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NUR 3414 - J1 PNP – Spring 2015

Exam One Review


Surgical Asepsis Hot Points


- Clean fingernails of each hand with 15 strokes

-Clean the palm sides of the thumb, fingers and posterior side of the hand with 10


-Scrub each 1/3


of the arm with 10 strokes

-Rinse from fingertips to elbows allowing water to run off

Types of Transmission and Associated Precautions:

-Direct: Person to person (fecal, oral) physical contact between source and susceptible


-Indirect: Personal contact of susceptible host with contaminated inanimate object

-Droplet: Large particles that travel up to 3 feet during coughing, sneezing or talking and

come in contact with susceptible host

-Precautions: Private Room, Mask or respirator depending on condition

-Airborne: Droplet nuclei or residue or evaporated droplets suspended in air during

coughing or sneezing and carried on dust particles.

-Negative Pressure Room, Mask, Respiratory protection device N95

-Contact Precautions: Private room, gown and gloves

-Protective Environment: Private room, positive airflow, mask to be worn by patient

when out of room during times of construction

Sta dard Pre autio s: If it’s et a d ot yours, use glo es

Stages of Illness:

-Incubation Period: Interval between entrance of pathogen into body and appearance of
first symptoms

-Prodromal Stage: Interval from onset of nonspecific symptoms to more specific


-Illness Stage: Interval when patient manifests signs and symptoms specific to type of


-Convalescence: Interval when acute symptoms of infection disappear

Random Definitions

- Iatrogenic Infections: type of HAI from a diagnostic or therapeutic procedure

Factors Influencing Infection Prevention in Patients

-Age: The older you get the more susceptible to disease and infection you are

-Nutritional Status: Patients who have undergone trauma or are healing have special

dietary needs such as increase protein

- Stress: The same conditions that increase nutritional requirements also increase

physiologic stress

Disease Process: Patients with specific diseases are at a special risk for certain infections

Laboratory Values

WBC: White Blood Cell count: Normal Range: 5000-10000/mm^3: Indicates acute infection

ESR: Erythrocyte Sedimentation Rate: Normal Range: Up to 15mm/hr for men and 20mm/hr for


-Elevated in presence of inflammatory response

Iron Level: 60-90g/100mL: decreased in chronic infection

HH: Hemoglobin and Hematocrit: Can tell you about patients protein level

Assessment of Infection Risk

-Check Results of Lab Tests

- Review Current Meds

- Identify potential sites of infection

Order of Putting PPE on

ON - Cap, gown, mask, goggles, gloves

OFF - Gloves, goggles, gown, mask, cap


-Basic Needs must be met such as Oxygen, Nutrition, and Temperature then we must

meet the need of the safe environment.

Physical Hazards

- Motor Vehicle Accidents

o Causative mainly in teens but also in older adults who have a decreased

nervous system response and decreased hearing and vision

- Poison

o Includes any substance that impairs health or destroys life when ingested,

inhaled or absorbed by the body

o Toddlers, Preschoolers, and young children are most at risk for this hazard in

the home

o Poison can come from the environment, ex: lead paint, lead paint on toys

o Tell patients to call Poison Control Center

- Falls

o Among adults 64 years and older, falls are the leading cause of unintentional


o d/t balance problems, orthostatic hypotension, gait and balance problems,

urinary incontinence, and effects of various medications

o Common Physical Hazards that lead to falls:

 Inadequate Lighting

 Barriers along normal walking paths ie rugs

 Lack of safety devices in the home

o Falls can lead to serious injury and internal bleeding

- Fire

o Leading causes of fire include

 Careless smoking
 Improper use of a stove

o Encourage Use of Smoke Detectors and Fire Extinguishers in the home

Developmental Stages and their impact on Safety

-Infant & Toddler: Injuries in the home, choking, fire and head trauma

-School Age: incidents with travel to and from school, learning complicated motor skills,

participating in sports

-Adoles e t: Sui ide, MVC’s, illegal drug use, risky eha ior

-Adult: excessive alcohol, smoking, stress related incidents

- Older Adult: Falls!

-Individual Risk Factors

-Lifestyle, Impaired Mobility, Sensory or Communication Impairment& Lack of

safety awareness

National Patient Safety Goals: HUGE!!!!!

- Identify patients correctly

o Use at least 2 patient identifiers

o Eliminate transfusion errors

- Improve Staff Communication

o Report important test results in a timely manner

- Use meds safely

o Label Meds

o Reduce harm to patients who take anti-coagulant therapy

- Reduce the Risk of HAI

o Meet hand hygiene guidelines

o Prevent multidrug-resistant organism infections

o Prevent central line-associated infections

o Use safe practices to treat the part of the body where surgery was performed

- Check Patient Meds

o Identify current medicines and make sure that it is okay for patients to take
any new meds with current meds

o Give a list of patients meds to provider, family, and patient before discharge



-Ask about the following areas

-Activity and Exercise (ADLs, bathing, cooking, cleaning, driving, assistive devices)

-Medication Hx (dizziness or associated events)

- History of Falls

-Home Maintenance &Safety (lawn mowing, snow shoveling, feeling of safety)

Fall Assessment Tool

-Patients are awarded points based on the following categories the lover the points the

higher the fall risk


-Fall Hx








Fall Reduction

-Hourly rounding, placement of bed in low position, clearing walkways, use of gait belt,

remove excess furniture, wear rubber soled shoes, safety bars near toilet, locks on beds

and wheelchairs and call lights within reach

Restraints & Restraint Alternatives

Restraint Alternatives

- Orient patients and families to environment

- Provide companionship and supervision, use trained sitters

- Offer diversionary activities

- Assig o fused or disorie ted patie ts to roo s ear urses’ statio

and observe them frequently

- Use calm, simple statements & use de-escalation

- Provide appropriate visual and auditory stimuli

- Remove cues that promote leaving

- Attend frequently to needs

- Camouflage IV lines and

- Reassess physical status and lab findings

Application of restraints & Protocol

-Skill of applying restraints can be done by the NAP, however nurse must assess

the patients behavior, level of orientation, need for restraints and the

appropriate type of restraint to use

-Belt Restraint: have patient in sitting position. Apply belt over waist not at chest

or abdomen. Remove wrinkles or creases in clothing. Bring ties through slots in


-Extremity Restraint: (ankle or wrist) restraint is designed to immobilize one or

all extremities. Commercially available limb restraints are made of sheepskin

with foam padding. Wrap limb restraint around wrist or ankle with soft part

toward skin and secure snugly in place by Velcro straps or buckle. Insert two

fingers under secured restraint

Mitten Restraint: Thu less itte de i e restrai s patie t’s hands. Place hands

in mitten, making sure Velcro straps are around wrist and not forearm

Elbow Restraint: Restraint consists of piece of fabric with slots in which you

place tongue blades. Insert patients arm so elbow joint rests against padded area

with tongue blades. Keeping joint rigid

Chapter 38

-Activity Tolerance: the type and amount of exercise or activity that the patient is able

to perform. Physiological, emotional and developmental factors influence the patie t’s

activity tolerance

-Isotonic contractions: cause muscle contraction and change the length of the muscle

-Activities such as walking, swimming, dance, aerobics, jogging, bicycling

-Increases muscle mass and strength

-Isometric Contractions: involve tightening or tensing muscles with out moving body


-Activities include quad set exercises and contraction of the gluteal muscles

-Ideal for patients ho do not tolerate increased activity

Joints: connection between bones

-Fibrous Joints: fit close together and are fixed and have little to no movement

-Cartilaginous Joints: Have little movement but are elastic and use cartilage to

unite separate body surfaces such as the ribs to the costal cartilage

-Synovial Joints: hinge type and are freely movable and the most mobile,

numerous, and anatomically complex

Ligaments: white shiny bands of fibrous tissue that bind joints and connect

bones and cartilage aid in flexibility and support

Tendons: white, glistening fibrous bands of tissue that connect muscle to bone

-Cartilage: avascular, supporting connective tissue with the flexibility of a firm,

plastic material. Sustains weight and serves as a shock absorber between

articulating bones

Influences on Body alignment and Mobility

-Congenital Defects: effect mobility in regards to alignment, balance, and appearance

-Osteogenisis: makes bones porous, results in curvature of spine, muscles

ligaments, and other soft tissues become shortened limiting mobility

-Disorders of Bones, Joints and muscles

-Osteoporosis reduces bone mass and density

-Osteomalacia: metabolic disease, delayed mineralization

-CNS Damage: any damage done to the CNS that regulates voluntary movement causes

impaired body alignment and immobility

-Musculoskeletal Trauma: results in bruises, contusions, sprains and fractures

Assessment of Activity/Exercise

-Nature of the Problem

-What type of problem are you having, what makes you think your activity is

inadequate, describe daily exercise, how long do you exercise

-Signs and Symptoms

-Do you experience muscular or joint pain after activity, SOB during activity, or

chest discomfort or pain during exercise or activity?

