NCLEX RN GUIDE                                                                                   the best of NCLEX

Basic Care and Comfort

  1. Nutrition

    1. Food guidelines (illustration )

      1. Nutritional needs through the life cycle

        1. infants: fluid and protein needs 2.5x adults

        2. breast milk or formula is adequate for first six months of life

          1. whole milk is difficult for young infants to digest

          2. the first food introduced is cereal

        3. childhood: gradual increasing of all nutrients adults: unchanged except for

          1. pregnancy: add per day: 300 calories, 15 mg iron, 30 g protein, 400 g calcium, and 200ug folic acid

          2. lactation: add 500 calories, 2 quarts extra fluid

        4. elderly over age 65: adequate protein to maintain immune system

      1. Factors affecting dietary patterns

        1. health status

        2. ability to chew, swallow, and drink

        3. culture and religion

        4. socioeconomic status

        5. personal preference

        6. psychological factors

        7. alcohol and drugs

      2. Energy needs

        1. basal metabolism – energy required for ongoing internal processes such as heartbeat

        2. basal metabolic rate (BMR) – influenced by gender, age, activity level, body composition

    1. Essential nutrients

      1. Carbohydrates

        1. include sugars, starches and cellulose

        2. simple sugars (monosaccharides) are most easily metabolized

        3. starches are more complex in structure and metabolism

        4. functions of carbohydrates

          1. quickest source of energy (4.1 kcal/gram)

          2. main source of fuel for brain, peripheral nerves, WBCs, RBCs, and healing wounds

          3. protein sparer

        5. dietary sources: plant foods, except for lactose

        6. recommended daily intake:

          1. factors influencing recommended intake of carbohydrates include body structure, energy expenditure, basal metabolism and general health status

          2. ideally, 50 to 60% of total calories should be complex carbohydrates

        7. excessive carbohydrate calories are stored as fat

      2. Lipids

        1. basic lipids are composed of triglycerides and fatty acids

        2. includes saturated fatty acids (from animal sources) and unsaturated fatty acids (vegetables, nuts and seeds)

        3. essential unsaturated fatty acids - linoleic acid is the only essential fatty acid in humans; linolenic acid and arachidonic acid can be manufactured by the body when linoleic acid is available

        4. deficiencies lead to skin, blood and artery problems

        5. functions

          1. most concentrated source of energy (nine kcal/gram)

          2. body’s major form of stored energy

          3. insulation

          4. cell membrane component

          5. carries fat-soluble vitamins A, D, E and K

          6. recommended dietary intake: no more than 30% total caloric intake and low in saturated fats

      1. Proteins

        1. complex organic compounds comprised of amino acids

        2. body breaks protein down into 22 amino acids

        3. all but eight amino acids are produced by the body

        4. “complete protein” food contains the eight essential amino acids not produced by the body (most meat, fish, poultry and dairy products)

        5. “incomplete protein” food lacks one or more of the eight amino acids (most vegetables and fruits)

        6. incomplete proteins can be combined to yield a complete protein: for example, beans and rice

        7. functions of protein

          1. secondary energy source (four kcal/gram)

          2. essential for cell growth

          3. efficiency can affect all of body - organs, tissues, skin, muscles

          4. recommended protein intake: 0.42 grams per 0.4 kg of body weight

          5. the body's only source of nitrogen

          6. negative nitrogen balance can occur with infection, burns, fever, starvation, and injury

      2. Vitamins

        1. organic substances essential for body growth and metabolism

        2. found only in plants and animals; body cannot synthesize them; depends on dietary intake

        3. types (according to their solvent)

          1. water soluble (B1, B2, B6, B12, C) 

            • cannot be stored in body; require daily intake

          2. fat soluble (A, D, E, K) 

            • can be stored in body

      1. Minerals

        1. inorganic substances essential as catalysts in biochemical reactions

        2. form most inorganic material in the body

        3. functions:

          1. catalyst for many body reactions such as regulation of acid-base balance

          2. help cells metabolize, tissues absorb nutrients, and heart muscle respond

          3. minerals work synergistically; a deficiency of one mineral can disturb the action of other minerals

          4. types - grouped according to amount found in body

      1. Water

        1. critical body component essential for cell function

        2. accounts for 60 to 70% total body weight in adults; 70 to 75% children functions

