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Nutrition A. Food guidelines (illustration ) 1. Nutritional needs through the life cycle a.

infants: fluid and protein needs 2.5x adults b. breast milk or formula is adequate for first six months of life i. whole milk is difficult for young infants to digest ii. the first food introduced is cereal c. childhood: gradual increasing of all nutrients adults: unchanged except for i. pregnancy: add per day: 300 calories, 15 mg iron, 30 g protein, 400 g calcium, and 200ug folic acid ii. lactation: add 500 calories, 2 quarts extra fluid d. elderly over age 65: adequate protein to maintain immune system 1. Factors affecting dietary patterns a. health status b. ability to chew, swallow, and drink c. culture and religion d. socioeconomic status e. personal preference f. psychological factors g. alcohol and drugs Energy needs a. basal metabolism energy required for ongoing internal processes such as heartbeat b. basal metabolic rate (BMR) influenced by gender, age, activity level, body composition

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Essential nutrients Carbohydrates a. include sugars, starches and cellulose b. simple sugars (monosaccharides) are most easily metabolized c. starches are more complex in structure and metabolism d. functions of carbohydrates i. quickest source of energy (4.1 kcal/gram) ii. main source of fuel for brain, peripheral nerves, WBCs, RBCs, and healing wounds iii. protein sparer e. dietary sources: plant foods, except for lactose

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g. Lipids a. b. c.

recommended daily intake: i. factors influencing recommended intake of carbohydrates include body structure, energy expenditure, basal metabolism and general health status ii. ideally, 50 to 60% of total calories should be complex carbohydrates excessive carbohydrate calories are stored as fat basic lipids are composed of triglycerides and fatty acids includes saturated fatty acids (from animal sources) and unsaturated fatty acids (vegetables, nuts and seeds) 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 deficiencies lead to skin, blood and artery problems functions i. most concentrated source of energy (nine kcal/gram) ii. bodys major form of stored energy iii. insulation iv. cell membrane component v. carries fat-soluble vitamins A, D, E and K vi. recommended dietary intake: no more than 30% total caloric intake and low in saturated fats complex organic compounds comprised of amino acids body breaks protein down into 22 amino acids all but eight amino acids are produced by the body complete protein food contains the eight essential amino acids not produced by the body (most meat, fish, poultry and dairy products) incomplete protein food lacks one or more of the eight amino acids (most vegetables and fruits) incomplete proteins can be combined to yield a complete protein: for example, beans and rice functions of protein i. secondary energy source (four kcal/gram) ii. essential for cell growth iii. efficiency can affect all of body - organs, tissues, skin, muscles iv. recommended protein intake: 0.42 grams per 0.4 kg of body weight v. the body's only source of nitrogen vi. negative nitrogen balance can occur with infection, burns, fever, starvation, and injury

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Proteins a. b. c. d. e. f. g.

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Vitamins a. organic substances essential for body growth and metabolism b. found only in plants and animals; body cannot synthesize them; depends on dietary intake c. types (according to their solvent) i. water soluble (B1, B2, B6, B12, C) I. cannot be stored in body; require daily intake ii. fat soluble (A, D, E, K) I. can be stored in body Minerals a. inorganic substances essential as catalysts in biochemical reactions b. form most inorganic material in the body c. functions: i. catalyst for many body reactions such as regulation of acid-base balance ii. help cells metabolize, tissues absorb nutrients, and heart muscle respond iii. minerals work synergistically; a deficiency of one mineral can disturb the action of other minerals iv. types - grouped according to amount found in body I. major minerals - calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine; function known II. trace minerals - iron, copper, iodine, manganese, cobalt, zinc and molybdenum; function unclear III. another group of trace minerals; found in even smaller amounts; function unclear

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Water a. critical body component essential for cell function b. accounts for 60 to 70% total body weight in adults; 70 to 75% children functions c. provides normal turgor d. regulates body temperature e. dietary sources: liquids and solids, such as fresh fruits and vegetables f. deficiency: severe deficiency leads to dehydration and death g. fluid intake normally equals fluid output

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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 a. cations i. 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 ) ii. 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 iii. calcium - essential for cell membrane integrity, cardiac contraction, healthy bones and teeth, and functioning of nerves and muscles iv. magnesium - normal constituent of bone; cofactor for enzymes in energy metabolism, neurochemical activities, muscular excitability )