-Onset and Duration

-Which activities cause you to become SOB and how long does it take you to

have normal breathing

-Barriers to Exercise Activity

-Effect on Patient

Assess Mobility based on ROM, Gait, and exercises

Observe Patients Gait, Observe patient performing tasks such as feeding dressing or

recreational activities

Factors influencing Activity Tolerance

 Skeletal & Muscular Abnormalities or impairments

 Endocrine or metabolic illnesses

 Hypoxemia

 Decreased Cardiac Fxn

 Anxiety, Depression

 Chemical Addictions

 Motivation

 Age, Sex, Pregnancy


-To measure for correct crutch size: Crutches should be 4 finger lengths under

axilla so weight is on the hand and not the axilla

-Crutch Gait

-Regular stance is tripod: formed when the crutches are placed 15cm in front of

and 15 cm to the side of each foot

-Going up the stairs, use good foot first. Weight is placed on crutch, weight is

transferred from crutches to unaffected leg on stairs, and crutches are aligned

with unaffected leg on stairs

-Going down the stairs: affected foot first! Body weight is on unaffected leg,

body weight is transferred to crutches, and unaffected leg is aligned on stairs

with crutches

Chapter 39

Types of Baths:

- Complete Bed Bath: Bath administered totally dependent patient in


- Partial Bed Bath: Bed bath that consists of bathing only body parts

that would cause discomfort if left un-bathed such as the hands, face,

axillae, and perineal areal. Partial bath may also include washing back

and providing a back rub. Provide a partial bath to dependent

patients in need of partial hygiene or self-sufficient patients who are

unable to reach all of the body parts

- Sponge bath at the sink: involves bathing from a bath basin or sink

with patient sitting in the chair. Patient is able to perform part of the

bath independently. Assistance is needed for hard to reach areas

- Tub bath: Involves immersion in a tub of water that allows fore

thorough washing and rinsing than a bed bath. Patient may still
require the urse’s help.

- Shower: Patient sits or stands under a continuous stream of water

- Bag Bath, Travel Bath: Contains several soft, nonwoven cotton cloths

that are pre-moistened in a solution of no rinse surfactant cleanser

and emollient. The bag bath offers an alternative because of the ease

of use, reduced time bathing and patient comfort

Oral Hygiene:

-Offer oral care q2 hrs

-Aspiration precautions

-Have 2 nurses provide the care

- Turn patient toward you and put in semi-fowlers

-One nurse does actual cleaning while the other suctions

-Use something to open the mouth (padded tongue blade or airway)

-If caring for a patient with stomatitis, brush teeth softly and floss lightly to

prevent bleeding

Denture Care

- Ask about fit of dentures & patient preferences for care

- Fill emesis basin with tepid water

- Remove dentures

- Apply cleansing agent to brush and brush surfaces use back

and forth motions for cleaning the biting surface and use short

circular motions for cleaning the tops and underneath

- Place adhesive if patient wants it


- Moisten skin

- Pull skin taut and shave in the direction of hair growth


Chapter 47

-Factors influencing Mobility/Immobility

- Metabolic Changes:

o Immobility disrupts normal metabolic functioning

o Decreases metabolic rate altering the metabolism of carbohydrates, fats and

proteins; causing fluid, electrolyte, and calcium imbalances and causes GI

disturbances such as decreased appetite and slowing of peristalsis

o A deficiency in calories and protein is characteristic of patients with decreased

appetite d/t immobility

o When the patient is immobile the body excretes more nitrogen which ultimately

leads to decreased muscle mass, and weakness as a result of tissue catabolism

o Immobility also causes the release of calcium into the body. Normally the

kidneys excrete this calcium but if they are unable then hypercalcemia occurs.

Pathological fractures can occur as well along with difficulty passing stool and

bowel occlusion


 Give the immobilized patient a high protein, high calorie diet

 Ensure that they are taking a Vitamin B&C supplement aids in skin

integrity, wound healing and metabolism

- Respiratory Changes

o Patients who are immobile are at a high risk for developing pulmonary

complications such as atelectasis (collapse of alveoli) and hypostatic pneumonia

 Order Chest Physiotherapy

 Increase fluid intake to 1100-1400mL of non-caffeinated fluids

 Cough/Deep Breath

 IS

- Cardiovascular Changes
o Orthostatic Hypotension

o Thrombus

 Treatment: Prophylactic Heparin

 Anti-embolism Stockings & SCD’S

 Dangling At bedside

- Musculoskeletal Changes

o Include permanent or temporary impairment

o Disuse Osteoporosis

o Osteoporosis

o Joint Contractures

 Caused by disuse, atrophy and shortening of the muscle fibers

o Foot drop

 Treatment: ROM exercises

- Urinary Elimination Changes

o Hypercalcemia can occur

o Increased risk for bladder infection

o Urinary Output decreases

- Integumentary Changes

o Pressure Ulcers

 Treatment: proper turning and positioning of patient

-Range of Motion Exercises

- Neck, Cervical Spine

o Flexion: Bring Chin to rest on chest

o Extension: Return Head to erect position

o Hyperextension: Bend head back as far as possible

o Lateral Flexion: Tilt head as far as possible toward each shoulder

o Rotation: Turn head as far as possible in circular motion

- Shoulder

o Flexion: Raise arm form side position forward to position above head

o Extension: Return arm to position at side of body

o Hyperextension: Move arm behind body, keeping elbow straight

o Abduction: Raise arm to side to position above head with palm away from head

o Adduction: Lower arm sideways and across body as far as possible

o Internal Rotation: With elbow flexed, rotate shoulder by moving arm until thumb

is turned inward and toward back

o External Rotation: With elbow flexed, move arm until thumb is upward and

lateral to head

o Circumduction: move arm in full circle

- Elbow

o Flexion: Bend elbow o lower arm moves toward its shoulder joint and hand is

level with shoulder

o Extension: Return elbow by lowering hand

- Forearm

o Supination: Turn lower arm and hand so palm is up

o Pronation: turn lower arm so palm is down



-Measure ROM during exercise of extremities

-Observe the patient attempt to move one leg

-Ask about perception of pain

-Ask about endurance and activity tolerance

-Assess Skin using the Braden Scale


Supported Fowlers: 45-60 degrees with support under knee

Sims: Supported Prone





If patient is more than 200 lbs use 3 people



 Identify patie t’s per eptio of safety

 Identify the actual and potential threats to safety

 Determine the impact of the underlying illness on the patients safety

 Identify the presence of risks for the patients developmental stage


 Determine effect of enviro e tal i flue e o the patie t’s safety

Infection Prevention and Control

 Check Lab Results

 Identify any potential sites of infection (catheter, IV)

 Review current Meds

 Ask about Risk Factors such as current wounds and recent diagnostic testing

 Identify Stressors

Activity and Exercise Assessment

 Assess the patients body alignment, posture, and mobility

 Identify the effect of activity and exercise on the patients overall level of health

 Assess the patients routine exercise patterns

 Observe the patients body systems response to activity and exercise


 Observe the patients physical condition and integrity of integument, oral cavity

and sense organs

 Explore any developmental factors influencing the patients hygiene needs

 Note the patients self care ability and hygiene practices

 Determine the patients cultural preferences, values, and beliefs regarding


Mobility and Immobility

 Identify the effect of diagnosed diseases on the patients mobility

 Determine the effect of medication on the patients mobility status

 Assess for hazards of immobility in all body systems

 Assess psychosocial factors influenced by the patients immobility


Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (n.d.). Fundamentals of nursing.

Chapter 26

Communication between caregivers (pg.349)

 Common reports given by nurses include

o Change-of-shift reports

o Telephone reports

o Hand-off reports

o Incident reports

 Team members communicate information through discussions or conferences

 Consultations – one professional caregiver gives formal advice about the care of a

patient to another caregiver

 Nurses do u e t referrals, o sultatio s a d o fere es i a patie t’s per a e t

record to allow all caregivers to plan care accordingly.

 Why is interdisciplinary communication essential within the healthcare team?

Completing incident reports (pg.358)

 An incident or occurrence is any event that is not consistent with the routine operation
of a health care unit or routine care of a patient.

o Examples: patient falls, needle stick injuries, medication administration errors,


 Co ta t the patie t’s health care provider whenever an incident happens.

o Do ot e tio i ide t report i patie t’s edi al re ord.

o Document an objective description of what happened, what you observed, and

the follow-up a tio s take i the patie t’s edi al re ord

o Evaluate and docu e t patie t’s respo se to error or i ide t

 File the report with the appropriate risk-management department of the agency

 Overall goal is to identify changes need to prevent future recurrence.

