/S - muscle weakness, tenderness, anorexia, constipation, cardiac arrest
Low levels of Mg+
Serum level < 1.3 mEq/l
S/S - neuromuscular irritability, cardiac manifestations, mental changes
High levels of Mg+
Serum level > 3 mEq/l
S/S - flushing (due to peripheral vasodilation), hypotension, depressed respiration
Non-physical traits, such as values, beliefs, attitudes, and customs that are shared by a group of people and passed from one generation to another.

Totality of socially-transmitted behavior patterns, beliefs, values, customs, lifeways, and all other products of human work and thought characteristics of population that giudes it's worldview and decisionmaking
  • guides behavior
  • adapted or remains constant only as these satisfies the needs of the group
  • is learned

Language is the primary means of transmitting culture
Primary Characteristics of Culture
Age   Generation   Nationality   Race   Color
Gender Religion
Secondary Characteristics of Culture
Education   Socioeconomics   Political beliefs   Residence
Enclave identity   Marital status   Parental status
Sexual orientation   Migratory status
Groups w/in culture
Dominant groups
Minority groups
a group of people who are members of a larger cultural group

the group has certain ethnic, occupational or physical characteristics that are common to the larger group
Provides a sense of identification
Common heritage
Belonging from birth or adoption
People who share common values
A way to categorize subgroups according to specific physical characteristics

1. Skin pigmentation/hair texture
2. Facial features and height
Caucasian - white
Negroid - black
Mongoloid - red/yellow
Assimilation occurs when one value is dropped and the value of the dominant culture is adopted.
Most important
Egotistical, selfish
Take care of self
USA, Germany, Scandinavian countries
Human interdependence
Part of the group
Stifles individuality
Common social identify
Latin America, Asians, Middle East, Africa
Factors Affecting Cultural Sensitivity
Cultural blindness
Cultural imposition
Cultural conflict
Cultural and Ethnic Influences on Health Care Issues
Gender role
Language and communications
Personal space
Food and nutrition
Socioeconomic factors
Orientation to time
Social Class
Cultural grouping of persons who, through consensus, similarity of occupation, wealth, or education, develop like status, lifestyle, interests, and attitudes.
Belief in a supernatural force that has power over the universe which commands worship and obedience.

A system of beliefs/a comprehensive code of behavior.

The conscious pursuit of any object the person holds supreme.
Religion/Spiritual Needs and Medicine
Prayer, relaxation training and guided imagery ... have been shown to enhance immune function and delay disease progression
Faith - Powerful Medicine
More than 1200 studies
Better health outcomes
Less prone to depression, suicide, addictions
Cut across age, gender, culture, and geographic boundaries
Sugars, starches, mainly foods from plants
sugars, starches,  mainly from plant food.
One gram =  4kcal
Most basic forms are amino acids

Mainly from animal products
most basic forms are amino acids.
One gram = 4kcal
Carbon, hydrogen, and oxygen

Fats - solid at room temperature
Oils - liquid at room temperature

    hydrogen and


Good vs. Bad Lipids
Saturated Fats - increases blood cholesterol levels

Unsaturated Fats - minimal effect on blood cholesterol levels

Poly-unsaturated Fats - lower blood cholesterol levles
Good vs. Bad Cholesterol
Men - 45mg/dl
Females - 55mg/dl

LDL - 60-180mg/dl
A measurement of energy
Basic Metabolic Rate
amount of energy required by the body at rest
Calories by Nutrients
Fats - 1g=9calories
Carb - 1g=4calories
Protein - 1g=4calories
Recommended Daily Allowance

typically set by the USDA
Average American Diet is High in Fats
Typical diet is 30 to 35% Fat while the recommended is no more than 20%
USDA Dietary Guidelines
Eat a variety of foods
Maintain/improve your weight
Choose of diet with plenty of grains, vegetables, and fruits
Choose a diet low in fat, saturated fats and cholesterol
Choose a diet moderate in sugars and moderate in salt and sodium
IF you drink alcohol, do so in moderation
Benefits of WHOLE Grains
improves blood pressure
decreases cholesterol
decreases inflammation

All of which reduces the risk of heart disease
Factors Affecting Nutrition
Developmental Stage/Age
Health status
Socioeconomic status
Psychological factors
Misinformation/Food fads
Nutritional Assessment
The degree of balance between nutrient intake and nutrient requirements
Nutritional History
Name   Age   Present Weight   Usual Weight   Recent changes in weight   Height
Person who prepares the meals   Food preferences, allergies, and aversions Use of dentures   Foods that cause indigestion, diarrhea, and gas   Usual bowel habits   Appetite changes   Type, size, and time of usual meals   Dietary problems   Activity/energy level   Usual # of meals/snacks   Chewing/swallowing difficulties   Past Medical History (diseases, surgeries, weight loss) Level of physical activity
Nutritional History
Present weight
Usual weight
Recent weight changes
Person who prepares meals
Food preferences, allergies, and aversions
Use of dentures
Medication History
Important because some medicine affect appetite

