Term
| 3 types of physical assessments |
|
Definition
1. complete assesment
2. daily assessment
3. focused assesment of body part |
|
|
Term
| who completes a "complete assessment" |
|
Definition
|
|
Term
| when ___________ the client, always explain the reason, when/where, what will happen, assist as needed, ask to empty bladder, collect sample if needed, continuously reassure, be specific about taking clothing off for gown |
|
Definition
|
|
Term
| when ___________ the patient, take into account the patients age, physical condition, energy level, ROM limitations |
|
Definition
|
|
Term
| most accessible positions |
|
Definition
|
|
Term
| _______ assessment includes: head to toe assessment, healthh history, level of activity/functioning |
|
Definition
|
|
Term
| __________ assessment usually not done by an lpn |
|
Definition
|
|
Term
| _____ may be delegated tasks such as these: inventory of personal property, allergies, medication list, dietary habits, past medical history, fall risk assessment, info related to impairments and disability |
|
Definition
|
|
Term
| conducted at the beginning and end of each shift; can be performed by rn; includes head to to systematic/efficient; energy level, fewest position changes, modified for different ages, general or specific |
|
Definition
|
|
Term
| when you enter the room, _______ begins |
|
Definition
|
|
Term
| important in ___________ assessment: LOC, alert, lethargic, sedated, or unconscious |
|
Definition
|
|
Term
|
Definition
|
|
Term
| person, place, time, incident = |
|
Definition
|
|
Term
| how to check _______ response: speech is clear, appropriate, slurred, incoherent, dysphagia, or aphasia (no speech) |
|
Definition
|
|
Term
| how to check _________ response: squeeze both fingers; equal bilaterally, grips, flexion/extension |
|
Definition
|
|
Term
| how to assess _________: description; sharp, dull, burning, non-existant, scale 0-10 |
|
Definition
|
|
Term
| pupils are normally ___-___ mL in diameter |
|
Definition
|
|
Term
|
Definition
| Pupils are Equal, Round, React to Light and Accommodate |
|
|
Term
| when you hold a piece of paper up and you can see something written behind it but paper loses focus, and then look at paper and written thing loses focus |
|
Definition
|
|
Term
| light makes the pupil ______ |
|
Definition
|
|
Term
| darkness makes the pupil ________ |
|
Definition
|
|
Term
| temperature, pulse, respirations, bloodpressure, and pulse oximetery (and pain) are all __________ ________ |
|
Definition
|
|
Term
| always record _______ and ________ at the same time each day and use the same, appropriate equipment. |
|
Definition
|
|
Term
| why might tattoos/piercings swell |
|
Definition
| hepatitis, infection, allergy |
|
|
Term
| pinching the skin to check for hydration |
|
Definition
|
|
Term
|
Definition
| 60-100 beats/min (resting) |
|
|
Term
| what is a bilateral pulse |
|
Definition
| means that the pulse rate should be the same throughout the whole body |
|
|
Term
| pulse is usually taken ______ or _________ |
|
Definition
|
|
Term
|
Definition
|
|
Term
| instrument used to listen to internal sounds in the body |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
0- absent
1- thready
2- weak
3- normal
4- bounding |
|
|
Term
| strong visible pulse that is difficult to stop with pressure |
|
Definition
|
|
Term
|
Definition
|
|
Term
| edema is a sign that the ________ may be beginning to fail |
|
Definition
|
|
Term
| how to display capillary refill |
|
Definition
| pushing the nail beds...white/pink |
|
|
Term
| way to test for capillary refill; frowned upon; may cause deep vein thrombosis |
|
Definition
|
|
Term
| difference between thrombosis and embolus blood clots |
|
Definition
thrombus is stationary
embolus moves |
|
|
Term
| fast breathing; more than 24 breaths per minute |
|
Definition
|
|
Term
| slow breathing; less than 10 breaths per min |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| measures oxygen saturation at the capillary level |
|
Definition
|
|
Term
| pulse oximetry normal level |
|
Definition
|
|
Term
| life threatening pulse oximetry |
|
Definition
|
|
Term
| always ___________ before you ____________ the abdomen |
|
Definition
|
|
Term