Documenting care rendered (pg.350-353)

 Quality documentation and reporting have five important characteristics:

o Factual

 Contains descriptive, objective information – what the nurse sees, hears,

feels, and smells

 EX. B/P 8 /5 , patie t diaphoretic, heart rate a d regular

 A oid ter s su h as appears, see s, or appare tly

 EX. Instead of the patie t see s a ious  the patie t s heart

rate is elevated at 110 beats/min, respiratory rate is slightly

labored at 22 breaths/min, and the patient reports increased

restless ess

 Only subjective data included are what the patient says

 EX. Patie t state, I feel ver ervous

o Accurate

 Use exact measurements

 Avoid the use of unnecessary words and irrelevant detail.

 Use abbreviations carefully to avoid misinterpretation

 TJC requires that health care institutions develop a list of standard

abbreviations, symbols, and acronyms to be used by all members

of the health are tea …

 Correct spelling demonstrates and level of competency and attention to


 All entries in medical records must be dated

 Each entry ends with the aregi er’s full a e or i itials a d status

 EX. Ja e Woods, RN for a student nurse enter Your Na e, NS

o Complete

 Writte e tries i a patie t’s edi al re ord des ri e the ursi g are

you ad i ister a d the patie t’s respo se.

 View Table 26-2 (pg.352) Examples of Criteria for Reporting and


o Current

 Delays in documentation lead to unsafe patient care

 Document the following activities or findings at the time of occurrence:

 Vital signs

 Pain assessment

 Administration of medication and treatments

 Preparation for diagnostic tests or surgery, including pre-

operative checklists

 Cha ge i patie t’s status a d ho as otified

 Admission, transfer, discharge, or death of a patient

 Treat e t for sudde ha ge i patie t’s status

 Patie t’s respo se to treatment or intervention

 Most health care facilities use military time

o Organized

 Communicate information in a logical order

 To document complex situations in an organized fashion think about the

situation and make a list of what you need to include before beginning to

enter data in the medical record.

Legal considerations (pg.351)

View Table 26-1 Legal Guidelines for Recording


Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2004). Medical-surgical nursing:

Assessment and management of clinical problems. St. Louis: Mosby.

Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (n.d.). Fundamentals of nursing.

Upchurch, S. L., Henry, T., Pine, R., & Rickles, A. (n.d.). HESI comprehensive review for the

NCLEX-RN examination.

Zerwekh, J. G., & Claborn, J. C. (2010). Illustrated study guide for the NCLEX-RN exam. St.

Louis, MO: Mosby Elsevier.


CHAPTER 48 – Skin Integrity and Wound Care

A nurses most important responsibilities include assessing and monitoring skin integrity;

identifying problems; and planning; implementing, and evaluating interventions to

maintain skin integrity

Scientific Knowledge Base


The thin stratum corneum protects underlying cells and tissues from dehydration and

prevents entrance of certain chemical agents but allows for evaporation and absorption of

certain topical agents

The basal layer consists of cells that proliferate and divide and migrate toward the surface

The dermis provides tensile strength, mechanical support, and protection to the
underlying muscles, bones, and organs

Consists of fibroblasts

Pressure ulcers

Any patient experiencing decreased mobility, decreased sensory perception, fecal or

urinary incontinence, and or poor nutrition is at risk for pressure ulcer development

Pathogenesis of pressure ulcers

Pressure intensity

Tissue ischemia can occur if the vessel is occluded for a prolonged period of


Redness is caused by vasodilation called hyperemia

If skin blanches and erythema returns the tissue is trying to repair, if not deep

tissue damage is possible

Pressure duration

Tissue tolerance

Shear, friction, and moisture affect the ability of the skin to tolerate pressure

The ability of the underlying skin structures to assist in redistributing pressure

Poor nutrition, increased aging, hydration status, and low blood pressure affect
the tolerance of the tissue to externally applied force

Risk factors for pressure ulcer development

Impaired sensory perception - cannot feel pain or pressure

Impaired mobility

Alteration in LOC - confused or unable to communicate discomfort

Shear - sliding of skin and subcutaneous tissue; tissue damage occurs deeps

Friction - mechanical force; superficial injury



Classification of Pressure Ulcers

Assessment includes depth of tissue involvement, type and approximate percentage of

tissue in wound bed, wound dimensions, exudate description, and condition of

surrounding skin

Stage 1: Nonblanchable redness of intact skin

Intact skin, nonblanchable, discoloration of the skin, warmth, edema,

hardness, pain

Stage 2: Partial-thickness skin loss or blister

Partial-thickness loss of dermis, shallow open ulcer with a red-pink wound bed

without slough, may be intact or ruptured blister

Stage 3: full-thickness skin loss (fat visible)

Full-thickness tissue loss, fat may be visible, no bone/tendon/muscle, some

slough, undermining or tunneling

Stage 4: full-thickness tissue loss (muscle/bone visible)

Full-thickness tissue loss with exposed bone, muscle, tendon, slough or eschar,

includes undermining or tunneling

Unstagable/unclassified: full-thickness skin or tissue loss

- depth unknown

Full-thickness tissue loss in which actual depth of the ulcer is completely

obscured by slough or eschar

Stable eschar on the heels serves as "the natural cover of the body" and should

not be removed

Suspected deep-tissue injury- depth unknown

Purple/maroon localized area of discolored intact skin or blood-filled blister

caused by damage of underlying soft tissue from pressure and/or shear

Redness, warmth, maceration, or edema indicates

wound deterioration

Wound Classifications

A wound is a disruption of the integrity and function of tissues in the body

Wound classification systems describe the status of skin integrity, cause of the wound,

severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive

qualities of the wound tissue such as color

Process of wound healing

Surgical incision heals by

primary intention

, skin edges are


(closed), and the risk of infection is low

A burn, pressure ulcer, or severe laceration heal by

secondary intention

, wound

is open until filled by scar tissue


Wound repair

Partial thickness wounds heal by regeneration

Full thickness wounds heal by scar formation


Partial Thickness

Use: inflammatory response, epithelial proliferation, and migration, and

reestablishment of the epidermal layers

Epidermal cells only migrate across a moist surface

Full Thickness


Injured blood vessels constrict and platelets gather to stop bleeding

Clots from a fibrin matric that provide a framework for cellular repair


Damaged tissue and mast cells secrete histamine

Results in local redness, edema, warmth, and throbbing

Neutrophils ingest bacteria and small debris

Macrophages continue the process of clearing the wound of debris and

release growth factors that attract fibroblasts, the cells that synthesize



Filling of the wound with granulation tissue, contraction of the wound,

and the resurfacing of the wound by epithelialization

The wound contracts to reduce the area that requires healing

The vascular bed is reestablished, the area is filled with replacement

tissue, and the surface is repaired



Complications of wound healing

Hemorrhage: bleeding from a wound site


After hemostasis indicates a slipped surgical suture, a dislodged clot, infection,

or erosion of a blood vessel by a foreign object

Occurs externally or internally

Distension, hematoma, surgical drainage

Greatest risk of hemorrhage is during the first 24-48 hours after surgery or



A wound is infected if purulent material drains from it

Wounds with more than 100,000 organisms/gram of tissue are infected

Bacterial wound infection inhibits wound healing

Traumatic wounds show signs of infection 2-3 days

Surgical wounds show infection 4-5 days


The layers of skin and tissue separate

When there is an increase in serosanguineous drainage from a wound, be alert

for potential dehiscence

Splint the area


Protrusion of visceral organs through a wound opening

Requires surgical repair

Nursing Knowledge Base

Prediction and Prevention of Pressure Ulcers

Maintenance of skin integrity

Braden scale:

sensory perception, moisture, activity, mobility, nutrition, friction and


 The lower the number, the higher the risk

Factors Influencing Pressure Ulcer Formation and Wound Healing

Shear force, friction, moisture, nutrition, tissue perfusion, infection, and



Serum albumin is a biochemical indicator of malnutrition

Patients need to consume an adequate amount of calories, protein, vitamin C,

Vitamin A, Zinc, fluid. The roles of each of these are:

Calories: fuel for cell energy

Protein: fibroplasia (fibrous tissue), angiogenesis (blood vessels), collagen

formation, wound remodeling, and immune function

Poultry, fish, eggs, beef

Vitamin C: Collagen synthesis, capillary wall integrity, fibroblast function,

immunological function, antioxidant


Citrus fruits, tomatoes, potatoes, fortified fruit juice

Vitamin A: epithelialization, wound closure, inflammatory response,

angiogenesis, collagen formation, can reverse the effects of steroid or delayed

wound healing

Green leafy vegetables, spinach, broccoli, carrots, sweet potatoes, liver

Zinc: collagen formation, protein synthesis, cell membrane and host defense

Vegetables, meats, legumes

Fluid: essential fluid environment for all cell functions

Noncaffeine, nonalcoholic, without sugar, water is best

Tissue Perfusion

Oxygen requirements depend on the phase of wound healing


Wound infection prolongs the inflammatory phase, delays collagen synthesis,

prevents epithelialization and increases the production of proinflammatory


Psychosocial Impact of Wounds

Stress alters body's adaptive mechanisms

Nursing Process


Baseline and continual assessment data provide critical information about a patient's skin

integrity and the increased risk for pressure ulcer development

Focus on level of sensation, movement and continence

Through the Patients eyes

Know the patients expectations


When you note hyperemia, document the location, size, and color and reassess the

area after 1 hour

Pressure ulcers

Assess the patient's mobility, nutrition, presence of body fluids, and comfort level

Mobility: If a patient has some degree of mobility independence, reinforce the

frequency of position changes and measures to relieve pressure; Note the patients

activity tolerance

Nutritional status: A loss of 5% of usual weight, weight less than 90% of ideal body

weight, and a decrease of 10 pounds in a brief period are all signs of actual or
potential nutritional problems

Body fluids: Reduce contact with body fluids


Type: Abrasion, laceration, puncture



Observe whether the wound edges are closed

Note the amount, color, odor, and consistency of drainage


Assess the number of drains, drain placement, character of drainage, and condition

of collecting equipment

Observe the security of the drain and its location with respect to the wound


Risk for infection

Imbalanced nutrition: less than body requirements

Acute or chronic pain

Impaired physical mobility

Impaired skin integrity

Risk for impaired skin integrity

Ineffective peripheral tissue perfusion

Impaired tissue integrity


Goal and outcomes

Setting priorities

Stable or emergent?

Preventative interventions

Promotion of healing

Teamwork and collaboration

The nurse and patient work together to establish ways of maintaining patient

involvement in nursing care and promoting wound healing


Most effective is prevention

Skin care and management of incontinence


Mechanical loading and support devices; which include proper

positioning and the use of therapeutic surfaces



Ensure patients skin is clean and dry, and assessment is done daily

Make an effort to control, contain, or correct incontinence, perspiration,

or wound drainage

Thick moisture barrier to exposed areas

Positioning interventions reduce pressure and shearing forces to the


A support surface is a specialized device for pressure redistribution

designed for management of tissue loads, microclimate, and or other

therapeutic functions


Acute Care

Management of pressure ulcers

Reassess the wound for location, stage, size, tissue type and

amount, exudate, and surrounding skin condition

Wound management

Maintain a healthy wound: prevent and manage infection, clean the

wound, remove nonviable tissue, manage exudate, maintain the

wound in a moist environment, and protect the wound

A wound does not move through the phases of healing if it is


Cytotoxic solutions are not used to clean granulating wounds

Irrigation is a common method of delivering a wound-cleaning

solution to the wound

Debridement: removal of nonviable, necrotic tissue

Rids the wound of a source of infection, enable visualization of

the wound bed, and provide a clean base necessary for healing

Methods: mechanical (wet-to-dry, irrigation, whirlpool

treatments), autolytic (synthetic dressings [transparent film

and hydrocolloid dressings]), chemical (topical enzyme

preparation, darkin's solution, sterile maggots), and

sharp/surgical (scalpel, scissors, sharp instrument)

Excessive exudate provides an environment that supports bacterial
growth, macerates the periwound skin, and slows the healing


A moist environment supports the movement of epithelial cells and

facilitates wound closure

Nutrition is fundamental to normal cellular integrity and tissue


A patient can lose as much as 50 g of protein per day from an open

weeping pressure ulcer (daily need ~50g/day)

Increased protein intake helps rebuild epidermal tissue

Increased caloric intake helps replace subcutaneous tissue

A low hemoglobin level decreases delivery of oxygen to the tissues

and heads to further ischemia


First Aid for Wounds

Traumatic wound interventions include stabilizing cardiopulmonary

function, promoting hemostasis, cleaning the wound, and

protecting it from further injury

Hemostasis: apply pressure, bandages, and elevate

Cleaning: use saline to maintain the moist surface needed to
promote the development and migration of epithelial tissue


Purposes: protects a wound from microorganism contamination;

aids in hemostasis; promotes healing by absorbing drainage and

debriding a wound; supports or splits the wound site; protects

patients from seeing the wound; promotes thermal insulation of

the wound surface; provides a moist environment

Pressure dressings promote hemostasis

Dressings applied to a draining wound require frequent changing to

prevent microorganism growth and skin breakdown

****Different types of dressings

Chronic pressure ulcer wounds use a clean technique; fresh surgical

wounds require sterile technique so as not to introduce

microorganisms into a healing wound

The first step in packing a wound is to assess its size, depth, and


The entire surface of the wound needs to be in contact with the

packed dressing

A V.A.C. is a device that assists in wound closure by applying

localized negative pressure to draw the edges of a wound together

NPWT supports wound healing by edema reduction and fluid

removal, macro deformation and wound contraction, and micro

deformation and mechanical stretch perfusion

Secondary effects include angiogenesis, granulation tissue

formation, and reduction in bacterial bioburden

Use tape, ties, or a secondary dressing and cloth binders to secure a

dressing over a wound site; the choice of anchoring depends on the

wound size, location, presence of drainage, the frequency of

dressing changes and the patients level of activity


Common adhesive tape adheres to the surface of the skin;

elastic adhesive tape compresses closely around pressure

bandages and permits more movement of a body part

When applying tape, ensure that it adheres to several inches of

skin on both sides of the dressing and that it is placed across

the middle of the dressing

Remove parallel with the skin and toward the wound/

direction of hair growth

Cleaning Skin and Drain Sites

Requires aseptic technique

Clean from least to most contaminated

Suture Care

Threads or metal used to sew body tissues together

The patient's history of wound healing, the site of surgery, the

tissues involved, and the purpose of the sutures determine the

suture material used

Never pull the visible portion of a suture through underlying tissue

Drainage Evacuation

Convenient portable units that connect to tubular drains lying

within a wound bed and exert a safe, constant, low-pressure

vacuum to remove and collect drainage

Bandages and Binders

Binders and bandages applied over or around dressings provide

extra protection and therapeutic benefits

Creating pressure over a body part

Immobilizing a body part

Supporting a wound

Reducing or preventing edema

Securing a splint

Securing dressings

Assesses circulation, skin integrity, comfort level and body function

Rolls of bandage secure or support dressings over irregularly

shaped body parts


Heat and Cold Therapy

Heat is contraindicated in bleeding patients, localized inflammation

such as appendicitis, cardiovascular problems

Cold is contraindicated if the site already is edematous, patients

with impaired circulation, neuropathy patients, shivering patients

Before using these therapies you need to understand normal body

responses to local temperature variations, assess the integrity of

the body part, determine the patient's ability to sense temperature

variations and ensure proper operation of equipment

Body can handle between 15-45C

Heat Application

Improves blood flow

Cold Application

Diminishes swelling and pain


Moist/Dry - depend on the type of wound or injury, the location of

the body part, and the presence of drainage or inflammation

Warm/moist compress - improve circulation, relieve edema,

promote consolidation or purulent drainage

Warm soaks - promotes circulation, lessens edema, increases

muscle relaxation, provides a means to apply medicated solution

Sitz baths - the patient who has had rectal surgery, an episiotomy

during childbirth, painful hemorrhoids, vaginal inflammation -

pelvic immersion

Commercial hot packs - disposable

Cold/moist/dry compresses - relieves inflammation and swelling

Cold soaks

Ice bags/collars - patient with muscle sprain, localized hemorrhage,

hematoma, or has undergone dental surgery - ideal to prevent

edema formation, control bleeding, and anesthetize the body part


Determine the patients response to nursing therapies and whether he or she achieved
each goal


The optimal outcomes are to prevent injury to the skin and tissues, reduce injury to the

skin and underlying tissues, and possible wound healing with restoration of skin integrity

Develop plan of care to provide education and support depending on how pt. feels

Evaluate need for additional referrals to other experts


Granulation tissue- is red, moist tissue composed of new blood vessels - progression

toward healing

Slough- soft yellow and white tissue

Eschar- black or brown necrotic tissue

Exudate- describe the color, amount, consistency, and odor of the drainage



- 30-degree lateral position

- Use only noncytotoxic agents to clean ulcers

- In some settings aspects of wound care such as changing dressing using clean technique

for chronic wounds are delegated

- Black foam has larger pores and is more effective in stimulating granulation tissue and

wound contraction; white foam is denser with smaller pores and is used when growth of

granulation tissue needs to be restricted

- Irrigate with 19 gage 35 mL

- The skill of applying an abdominal binder can be delegate to nursing assistive personnel

