Care Case Study (1) -Altered Nutrition – Flashcards

In developing the plan of care, the nurse recognizes pt's dysphagia may impact her fluid and nutritional status--nurse plans interventions related to pt dysphagia. To which member of the interprofessional team should nurse refer Pt?

The nurse recognizes that pt's right-sided weakness is also a factor contributing to her risk for altered nutrition. With which member of the team should the nurse consult regarding this problem?

Speech therapist is consulted and makes a home visit to evaluate pt. Therapist determines dysphagia precautions are needed. The nurse and unlicensed assistive personnel (UAP) arrive at home shortly after therapist eval completed. UAP prepares to assist pt with her non meal and with her personal care. What instruction should nurse provide to UAP ?

The nurse visits with pt's husband and observes UAP assist pt with meal. UAP gives pt glass of iced tea. Considering dysphagia precautions, how should the nurse intervene?

During home visit a week later, nurse assesses pt's nutritional status. Which data indicates the need for nurse to eval. pt further for altered nutrition?

Nurse obtains further data regarding Mrs. Rusk's nutritional status. Which info is best to use for assessment of the client's functional ability related to nutrition

Which intervention should be included in plan of care to provide nurse with the most accurate information regarding pt ongoing nutritional status?

2 weeks later, nurse notes change in pt weight. Nurse consults w nutritionist, who completes 24 hr calorie count. Nutritionist reports to nurse pt who is 125lb and 67" tall, is consuming 800 cal/day. How should nurse explain results of the cal count to pt and her husband?

Before notifying the HCP of the data reported by nutritionist, what info is most important for nurse to obtain?

Nurse reports the data about pt's nutritional status to HCP, who asks nurse to obtain a blood sample for labs. Nurse obtains copy of lab results the next day. What serum lab value reflects pt's altered nutrion?

Nurse and nutritionist collaborate to develop plan of care to improve pt nutritional status. Nurse teaches the pt and family about foods high in protein and provides them with sample menus. Which breakfast selection(s) are good sources of protein?

Nurse also encourages husband to prepare high calorie snacks for pt. Husband states that his wife loves applesauce and asks if this is a good snack choice. How should nurse response?

Pt has new prescription for an appetite stimulant. Before advising when pt to take Rx, nurse should obtain what info about the drug?

Pt's husband looks at the new Rx, which is brand name, and states "Next time we fill this prescription, I hope we can get the generic form. Maybe it won't be so expensive." How should nurse respond?

Pt gradually weakens and is admitteed to nearby medcenter. HCP rec the instertion of feeding tube, by means of a percutaneous espohageal gastrostomy (PEG). Pt signs consent form, and the procedure is schedules for next day. That night, nurse notes pt's med record contains an advanced directive requestion that she is not resuscitated in the event of an arrest, confirmed by Rx's by HCP. While nurse is conversing with pt and husband, husband confirms that pt wants "no heroic measures to be taken to save her life". What action should nurse take ?

The next morning, nurse enters pt room to prepare her for the procedure room. Nurse states procedure is scheduled in 30 min. Pt who is still lethargic from sleeping pills, tells nurse she's changed her mind and doesn't want the procedure performed, stating she would rather "go ahead and die." Her husband is in the room and is very upset by wife's comment. What action should nurse implement?

The couple discusses the decision and pt decides to have procedure as scheduled. She is taken to procedure room where PEG tube inserted. Pt returns to room following insertion of tube. She has IV of Lactated Ringer's Solution infusing at 50mL/hour but doesn't have any feeding solution attached to PEG tube. What initial action should nurse implement?

The nurse observes the dressing around the PEG tube insertion site is intact, with a small amount of serosanguineous drainage. What action should nurse implement?

The next day, the nurse initiates he feeding prescribed by the HCP. The prescription is for half-strength formula to infuse at 40mL/hr. Formula is available in 8 oz cans. The nurse is preparing enough formula for 12 hours. How many cans of formula will the nurse need?

After infusing half-strength formula at 40mL/hr for 6hrs, nurse checks the pt residual volume and obtains 75mL. The prescription for the formula states that the prescription for the formula states that the prescription should be increased by 10mL/hr as long as the client's residual volume is less than half the previously infused total volume. What action should nurse implement?

Over time, continuous feeding is increased to 80mL/hr and changed to full strength formula. The nurse plans to teach pt's husband how to manage the continuous feeding when pt is discharged. Before educating pt's husband about managing continuous feed, what info is most important for the nurse to collect prior discharge instructions?

When nurse demonstrates use of feeding equipment, pt's husband looks away. Nurse observes him crying. What action should nurse implement?

While husband administers feeding, pt tells nurse she has had 5-7 liquid diarrhea stools/day for last 2 days. Feedings are changed to bolus feeding 3x/day. After instruction, pt's husband demonstrates correct ability to perform the skill and states that he feels he can handle this responsibility. Pt discharged home and home healthcare service resume. During a home visit, nurse observes pt's husband as he administers a bolus feeding to pt, who is sitting upright in bed. After checking residual volume, pt's husband pours feeding into the syringe attached to feeding tube. He then holdsthe syringe upright while feeding enters stomach. In observing the procedure, what action should nurse take?

While pt's husband administers feeding, pt tells nurse she has had 5-7 liquid diarrhea stools/day for the last 2 days. What is the sequence of nursing actions?