| when muscles in the abdomen cease to hold the intestines back and the abdomen is distende |
|
Definition
|
|
Term
| what quadrant for appendicitis |
|
Definition
|
|
Term
| ___________ in old people can be a sign of constipation |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| newborns with increased pigmentation in sacral area |
|
Definition
|
|
Term
| newborns with tiny whiteheads on the face and nose |
|
Definition
|
|
Term
|
Definition
|
|
Term
| where to assess infant respirations |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| medical term for "hearing loss" |
|
Definition
|
|
Term
| _________ fontanel closes at 8 weeks |
|
Definition
|
|
Term
| ____________ fontanel closes at 18 weeks |
|
Definition
|
|
Term
| voluntary head control by ____ months |
|
Definition
|
|
Term
| top of ears line with (BOTTOM/TOP) of eyes |
|
Definition
|
|
Term
| __________ of feet up to age 2 1/2 years old |
|
Definition
|
|
Term
| may be expressed after 1st trimester; milk |
|
Definition
|
|
Term
| The organic, inorganic, and energy producing substances found in foods required for body functioning |
|
Definition
|
|
Term
| the result of the interaction between nutrients and the human body |
|
Definition
|
|
Term
| 3 major functions of nutrients |
|
Definition
1. provide energy for body process and movement
2. structural material for body tissues,
3. regulate body processes |
|
|
Term
|
Definition
1. water
2. macronutrients
3. micronutrients |
|
|
Term
| the body's most basic nutrient need |
|
Definition
|
|
Term
| water's functions (nutrition) |
|
Definition
1. metabolism
2.transporter
3.lubricant
4.insulator
5.shock absorber
6. temperature |
|
|
Term
| provide fuel that converts to energy; found in carbohydrates, proteins and fats |
|
Definition
|
|
Term
| two basic kinds of carbohydrates |
|
Definition
|
|
Term
| simple carbohydrates consist of |
|
Definition
|
|
Term
| complex carbohydrates consist of |
|
Definition
|
|
Term
| 3 Kinds of simple carbohydrates |
|
Definition
1. monosaccharides
2. disaccharides
3. polysaccharides |
|
|
Term
| _________ simplest form of all carbohydrates |
|
Definition
|
|
Term
| ________ are water soluble |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| _________ means "does not dissolve in water" |
|
Definition
|
|
Term
| _________ means "dissolves in water" |
|
Definition
|
|
Term
| ________ cannot be digested |
|
Definition
|
|
Term
| supplies roughage, or bulk, to the diet, helping the digestive track eliminate waste |
|
Definition
|
|
Term
| _______ helps weight control, treats constipation, lowers blood cholesterol, stabilizes blood glucose |
|
Definition
|
|
Term
| daily recommended fiber intake per day |
|
Definition
|
|
Term
| altering of food from natural state |
|
Definition
|
|
Term
| often referred to as empty calories |
|
Definition
|
|
Term
| the end products of carbohydrate digestion are _____________ |
|
Definition
|
|
Term
| body uses ________ to produce energy |
|
Definition
|
|
Term
| digested carbohydrate is absorbed by the _______ ____________ |
|
Definition
|
|
Term
| hormone secreted by pancreas needed for glucose to be transported into the cells |
|
Definition
|
|
Term
| medical condition where the pancreas fails to produce adequate amounts of insulin in the bloodstream to lower/control blood glucose level, or facilitate glucose entering cells |
|
Definition
|
|
Term
| digested carbohydrates are maintained in the body either as _________ or _________ |
|
Definition
|
|
Term
| glycogen formation process |
|
Definition
|
|
Term
| process of glycogen being converted back into glucose when needed to maintain blood levels or provide energy |
|
Definition
|
|
Term
| organic substances composed of amino acids |
|
Definition
|
|
Term
| the building blocks of proteins |
|
Definition
|
|
Term
| amino acids are categorized as either _________ or __________ |
|
Definition
| essential or nonessential |
|
|
Term
| _______ amino acids are those that cannot be manufactured in the body and must be supplied by ingesting protein |
|
Definition
|
|
Term
| ________ amino acids are those that the body can manufacture |
|
Definition
|
|
Term
| amino acids that in certain conditions cannot be produced in sufficient quantities from other amino acids |