Observe patients ability to breathe deeply and cough

- The skill of applying an elastic bandage can be delegated to NAP

- Apply bandages to lower extremities before patient sits or stands; elevate dependent

extremities for 20 min before bandage application to enhance venous return

- Bandage is applied in manner that conforms evenly to body part and promotes venous



CHAPTER 31 – Medication Administration

Nurses play an essential role in safe medication preparation, administration, and

evaluation of medication effects

Nurses are responsible for evaluating the effects of medications on the patient's ongoing

health status, teaching them about their medications and side effects, ensuring adherence

to the medication regiment, and evaluating the patient's and family caregiver's ability to


Scientific Knowledge Base

Medication Legislation and Standards

Federal Regulations

Regulates the pharmaceutical industry to protect the health of the people

Pure food and drug act was the first American law to regulate medications

Free of impure products

Legislation has set standards related to safety, potency, and efficacy

Enforcement of medication laws currently rests with the FDA

Official publications set standards for medication strength, quality, purity, packaging,

safety, labeling, and dose form

MedWatch encourages nurses and other health care professionals to report when a

medication, product, or medical event causes serious harm to a patient

State and Local Regulation of Medication

Conform to federal legislation

Local governmental bodies regulate the use of alcohol and tobacco

Health care institutions and Medication Laws

Establish individual policies to meet federal, state, and local regulations

Ex) automatic discontinuation of narcotics after a set number of days

Medication Regulations and Nursing Practice

Nurse Practice Acts have the most influence over nursing practice by defining the

scope of nurses' professional functions and responsibilities

The primary intent of NPA's is to protect the public from unskilled, undereducated,
and unlicensed personnel

Violations of the Controlled Substances Act are punishable by fines, imprisonment,

and loss of nurse licensure

Pharmacological Concepts

Medication Names

The chemical name of a medication provides an exact description of its composition

and molecular structure

Generic/nonproprietary name

- ex. Acetaminophen, given by the manufacturer


Trade name/brand name/proprietary name- how the manufacturer markets the




Indicates the effect of the medication on a body system, the symptoms the

medication relieves, or its desired effect

Medication Forms

The form of the medication determines its route of administration

The composition of a medication enhances its absorption and metabolism

Pharmacokinetics as the Basis of Medication Actions

The study of how medications every the body, reach their site of action, metabolize, and

exit the body


: the passage of medication molecules into the blood from the site of

medication administration

Route of Administration

Topical, mucous membranes, oral, IV

Ability of the medication to dissolve

Depends on form or preparation

Liquids are faster than tablets

Acidic is faster than basic

Blood flow to the side of administration

Body surface area

Lipid solubility

Highly lipid-soluble medications cross cell membranes easily and are absorbed


Food in the stomach affects absorption - some need to be given with food,

without, in-between meals

Can they be given with other medications? - may affect absorption


: it is distributed within the body to tissues and organs and ultimately to its

specific site of action


Membrane permeability

Refers to the ability of the medication to pass through tissues and membranes

to enter target cells

To be distributed to an organ, a medication has to pass through all of the

tissues and biological membranes of the organ

Some membranes serve as barriers to the passage of medication

BBB - allows only fat-soluble medication to pass into the brain and cerebral

spinal fluid

Placental membrane also has a nonselective barrier to medications

Protein Binding

Most medications partially bind to albumin

The unbound or "free" medication is its active form



Biotransformation occurs under the influence of enzymes that detoxify, break down,

and remove biologically active chemicals

Most biotransformation happens in the liver however the lungs, kidneys, blood and

intestines also metabolize medications


: exit through the kidneys, liver, bowel, lungs, and exocrine glands

Maintenance of adequate fluid intake promotes proper elimination of medications

for the average adult

Types of Medication Action

Therapeutic Effects:

expected or predicted physiological response that a medication


Side effects/Adverse effects

Side effects: predictable and often unavoidable secondary effects produced at a

usual therapeutic dose

Adverse effects: unintended, undesirable, and often unpredictable severe responses

to medication

Toxic effects: develop after prolonged intake of a medication or when a medication

accumulates in the blood because of impair metabolism or excretion

Idiosyncratic reactions: unpredictable effects in which a patient overreacts or

underreacts to a medication or has a reaction different from normal

Allergic reactions: unpredictable response, the medication or chemical acts as an

antigen, triggering the release of the antibodies in the body

Anaphylactic reactions: sudden constriction of bronchiolar muscles, edema of

the pharynx and larynx, and sever wheezing and shortness of breath

Medication Interactions

When one medication modifies the action of another

Common in individuals taking several medications

Synergistic effect: combination effect is greater than the effect of the medications given


Timing of medication dose responses

The minimum effective concentration is the plasma level of a medication below which the
effect of the medication does not occur

Goal is between MEC and toxic levels

Peak highest, trough lowest

Trough is drawn 30 min prior to administration

Biological half-life: the time it takes for excretion to lower the amount of unchanged

medication by half

Medications are time-critical (30 min before/after) or non-time-critical (1-2 hrs.



Routes of Administration


- easiest and most commonly used, slower onset of action and a more prolonged

effect than parenteral medications

Sublingual administration: should not be swallowed

Buccal administration: alternate cheeks with subsequent doses , do not chew or


Parenteral Routes





Additional routes: epidural (regional analgesia), intrathecal (long term), intraosseous

(infants, toddlers), intraperitoneal (chemotherapeutic, insulin, antibiotics),

intrapleural (chemotherapeutic, pleural effusion), intraarterial (arterial clots),

intracardiac (cardiac tissue), intraarticular (joints)

Nurses remain responsible for monitory the integrity of the medication delivery

system, understanding the therapeutic value of the medication, and evaluating the

patient's response to the therapy

Topical Administration

Local effects

Painting or spreading the medications over an area, applying moist dressings,

soaking body parts in a solution, or giving medicated baths

Transdermal disk or patch has systemic effects

Directly applying liquid or ointment

Inserting a medication into a body cavity

Instilling fluid into a body cavity

Irrigating a body cavity

Spraying a medication into a body cavity

Inhalation Route

The deeper passages of the respiratory tract provide a large surface area for

medication absorption

Quick local or systemic effects

Intraocular Route

Prescribers Role

Prescribers medications by writing an order on a form in the patient's medical record

Read backs's must be countersigned within 24 hours

Do not use abbreviations when documenting medication orders or other information

about medications

Types of Orders in Acute Care Agencies

Standing orders or routine medication orders: carried out until the prescriber cancels it

by another order or a prescribed number of days elapse


Prn orders: when administering medications, document the assessment finding that show

why the patient needs the medication and the time of administration

Single (One-Time) orders

STAT orders: a single dose of a medication is to be given immediately and only once

RN has up to 90 minutes

Now Orders: more specific than a one-time order and is used when a patient needs a

medication quickly but not right away, as in a STAT order; the nurse has up to 90 min

Prescriptions: take medications outside the hospital

Pharmacist's Role

Prepares and distributes prescribed medications

Responsible for filling prescriptions accurately and being sure that prescriptions are valid

Dispensing the correct medication, in the proper dose and amount, with an accurate label

is the pharmacist's main task

Also provide information about medication side effects, toxicity, interactions, and


Distribution Systems

Unit dose: 24- hour supply of medications for each patient excluding controlled


Automated medication dispensing systems

Nurse's Role

Medication ordered is correct

Assess the patient's ability to self-administer

Determine whether a patient should receive a medication


Monitor effects


Do not delegate medication administration

Medication Errors

Inaccurate prescribing, administering the wrong medication, giving the medication using

the wrong route or time interval, administering extra doses or failing to administer a


When an error occurs the nurse first assesses and examines the patient's condition and

notifies the health care provider of the incident as soon as possible

Report all medication errors, including those that do not cause obvious or immediate

harm or near misses

Medication reconciliation

Nurses need to consult with the patient, caregivers, family members, pharmacists, and

other members of the health care team when reconciling medications


Critical Thinking


Nurses need to acquire the knowledge needed to safely administer unfamiliar



Psychomotor skills represent a small part of medication administration; patient attitudes,

knowledge, physical and mental status, and responses make medication administration