Includes OTC and recreational drugs
Medication history
Use of medications
over the counter (OTC)
Significant Lab Values
CBC - iron and protein
Creatinine/BUN - renal function/dehydration
Albumin - protein
Transferrin - iron
Prealbumin - protein
Glucose - pancreas, insulin, sugar intake
Electrolytes - Na+, K+, Ca+2 etc.
Triglycerides - lipid intake/utilization
Dietary Patterns/Assessment
Usual meal times
Two/three day calorie counts
24-hour diet recall
What triggers you to eat? (hunger vs, time, stressors, cravings, boredom, social setting/events, family)
Dietary Patterns, Assessments
What “triggers” you to eat?
hunger versus meal time
stressors  cravings
social setting/event
Usual meal times
Two/three Day Calorie Count
24 hour recall
Clinical Signs of Nutritional Status
General appearance
GI function
Cardiovascular function
Other Clinical Signs of Nutritional Status
General vitality
Oral Mucosa
Clinical signs of nutritional status
General appearance
Weight / Height
G.I. Function
Cardiovascular function
Body Mass Index
Measurement of body fat based upon height and weight that applies to both adult men and women
Underweight - <18.5
Normal weight - 18.5-24.9
Overweight - 25-29.9
Obesity - greater than 30
Anthropometry Measurement
System of measurement based upon the size and makeup of the body at a specific body site

circumference of the wrist
mid-upper arm circumference
tricep skin fold
Anthropometry measurement
System of measurement of the size

  and makeup of the body at specific body sites.

circumference of the wrist
mid-upper-arm circumference
triceps skin fold
Nutritional Assessment - Measurement
All patients should have weight and height recorded upon admission (unless contraindicated)  
Various Related Nursing Diagnosis
Potential for aspiration
Body image disturbance
Fluid volume deficit
Self care deficit, feeding
More Potential Nursing Diagnosis
Tissue perfussion, altered: gastrointestinal

Altered nutrition (less/more than body weight requirements)
Predisposing Factors to Alterations
  • Involuntary loss or gain of greater or equal to 10% of usual body weight within 6 mos.
  • Greater or equal to 5% over or under ideal body weight
  • Presence of chronic illness or increased metabolic requirements
  • Altered diets/diet schedules
  • Inadequate nutrient intake for 7 days
Predisposing factors to alterations
Involuntary loss or gain of greater or equal to 10% of usual body weight within 6 months
Greater or equal to 5% over or under ideal body weight
Predisposing factors to alterations
Presence of chronic disease or increased metabolic requirements
Altered diets or diet schedules
Inadequate nutrient intake for 7 days or more
Anorexia Nervosa
denial of appetite
bizarre eating patterns
usually adolescent females

Unstable body image

Usually college age females
Ways to Enhance Nutritional Intake
Food from home   Favorite Foods   Ethnic foods   Frequent/small meals   Treats   High calorie/high protein foods (Ensure/Boost/Milkshakes)   Low/no fat foods (for patients who need those diets)
Enteral Feeding
PEG Tube - into the stomach or NGT (nasal gastric tube)

Continuous - 24/7 flow rate (bag changed daily)
Bolus - larger amounts several times a day (like meals)/irrigation set changed daily
Total Parenteral Nutrition (TPN)
  • aka Hyperalimentation (Hyperal)
  • Glucose 25%, Lipids 20%
  • Administered via Central Venous Catheter (subclavian/internal jugular)
  • Tubing changed daily
Peripheral Parenteral Nutrition (PPN)
  • aka Parenteral Nutrition
  • 10% glucose, lipids 10% (if administered)
  • can be administered via peripheral or central venous catheter
    • tubing changed daily
No modifications

Normal nutritional requirements
Amino Acids
basic component of proteins
liquid at room temperature.

solid at  room temperature

One gram = 9kcal

Saturated fatty acids
Increases blood cholesterol levels
Unsaturated fatty acids

    -  minimal effect on blood cholesterol levels

Polyunsaturated fatty acids
lowers blood cholesterol levels
HDL Cholesterol male and female levels

Males –    45mg/dl

Females – 55mg/dl

LDL Cholesterol Levels
Kilocalorie AKA
Basic Metabolic Rate (BMR)
Dietary recommendations for americans
Eat a variety of foods
Maintain / improve your weight
Choose a diet with plenty of grain products, vegetables & fruits
Choose  a diet low in fat, saturated fat and cholesterol
Dietary recommendations for americans cont.
Choose a diet moderate in sugars
Choose a diet moderate in salt & sodium
If you drink alcoholic beverages, do so in moderation
Nutritonal Assessment
The degree of balance between nutrient intake and nutrient requirements.
Nutritional History cont.
Foods that cause  indigestion, diarrhea, gas
Usual bowel habits
Appetite changes
Type, size, time of usual meals
Dietary problems
Activity / energy level
Nutritional history cont 2
Usual number of meals & snacks consumed per day
Chewing or swallowing difficulties
weight problems
Level of physical activity
Significant Laboratory Values: Triglycerides
lipid intake / utilization
Significant Laboratory Values: Glucose
pancreas, insulin, sugar intake
Significant Laboratory Values:
Significant Laboratory Values: CBC
iron, protein
Significant Laboratory Values: Creatinine/BUN
renal function, hydration
Significant Laboratory Values: Albumin/Prealbumin
Significant Laboratory Values: Transferrin
Clinical Signs of nutritonal status
General vitality
Skin – general
Oral membranes

      / mouth

Body Mass Inddex (BMI)
A measure of body fat based on height and weight that applies to both adult men and women.