|
Definition
| conditionally essential amino acids |
|
|
Term
| there are ____ essential amino acids |
|
Definition
|
|
Term
| there are ____ nonessential amino acids |
|
Definition
|
|
Term
| proteins may be _____ or ______ |
|
Definition
|
|
Term
| __________ proteins contain all nine essential amino acids plus many nonessential ones |
|
Definition
|
|
Term
| __________ proteins lack one or more essential amino acids and are usually derived from vegetables |
|
Definition
|
|
Term
| only plant source of complete proteins |
|
Definition
|
|
Term
| when foods containing some essential amino acids are combined with others so that together they contain all nine essential amino acids, the foods are called: |
|
Definition
|
|
Term
| __________ proteins are plant based, less expensive, and contain less fat |
|
Definition
|
|
Term
| most protein is digested in the _____ ________ where enymes break it down into the end products of protein digestion |
|
Definition
|
|
Term
| end products of protein digestion |
|
Definition
|
|
Term
| _______ are transported to the liver, where some are used to synthesize specific proteins such as albumin, globulin, and fibrinogen |
|
Definition
|
|
Term
|
Definition
|
|
Term
| body cannot store excess _____ ______ for future use |
|
Definition
|
|
Term
| protein metabolism includes 3 activities |
|
Definition
1. anabolism
2. catabolism
3. nitrogen balance |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| a measure of the intake and loss of nitrogen |
|
Definition
|
|
Term
| organic substances that are greasy and insoluble in water but soluble in alcohol |
|
Definition
|
|
Term
| _____ are lipids that are solid at room temperature |
|
Definition
|
|
Term
| ______ are lipids that are liquid at room temperature |
|
Definition
|
|
Term
| the basic structural units of most lipids (made of carbon chains and hydrogen) |
|
Definition
|
|
Term
| simple lipids (most common) |
|
Definition
|
|
Term
| account for over 90% of the lipids in food and in the body; contain 3 fatty acids |
|
Definition
|
|
Term
| triglycerides may be ________ or __________ |
|
Definition
|
|
Term
| found in animal products, such as butter, and are usually solid at room temperature (harder means more fat); contribute to elevated blood cholesterol; considered unhealthy |
|
Definition
|
|
Term
| usually liquid at room temperature and are found in plant products; lower blood cholesterol; healthier |
|
Definition
| unsaturated triglycerides |
|
|
Term
| fat like substance that is both produced by the body and found in foods of animal origin; most of it is synthesized in the liver |
|
Definition
|
|
Term
| needed by the body to form bile acids and to synthesize steroid hormones; primary lipid connected to heart disease |
|
Definition
|
|
Term
| normal "total cholesterol" |
|
Definition
|
|
Term
| triglycerides normal level |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| test for lipoproteins and triglycerides |
|
Definition
|
|
Term
| it is desirable to have a higher _____ level and a lower ______ evel because the risk of heart disease is greater when _____ is elevated |
|
Definition
|
|
Term
| an organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze (trigger) metabolic processes |
|
Definition
|
|
Term
| when _______ are lacking in the diet, _______ deficits result. |
|
Definition
|
|
Term
| generally classified as fat soluble or water soluble |
|
Definition
|
|
Term
| water-soluble vitamins include: |
|
Definition
| vitamins c, B-complex, B1, B2, B3, B6, B9, B12, pantothenic acid, and biotin. |
|
|
Term
| the body ________ store water-soluble vitamins |
|
Definition
|
|
Term
| fat soluble vitamins include |
|
Definition
|
|
Term
| The body _____ store fat soluble vitamins |
|
Definition
|
|
Term
| Two categories of minerals |
|
Definition
1.macrominerals
2.microminerals |
|
|
Term
| minerals that people require daily in amounts over 100mg; including calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur |
|
Definition
|
|
Term
| minerals that people require daily in amounts less than 100 mg; including iron, zinc, manganese, iodine, fluoride, copper, cobalt, chromium, and selenium |
|
Definition
|
|
Term