        3. provides normal turgor

        4. regulates body temperature

        5. dietary sources: liquids and solids, such as fresh fruits and vegetables

        6. deficiency: severe deficiency leads to dehydration and death

        7. fluid intake normally equals fluid output

    1. Fluid and electrolyte balance

      1. Total volume of fluid and amount of electrolytes remain relatively constant in the body

      2. Fluid balance and electrolyte balance is interdependent

      3. Body balances fluid and electrolytes primarily by adjusting output, and secondarily by adjusting intake.

      4. Fluid balance is also maintained by osmosis (illustration )

      5. Major electrolytes

        1. cations

          1. sodium - most abundant cation in extracellular fluid

            • regulates cell size via osmosis

            • essential in maintaining water balance, transmitting nerve impulses, and contracting muscles

            • regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney

            • normal lab value for serum sodium is 135 to 145 mEq/L

            • sodium is regulated by salt intake, aldosterone, and urinary output

            • sources include table salt, processed meats, snacks and canned food (illustration )

          2. potassium - most abundant cation of intracellular fluid

            • potassium pump draws potassium into cell

            • essential for polarization and repolarization of nerve and muscle fibers

            • regulates neuro muscular excitability and muscle contraction

            • sources include wholegrains, meat, legumes, fruits and vegetables

            • regulated by kidneys

            • normal lab value for serum potassium is 3.5 to 5.3 mEq/L

          3. calcium - essential for cell membrane integrity, cardiac contraction, healthy bones and teeth, and functioning of nerves and muscles

          4. magnesium - normal constituent of bone; cofactor for enzymes in energy metabolism, neurochemical activities, muscular excitability

        2. anions

          1. chloride

            • most abundant anion in extracellular fluid

            • helps balance sodium

            • normal lab value for serum chloride is 100 to 106 mEq/L

          1. bicarbonate - part of bicarbonate buffer system; limits the drop in pH by combining with an acid to form carbonic acid and a salt

          1. phosphate - participates in cellular energy metabolism, combines with calcium in bone, assists in structure of genetic material

      1. Maintenance of fluid volume

        1. osmoreceptor system

          1. balances fluid intake volume by the regulation of water output volume

          2. dehydration stimulates osmoreceptors which activate the thirst control center; person feels thirsty and seeks water

          3. also stimulates antidiuretic hormone (ADH) secretion which decreases urinary output by causing the reabsorption of water in the tubules

        2. circulatory system

          1. increases in fluid intake increase circulatory volume

          2. this increased volume stimulates the kidney for an increased glomerular filtration rate

          3. end result is an increase in urine output to decrease the initial curculatory volume

        3. thirst center

          1. located in hypothalamus

          2. stimulated by

            • increased plasma osmolality

            • angiotensin II

            • dry pharyngeal muscous membranes

            • decreased plasma volume

            • depleted potassium

            • psychological factors

      1. Maintenance of electrolyte balance

        1. aldosterone - hormone (mineralcorticoid)

          1. when extracellular fluid sodium decreases or potassium levels increase

          2. adrenal cortex secretes aldosterone

          3. kidneys stimulated by aldosterone to increase reabsorbtion of sodium and decreased reabsorbtion of potassium

          4. results in water reabsorption and increased blood volume

        2. parathyroid

          1. parathyroid secretes parthyroid hormone (PTH), also called parathormone

          2. stimulates release of calcium from bone, reabsorbtion in small intestine and kidney tubules

          3. when serum calcium level is low, PTH secretion increases

          4. when serum calcium level rises, PTH secretion falls

          5. high levels of active vitamin D inhibit PTH and low levels or magnesium stimulate PTH secretion

    1. Normal and therapeutic diets

      1. Guidelines:

        1. dietary reference intakes (DRI's)- average daily nutrient intake of apparently healthy people over time.

          1. recommended dietary allowance (RDA)

          2. adequate intake (AI)

          3. tolerable upper intake level (UL)

          4. estimated average requirement (EAR)

        1. 2001 dietary guidlines for Americans

          1. aim for fitness

          2. build a healthy base

          3. choose sensibly

      1. Therapeutic nutrition

        1. modification of the nutritional needs based on disease condition

        2. considerations for administering therapeutic diets

          1. condition of client - physical, emotional, mental ability of client to tolerate diet

          2. willingness of client to comply with diet

        3. types of therapeutic diets

          1. diabetic

            1. goal is maintenance of normal weight

            2. dietary ratio 5:2:1 (carbohydrates to fat to protein)

            3. level of activity determines energy requirements

            4. non-insulin dependent diabetes mellitus (NIDDM) can usually be controlled by diet therapy