Follow the same procedure each time

Be disciplined, responsible, accountable

Standards: ensure safe nursing practice

Right medication

Right dose

Right patient

Right route

The injection of a liquid designed for oral use produces local complications such as

sterile abscess or fatal systemic effects

Right time

Right documentation

Required to document any preassessment data

Maintaining patients' rights

To be informed of the name, purpose, action, and potential undesired effects of a


To refuse a medication regardless of the consequences

To have qualified nurses or physicians assess a medication history, including allergies

and use of herbals

To be properly advised of the experimental nature of medication and give written


To receive labeled medications safely without discomfort in accordance with the six

rights of medication administration

To receive appropriate supportive therapy in relation to medication therapy

To not receive unnecessary medication


To be informed if medications are a part of a research study

Nursing Process


Through the patient's eyes

Take the patients preferences, values and needs into consideration

Encourage them to express their beliefs, feelings, and concerns about their




Indications or contraindications for medication therapy



Length of time the medication has been taken, current dosage, and whether or not

the patient experiences side effects

Diet History

Teach which medications are to be given with food

Patients perceptual or coordination problems

Patients current condition

Assessment finding serve as a baseline in evaluating the effects of medication


Patients attitude about medication use

Level of medication dependence or drug avoidance

Patients understanding of and adherence to medication therapy

Patients knowledge and understanding of medication therapy influence the

willingness or ability to follow a medication regimen

Patients learning needs



Ineffective health maintenance

Readiness for enhanced immunization status

Deficient knowledge (medications)

Noncompliance (medications)

Disturbed visual sensory perception

Impaired swallowing

Effective therapeutic regiment management


Goals and outcomes

Setting priorities

Teamwork and collaboration


Health promotion

Health beliefs, personal motivations, socioeconomic factors, and habits

influence the patient's adherence with medications


Teach the patient the benefits, help establish a routine, make

community referrals, teach how to administer, teach the symptoms or

side effects or toxicity

Acute Care

Receiving, transcribing, and communicating medication orders

Nurses take patients' current problems, treatments, laboratory

values, and other prescribed medications into consideration to

determine if the ordered medication is safe and appropriate

Includes: patient's name, room, and bed number, medical record

number, medical and food allergies, other patient identifiers,

medication name, dose, frequency, and route and time of


Accurate dose calculation and measurement

Correct administration

Recording medication administration

Explain why medications weren't given in the nurses notes

Restorative care

The nurse is responsible for instructing patients and families in

medication action, administration, and side effects; the nurse is also

responsible for monitoring compliance with medication and determining

the effectiveness

Special Considerations for Administering medications to specific


Have another nurse verify all pediatric dose calculations


Polypharmacy: when a patient takes two or more medications to treat

the same illness , takes two or more medications from the same

chemical class, uses two or more medications with the same or similar

actions to treat several disorders simultaneously, or mixes nutritional

supplements or herbal products with medications


Through the patient's eyes

Evaluation is more effective when you value your patients participation

Ask patients to describe effectiveness

Patient outcomes

Compare expected outcomes with findings


Medication Administration

Oral Administration

Food delays stomach emptying which may decrease therapeutic effects of oral


Most are 30 min to 1 hour before a meal

Protect from aspiration- something enters the respiratory tract that was meant for the GI

Proper positioning

Topical Medication Applications

Skin applications

Apply using gloves and applicators

Ensure safe administration of transdermal patches

Nasal instillation

Overuse can lead to a rebound effect in which the nasal congestion worsens

Eye instillation

Intraocular administration

May remain for 1 week

Ear instillation

Instill at room temperature

Vertigo, dizziness, nausea

Never occlude the ear canal

Vaginal instillation

Rectal instillation

Thinner and more bullet-shaped than vaginal suppositories

Can cause systemic effects

Administering Medications by Inhalation

Pressurized metered-dose inhalers (pressure), breath-actuated metered dose inhalers

(inhalation force), dry powder inhalers (breath)

Administering Medications by Irrigations

Sterile water, saline, antiseptic solutions (used for break in mucosa/skin)

Parenteral Administration of Medications



1-3 mL - sub- Q or IM

Teberculin syringe is useful when preparing small, precise doses


Hub, the shaft, the bevel

Disposable injection units


Preparing an injection from an Ampule

Single doses

Preparing an injection from a Vial

Closed system

Mixing Medications

Mixing medications from a vial and an ampule

Vial -> ampule

Mixing medications from two vials

Do not contaminate one medication with another

Ensure that the final dose is accurate

Maintain aseptic technique

Insulin Preparation

Verify the dose

Insulin is classified by rate of action, including rapid, short, intermediate, and long

*Need to know onset, peak and duration

Patients whose blood glucose levels are well controlled on a mixed-insulin dose

need to maintain their individual routine when preparing and administering their


Do not mix insulin with any other medications or diluents unless approved by the


Never mix insulin glargine or insulin determir with other types

Inject rapid-acting insulin's mixed with NPH insulin within 15 min before a meal

Verify insulin doses with another nurse while preparing them

Administering Injections

The characteristics of the tissues influence the rate of medication absorption and thus the

onset of medication action

Minimize the patients discomfort

Use a sharp-beveled needle in the smallest length and gauge

Proper injection site

Topical anesthetic

Divert the patients attention

Insert quickly and smoothly

Hold steady

Inject medication slowly and steadily

Subcutaneous injections

Outer posterior aspect of the upper arms, abdomen from below the costal margins

to the iliac crests, anterior aspects of the thighs, scapular areas, upper back and

upper ventral or dorsal gluteal areas

Injection site chosen needs to be free of skin lesions, bony prominences and larger

underlying muscles or nerves

The rate of insulin absorption varies based on the site; the abdomen has the

quickest, followed by the arms, thighs and buttocks

25-gauge, 5/8 inch needles inserted at a 45 degree

1/2 in needle inserted at a 90 degree

Pinch 1 inch - 45; pinch 2 inch 90

Intramuscular Injections

A normal, well-developed adult patient tolerates 2-5 mL of medication into a larger

muscles without severe muscle discomfort

Do not give more than 1 mL to smaller children




Vastus lateralis


Z-track method is used to minimize local skin irritation by sealing the medication in

muscle tissue

The needle remains inserted for 10 seconds to allow the medication to

disperse evenly rather than channeling back up the track of the needle

Intradermal Injections

Skin testing requires that the nurse be able to clearly see the injection sites for

changes in color and tissue integrity

The inner forearm and upper back are ideal locations

Bleb needs to be present

Safety in Administering Medications by Injections

Needle stick injuries commonly occur when health care workers recap needles,

mishandle IV lines and needs, or leave needles at a patient's bedside

Intravenous Administration

As mixtures within large volumes of IV fluids

Safest and easiest

By injection of a bolus or small volume of medication through and existing IV

infusion line or intermittent venous access (heparin or saline lock)

Most dangerous because there is no time to correct errors


By piggyback infusion of a solution containing the prescribed medication and a small

volume of IV fluid through and existing IV line

There is a danger with continuous infusion: if the IV fluid is infused too rapidly, the

patient is at risk for medication overdose and circulatory fluid overload

Check the site frequently for infiltration and phlebitis

Volume Controlled infusions

Reduces risk of rapid-dose infusion by IV push

Allows for administration of medications that are stable for a limited time in a


Allows for control of IV fluid intake

Intermittent Venous Access

Saline lock

Always assess for patency before beginning medication, and flushed afterward



- Caution patient against chewing or swallowing lozenges

Medication acts through slow absorption through oral mucosa, not gastric


- Give effervescent powders and tablets immediately after dissolving

Effervescence improves unpleasant taste and often relieves GI problems

- For highly acidic medications offer patient nonfat snack (crackers)

Reduces gastric irritation

- Eye drops are given at room temperature

Reduces irritation

- When administering medications that cause systemic effects, apply gentle pressure with

your finger and clean tissue on the patient’s nasolacrimal duct for 30-60 seconds

Prevents overflow of medication into nasal and pharyngeal passages

Prevents absorption into systemic circulation

- If patient is using an MDI with or without a spacer and the inhaler is new or has not

been used for several days, push a test spray into the air. You do not need to do this

for a DPI

- Use a three-point or lateral hand position when using an inhaler

- Always give bronchodilators before steroids

First inhalation opens airways

Second or third inhalation reduces inflammation and/or penetrates deeper


- Rinse mouth to reduce the risk of fungal infection


- Never administer IV medications through tubing that is infusing blood, blood

products, or parenteral nutrition solutions

Tables and Boxes

Chapter 31

Uticaria: raised, irregularly shaped skin eruptions with varying sizes and shapes;

eruptions have reddened margins and pale centers

Rash: small, raised vesicles that are usually reddened; often distributed over entire body

Pruritus: itching of skin; accompanies most rashes

Rhinitis: inflammation of mucous membranes lining nose; causes swelling and clear,
watery discharge


CHAPTER 41 – Fluid, Electrolyte, and Acid-Base Balance


- Age: very young and old at risk

- Environment: excessively hot?