| Micro/Macrominerals are both found in vegetables, fruits, meats, and most essentially, ____ _____ |
|
Definition
|
|
Term
| the relationship between the energy obtained from food and the energy used by the body |
|
Definition
|
|
Term
|
Definition
|
|
Term
| body gets ______ from calories, carbohydrates, protein, fat, and alcohol |
|
Definition
|
|
Term
| the term for all the biochemical and physiological processes by which the body grows and maintains itself |
|
Definition
|
|
Term
| rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest |
|
Definition
| basal metabolic rate (bmr) |
|
|
Term
| lean people have _______ bmr's than overweight people |
|
Definition
|
|
Term
| changes in __________ and ___________ occur in older adults and can affect food intake |
|
Definition
|
|
Term
| clients should be reminded of the dangers of high _________ intake |
|
Definition
|
|
Term
| _______ increase through food, supplements, or both is important for older adults |
|
Definition
|
|
Term
| Clients who do not have special needs eat the _______ diet; a balanced diet that supplies the metabolic requirements of a sedentary person |
|
Definition
|
|
Term
| diet where food and fluid are prohibited |
|
Definition
|
|
Term
| Diet limited to water, tea, coffee, clear broths, ginger ale, and other carbonated beverages, strained and clear juices, and plain gelatin; must be able to see thru |
|
Definition
|
|
Term
| diet contains only liquids or foods that turn to liquid: I.e. melted icecream, blended pb&j |
|
Definition
|
|
Term
| nutritional concerns with this diet because of the amount of milk offered |
|
Definition
|
|
Term
| diet that is easily chewed and digested |
|
Definition
|
|
Term
| diet that is ordered when the client's appetite, ability to eat, and the tolerance for certain foods change; allows for choice and evaluation of progress |
|
Definition
|
|
Term
| diet consist of plant foods only |
|
Definition
|
|
Term
| diet consists of plant foods along with dairy products |
|
Definition
|
|
Term
| diet consists of plant foods, dairy products, and eggs |
|
Definition
| ovo-lacto vegetarian diet |
|
|
Term
| the first priority in nursing care when performing a nutritional assessment is to obtain the client's |
|
Definition
|
|
Term
| the nurse must know how to obtain the client's weight and height accurately, meaning: |
|
Definition
| the nurse must use the appropriate equipment |
|
|
Term
| weight recommended for optimal health |
|
Definition
|
|
Term
| A person is said to be __________ when the body weight exceeds IBW by up to 20% |
|
Definition
|
|
Term
| a person is said to be __________ when the body weight exceeds the IBW by more than 20% |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| means that nutrient intake is insufficient to meet daily energy requirements; it can occur because the person does not eat enough food or because he or she cannot digest or absorb food |
|
Definition
|
|
Term
|
Definition
|
|
Term
| excess body weight causes _______ on body organs and contributes to chronic health problems such as ________ and __________ ___________ |
|
Definition
| stress, hypertension, diabetes mellitus |
|
|
Term
| obesity that interferes with mobility or breathing |
|
Definition
|
|
Term
| associated mostly with the starving children of developing countries, and as a significant problem of clients with cancer and chronic disease; characteristics include weight loss and visible muscle and fat wasting |
|
Definition
| protein-calorie malnutrition PCM |
|
|
Term
| The 3 most frequent nursing diagnoses related to nutrition are |
|
Definition
1. Imbalanced Nutrition: More than body Requirements
2.Imbalanced Nutritioin: Less than Body Requirements
3. Risk for Imbalanced Nutrition |
|
|
Term
| Nursing care of clients with imbalanced nutrition includes assisting with |
|
Definition
| changes in diet, monitoring blood glucose, stimulating appetite, assisting with meals, and providing enteral nutrition |
|
|
Term
| clients who have _________ may need to monitor random blood glucose levels throughout the day |
|
Definition
|
|
Term
| physical illness, unfamiliar or unpalatable food, environmental and psychological factors, and physical discomfort or pain may _______ a client's appetite |
