NUR2392 Final Exam Review: Multidimensional Care II, Exams of Nursing

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NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen NUR2392 Final Exam Multidimensional Care II MDC 2 Final Exam Review (2021-2022) Assessment and Care of Patients with Pain Concepts • The priority concept in this chapter is comfort • The interrelated concepts in this chapter are cognition sensory Perception Pain The Scope of the Problem • Pain is a major economic problem and a leading cause of disability that changes the lives of many people, especially older adults. • Chronic non-cancer pain such as osteoarthritis, rheumatoid arthritis, and diabetic neuropathy is the most common cause of long-term disability, affecting millions of Americans and others throughout the world. • Universal, complex personal experience • Is an impairment in comfort; major economic concern; leading cause of disability • Failure to manage pain is a worldwide health problem • Inter-professional pain initiatives help patients receive best treatment Definitions of Pain • Unpleasant sensory and emotional experience associated with actual or potential tissue damage • Whatever person experiencing it says it is; exists whenever person says it does • Self-report always most reliable indication of pain Categorization of Pain by Duration • Acute pain - Short-lived - Results from sudden, accidental trauma; surgery; ischemia; acute inflammation • Chronic (persistent) pain - Can last a person‘s lifetime - Chronic cancer pain - Chronic non-cancer pain • Pain is treated inadequately in almost all health care settings. • Populations at the highest risk in medical-surgical nursing are older adults, patients with substance use disorder, and those whose primary language differs from that of the health care professional. • Older adults in nursing homes are at especially high risk because many residents are unable to report their pain. In addition, there often is a lack of staff members who have been educated to manage pain in the older-adult population. Acute Pain • Acts as warning sign • Activation of sympathetic nervous system • ―Fight-or-flight‖ reactions - Increased vital signs - Sweating - Dilated pupils - Restlessness - Apprehension - Distress of varying degrees NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen Acute Pain (Cont.) • Absence of physiologic and behavioral responses does not mean absence of pain • Usually temporary with sudden onset, and easily localized • Sensory perception of pain changes as injured area heals Chronic (Persistent) Pain • Lasts or recurs for indefinite period (more than 3 months) • Gradual onset • Character and quality often change over time • Serves no biological purpose • Can result in emotional, financial, and relationship burdens, as well as depression/hopelessness Chronic Cancer Pain • Usually result of tumor growth, nerve compression, tissue invasion, metastasis • Cancer treatment can also cause acute pain (e.g., procedures, surgery, toxicities from chemo and radiation) Chronic Non-Cancer Pain • Global health issue for people > 65 years old • Formerly called chronic nonmalignant pain • Neck, shoulder, low back • Over half of veterans of recent wars have this condition - Can cause depression, decreased sense of well-being Categorization of Pain by Underlying Mechanisms • Nociceptive pain - Somatic - Visceral • Neuropathic pain Pain Transmission • Painful stimuli often originate in extremities • If pain is not transmitted to the brain, person feels no pain • Two specific fibers transmit periphery pain: - A delta fibers - C fibers Assessment: Noticing • Patient‘s self-report is ―gold standard‖ for assessment • Nurse‘s role - Accept patient self-report - Serve as advocate - Act promptly to relieve pain - Respect patient values and preferences Pain Assessment (Cont.) • Location • Intensity • Quality • Onset and duration • Aggravating and relieving factors • Effect of pain on function and quality of life NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Occupational therapy • Aquatherapy • Functional restoration • Acupuncture • Low-impact exercise such as walking or yoga • Cutaneous stimulation (e.g.,TENS) Cognitive/Behavioral Strategies (Examples) • Prayer • Relaxation breathing • Artwork • Reading • Watching television • Mindfulness • Meditation • Guided imagery • Hypnosis • Biofeedback • Virtual reality Care Coordination and Transition Management • Home care management • Self-management education • Health care resources Chapter 4 Audience Response System Questions Question 1 The patient is receiving the first oral dose of an opioid analgesic for chronic pain. Which additional drug does the nurse anticipate will be prescribed? A. NSAID B. Epidural C. Stool softener D. Anti-anxiety agent Rational; Opioids inhibit peristalsis in the GI tract. Patients who take regular doses of opioids frequently become constipated. Interventions such as diet modifications and laxative agents may be needed to prevent or minimize the problem of constipation. Question 2 Which patient does the nurse recognize that would benefit most from the use of a patient- controlled analgesia pump? A. 19-year-old with head injury following MVA today B. 34-year-old with ankle fracture after skiing accident yesterday C. 56-year-old with slurred speech after falling and breaking hip one week ago D. 78-year-old with delirium and fever following surgery 2 days prior NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen Rational; The mentally alert patient is the best candidate to receive PCA. When a patient is cognitively impaired or unable to push the PCA button, another method of administration should be considered. Question 3 The nurse has discussed nonpharmacologic pain management measures with a patient who takes opioid medication for chronic pain. Which patient statement requires further nursing teaching? A. ―I can practice meditation while taking opioid medication.‖ B. “Reading should be used in place of drug therapy.” C. ―Nonpharmacologic interventions can help to control pain.‖ D. ―I plan to practice relaxation breathing tonight.