Care Case Study (1) -Altered Nutrition
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?
Speech therapist (expertise in the evaluation and management of clients with dysphagia
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?
Occupational therapist (expertise in helping clients adapt FINE MOTOR movements for the provision of self care)
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 ?
Bathe client first then place pt in HI-FOWLER’s position during and after the meal– should be kept elecated for at least 1 hour after meal to reduce risk of aspiration
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?
Instruct UAP to add thickening agent to all liquids
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?
-skin over sternum tents when pinched
-lips are dry and cracked
-conjunctival sac is pale in appearance when exposed ( dark pink–pallor indicates anemia)
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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
client’s ability to feed herself with her left hand
Which intervention should be included in plan of care to provide nurse with the most accurate information regarding pt ongoing nutritional status?
Instruct home health aide to weigh the client once a week-pattern
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?
Pt calorie consumption is insufficient and will result in weight loss (
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?
Protein of 5.0g/dL
(range normal 6.5-8.3g/dL)
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?
-Scrambled eggs & sausage
-egg, potato and onion omelet
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?
Provide applesauce since she likes it, along with higher calorie snacks
Pt has new prescription for an appetite stimulant. Before advising when pt to take Rx, nurse should obtain what info about the drug?
Onset of action–when it will start so med can be taken with greatest therapeutic effect achieved
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?
Your pharmacist and HCP can determine if there is a generic drug that’s safe alternative to brand name of the drug. (Although bioequivalent, inert ingredients vary–different effects)
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 ?
Advise pt that an ID bracelet needs to be secured on her wrist in case of emergency. (An ID band that indicates resuscitation shouldn’t be performed helps that pt wishes are known/respected)
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?
Provide the couple with privacy to discuss decision. (Nurse must address client’s expressed desire to cancel provedure. Nurse initial actions should include allowing privacy, addressing any concerns of client, and encouraging further communication)
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?
continue to monitor the client without infusing any solution through the PEG tube (feeding supplements are initiated when bowel sounds are present (within 24 hrs after PEG tube insertion)
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?
Circle the amount of drainage on initial dressing (circling allows the nurse to compare any changes in the amount of drainage at a later time)
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?
1 can. Half strength means that half of the total volume is diluted with water so (12hr)(20mL formula/1hr)(1oz/30mL)(1 can formula/8oz formula)
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?
Increase rate to 50mL/hr
(client has received 240mL during the previous 6 hours. Half of that volume is 120mL. The residual volume obtained=75mL, so rate should be increased by 10mL/hr)
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?
Determine if Mr. Rusk feels ready to learn the skill–readiness to learn is essential for effective teaching
When nurse demonstrates use of feeding equipment, pt’s husband looks away. Nurse observes him crying. What action should nurse implement?
Acknowledge the stressful nature of the situation and ask husband if he’s ready. This is a therapeutic response, offering support and allowing husband to feel “in control”
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?
Ensure pt’s husband flushes tubing with water after syringe is empty of feeding (it reduces risk of obstruction of tubing)
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?
1. Tell husband to hold feeding
2. Auscultate for bowel sounds
3. Assess elasticity of skin
4. Notify HCP of diarrhea