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anions i. chloride most abundant anion in extracellular fluid helps balance sodium normal lab value for serum chloride is 100 to 106 mEq/L ii. bicarbonate - part of bicarbonate buffer system; limits the drop in pH by combining with an acid to form carbonic acid and a salt phosphate - participates in cellular energy metabolism, combines with calcium in bone, assists in structure of genetic material

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6. Maintenance of fluid volume a. osmoreceptor system i. balances fluid intake volume by the regulation of water output volume ii. dehydration stimulates osmoreceptors which activate the thirst control center; person feels thirsty and seeks water iii. also stimulates antidiuretic hormone (ADH) secretion which decreases urinary output by causing the reabsorption of water in the tubules 1. circulatory system a. increases in fluid intake increase circulatory volume b. this increased volume stimulates the kidney for an increased glomerular filtration rate c. end result is an increase in urine output to decrease the initial curculatory volume 2. thirst center a. located in hypothalamus b. stimulated by

i. increased plasma osmolality ii. angiotensin II iii. dry pharyngeal muscous membranes iv. decreased plasma volume v. depleted potassium vi. psychological factors ii. Maintenance of electrolyte balance 1. aldosterone - hormone (mineralcorticoid) a. when extracellular fluid sodium decreases or potassium levels increase b. adrenal cortex secretes aldosterone c. kidneys stimulated by aldosterone to increase reabsorbtion of sodium and decreased reabsorbtion of potassium d. results in water reabsorption and increased blood volume 2. parathyroid a. parathyroid secretes parthyroid hormone (PTH), also called parathormone b. stimulates release of calcium from bone, reabsorbtion in small intestine and kidney tubules c. when serum calcium level is low, PTH secretion increases d. when serum calcium level rises, PTH secretion falls

e. high levels of active vitamin D inhibit PTH and low levels or magnesium stimulate PTH secretion D. Normal and therapeutic diets 1. Guidelines: a. dietary reference intakes (DRI's)- average daily nutrient intake of apparently healthy people over time. i. ii. iii. iv. recommended dietary allowance (RDA) adequate intake (AI) tolerable upper intake level (UL) estimated average requirement (EAR)

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b. 2001 dietary guidlines for Americans i. aim for fitness ii. build a healthy base iii. choose sensibly Therapeutic nutrition b. modification of the nutritional needs based on disease condition c. considerations for administering therapeutic diets i. condition of client - physical, emotional, mental ability of client to tolerate diet ii. willingness of client to comply with diet d. types of therapeutic diets i. diabetic I. goal is maintenance of normal weight II. dietary ratio 5:2:1 (carbohydrates to fat to protein) III. level of activity determines energy requirements IV. non-insulin dependent diabetes mellitus (NIDDM) can usually be controlled by diet therapy V. diet individualized according to client's age, build, weight, and activity level VI. keeping a regular schedule of meals and snacks is essential ii. low protein diet I. for renal disease such as pyelonephritis, uremia, kidney failure II. normal protein intake 40 to 60 gm/day III. restricted foods: meats and other foods high in protein such as legumes, fish, dairy iii. high protein diet

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for conditions such as burns, anemia, malabsorbtion syndromes, ulcerative colitis II. include high quality proteins or protein supplements such as sustagen low calcium diet I. prevents formation of renal calculi II. limit 400 mg per day instead of normal 800 mg III. restricts dried fruits and vegetables, shell fish, cheese, nuts acid ash diet I. prevents stone formation II. restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives, pickles low purine diet I. prevents uric acid stone; used with gout clients II. lowers levels of purine, the precursor of uric acid III. restricts glandular meats, gravies, fowl, fish, and high meat quantities low cholesterol I. used for cardiovascular disease, high serum cholesterol levels II. normal amount of cholesterol intake - 250 to 300 mg/day III. restricts eggs, beef, liver, lobster, ice cream low sodium I. used in congestive heart failure, hypertension II. used for correcting the retention of sodium and water III. levels of restriction I. mild (2 to 3 g sodium) II. moderate (1000 mg sodium) III. strict (500 mg) IV. restricts table salt, canned vegetables, smoked meats, butter, cheese high fiber I. used to correct constipation, lower risk of colon cancer II. 30 to 40 gm fiber/day recommended III. increased intake of fruits, vegetables, bran cereals low residue I. used for conditions such as diarrhea, diverticulitis II. foods high in carbohydrates are usually low fiber

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increased use of ground meat, fish, broiled chicken without skin, white bread mechanical soft I. used with difficulty in chewing, such as poorly fitted dentures or endentulous II. includes any foods which can be easily broken down by chewing puree diet I. used with dysphagia or difficulty in chewing II. used for tube feedings, small babies III. food is blended to smooth consistency liquid diets I. clear liquid consisting of nonirritating easily digested and absorbed liquids II. full liquid