‖ Rational; Nonpharmacologic pain management measures can be used in addition to opioid medication; for patients with moderate to severe intensity pain, these measures should be used in tandem with (instead of in place of) opioid therapy. Chapter 27 Assessment of the Respiratory System Health Promotion and Maintenance • Minimize exposure to inhalation irritants - Home, occupation, work exposures • Smoking cessation (including hookah, water pipe, ―vaping‖) • Limit or cease exposure to secondhand and thirdhand smoke Assessment: Noticing and Interpreting • Family and personal data (including genetic risk) Family hx of COPD, Cancer, Asthma, • Smoking (pack-years) 2 packs /day x 20 yrs • Drug use (prescribed and illicit) • Allergies - asthma • Travel, geographic area of residence • Veterans: location of deployments agent orange, gases • Current health problems • PND, paroxysmal nocturnal dyspnea. Physical Assessment: Pharynx, Trachea, and Larynx (Cont.) • Pharynx the membrane-lined cavity behind the nose and mouth, connecting them to the esophagus. • The trachea, colloquially called the windpipe, is a cartilaginous tube that connects the pharynx and larynx to the lungs • Left: Structures of the larynx. the hollow muscular organ forming an air passage to the lungs and holding the vocal cords in humans and other mammals; the voice box. • Right: Detail of the glottis (two vocal folds and the intervening space, the rima glottis). Physical Assessment: Lungs and Thorax • Inspect thorax with patient sitting up • Observe chest, compare one side with the other • Work from the apex, move downward toward base (from side to side) • Rate, rhythm, depth of inspiration as well as symmetry of chest movement Physical Assessment: Lungs and Thorax (Cont.) NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen Examine AP diameter with lateral diameter Physical Assessment: Lungs and Thorax (Cont.) • Lung sounds – Normal sounds - Bronchial - Bronchovesicular - Vesicular • Adventitious sounds – Pathologic - Crackles - Wheezes - Rhonchus - Pleural friction rub Physical Assessment: Lungs and Thorax (Cont.) • Lung chart Other Indicators of Respiratory Adequacy • Skin and mucous membrane changes • General appearance • Endurance Promoting smoking cessation is a sensitive and sometimes uncomfortable issue for nurses and other health care professionals to approach with patients who smoke. However, this opportunity for a ―teachable moment‖ may be the beginning support a patient needs to be successful in this healthful pursuit, especially if the patient is hospitalized for a smoking-related illness (Keating, 2016). Acute care settings have automatic smoking-cessation protocols that attach to the patient's electronic medical record when an active smoking history is recorded. The Joint Commission requires documentation of screening for tobacco use and that a tobacco treatment program be offered or provided as part of their quality measures. Ask about the patient's desire to quit, past attempts to quit, and the methods used. A ―yes‖ response to any of the following questions indicates nicotine dependence. The more ―yes‖ responses, the greater the nicotine dependence. Ask the smoker these questions: • How soon after you wake up in the morning do you smoke? • Do you wake up in the middle of your sleep time to smoke? • Do you find it difficult not to smoke in places where smoking is prohibited? • Do you smoke when you are ill? Diagnostic Assessment • Laboratory assessment - RBC - ABG - Sputum • Imaging assessment - x-rays - CT • Other noninvasive diagnostic assessments - Pulse oximetry - Capnometry and capnography - PFTs - Exercise testing Invasive Diagnostic Assessment • Endoscopic examinations NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen Hazards & Complications of Oxygen Therapy • Combustion • Oxygen-induced hypoventilation - Hypercarbia—retention of CO2 - CO2 narcosis—loss of sensitivity to high levels of CO2 • Oxygen toxicity • Absorption atelectasis—new onset of crackles/decreased breath sounds • Drying of mucous membranes • Infection Nursing Safety Priority Action Alert • Assess the tubing system used for oxygen delivery to recognize buildup of condensation. Respond by draining condensation. • To prevent bacterial contamination of the oxygen delivery system, never drain the fluid from the water trap back into the humidifier or nebulizer. Oxygen Delivery Systems • Type used depends on: - Oxygen concentration required/achieved - Importance of accuracy and control of oxygen concentration - Patient comfort - Importance of humidity - Patient mobility Low-Flow Oxygen Delivery Systems • Does not provide enough flow to meet total oxygen and air volume - Nasal cannula (1-6 L) - Face-mask o Simple o Partial rebreather o Non-rebreather Nasal Cannula • Flow rates of 1-6 L/min • O2 concentration of 24%-44% (1-6 L/min) • Flow rate >6 L/min does not increase O2 because anatomical dead space is full • Assess patency of nostrils • Assess for changes in respiratory rate and depth Simple Face-mask • Delivers O2 up to 40%-60% • Minimum of 5 L/min • Mask fits securely over nose and mouth • Monitor closely for risk of aspiration Partial Rebreather Mask • Provides 60%-75% with flow rate of 6-11 L/min • One third exhaled tidal volume with each breath • Adjust flow rate to keep reservoir bag inflated Non-Rebreather Mask • Highest O2 level • Can deliver FIO2 greater than 90% NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Used for unstable patients requiring intubation • Ensure valves are patent and functional High-Flow Oxygen Delivery Systems • High-flow—can deliver 24%-100% at 8-15 L/min - Venturi mask - Face tent - Aerosol mask - Tracheostomy collar - T-piece Venturi Mask • Adaptor located between bottom of mask and O2 sources • Delivers precise O2 concentration—best device for chronic lung disease • Switch to nasal cannula during mealtimes • A Venturi mask for precise oxygen delivery. T-Piece • Delivers desired FIO2 for tracheostomy, laryngectomy, ET tubes • Ensures humidification through creation of mist • Mist should be seen during inspiration and expiration • A T-piece apparatus for attachment to an endotracheal or tracheostomy tube. Noninvasive Positive-Pressure Ventilation (NPPV) • Uses positive pressure to keep alveoli open, improve gas exchange without airway intubation - BiPAP - CPAP CPAP (Cont.) • Delivers set positive airway pressure throughout each cycle of inhalation and exhalation • Opens collapsed alveoli • Used for atelectasis after surgery or cardiac-induced pulmonary edema; sleep apnea Transtracheal Oxygen Delivery (TTO) • Long-term delivery of O2 directly into lungs • Small flexible catheter is passed into trachea through small incision • Avoids irritation that nasal prongs cause; is more comfortable • Flow rates prescribed for rest, activity Home Oxygen Therapy • Criteria for equipment • Patient education: - Compressed gas in tank or cylinder - Liquid oxygen in reservoir - Oxygen concentrator Tracheostomy • Tracheotomy—surgical incision into trachea for purpose of establishing an airway • Tracheostomy—stoma (opening) that results from tracheotomy • May be temporary or • Permanent NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • tracheostomy is a surgically created opening into the windpipe (trachea). This is done to relieve and bypass obstruction of the windpipe, to help ventilate comatosed patients or to allow for clearance of secretions pooling in the upper windpipe. Possible Complications of Tracheostomy • Pneumothorax • Subcutaneous