            5. diet individualized according to client's age, build, weight, and activity level

            6. keeping a regular schedule of meals and snacks is essential

          2. low protein diet

            1. for renal disease such as pyelonephritis, uremia, kidney failure

            2. normal protein intake 40 to 60 gm/day

            3. restricted foods: meats and other foods high in protein such as legumes, fish, dairy

          3. high protein diet

            1. for conditions such as burns, anemia, malabsorbtion syndromes, ulcerative colitis

            2. include high quality proteins or protein supplements such as sustagen

          4. low calcium diet

            1. prevents formation of renal calculi

            2. limit 400 mg per day instead of normal 800 mg

            3. restricts dried fruits and vegetables, shell fish, cheese, nuts

          5. acid ash diet

            1. prevents stone formation

            2. restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives, pickles

          6. low purine diet

            1. prevents uric acid stone; used with gout clients

            2. lowers levels of purine, the precursor of uric acid

            3. restricts glandular meats, gravies, fowl, fish, and high meat quantities

          7. low cholesterol

            1. used for cardiovascular disease, high serum cholesterol levels

            2. normal amount of cholesterol intake - 250 to 300 mg/day

            3. restricts eggs, beef, liver, lobster, ice cream

          1. low sodium

            • used in congestive heart failure, hypertension

            • used for correcting the retention of sodium and water

            • levels of restriction

              • mild (2 to 3 g sodium)

              • moderate (1000 mg sodium)

              • strict (500 mg)

            • restricts table salt, canned vegetables, smoked meats, butter, cheese

          2. high fiber

            • used to correct constipation, lower risk of colon cancer

            • 30 to 40 gm fiber/day recommended

            • increased intake of fruits, vegetables, bran cereals

          3. low residue

            • used for conditions such as diarrhea, diverticulitis

            • foods high in carbohydrates are usually low fiber

            • increased use of ground meat, fish, broiled chicken without skin, white bread

          4. mechanical soft

            • used with difficulty in chewing, such as poorly fitted dentures or endentulous

            • includes any foods which can be easily broken down by chewing

          5. puree diet

            • used with dysphagia or difficulty in chewing

            • used for tube feedings, small babies

            • food is blended to smooth consistency

          6. liquid diets

            • clear liquid consisting of nonirritating easily digested and absorbed liquids

            • full liquid

      1. Nutritional assessment: evaluate

        1. weight change

        2. appetite

        3. food intolerance

        4. chewing and swallowing

        5. indigestion

        6. elimination habits

        7. eating behaviors

        8. nutrient-drug interacions

        9. anthropometric measurements

      2. Feeding tubes

        1. indications-inability to ingest, chew, or swallow food, but GI tract intact

        2. tube inserted through nose into stomach or small bowel; or inserted endoscopically; gastrostomy tube or PEG tube, jejunostomy tube

        3. types of tubes and feedings

          1. small bore feeding tube: 8 to 12 Fr and 36 to 43 inches long

            • difficult to aspirate stomach contents

            • may be impossible to auscultate an air bolus; or air bolus may be heard even when tube is not in stomach

            • tubes may become displaced even when securely taped

            • hard to verify placement; best method is by xray

          2. enteral tube feedings

            • keep head of bed raised, to prevent aspiration

            • assess placement of tube

            • inject ten ml air into nasogastric tube (ng tube) and listen with stethoscope for rush of air over stomach

              • aspirate gastric contents and check if pH is acidic

              • radiologic confirmation

            • administer enteral feeding

              • continuous

              • to prevent bacterial growth, do not hang tube feeding for longer than eight hours

            • assess gastric residual

              • every four hours if continuous feeding or

              • before you begin intermittent feedings

          3. tube feeding formulas

            • Vivonex, Isocal, Portagen, etc.

          4. complications

            • aspiration

            • gastrointestinal complications (diarrhea)

            • electrolyte or metabolic problems

      1. Nutritional supplements/liquids

        1. dehydration/diarrhea:

          1. infants: Infalyte, Pedialyte, Ricelyte

          2. older children: sports electrolyte replacement drinks

          3. infant formulas: standard and high-calorie

          4. specialty formulas:

            • predigested (e.g. Pregestamil, Nutramigen)

            • high-calorie supplements (Scandishakes, Carnation instant breakfasts)

      2. Parenteral nutrition: see Lesson 6 of this course

      3. Measures to improve nutrition intake of client

        1. frequent small feedings

        2. feeding assistance

        3. offering preferred foods

        4. ethnic foods