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Nutritional assessment: evaluate a. weight change b. appetite c. food intolerance d. chewing and swallowing e. indigestion f. elimination habits g. eating behaviors h. nutrient-drug interacions i. anthropometric measurements Feeding tubes a. indications-inability to ingest, chew, or swallow food, but GI tract intact b. tube inserted through nose into stomach or small bowel; or inserted endoscopically; gastrostomy tube or PEG tube, jejunostomy tube c. types of tubes and feedings i. 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 ii. enteral tube feedings keep head of bed raised, to prevent aspiration assess placement of tube

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inject ten ml air into nasogastric tube (ng tube) and listen with stethoscope for rush of air over stomach o aspirate gastric contents and check if pH is acidic o radiologic confirmation administer enteral feeding o continuous o to prevent bacterial growth, do not hang tube feeding for longer than eight hours assess gastric residual o every four hours if continuous feeding or o before you begin intermittent feedings iii. tube feeding formulas Vivonex, Isocal, Portagen, etc. iv. complications aspiration gastrointestinal complications (diarrhea) electrolyte or metabolic problems Nutritional supplements/liquids a. dehydration/diarrhea: i. infants: Infalyte, Pedialyte, Ricelyte ii. older children: sports electrolyte replacement drinks iii. infant formulas: standard and high-calorie iv. specialty formulas: predigested (e.g. Pregestamil, Nutramigen) high-calorie supplements (Scandishakes, Carnation instant breakfasts) Parenteral nutrition: see Lesson 6 of this course Measures to improve nutrition intake of client a. frequent small feedings b. feeding assistance c. offering preferred foods d. ethnic foods

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Mobility A. Prevent complications of immobility 1. Skin changes - decubitus ulcers a. b. c. d. turn client every two hours use heel/elbow protectors use alternate pressure mattress or other skin care devices do not massage reddened areas; doing so increases damage to tissues

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limit sitting in a chair to 2 to 4 hours or as tolerated with a shift in weight at least every 30 to 60 minutes

2. Musculoskeletal changes-contractures f. g. h. i. do range of motion exercises to joints on a scheduled basis daily provide foot board and/or foot cradle or high-topped tennis shoes to prevent foot drop reposition every 2 hours maintain correct body alignment

3. Respiratory changes - pneumonia, atelectasis j. k. l. m. instruct client to cough and deep breathe every two hours, or more frequently turn every two hours suction if needed chest physiotherapy (physical therapy) as ordered

4. Cardiovascular system changes-decreased cardiac output, clots,emboli n. o. orthostatic hypotension: i. instruct client to change position slowly ii. highest risk is from supine to standing position increased cardiac workload i. reinforce for client to avoid bearing down or valsalvar manuever ii. minimize coughing iii. limit sitting in high Fowler's position to one to two hours thrombus/emboli formation i. apply thigh or knee-high antiemboic stockings as ordered ii. turn every tow hours iii. monitor anticoagulation therapy, as indicated iv. initiate ambulation or exercise of dorsi and plantar flexion of the foot v. limit sitting with feet in a dependent position to 1 to 2 hours

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5. Urinary changes: renal, calculi, urinary tract infection, glomerular nephritis q. r. increase fluid intake (2000 - 3000 cc/day) restrict foods that contribute to renal stone formation

6. Psychosocial changes:

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provide stimuli to maintain orientation develop mutually with client, a schedule to maintain mental sharpness

B. Types of exercise 1. Passive - carried out by the health care provider without assistance from client; purpose is to retain joint mobility and blood circulation 2. Resistive - carried by the client working against resistance; purpose is to increase muscular strength; enhance bone integrity 3. Isometric - carried out by the client with no assistance by contracting muscle group for ten seconds and then relaxing muscle group; purpose is to maintain muscular strength when the joint is immobilized 4.Range of motion (ROM) - joint is moved through entire range; purpose is to maintain joint mobility C. Use of mechanical aids to promote mobility 1. Crutches-support; balance feet, and legs during walking keep tips of crutches 12 to 16 inches to side of feet adjust handbars to allow 15 to 30 degrees of elbow flexion use well fitting shoes with nonslip soles use rubber suction tips on crutches i. inspect weekly ii. replace when worn y. may be used temporarily or permanently z. teach client crutch walking 4. Cane-provides stability when walking and relieves pressure on weightbearing joints a. adjust cane with handle at level of greater trochanter, elbow flexed at 30 degree angle b. teach client to hold cane close to body, and hold in hand on stronger side. c. move cane at same time as the weaker leg. 5. Walker-assists in weight bearing and mobility a. assists in weight bearing and mobility b. teach client how to sit, stand and turn 6. Gait belt a. leather or canvas belt around client's waist with handles b. safety devices for ambulatory clients who may have some balance problems F. Prosthetic devices - used to replace a missing body part G. Brace - support for weakened muscles Elimination E. Promotion of normal elimination u. v. w. x.