emphysema • Bleeding • Infection Tracheostomy Tubes • Disposable or reusable • Cuffed tube or tube without cuff for airway maintenance • Inner cannula disposable or reusable • Fenestrated tube Care Issues for the Patient with a Tracheostomy • Prevention of tissue damage: - Cuff pressure can cause mucosal ischemia - Check cuff pressure often - Prevent tube friction and movement - Prevent/treat malnutrition, hemodynamic instability, hypoxia Causes of Hypoxia in the Tracheostomy • Ineffective oxygenation before, during, after suctioning • Use of catheter that is too large for the artificial airway • Prolonged suctioning time • Excessive suction pressure • Too frequent suctioning Tracheostomy Care • Assess the patient • Secure tracheostomy tubes in place • Prevent accidental decannulation Air Warming and Humidification • Tracheostomy tube bypasses nose and mouth, which normally humidify, warm, and filter air • Air must be humidified • Maintain proper temperature • Ensure adequate hydration Suctioning • Maintains patent airway, promotes gas exchange • Assess the need in patients who cannot cough adequately • Done through nose or mouth Complications of Suctioning Hypoxia • Tissue (mucosal) trauma • Infection • Vagal stimulation, bronchospasm • Cardiac dysrhythmias from induced hypoxia Bronchial and Oral Hygiene NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen S2 Dup sound =beginning of ―diastole ‖ aortic and pulmonary valves close (mitral and tricuspid valves open) Cardiac Valves the lub-dub 1) Tricuspid valve 2) Mitral valve 3) Pulmonic valve 4) Aortic valve 3 2 S When present, occurs immediately after S produced from ventricular filling. S 4 When present, heart sound occurs just before S 1 produced from atrial contraction and indicates impaired ventricle compliance or fluid overload. Perfusion Concept Exemplar: Hypertension • Desired blood pressure - For people over 60 - Below 150/90 - For people younger than 60 - Below 140/90 - According to Joint National Committee 8 (JNC 8) guidelines, patients whose blood pressures are above these goals should be treated with drug therapy Blood Pressure Regulation • Autonomic nervous system: - Baroreceptors - Chemoreceptors – Hypercapnia • Renal system • Endocrine system • External factors also affect BP Mean Arterial Pressure (MAP) • Normal 70 – 100 mm Hg • Must be at least 60 mm Hg to maintain adequate blood flow through coronary arteries and perfuse major organs (brain). • If the M A P falls below this number for an appreciable time, vital organs will not get enough oxygen perfusion, and will become hypoxic, a condition called ischemia. Chapter 36 Care of Patients with Vascular Problems Point to Remember… • Best indicator of fluid balance is weight • 2.2 lb = 1 kg = 1 L of fluid Assessment: Noticing Abdominal Aortic Aneurysm (AAA) • Pain related to AAA is usually steady with a gnawing quality, unaffected by movement, may last for hours or days • Pain in abdomen, flank, back • Abdominal mass is pulsatile • Rupture is most frequent complication and is life threatening Cardiovascular System Physical Assessment • General appearance NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Skin - Cyanosis, rubor (red/flushing) • Extremities - Clubbing, edema • Blood pressure - Hypotension and hypertension - Postural (orthostatic) hypotension Aortic Dissection • May be caused by sudden tear in aortic intima • Pain described as tearing, ripping, stabbing • Life threatening • Emergency care goals - Eliminate pain - Reduce blood pressure - Decrease velocity of left ventricular ejection • Nonsurgical treatment • Surgical treatment Assessment: Noticing Thoracic Aortic Aneurysm • Assess for - Back pain o Manifestation of compression of aneurysm on adjacent structures - Assess for shortness of breath - Hoarseness - Difficulty swallowing - Mass may be visible above suprasternal notch • Sudden excruciating back or chest pain symptomatic of thoracic rupture Precordium • Assessment • Inspection • Palpation • Percussion • Auscultation - Normal heart sounds - Paradoxical splitting - Gallops and murmurs - Pericardial friction rub Serum Markers of Myocardial Damage • Troponin: Troponin T and troponin I • Creatine kinase (CK) • Myoglobin • Serum lipids - Total cholesterol < 200 mg/dL - Triglyceride < 150 mg/dL - HDL > 40 mg/dL - LDL < 70 mg/dL for cardiovascular patients NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Homocysteine • Highly sensitive C-reactive protein Laboratory Assessment • Microalbuminuria • Blood coagulation studies - PT/INT - PTT • ABG • F&E • Erythrocyte count • H&H • Leukocyte count Management of Cardiac Arrest • CPR - Maintain patent airway - Ventilate with mouth-to-mask device - Start chest compressions • Advanced cardiac life support Automated External Defibrillation • AEDs create an opportunity for laypersons to respond to cardiac arrest • AEDs analyze the rhythm and shocks are delivered for ventricular fibrillation or pulseless ventricular tachycardia only Defibrillation • Asynchronous countershock that depolarizes critical mass of myocardium simultaneously to stop re-entry circuit and allow sinus node to regain control of heart Diagnostic Assessment • PA and lateral CXR • Angiography • Arteriography • Cardiac catheterization Cardiac Conduction System Normal Sinus Rhythm Normal sinus rhythm. Both atrial and ventricular rhythms are essentially regular (a slight variation in rhythm is normal). Atrial and ventricular rates are both 83 beats/min. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology, or shape. The PR interval measures 0.18 second and is constant; the QRS complex measures 0.06 second and is constant. and Transition Management Care Coordination • Self-management education - Medication therapy o Antidysrhythmics o Anticoagulants • Health care resources Non-surgical Interventions • Non-surgical interventions NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen influence preload. Blood flow from the heart into the systemic arterial circulation is measured clinically as cardiac output (CO), the amount of blood pumped from the left ventricle each minute. CO is derived from the patient’s heart rate and stroke volume. Stroke volume is the amount of blood ejected by the left ventricle during each contraction. Question 3 The nurse understands that which assessment finding is the best indicator of fluid retention? A. Tachycardia B. Weight gain C. Crackles in the lungs D. Increased blood pressure Rationale: Weight gain is the best indicator of fluid retention and is commonly called edema. Week 2 Chapter 9 Care of Patients with Common Environmental Emergencies Concepts • The priority of this chapter is tissue integrity. • The interrelated concept in this chapter is comfort. Heat-Related Illnesses • High environmental temperature • High humidity • At-risk populations - Older