- Dietary intake: fluids, salt, foods rich in potassium, calcium, and magnesium

- Lifestyle: alcohol intake history

- Medications: include over-the-counter (OTC) and herbal, in addition to prescription


- Medical history

Recent surgery (physiological stress)

Gastrointestinal output

Acute illness or trauma

 Respiratory disorders

 Burns

 Trauma

Chronic illness

 Cancer

 Heart failure

 Oliguric renal disease

Nursing Diagnosis

Decreased cardiac output

Acute confusion

Risk for electrolyte imbalance

Deficient fluid volume

Excess fluid volume

Impaired gas exchange

Risk for injury

Deficient knowledge regarding disease management

Impaired oral mucous membrane

Impaired skin integrity

Ineffective tissue perfusion


Goals and outcomes

Set priorities

Teamwork and collaboration

DO NOT delegate administration of IV fluid and hemodynamic assessment to NAP


When the patient is stable you can delegate daily weight's, I&O, and direct physical

care to NAP



Health promotion

Focuses primarily on patient education

Replace with sodium-containing fluid and water

Acute care

Enteral replacement of fluids

Obstruction of the GI tract, is at high risk for aspiration, or has impaired


Liquids containing lactose, caffeine, or low-sodium content are not appropriate

when a pt. has diarrhea

Restriction of fluids

Need frequent mouth care

Parenteral replacement of fluids and electrolytes

Parenteral nutrition, IV fluid, electrolyte therapy (crystalloids), blood, and

blood component (colloids) administration

Intravenous Therapy


- the same effective osmolality as body fluids


- effective osmolality less than body fluids, thus decreasing

osmolality by diluting body fluids and moving water into cells


- effective osmolality greater than body fluids, pulls water out of


Potassium should never be given by a push

Vascular Access Devices

Designed for repeated access

Central lines require monitoring, flushing and site care dressing changes

Sterile technique is necessary

Initiating the Intravenous Line

Assess the patient for venipuncture site

Contraindicated in sites with signs of infection, infiltration, or thrombosis

Infected site is red, tender, swollen , and possibly warm , exudate may be


Avoid the same side as a dialysis or mastectomy

Choose the most distal

Regulating the Infusion Flow Rate

Infusion rate insures patient safety


Infiltration, vasospasm, a knot or kink in the tubing. External pressure on the

tubing, and position changes of the person's extremity can cause slowing of

the IV rate

Before discontinuing a site start a new one to verify that the patient has other

accessible vein

Maintaining the system

Keeping the system sterile and intact

Changing the IV fluid, containers, tubing, and contaminated site dressings

Assisting a patient with self-care activities so as not to disrupt the systems

Monitoring for complications of IV therapy

Maintain integrity to prevent infection

Never let the IV tubing touch the floor

Changing Intravenous Fluid containers, tubing, and dressings

Change continuous infusions tubing every 96 hours

Intermittent is every 24 hours

Complications of Intravenous Therapy

Circulatory overload

Infiltration occurs when the IV becomes dislodged or a vein ruptures and IV

fluids inadvertently enter subcutaneous tissue around the venipuncture site

Extravasation is when IV fluid contains additives

Both cause coolness, paleness, swelling

Phlebitis is cause by chemicals, bacteria, or mechanical

Discontinuing Peripheral Intravenous Access

Moving from IV to oral is a sign of progress

Blood Transfusion

Increasing circulating blood volume after surgery, trauma, or hemorrhage

Increased the number of RBC's and maintaining hemoglobin levels in patients

with severe anemia

Providing selected cellular components as replacement therapy

Most important grouping is ABO

Autologous transfusion is the collection and reinfusion of a patient's own blood

Pretransfusion assessment: have they had a transfusion, have they had a

reaction, do they know why they are having a transfusion


The blood delivered is the one ordered


Patient receives

Stay with the patient for the first 15 min

Bacteria can cause sepsis especially gram –

Interventions for Electrolyte Imbalances

Patients with hypercalcemia need more fluid to prevent renal damage

Interventions for Acid-Base Imbalances

Support compensatory hyperventilation for patients with metabolic acidosis by

keeping their oral mucous membranes moist and positioning them to facilitate

chest expansion

ABG reveals acid-base status and the adequacy of ventilation and oxygenation

Submerge in ice to reduce oxygen usage by blood cells

Restorative care

Home intravenous therapy

IV therapy nurse works closely with the patient to ensure that a sterile IV

system is maintained and complications can be avoided

Nutritional support

Patients with electrolyte disorders or metabolic acid-base imbalances

Medication safety

Patient and family education regarding potential side effects and drug

interactions that can alter fluid, electrolyte, or acid-base balance is essential

Encourage to consult with pharmacist if they would like to add more OTC drugs


Through the patients eyes

Review with patients how well their major concerns regarding fluid, electrolyte, or

acid-base situations were alleviated or addressed

Patient outcomes

Evaluate effectiveness of interventions using goals and outcomes

Knowledge of how various pathophysiological conditions affect fluid, electrolyte,

and acid-base balance; the effects of medications and fluids; and the patient's

presenting clinical status aid in evaluation

The patients level of progress determines whether the plan of care needs to

continue or be revised



- Daily weight reflects fluid retention or loss

One liter = 2.2lb = 1 kg

- Decreased BP = ECV deficit

- Rapid, thread pulse = ECV deficit

- Average daily urine output is 1500 mL


Oliguria is urine output of less than 400 mL/day

- Methods to foster venous distention:

Stroking extremity from distal to proximal below proposed venipuncture site

Applying warmth to extremity

Placing in dependent position

- If hair removal is needed, do not shave area with a razor, shaving may cause

microabrasions that increase risk of infection

- Do not apply tape over the catheter insertion site, over the connection between the

tubing or port and the IV catheter hub, or on top of the transparent dressing

- KVO rate prevents catheter clotting, thus preserving venous access while infusing a

minimal amount of fluid

- Prepare to change solution when about 50 mL of fluid remains

- Keep one finger stabilizing VAD at all times until dressing is applied

Tables and Boxes

Chapter 41

- Fluid: water that contains dissolved or suspended substances such as glucose, mineral

salts, and proteins

- Fluid amount: volume

- Fluid concentration:


– measure of the number of particles per kilogram of

- Fluid composition: electrolyte concentration

- Degree of acidity: pH

- Intracellular – inside the cells

- Extracellular – outside

Intravascular – liquid portion of the blood

Interstitial – between the cells and outside the blood vessels

- Active transport: movement of ions against osmotic pressure to an area of higher

pressure; requires energy

- Diffusion: passive movement of electrolytes or other particles down the concentration


High to low

- Osmosis: movement of water from an area of lesser to one of greater concentration

Osmotic pressure: inward-pulling force caused by particles in the fluid

- Filtration: movement across a membrane, under pressure, from higher to lower


Hydrostatic pressure: force of the fluid pressing outward against a surface –

outward pushing

Oncotic pressure is an inward pulling force cause by blood proteins that helps

move fluid from the interstitial area back into capillaries


- Hormonal influences

ADH: stimulates thirst center to decrease BOP

Renin-angiotensin-aldosterone mechanism: increases BOP

Atrial natriuretic peptides

- Hypernatremia – water deficit

- Hyponatremia – water excess

Insulin 5ml= tsp, 30ml=1oz=2tbs


- Onset: 10-30 min

- Peak: 30min-3hrs

- Duration: 3-5hrs

Short acting

- Onset: 30min- 1hr

- Peak: 2-5hrs

- Durations: 5-8hr


Intermediate acting

- Onset: 1.5-4hrs

- Peak: 4-12hrs

- Duration: 12-18hr


- Onset: 0.8-4hr

- Peak: no pronounced peak

- Duration: 24+ hrs.

Albumin 3.4-5 g/dL

Glucose 70-110 mg/dL

Hemoglobin A1c >7 is poor diabetic control

Potassium 3.5-5.0 mEq/L

Sodium 135-145 mEq/L

Chloride 98-107 mEq/L

Magnesium 1.6-2.6 mg/dL

Calcium 8.6-10mg/dL



Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (n.d.). Fundamentals of nursing.