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Urination a. adequate fluid intake b. normal adult urinary output - 30 ml/hour c. alternative methods to promote client voiding, such as running water 4. Bowel elimination a. adequate fluid intake b. regular exercise c. regulate fruit juices, raw fruits and vegetables as needed d. normal bowel evacuation: varies in healthy individuals; no more than 3 movements per day to 3 times a week F. Urinary incontinence: involuntary release of urine 3. Types a. stress incontinence - sudden increase in intra-abdominal pressure (such as sneezing, coughing) causes urine to leak from bladder b. overflow (reflex) incontinence - bladder empties incompletely, so urine dribbles constantly c. urge incontinence - uncontrolled contraction of the bladder results in leakage of urine before one reaches the bathroom d. functional incontinence - incontinence not due to organic reasons; for instance, impaired mobility may prevent the client from reaching the bathroom in time. 4. Diagnosis of urinary incontinence a. history and physical examination b. urinalysis - tells whether blood or infection present c. cystoscopy - tells whether abnormalities are present d. post-void residual - measures amount of urine remaining in bladder after voiding e. stress test - determines if urine leaks after bladder is stressed due to coughing, lifting etc. 5. Treatment a. drug therapy i. antispasmodics and anticholinergics - relax and increase capacity of bladder ii. alpha-adrenergic agonists - increase urethral resistance b. kegel exercises - strengthen weak muscles around the bladder c. behavioral training - client learns different way to control urge to urinate d. bladder retraining e. surgery - repair of weakened or damaged pelvic muscles or urethra 6. Nursing interventions a. provide skin care, protective undergarments b. establish toileting schedule - provide easy access to bathroom and privacy c. teach client Kegel exercises:

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stop and start urinary stream while voiding hold contraction for 10 seconds and relax for 10 seconds iii. work up to 25 repetitions three times a day prevent infection i. cleanse urethral meatus after each void ii. acidify urine iii. increase daily intake of fluids

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Catheterization 3. Purposes a. relieve acute urinary retention b. relieve chronic urinary retention c. drain urine preoperatively and postoperatively d. determine amount of post-void residual e. accurately measure output in the critically ill f. obtain sterile urine specimen g. continuous or intermittent bladder irrigation (illustration ) 4. Types of catheters and general guidelines a. indwelling catheter i. use a closed drainage system ii. advance catheter almost to bifurcation of catheter, especially in male patients (illustration ) iii. inflate balloon within guidelines of manufacturer only after urine is draining properly, then slightly withdraw catheter iv. secure catheter to patient's thigh, allowing for some slack to accommodate movement and to lessen drag on patient v. ensure tubing is over patient's leg vi. care of indwelling catheter: cleanse around area where catheter enters urethral meatus. do this with soap and water during the daily bathing routine and after defecation do not pull on catheter while cleansing do not use powder or spray around perineal area do not open the drainage system avoid raising the drainage bag above the level of the bladder avoid clamping the drainage tubing catheter is only irrigated when an obstruction, usually following prostate or bladder surgery (e.g., potential blood clots) is anticipated b. suprapubic catheter i. placed to drain the bladder ii. achieved via a percutaneous catheter or by way of an incision through the abdominal wall c. intermittent self-catheterization

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purpose: to drain the bladder employed by the client with Spina Bifida and other neuromuscular diseases; can be taught to children ages 6 to 8 procedure: gather equipment: catheter, water-soluble lubricant, soap, water, urine collection container wash hands cleanse urethral meatus and surrounding area lubricate tip of catheter insert catheter until urine flows withdraw catheter when urine flow stops clean off residual lubricant from meatus dispose of urine wash hands