adults - Those with mental health conditions - Those who work outside - Homeless individuals - Users of illicit drugs - Outdoor athletes - Military in hot climates Heat Exhaustion • Heat exhaustion often occurs when people work or play in a hot, humid environment and body fluids are lost through sweating which causes the body to overheat and become dehydrated. The temperature may be elevated, but not above 104 F (40 C). • Dehydration from heavy perspiration and inadequate fluid and electrolyte intake during heat exposure over hours to days • Flu-like symptoms • Treatment - Stop physical activity, - transfer to a cool place - Cooling measures - Rehydration therapy Heat Stroke NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Heat stroke (also called heatstroke or sunstroke) also is a heat-related illness, and it is a life-threatening medical condition. It usually develops because of untreated heat exhaustion. The body's cooling system, which is controlled by the brain, stops working and the internal body temperature rises to the point at which brain damage or damage to other internal organs may result (temperature may reach 105 F or greater [40.5 C or greater]). • True medical emergency • Body temp may exceed 104° F (40° C) • High mortality rate without treatment • Exertional—sudden onset; from strenuous physical activity in hot, humid conditions • Non-exertional (classic)—occurs over period of time from chronic exposure to hot, humid environment Heat Stroke (cont.) • Can be fatal if untreated. • Treatment; - Oxygen therapy - IV lines - Urinary catheterizing - Continuous cooling - Benzodiazepines if shivering - Monitor organs and electrolytes. Snakebites, and Arthropod Bites and Stings • Most North American snakes aren't dangerous to humans. Some exceptions include the rattlesnake, coral snake, water moccasin and copperhead. Their bites can be life- threatening. 8,000 snakebites happen in the U.S. each year. Even a bite from a "harmless" snake can cause infection or allergic reaction in some people. Snakebite Hospital Care • Supplemental oxygen anxiety sympathetic nervous system • IV lines for NSS or RL • Continuous cardiac, BP monitoring • Opioids for pain • Tetanus prophylaxis • Wound care • Broad-spectrum antibiotics • Baseline laboratory values with CBC, CK, crossmatch Before ER • Wash the bite with soap and water. • Keep the bitten area still and lower than the heart. • Cover the area with a clean, cool compress or a moist dressing to ease swelling and discomfort. • Monitor breathing and heart rate. • Remove all rings, watches, and constrictive clothing, in case of swelling. • Note the time of the bite so that it can be reported to an emergency room healthcare provider if needed. NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • If possible, try to remember to draw a circle around the affected area and mark the time of the bite and the initial reaction. If you are able, redraw the circle around the site of injury marking the progression of time. • It is helpful to remember what the snake looks like, its size, and the type of snake if you know it, in order to tell the emergency room staff. • Don't apply a tourniquet. • Don't try to suck the venom out. • At the emergency department you may be given: • Antibiotics to prevent or treat developing infections • Medicine to treat your pain • A special type of antivenin depending on the type of snake that bit you and the severity of your symptoms Arthropods • Spiders • Scorpions • Bees • Wasps Table 9-2 • See Table 9-2 for detailed information about organisms, characteristics, pathophysiology, and associated care Lightning Injuries • Usually highly preventable. • Cardiopulmonary and central nervous system highly effected. • Treatment; - Immediate CPR in the field. (Victim is not not charge so there is no danger to rescuer) - Provide for advance life support management. - ECG, CT of head, CK, tetanus prophylaxis. Cold-Related Injury: Hypothermia • Occurs at core body temperature <95° F (35° C) • Mild: 90 to 97° F (32 to 36° C) • Moderate: 82 to 90° F (28 to 32° C) • Severe: Below 82° F (<28° C) Hypothermia (Cont.) • Treatment - Shelter from the cold - Remove wet clothing - Engage in rewarming - Monitor hospitalized patients for cardiovascular instability, ARDS, acute renal failure, pneumonia Cold-Related Injury: Frostbite • Occurs when body tissue freezes and causes tissue integrity damage • Categorized between first-degree and fourth-degree • Edema and blister formation 24 hours after frostbite injury occurring in an area covered by a tightly fitted boot. Frostbite (Cont.) 1. Rapid rewarming. NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen - Inside the cells - 70% of body water - Primary cation = Potassium (K+) • Extracellular Fluid (ECF) - Outside the cells - 30% of body water - Primary cation = Sodium (Na+) - Intravascular o Inside the blood vessels o 20% of ECF o Primarily blood plasma - Interstitial o In the tissues, outside blood vessels o 80% of ECF • Fluid Definitions • Solution – A substance containing both a liquid (solvent) and particles (solutes) • Solvent – Liquid in which particles are dissolved or carried • Solutes – P articles which are dissolved in a solution • Example: • Solution = Salt Water • Solvent = Water • Solute = Sodium Chloride Differences in % of Fluid Weight to Body Weight • The percentage of body weight that is water is higher (70%) at birth and in early childhood • The percentage of body weight is also lower in older and obese people. . Body Fluids • A 154-pound (70-kilogram) man has a little over 10.5 gallons (42 liters) of water in his body: - 7 gallons (28 liters) inside the cells, - 2.5 gallons (about 10.5 liters) in the space around the cells, and - slightly less than 1 gallon (3.5 liters, or about 8% of the total amount of water) in the blood. Homeostasis • Proper functioning of all body systems; requires fluid and electrolyte balance • Normal distribution of total body water in adults. - Intracellular Fluid (ICF) o Inside the cells o 70% of body water o Primary cation = Potassium (K+) - Extracellular Fluid (ECF) o Outside the cells o 30% of body water o Primary cation = Sodium (Na+) - Intravascular NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen o Inside the blood vessels o 20% of ECF o Primarily blood plasma - Interstitial o In the tissues, outside blood vessels o 80% of ECF Fluid Pressures • Movement of fluid through cell or blood vessel membrane because of differences in water pressure (hydrostatic pressure) • 3 Pressures are - Osmotic Pressure, - Hydrostatic Pressure and - Oncotic Pressure ((AKA Colloid Osmotic Pressure) • We’re going to talk about why the fluid moves around in the body. There are three main pressures within the bloodstream and body fluids that force the movement of fluid and electrolytes throughout