|
Definition
|
|
Term
| decreased food intake is often accompanied by a ________ in fluid intake, which may cause __________ |
|
Definition
|
|
Term
| Never _______ the feeding process! |
|
Definition
|
|
Term
| the nurse ________ decide if an adaptive feeding aid should be used on a client |
|
Definition
|
|
Term
| two types of alternative feeding methods are |
|
Definition
1. enteral nutrition
2. parenteral nutrition |
|
|
Term
| nutrition through the gastrointestinal system |
|
Definition
|
|
Term
|
Definition
|
|
Term
| enteral access is achieved by _______, ________, ____________, and __________ |
|
Definition
1. nasogastric tubes
2. nasointestinal tubes
3. gastrostomy tubes
4. jejunostomy tubes |
|
|
Term
| inserted through one of the nostrils, down to the nasopharynx, and into the stomach; usually firm; |
|
Definition
| nasogastric tube (NG Tube) |
|
|
Term
| _________ tubes are used for clients who have INTACT gag reflexes, who have adequate gastric emptying, and who require short-term feedings |
|
Definition
|
|
Term
| nasogastric tubes may also be required for other reason than feeing; including |
|
Definition
1. prevention of nausea and vomiting
2. to remove stomach contents (i.e. overdose)
3. to wash the stomach of poisons |
|
|
Term
|
Definition
|
|
Term
| ____________ tube is longer than the _____________ tube |
|
Definition
|
|
Term
| tube that is inserted into one nostril, through the pharynx, esophagus, and stomach, and into the upper small intestine |
|
Definition
|
|
Term
| insertion of the _______ tube may require special training; used when risk of aspiration is high |
|
Definition
|
|
Term
| clients are at risk for aspiration if presenting these 5 conditions |
|
Definition
1. Decreased LOC
2. poor cough or gag reflex
3. endotracheal intubation or recent extubation
4. inability to cooperate with the procedure
5. restlessness or agitation |
|
|
Term
| _________ and ___________ devices are used for long term nutritional support, generally for more than 6 to 8 weeks. |
|
Definition
|
|
Term
| tube placed surgically or by laparoscopy through the abdominal wall into the stomach |
|
Definition
|
|
Term
| tube placed surgically or by laparoscopy through the abdominal wall into the intestine |
|
Definition
|
|
Term
| before feedings are introduced, tube placement is confirmed by _________ |
|
Definition
|
|
Term
| the administration of 300 to 500 mL of enteral formula several times per day; usually administered thru the tube into the stomach over at least 30 mins. |
|
Definition
|
|
Term
| generally administered over a 24 hour period using an infusion pump that guarantees a constant flow |
|
Definition
|
|
Term
| continuous feedings that are administered in less than 24 hours; often administered at night and referred to as "nocturnal feedings", allows the client to eat regular meals throught the day |
|
Definition
|
|
Term
| any formula that has passed the expiration date or solution that has been opened at room temperature for more than ______ hours must be discarded |
|
Definition
|
|
Term
| a feeding tube used intermittently can become clogged. this can be prevented by |
|
Definition
| flushing the tube with clear water after bolus feedings or administration of medication; always follow facility approved method; prevention is the best way to ensure that the client will be able to receive nutrition via the tube |
|
|
Term
| feedings must be given through _________ when a client is unable to tolerate foods or formula through the gastrointestinal tract |
|
Definition
|
|
Term
| there are 2 forms of parenteral nutrition |
|
Definition
1. peripheral vein infusions
2. central vein infusions |
|
|
Term
| limited vein infusions that are done in peripheral veins |
|
Definition
| peripheral vein infusions |
|
|
Term
| when nutritional needs are great, the use of a large central vein is desirable; TPN is infused throuh a catheter that is surgically inserted into a central vein such as the _________ or the _________ vein; added risk of infection and must be closely monitored. |
|
Definition
| central vein infusions; subclavian or femoral vein |
|
|
Term
| two main veins used for central vein infusions |
|
Definition
1. subclavian vein
2. femoral vein |
|
|