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Ostomies 1.Types of ostomies a. ileostomy i. liquid to semi-formed stool, dependent upon amount of bowel removed ii. may skew fluid and electrolyte balance, especially potassium and sodium iii. digestive enzymes in stool irritate skin iv. do not give laxatives v. ileostomy lavage may be done if needed to clear food blockage vi. may not require appliance; if continent ileal reservoir or Kock pouch colostomy i. ascending - must wear appliance - semi-liquid stool ii. transverse - wear appliance - semi-formed stool iii. loop stoma proximal end - functioning stoma distal end - drains mucous plastic rod used to keep loop out usually temporary iv. double barrel 2 stomas similar to loop but bowel is surgically severed v. sigmoid formed stool bowel can be regulated so appliance not needed may be irrigated

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Stoma assessment a. color - should be same color as mucous membranes b. edema - common after surgery c. bleeding - slight bleeding common after surgery Psychological reation to ostomy a. disturbed body image b. anxiety related to feared rejection c. ineffective coping related to ostomy care

V.

Sleep a. Factors affecting sleep 1. Physical illness 2. Drugs 3. Lifestyle 4. Excessive daytime sleep 5. Emotional stress 6. Environment 7. Exercise/fatigue 8. Food intake B. Sleep disorders 1. Bruxism: tooth grinding during sleep 2. Insomnia: chronic difficulty with sleep patterns a. initial insomnia: difficulty falling asleep b. intermittent insomnia: difficulty remaining asleep c. terminal insomnia: difficulty going back to sleep 3. Narcolepsy: fall asleep without warning 4. Sleep apnea: intermittent periods of not breathing while asleep; usually due to problems with upper airway; can be treated with CPAP (continuous positive airway pressure) at bedtime 5. Sleep deprivation: decrease in the amount and quality of sleep 6. Somnambulism: sleepwalking, night terrors, or nightmares 7. Depression a. secondary to disease process b. can occur with any sleep disorder C. General nursing interventions for promoting restorative sleep 1. Comfort measures 2. Medications: sedatives, hypnotics 3. Sleep routine 4. Encourage daytime activity 5. Eliminate naps 6. Relaxation techniques 7. Environmental control 8. Limit alcohol, caffeine, and nicotine in evening VI. Pain D. Theories of pain

1. Specificity theory proposes that pain can be initiated only by painful stimuli. 2. Pattern theory - stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and muscles to respond. 3. Gate control theory - pain impulses can be altered or regulated by gating mechanisms along nerve pathways. This theory explains how past and present experiences can influence the perception of pain. E. Variables influencing the perception of pain 1. Culture and social groups shape attitude towards pain 2. Religious beliefs regarding reasons for pain 3. Previous experience with pain 4. Age 5. Sex 6. Coping style 7. Family support F. Types of pain 1. Acute - pain episode lasting up to 6 months 2. Chronic - pain lasting longer than 6 months. May be intermittent or constant. G. Medical treatment 1. Pharmacologic intervention (discussed in Lesson 6: Pharmacological and Parenteral Therapies) 2. Nonpharmacologic intervention a. acupuncture i. oriental method: insert fine needles at specified body sites ii. unknown how acupuncture works physiologically b. relaxation techniques - biofeedback, visualization, meditation and hypnosis, to help client control anxiety c. electronic stimulation such as transcutaneous electric nerve stimulation (TENS) - electrodes applied over the painful area or along nerve pathway d. distraction - focusing client's attention on something other than pain e. massage - generalized cutaneous stimulation of the body. Makes the client more comfortable due to muscle relaxation f. ice and heat therapies - effective in some circumstances. Ice may decrease prostaglandins which intensify the sensitivity of pain receptors g. guided imagery - using one's imagination in a guided manner to achieve a specific positive effect 3. Nursing interventions in pain a. assess pain using pain assessment scale b. assess client's coping strategies and factors that produce ineffective coping c. teach client appropriate strategies to deal with pain

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Communication H. Cross-cultural communication - guidelines 1. Findings of a lack of effective communication a. efforts to change the subject - client may not understand what the nurse is saying b. lack of questions - client may not understand what was said c. nonverbal cues such as blank expression, lack of eye contact 2. Nursing interventions a. use simple sentence structure and pantomime while talking b. use visual aids c. discuss one topic at a time d. use any words you know in the client's language e. ask among the client's family and friends if anyone could serve as interpreter f. obtain phrase books or use flash cards 3. Cultural interpretations a. silence b. touch c. eye contact I. Client with hearing loss 1. Findings of hearing loss a. speech deterioration b. indifference c. social withdrawal d. suspicion e. tendency to dominate conversation 2. Nursing interventions a. speak slowly and distinctly; do not shout b. face client directly c. make sure your face is clearly visible d. before the discussion, tell client the topic you are going to discuss e. insure that client has access to hearing aid and that it is functional f. keep sentences short and simple g. use written information to enhance spoken word J. Client with aphasia 1. Injured cerebral cortex blocks some language-related functions 2. Nursing interventions a. face client and establish eye contact b. avoid completing client's statements c. use gestures, pictures, and communication boards d. limit conversation to practical matters e. use the same words and gestures for objects f. keep background noise to a minimum g. do not shout or speak loudly h. give the client time to understand and respond i. if client has problems speaking ask "yes" or "no" questions