the body, so let’s look at each of those now. • The three pressures are Osmotic Pressure, Hydrostatic Pressure, and Oncotic Pressure – also known as ―Colloid Osmotic Pressure‖. When you think of Osmotic Pressure, I want you to think concentration. This pressure refers to how water moves through the body because of concentration gradients – remember we talked about Osmosis? Hydrostatic Pressure • ―Water-pushing pressure‖ • Force that pushes water outward from a confined space through a membrane • Amount of water in any body fluid space determines pressure • Example: Blood pressure - Moving whole blood from the heart to capillaries where filtration occurs to exchange water, nutrients, and waste products between the blood and tissues Clinical Significance: Peripheral Edema • Fluid Volume Excess • Develops with changes in normal hydrostatic pressure differences • The symptoms of peripheral edema depend on the cause of the condition: - Simple water retention - Inflammation - Certain medications - Low protein levels in the blood - Problems with your veins - Kidney diseases - Congestive heart failure - Lung conditions • Your body works to make sure that you maintain proper water levels in your cells. It naturally balances water intake and water loss. It works to keep the total amount of water and electrolytes in the blood constant. However, a number of health conditions or situations can cause too much fluid to collect in the tissues and cause noticeable swelling. When the capillaries in your blood vessels begin to leak fluids into your tissues, NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen this causes puffiness and skin tightness, usually in your lower limbs because there’s more pressure on these areas. - Simple Water Retention - This can happen when you consume too much sodium. The sodium holds on to water and keeps it in the body. Water retention is also caused by sitting or standing in one position for too long and hormone changes during a women’s monthly period or pregnancy. - Inflammation: Inflammation in your tissues may cause swelling in your legs. Inflammation may be a response to allergies, trauma (like a broken bone or sprained ankle), an infection or wound in the leg, arthritis, gout or cellulitis. - Certain medications: Certain drugs can cause edema because they cause the body’s sodium and water levels to become unbalanced, or they contribute to renal dysfunction. Medications that may cause this issue include NSAIDs (such as ibuprofen or naproxen), insulin, steroid therapy and drugs for high blood pressure. - Low protein levels in the blood: Fluid leaks out of your blood vessels more easily when there isn’t enough of the protein called albumin (protein that is made by the liver) in your blood. Malnutrition or health conditions that affect how much protein the body produces, like liver and kidney diseases can cause low protein levels in your blood. - When veins aren’t able to transport enough blood to the feet and then back to the heart — which is called venous insufficiency — your ankles and feet become swollen. Blood gathers in your legs, forcing fluid out of your blood vessels and into the surrounding tissue. This is the most common cause of leg swelling among people over 50 years old, especially in women. - Kidney diseases: When the kidneys aren’t able to remove enough sodium and water from the body, this creates pressure on your blood vessels and can lead to peripheral edema. - Congestive heart failure: If the heart becomes too weak to pump blood around the body, it will gather in front of the heart and put pressure on your veins. This can cause fluid to seep out into the surrounding tissue. This leaking fluid leads to swelling in the legs or in the abdomen. - Lung conditions: If pressure in the lungs and heart gets very high, which can happen when your body is reacting to certain medical conditions, this can cause the legs and feet to swell. This can happen as a result of serious lung conditions like emphysema or pulmonary fibrosis. Or it can occur if you have congestive heart failure and your heart isn’t strong enough to pump the blood that’s returning from your lungs. Since the heart, lung, kidneys and brain all work together to regulate fluid levels in the body, when one organ is forced to work harder as a result of a medical condition, hormones are often released to either retain or provide more fluids. Fluid buildup in the lungs is called pulmonary edema. This means water collects in the air sacs of the lungs. Pulmonary edema can make it very difficult to breathe. Peripheral Edema Fluid Volume Excess Conventional Treatment • Reduce Sodium Consumption NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen - Cardiovascular - Respiratory - Skin - Neurologic - Renal Facts to Remember ... • 1 L of water weighs 2.2 lbs, equal to 1 kg • Weight change of 1 lb = fluid volume change of about 500 mL Assessment: Noticing • Physical assessment • Patient safety • Pulmonary edema • Drug therapy • Nutrition therapy • Monitoring of intake and output (I&O) Electrolyte Imbalance • Can occur in healthy people as result of changes in fluid I&O • Can be life threatening if severe; can occur in any setting Analysis: Interpreting • Dehydration as a result of excess fluid loss or inadequate fluid intake • Potential for injury as a result of blood pressure changes and muscle weakness Planning and Interventions: Responding • Restoring fluid balance - Fluid replacement - Drug therapy • Preventing injury Sodium • Normal level: 136 to 145 mmol/L • ―Where sodium goes, water follows‖ • Hyponatremia • Hypernatremia Potassium • Normal level: 3.5 to 5.0 mEq/L • Some control over intracellular osmolarity and volume • Regulate protein synthesis, glucose use, and storage • Hypokalemia • Hyperkalemia Calcium • Normal level: 9.0 to 10.5 mg/dL • Absorption requires active form of vitamin D • Stored in bones • Parathyroid hormone • Thyrocalcitonin • Hypocalcemia • Hypercalcemia • Hypocalcemia NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen - Palmar flexion indicating a positive Trousseau‘s sign in hypocalcemia. - Facial muscle response indicating a positive Chvostek‘s sign in hypocalcemia. Phosphorus • Normal level: 3.0 to 4.5 mg/dL • Found in bones • Activates vitamins and enzymes; assists in cell growth and metabolism • Plasma levels of calcium and phosphorus exist in a balanced reciprocal relationship • Hypophosphatemia • Hyperphosphatemia Magnesium • Normal level: 1.3 to 2.1 mg/dL • Critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation, cell growth • Hypomagnesemia • Hypermagnesemia Chloride • Normal level: 98 to 106 mEq/L • Imbalance occurs as a result of other electrolyte imbalances • Treat underlying electrolyte imbalance or acid–base problem Considerations for Older Adults • At risk for most electrolyte imbalances