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NURS 4406 EXAM 3 REVIEW Texas Tech University/UPDATED
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NURS 4406 EXAM 3 REVIEW Texas Tech University/UPDATED
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NURS 4406 EXAM 3 REVIEWNURS 4406 EXAM 3 REVIEW
• Acute Nutritional Support (3-5)
o Enteral Feeding (1-2)
▪ Assessment
• Inability to eat due to medical condition – comatose or intubated
• Trouble swallowing due to risk of aspiration – stroke, advanced Parkinson’s, MS
• Inability to maintain adequate oral nutritional intake and need for supplementation due to
increased metabolic demands
• Impaired GI tracts
• Oral or neck surgery
▪ Complications
Problem Manifestations Nursing Actions
Overfeedin - Results from infusion of a great amount - Check residual every 4-6 hrs
g of formula than the body can digest - Slow or withhold feeding for excess residual volumes
- Abdominal distention - Hold for residuals 100-200 mL
- Nausea, and vomiting - Restart a lower rate after residual is lowered
Diarrhea - Occurs secondary to concentration of - Slow rate and report
feeding and constitutes - Confer with dietitian
- Provide skin care
- Evaluate for C. diff if odor is foul
Aspiration - Occurs secondary to aspiration of feeding - Stop the feeding.
Pneumonia - Life threatening - Turn on side and suction the airway
- Tube displacement is primary cause - Administer oxygen
of aspiration - Monitor for an elevated temperature
- Listen to breath sounds for increased congestion &
diminishing sounds
Refeeding - Life-threatening - Monitor for new onset of confusion or seizures
Syndrome - Occurs when enteral feeding is started on - Assess for shallow respirations.
client who is in a starvation state & whose - Monitor for increased muscular weakness
body has begun to catabolize protein and
fat
for energy
o Parenteral Feeding (2-3)
▪ Composition
• Contains complete nutritional
o Total Parenteral Nutrition
▪ Calories in high concentrations (10-50%) of dextrose
▪ Lipids & essential fatty acids
▪ Proteins
▪ Electrolytes, vitamins, & trace elements
o Partial Parenteral Nutrition
▪ Less hypertonic
▪ Dextrose < 10%
▪ Nursing Care
• Flow rate is gradually increased and gradually decreased to allow body to adjust (no more than a
10% hourly increase)
• Assess vitals every 4-8 hrs
• Follow sterile procedures to minimize the risk of sepsis
o TPN solution is prepared by the pharmacy using aseptic technique with a laminar flow hood
o Change tubing and solution bag (even if not empty) every 24 hrs
o Use filtered tubing to collect particles & do not use the line for other IV bolus solutions
,NURS 4406 EXAM 3 REVIEW
o Do not add anything to the solution except insulin or heparin
o Use sterile procedures, including a mask, when changing the central line dressing
, NURS 4406 EXAM 3 REVIEW
• Check glucose every 4 to 6 hr for at least first 24 hrs
• Clients receiving TPN frequently need supplemental regular insulin until the pancreas can increase
its endogenous production of insulin
• Keep dextrose 10% in water at the bedside in case solution is unexpectedly ruined or next bag is not
available
o This will minimize the risk of hypoglycemia
o If a bag is unavailable and administered late, do not attempt to catch up by increasing the
infusion rate because the client can develop hyperglycemia
▪ Complications
Complication Manifestations Nursing Actions
Metabolic - Hyper/hypoglycemia - Obtain labs before prepping
Complications - Vitamin deficiency new formula
- Fluid replacement in separate IV bolus
Air Embolism - Pressure change during tubing changes - Clamp catheter immediately
- Sudden dyspnea, hypoxia - Place patient on left side in
- Chest pain, anxiety Trendelenburg position to trap
air
- Admin oxygen & report
Infection -Concentrated glucose is medium for bacteria - Change sterile dressing on central
- Erythema, tenderness, exudate at insertion site line every 48 – 73 hrs
- Fever, chills, malaise - Change IV tubing every 24 hrs
- Watch for increased WBC
Fluid -TPN is 3-6 times the osmolarity of blood, - Daily weights & I/O
Imbalance poses risk for fluid shifts - Use controlled infusion pump
- Fluid volume excess - Do not speed up infusion to catch up
- Crackles in lungs, respiratory distress - Gradually increase flow by 10% per hr
• Inflammation (4-6)
o Acute Abdominal Pain (2-3)
▪ Clinical Manifestations
• Nausea & vomiting
• Diarrhea or constipation
• Fever
• Increased abdominal girth
▪ Abdominal trauma
• Caused by blunt force or penetration to the abdomen
▪ Nursing actions
• ABCs • Inspect, auscultate, percuss, & palpate
• Oxygen if needed abdomen
• Fluids – 2 large bore IVs o Decreased or absent bowel sounds
• Assess pain location, when it started, what indicate a possible obstruction
it feels like, and how long it’s been going • Obtain labs: CBC, CMP, amylase,
on lipase, urinalysis, & pregnancy test
• Assess LOC for signs of shock • Admin pain medications
• Vitals – BP & temp for shock or infection
o Appendicitis (2-3)
▪ Clinical manifestations
• Obstruction of lumen or opening of appendix, inflammation of appendix
• Abdominal pain in RLQ & rigid board like abdomen
• Decrease or absent bowel sounds
• Fever, lethargy, anorexia
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