K. Client with stroke 1. Approach client from side of intact field of vision 2. Remind client to turn head in direction of visual loss to compensate for loss of visual field 3. Explain location of object when placing it near the client 4. Always put client care items in same places 5. Put objects within client's reach, and on unaffected side 6. Encourage client to repeat sounds of the alphabet 7. Speak slowly and clearly 8. Use simple sentences with gestures or pictures 9. Reorient client to time, place, and situation 10. Provide familiar objects 11. Minimize distractions 12. Repeat and reinforce instructions L. Client with dementia 1. Be calm and unhurried 2. Keep conversations short and focused 3. Do not ask the client to make decisions 4. Be consistent 5. Avoid distractions 6. Use reality orientation techniques

VIII.

Alternative and Complementary Medicine M. Herbal therapy 1. Used as dried herbs in capsules or tablets, tinctures, teas, ointments 2. Use only products standardized with a specific amount of active ingredients 3. Some may interfere with medications N. Chiropractic treatment 1. Effective by manipulating the musculosketal system 2. Manipulation to put the vertebrae in proper alignment O. Acupuncture and acupressure 1. Based on belief that channels of energy are blocked causing diseases or discomfort 2. Acupuncture is primary treatment used by physicians of Chinese medicine a. insert fine needles at specific points to open channels of energy (meridians) b. used to decrease pain and to treat or prevent illness 3. Acupressure a. uses gentle pressure at specific points b. used for prevention and relief of muscle tension P. Therapeutic massage 1. Manipulates the soft tissue of the body and assists with healing 2. Can be either relaxing or energizing

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3. Is contraindicated for a client with phlebitis, thrombosis, or infectious skin diseases Aromatherapy 1. Uses oils produced by plants for inhalation or topical application 2. Different scents are thought to produce different responses in the body Reflexology applies pressure to specific areas of the feet thought to correspond with all the different parts of the body Relaxation therapy 1. Rhythmic breathing 2. Progressive relaxation Yoga 1. Treatment of the mind-body connection 2. Can tone the muscles that balance all parts of the body and control the emotions and mind through correct posture and breathing

All individuals require the same nutrients, but the amounts vary according to factors such as age, weight, activity level, and health state. The energy value of foods is defined in calories; only proteins, fats and carbohydrates provide calories. The average adult drinks 2 to 3 liters of water per day. The normal thirst mechanism in the elderly may be diminished and they may need encouragement to drink sufficient water to prevent dehydration. Discontinue ROM exercises at point of pain. Use rubber suction tips on crutches and canes to prevent slipping. Prevent deformities and complications such as contractures, thrombophlebitis, and pressure ulcers by turning and positioning the client in good alignment. There should be at least two inches between axilla and top of arm piece of crutch to prevent pressure on the brachial plexus. The majority of residents in nursing homes are incontinent. Incontinence is not a normal sequela of aging. Initiate pain relief before the pain becomes unbearable. Essential amino acids cannot be synthesized. They must be ingested daily.

Weight is maintained when daily food intake equals energy expenditure. Age affects daily requirements: young, old, pregnancy, lactation. Weight loss is a long-term process and patients need long-term support. Reconstructive surgery may be required after large amount of weight loss. Support groups are available for patients losing weight. Increased fiber in the diet may cause flatulence. In constipation, increase fluid to 3000 cc/day (unless contraindicated). Small frequent loose stools or seepage of stool are often indicative of a fecal impaction. Use transparent drainage bag initially for assessment of stoma and drainage.

Avoid foods that cause odor, gas, diarrhea, or may block ileostomy. Allow the client to rate his degree of pain and the degree of relief from pain relief measures. Self-control methods to manage pain: distraction, massage, guided imagery, relaxation, biofeedback, hypnosis. Change ostomy appliance as needed

Achalasia Anabolism Antioxidant Beta-carotene Diffusion Emulsifier Ferritin Flatulence Hyperkalemia Hypernatremia Kilocalorie Malnutrition Nutrients Osmosis Tenesmus Valsalva's maneuver