from age-related organ changes • Have less total body water than younger adults; more at risk for fluid imbalances; more likely to be taking drugs affecting fluid or electrolyte balance Chapter 11Audience Response System Questions Question 1 While monitoring a patient who has fluid overload, which assessment is most concerning to the nurse? A. Bounding pulse B. Neck vein distention C. Pitting edema in the feet D. Presence of crackles in the lungs Reasoning; Fluid overload may lead to pulmonary edema and heart failure. Any patient with fluid overload, regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in patients with fluid overload. Question 2 A patient has been having frequent liquid diarrhea for the last 24 hours. A stool sample was sent to the laboratory to confirm possible Clostridium difficile infection. The nurse should monitor the patient for which electrolyte imbalance? NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen A. Dehydration B. Hypokalemia C. Hyponatremia D. Hypocalcemia Reasoning; Potassium re-absorption primarily occurs through the renal system. However, approximately 10% of potassium regulation occurs in the gut. Hypokalemia can result when clients experience significant diarrhea. Question 3 A 25-year-old student has been taken to an urgent care clinic because of dehydration. She says she has had ―the flu,‖ with vomiting and diarrhea ―all night‖ and has had very little to eat or drink. She says the GI symptoms have subsided, but she feels weak. The nurse expects which type of rehydration to occur? A. IV fluid replacement B. Oral rehydration therapy with tea C. Oral rehydration therapy with water D. Oral rehydration therapy with a solution containing glucose and electrolytes Reasoning; Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life threatening, or the patient is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy (ORT) is a cost-effective way to replace fluids for the patient with dehydration. Specifically formulated solutions containing glucose and electrolytes are absorbed even when the patient is vomiting or has diarrhea. Chapter 12 Assessment and Care of Patients with Problems of Acid-Base Balance Concepts • The priority concept for this chapter is Acid–Base Balance Imbalance of Acid Base ratio can be detrimental to the following body functions: - Change the shape and reducing the function of hormones and enzymes - Change the distribution of other electrolytes, causing fluid and electrolyte imbalances - Change excitable membranes, making the heart, nerves, muscles, and GI tract either less or more active than normal - Decrease the effectiveness of many drugs Normal Blood pH • Balance of acids and bases in body fluids • Normal for; - Arterial blood = 7.35 to 7.45 - Venous blood = 7.31 to 7.41 • Changes can affect; - Shape of hormones and enzymes - Distribution of other electrolytes (fluid and electrolyte imbalance) - Excitable membranes – muscle twitching NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Pathophysiology- pH below 7.35 - In acidosis, the acid–base balance of the blood and other extracellular fluid (ECF) is upset by an excess of hydrogen ions (H+). Metabolic Acidosis is caused by: • Hydrogen ions - Overproduction - Under-elimination • Bicarbonate ions - Under-production - Over-elimination Planning and Implementation: Responding • Drug therapy • Insulin to treat DKA • Antidiarrheals • Bicarbonate (only with low serum level) • DKA, diabetic ketoacidosis. Respiratory acidosis • CNS, central nervous system. Assessment: Noticing • History • CNS changes • Neuromuscular changes • ↓ Muscle tone, deep tendon reflexes • Cardiovascular changes • Early: ↑ Heart rate, cardiac output changes • Worsening: Hyperkalemia; ↓ heart rate; T wave peaked and QRS widened; weak peripheral pulses; hypotension • Respiratory changes • Kussmaul respiration - Skin changes (metabolic and respiratory acidosis) - Warm, dry, and pink (vasodilation) - Psychosocial assessment Analysis: Interpreting • The priority patient problem for the patient experiencing respiratory - acidosis is - Reduced gas exchange resulting from underlying pulmonary disease Planning and Implementation:Responding (Cont.) • Respiratory Acidosis • Focus on improving gas exchange • Drug therapy - Bronchodilators - Anti-inflammatories - Mucolytics • Oxygen therapy • Pulmonary hygiene • Ventilation support • Prevention of complications NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen Evaluation: Reflecting • Maintains adequate gas exchange • Arterial pH above 7.2 and closer to 7.35 • PaO2 level above 90 mm Hg or at least 10 mm Hg higher than his or her admission level • PaCO2 levels below 45 mm Hg or at least 15 mm Hg below his or her admission level Alkalosis • Pathophysiology - Alkalosis is a decrease in the free hydrogen ion level of the blood and is reflected by an arterial blood pH above 7.45. • Hypocalcemia • Hypokalemia CNS changes—Positive Chvostek‘s and Trousseau‘s signs • Neuromuscular changes—Tetany • Cardiovascular changes Respiratory changes Respiratory Alkalosis • Hyperventilation—due to: - Anxiety, fear, - improper vent settings, - stimulation of central respiratory center due to fever, - CNS lesion, - Salicylates • Hallmark of respiratory alkalosis - ABG result with ↑ pH coupled with low CO2 level - O2 and bicarbonate usually normal Interventions: Responding Alkalosis • Prevent further losses of hydrogen, potassium, calcium, chloride ions • Restore fluid balance • Monitor changes, provide safety • Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion Chapter 12 Audience Response System Questions Question 1 A patient is brought to the ED with respiratory depression. The patient has a history of COPD. What acid–base imbalance is most likely? A. Metabolic alkalosis B. Respiratory acidosis C. Metabolic acidosis and respiratory acidosis D. Metabolic alkalosis and respiratory alkalosis Reasoning; Respiratory acidosis results when respiratory function is impaired and the exchange of oxygen (O2) and carbon dioxide (CO2) is reduced. This problem causes CO2 retention, which leads to the same increase in hydrogen ion levels and acidosis. NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen Question 2 The nurse is evaluating the laboratory work of a patient who has uncontrolled metabolic acidosis. Which outcome would result from this condition? A. pH 7.40 B. Pao2 98 mm Hg C. Bicarbonate 38 mEq/L D. Serum potassium 5.7 mEq/L Reasoning; Metabolic acidosis is reflected by several changes in ABG values. The pH is low (<7.35). The bicarbonate level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because gas exchange is adequate. The serum potassium level is often high in acidosis as the body attempts to maintain electroneutrality during buffering. Question 3 The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD) and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A. Encourage oral fluids B. Keep head of bed elevated C. Oxygen therapy at 4 L/min as needed D. Bedrest with bathroom privileges only Reasoning; The bedrest order will help the patient conserve energy. The upright position (mid- Fowler’s to high-Fowler’s position) helps increase lung expansion. Increasing fluid intake may reduce the thickness of lung secretions and assist in their removal. Oxygen therapy helps promote gas exchange for patients with respiratory acidosis. However, use caution when giving oxygen to patients with COPD and CO2 retention as evidenced by a high Paco2 level. The only breathing trigger for these patients is a decreased arterial oxygen level. Giving too much oxygen to these patients decreases their respiratory drive and may lead to respiratory arrest. Chapter 13 Concepts of Infusion Therapy Concepts • The priority concept in this chapter is Fluid and electrolyte balance • The interrelated concept in this chapter isTissue Integrity Infusion Therapy • Delivery of medications in solutions and fluids by parenteral route • Intravenous (IV) therapy most common route • IV therapy most common invasive therapy administered to hospitalized patients Specialized Infusion Team NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Noncoring needle. The safety mechanism traps the needle to prevent needle stick injury. Hemodialysis Catheter Covered in Renal Dialysis • Large lumens accommodate hemodialysis or pheresis procedure (harvests specific blood cells) • Catheter-related bloodstream infections (CR-BSI), vein thrombosis are common problems • Do not use for administering other fluids/medications (except in emergency) Remember ... • Change lipid tubing every 24 hr • Change blood tubing within 4 hr • *Check facility protocol for possible deviations Local Complications of IV Therapy • Infiltration • Phlebitis and post-infusion phlebitis • Thrombosis • Thrombophlebitis • Ecchymosis and hematoma • Site infection • Venous spasm • Nerve damage Systemic Complications of IV Therapy • Circulatory overload • Speed shock • Allergic reaction • Catheter embolism Remember ... • Interventions to reduce infection risk; - Clean needles system connections before use with antimicrobial for 30 seconds - Do not tape connections between tubing sets - Use evidence-based hand hygiene guidelines from CDC and OSHA Compartment Syndrome • When increased tissue perfusion in a confined space causes decreased flow to the area Older Adult Care • Skin care • Vein and catheter selection • Cardiac and renal changes Alternative Sites for Infusion • Intra-arterial therapy • Intraperitoneal (IP) infusion • Subcutaneous infusion • Intraspinal infusion • Intraosseous therapy Chapter 13 Audience Response System Questions Question 1 NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen A nursing student is preparing to insert a vascular access device in an older patient. Which action by the nursing student requires intervention by the nurse? A. Performing hand hygiene prior to insertion. B. Preparing for insertion immediately following cleaning with iodophors. C. Using friction to clean the skin around the insertion site. D. Clipping the hairs in the preferred insertion area. Reasoning; Current recommendations call for using friction when cleaning the skin to penetrate the layers of the epidermis. Iodophors such as povidone-iodine require contact with the skin for a minimum of 2 minutes to be effective. Skin should never be shaved before venipuncture, but excessive amounts of hair should be clipped. Question 2 A man with severe burns over 90% of his body has been brought to the ED. The rescue personnel were unable to establish IV access during transport to the hospital. Which type of IV device would be most appropriate at this time? A. PICC line B. Central line C. Intraosseous catheter D. Subcutaneous infusion Reasoning; Intraosseous (IO) therapy allows access to the rich vascular network located in the long bones. Victims of trauma, burns, cardiac arrest, and other life-threatening conditions benefit from this therapy because often clinicians are unable to access these patients’ vascular systems for traditional IV therapy. If IV access cannot be obtained within the first few minutes of resuscitation procedures, IO may be attempted. After establishing IO access, efforts should continue to obtain IV access as well. Question 3 During the insertion of an IV catheter, a patient with dehydration reports feeling ―pins and needles‖ in his arm. The nurse is aware that this sensation may have been caused by what? A. Nerve puncture may have occurred. B. The patient‘s dehydration caused this sensation. C. The vein has collapsed during the catheter insertion. D. The vein has been accessed properly for the infusion. Reports of tingling, feeling ―pins and needles‖ in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. The procedure should be stopped immediately, the catheter removed, and a new site chosen. Transsection of the nerve can result in NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen permanent loss of function, and local nerve damage can become a chronic systemic pain syndrome. ATI Chapter 1 Carbohydrates & Fiber • All carbohydrates are organic compounds composed of carbon, hydrogen, and oxygen (CHO). • The main function of carbohydrates is to provide energy for the body. • The average minimum amount of carbohydrates needed to fuel the brain is 130 g/day. • Median carbohydrate intake is - 296 g/day among men aged 20 years and older, - 256 g/day among women in the same age range. • The acceptable macronutrient distribution range for carbohydrates is 45% to 65% of calories. • Carbohydrates provide energy for cellular work, and help to regulate protein and fat metabolism. They are essential for normal cardiac and central nervous system (CNS) functioning. TYPES OF CARBOHYDRATES (1.1) • Carbohydrates are classified according to the number of saccharide units making up their structure. - Monosaccharides: simple carbohydrates (glucose, fructose, and galactose) - Disaccharides: simple carbohydrates (sucrose, lactose, and maltose) - Polysaccharides: complex carbohydrates (starch, fiber, and glycogen) Considerations • The liver converts fructose and galactose into glucose, which is then released in the bloodstream. This elevates blood glucose levels, which causes the release of insulin from the pancreas. With insulin production, glucose is moved out of the bloodstream into cells in order to meet energy needs. • The body digests 95% of starch within 1 to 4 hr after ingestion. Digestion occurs mainly in the small intestine using pancreatic amylase to reduce complex carbohydrates into disaccharides. • Glycogen is the stored carbohydrate energy source found in the liver and muscles. It is a vital source of backup energy, but is only available in limited supply. • To maintain expected glucose levels between meals, glucose is released through the breakdown of liver glycogen. • Digestible carbohydrates provide 4 cal/g of energy. Fiber • Fiber is categorized as a carbohydrate. • Dietary fiber is the substance in plant foods that • is indigestible. Types are pectin, gum, cellulose, • and oligosaccharides. • Fiber is important for proper bowel elimination. It • adds bulk to the feces and stimulates peristalsis to • ease elimination. • Studies show fiber helps to lower cholesterol and lessen the incidence of intestinal cancers. NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Phospholipids (e.g., lecithin) are important to cell membrane structure, as well as the transport of fat-soluble substances across the cell membrane. Sterols • Sterols (e.g., cholesterol) are found in the tissues of animals, and are not an essential nutrient because the liver is able to produce enough to meet needs. • If cholesterol is consumed in excess, it can build up in the tissues, causing congestion and increasing the risk for cardiovascular disease. Considerations • The AMDR for fats is approximately 20% to 35% of total calories. 10% or less of total calories should come from saturated fat sources). • Cholesterol should be limited to 200 to 300 mg/day. • A diet high in fat is linked to cardiovascular disease, hypertension, and diabetes mellitus. • The exception is for children under 2 years of age, who need a higher amount of fat to form brain tissue. • Conversely, a diet with less than 10% of fat cannot supply adequate amounts of essential fatty acids and results in a cachectic (wasting) state. Considerations • The majority of lipid metabolism occurs after fat reaches the small intestine, where the gallbladder secretes concentrated bile and acts as an emulsifier to break fat into smaller particles. • At the same time, the pancreas secretes pancreatic lipase, which breaks down fat. • Intestinal cells absorb the majority of the end products of digestion, with some being excreted in the feces. Lipid Considerations • Very-low-density lipoproteins (VLDL) carry triglycerides to the cells. • Low-density lipoproteins (LDL) carry cholesterol to the tissue cells. • High-density lipoproteins (HDL) remove excess cholesterol from the cells, and transport it to the liver for disposal. • Lipids provide 9 cal/g of energy and are the densest form of stored energy. Vitamins • Vitamins are organic substances required for many enzymatic reactions. The main function of vitamins is to be a catalyst for metabolic functions and chemical reactions. • There are 13 essential vitamins, each having a specialized function. • There are two classes of vitamins. - Water-soluble: Vitamins C and B-complex - Fat-soluble: Vitamins A, D, E, and K • Vitamins yield no usable energy for the body. Review • ATI Page 6 1.2 Water Soluble Vitamins at a Glance • 1.3 Page 7 Fat-soluble Vitamins at a Glance ATI P ATI Chapter 2 Ingestion, Digestion, Absorption, and Metabolism METABOLIC RATE • Metabolic rate refers to the speed at which food energy is burned. NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Basal metabolic rate (BMR), also called basal energy expenditure (BEE), refers to the amount of energy used in 24 hr for involuntary activities of the body, such as maintaining body temperature, heartbeat, circulation, and respirations. This rate is determined while at rest,and following a 12-hr fast. • Resting metabolic rate (RMR), also called resting energy expenditure (REE), refers to the calories needed for involuntary activities of the body at rest. This rate does not consider the 12-hr fast criteria. Basel Metabolic Rate (BMR) • BMR is affected by lean body mass and hormones. • Body surface area, age, and gender are also factors that • contribute to BMR. • In general, men have a higher metabolic rate than women due to their higher amount of body muscle and decreased amount of fat. • Thyroid function tests can be used as an indirect measure of BMR. Acute Stress & Metabolism • Acute stress causes an increase in metabolism, blood glucose levels, and protein catabolism. • A major nutritional concern during acute stress is protein deficiency as stress hormones break down protein at a very rapid rate. • Protein deficiency increases the risk of complications from severe trauma or critical illness (skin breakdown, delayed wound healing, infections, organ failure, ulcers, impaired medication tolerance). • Protein requirements may be increased to more than 2 g/kg of body weight, or up to 25% of total calories, depending on the client‘s age and prior nutritional status. Metabolism • Any catabolic illness (surgery, extensive burns) increases the body‘s requirement for calories to meet the demands of an increased BMR. • Disease and sepsis also increase metabolic demands and can lead to starvation/death. Nitrogen Balance • Positive nitrogen balance indicates that the intake of nitrogen exceeds excretion. Specifically, the body builds more tissue than it breaks down. This normally occurs during periods of growth: infancy, childhood, adolescence, pregnancy, and lactation. • Negative nitrogen balance indicates that the excretion of nitrogen exceeds intake. The individual is receiving insufficient protein, and the body is breaking down more tissue than it is building, as seen during periods of illness, trauma, aging, and malnutrition. ASSESSMENT/DATA COLLECTION • Weight and history of recent weight patterns • Medical history for diseases that affect metabolism and nitrogen balance? • Extent of traumatic injuries, as appropriate IE Fluid and electrolyte status • Laboratory values? Esp. albumin, transferrin, glucose, and creatinine • Clinical signs of malnutrition: pitting edema, hair loss, and wasted appearance • Medications? side effects that can affect nutrition • Usual 24-hr dietary intake • Use of nutritional supplements, herbal supplements, vitamins, and minerals • Use of alcohol, caffeine, and nicotine Nursing Interventions NUR 2392 / NUR2392 Final Exam: Multidimensional Care II / MDC 2 Final Exam Review (2021/2022) Rasmussen • Monitor food intake. • Monitor fluid intake and output. • Use patient-centered approach to address disease-specific problems with ingestion, digestion, or • medication regime. • Collaborate with nutritionist. • Provide adequate calories and high-quality protein. STRATEGIES TO INCREASE PROTEIN, CALORIC CONTENT • Add skim milk powder to milk (double-strength milk). • Use whole milk instead of water in recipes. • Add cheese, peanut butter, chopped hard-boiled eggs, or yogurt to foods. • Dip meats in eggs or milk and coat with bread crumbs before cooking. • Nuts and dried beans are significant sources of protein. • These are good alternatives for a dairy allergy or lactose intolerance