Exam 3 Study Guide PNP

Nutrition- Chapter 44

 Nutrition is essential for normal growth and development, tissue maintenance and

repair, cellular metabolism, and organ function

 Food security is critical for all members of a household

o People living in a household have access to sufficient, safe, and nutritious food

 Food has a symbolic meaning

o Giving or taking food is part of ceremonies, social gatherings, holiday traditions,

religious events, the celebration of births, and the mourning of deaths

o Can be difficult to withdrawal food in terminal events

 Medical nutritional therapy and counseling used to manage diseases

o Type I diabetes mellitus

o Mild hypertension

 Major treatment for these

o Severe inflammatory bowel disease- Ch o ’s Disease a d Ul e ati e Colitis

 Supported with either enteral nutrition or parenteral nutrition

 Care standards promote optimal nutrition in ALL ill patients

 Healthy people 2020

o Guideline for dietary change recommend reduced fat, saturated fat, sodium,

refined sugar, and cholesterol, and increased intake of complex carbohydrates

and fiber
o Baseline data should be gathered for each patient to measure progress

o Biggest challenge is to motivate consumers to follow these guidelines

 The Biochemical Units of Nutrition

o Basal metabolic rate (BMR)- the energy needed to maintain life-sustaining

activities (breathing, circulation, heart rate, and temperature) for a specific

period of time at rest

 Factors that influence BMR:

 Age and gender

 Body mass

 Fever

 Starvation

 Menstruation

 Illness

 Injury

 Infection

 Activity level

 Thyroid function

o Resting energy expenditure (REE) (Resting metabolic rate)- the amount of energy

that an individual needs to consume over a 24-hour period for the body to

maintain all of its internal working activities while at rest

 Factors that influence REE:

 Illness

 Pregnancy

 Lactation

 Activity level

o Kilocalorie intake

 When needs are met weight does not change

 Needs exceeded leads to weight gain

 Needs are not met leads to weight loss

o Nutrients are the elements necessary for the normal function of body processes

 Nutrient density- proportion of essential nutrients to the number of


 High-nutrient dense foods

 Fruits and vegies

 Low-nutrient dense foods

 Alcohol or sugar

o Carbohydrates

 Complex and simple saccharides

 Main source of energy

 Fuels the brain, skeletal muscles during exercise, erythrocytes and

leukocyte production, and cell function of the renal medulla

 4K cals/gram

 Obtained primarily from plant foods, except for lactose which is obtained

in milk

 Monosaccharides and disaccharides are both considered simple


 Glucose (dextrose) and fructose

 Sucrose, lactose, and maltose

 Polysaccharides are complex carbs

 Glycogen

 Starches

 Fiber are polysaccharides that cannot be digested

 Cellulose, hemicellulose, and lignin- insoluble fibers

 Soluble fibers dissolve in water

 Barley

 Cereal grains
 Cornmeal and oats

o Proteins

 Provide energy source

 Made of amino acids

 4K cals/gram

 Important in growth, maintenance, and repair

 Examples


 Also important in blood clotting, fluid regulation, and acid-base balance

 Ingestion of proteins maintains nitrogen balance

 Indispensable amino acids- not made naturally and must be provided by


 Histidine, lysine, and phenylalanine

 Dispensable amino acids- made naturally by the body

 Alanine, asparagine, and glutamic acid

 High-quality protein contains all essential amino acids

 Fish

 Chicken

 Soybeans

 Turkey

 Cheese

 Incomplete-proteins are missing at least 1 amino acids

 Cereals

 Legumes

 Vegetables

 Complementary proteins- combining 2 incomplete to make a complete


 Nitrogen balance occurs when intake and outtake of protein are equal
 Positive nitrogen balance is required for growth, pregnancy,

maintenance of lean muscle mass and vital organs, and wound


o Uses nitrogen to build, repair, and replace body tissues

 Negative nitrogen balance occurs with infections, burns, fever,

starvation, head injury, and trauma

o Results in tissue destruction or loss of nitrogen-containing

body fluids

o Nutrition during this period should promote the reversal of

negative nitrogen balance

 Protein is used as the energy source if carbs are not available

o Fats

 Calorie-dense

 9 kcal/grams

 Triglycerides- circulate in blood

 Fatty acids

 Saturated- carbon chain has two attached hydrogen atoms

 Unsaturated- unequal number of hydrogen atoms are attached

and the carbon atoms attach to each other and form double


 Monounsaturated- One double bond

 Polyunsaturated- Two or more double carbon bonds

 Essential or nonessential

 Linoleic acid is ONLY essential fatty acid in humans

 Linoleic and arachidonic acids are important in metabolism

 Deficiency occurs when fat intake falls below 10%

 Animal products have high proportions of saturated fatty acids

 Vegetables have higher amounts of unsaturated and polyunsaturated

fatty acids

o Water

 Cell function depends on fluid environment

 Total body water is greater for lean people

 Infants have the greatest percentage of total body water

 Old people have the least

 Fresh fruits and vegetables have high water content

 Used during digestion

 Healthy people have equal intake and output

 Ill people need increased fluids, but some also has a decreased ability to

excrete fluids which can end up leading to fluid

o Vitamins

 Organic substances present in small amounts in food

 Essential for metabolism

 Catalysts in biochemical reactions

 Too much of a vitamin can be toxic

 Some vitamins are antioxidants

 Neutralize free radicals which produce oxidative damage to cells

and tissues

 It is believed that oxidative damage increases the risk for cancer

 Betacarotene, A, C, and E

 Bod a ’t s thesize ita i s i the e ui ed a ou ts

 Highest vitamin content usually in fresh foods

 Fat-Soluble Vitamins

 A, D, E, and K

 Stored in fat compartments of the body with the exception of D

 Hypervitaminosis results from megadoses (intentional or

o Excessive intake of supplemental vitamins

o Excessive amount of fortified food

o Large intake of fish oils

 Water-Soluble Vitamins

 C and B

 Bod does ’t sto e these

 Easily absorbed from GI tract

 Toxicity can still occur

 Minerals

 Inorganic elements essential to the body as catalysts for

enzymatic reactions

 Macrominerals- more than 100mg needed per day

o Help balance pH

o Some needed in blood and cells to promote acid-base


 Trace elements- less than 100mg needed per day

o Interaction can occur (excess of one trace mineral can

cause deficit of another)

 Silicon, vanadium, nickel, tin, cadmium, arsenic, aluminum, and

boron play unidentified rolls

 Arsenic, aluminum, and cadmium have toxic effects

 Anatomy and physiology

o Salivary glands- saliva moistens and lubricates food. Amylase digest carbs

specifically starch- START OF DIGESTION

o Mouth- breaks up food particles and assists in producing spoken language

o Pharynx- Swallows

o Esophagus- Transports food

o Gallbladder- Stores and concentrates bile

o Liver- Breaks down and builds up many biological molecules, stores vitamins and

iron, destroys old blood cells, destroys poisons, and produces bile to aid


o Stomach- stores and churns food, HCl activates enzymes, breaks up food kills

germs, mucus protects stomach wall, has limited absorption

o Pancreas- hormones regulate blood glucose levels, bicarbonates neutralize

stomach acid

o Small intestine- completes digestion, mucus protects gut wall, absorbs nutrients,

most water

o Large intestine- reabsorbs some water, ions, and vitamins, forms and stores


o Rectum- stores and expels feces

o Anus- opening for elimination of feces

 Digestion

o Begins in the mouth and ends in the small and large intestines

o Enzymes are substances that act as catalysts to speed up chemical reactions

 Each enzyme works best at a specific pH

 Saliva- neutral

 Gastric juices- acidic

 Small intestine- basic

o Mechanisms of digestion are interdependent

 Enzyme activity depends on the mechanical breakdown of food to

increase its surface area for chemical action

 Hormones regulate secretions

 Physical, chemical, and hormonal factors regulate the secretions of

digestive juices and the motility of the GI tract

 Parasympathetic stimulation increases GI motility

o How it works
 Salivary amylase in saliva converts starch to maltose

 Protein and fats are broken down physically in the mouth but are not

chemically altered

 Peristalsis moves food through the esophagus

 Pressure from food causes the cardiac sphincter to open and food enters

the fundus (upper portion of the stomach)

 Chief cells in the stomach secrete pepsinogen, pyloric glands secrete

gastrin, and parietal cells secrete HCl and intrinsic factor

 HCl turns pepsinogen into pepsin which splits proteins

 Gastric lipase and amylase begin fat digestion

 Alcohol and aspirin get absorbed directly though the lining of the


 Food leaves antrum (lower stomach) through pyloric sphincter and enters

duodenum and food is now an acidic mass referred to as chyme

 Pancreatic secretions, bile, and intestinal juices mix into chyme in


 Bicarb gets releases and raises the pH of the chyme

 Bile is manufactured in the liver and emulsifies fat when released

 Peristalsis continues in the small intestine and as it becomes increasingly

basic amylase is inhibited and the action of duodenal secretions is


 The major portion of digestion occurs in the SMALL INTESTINE producing

monosaccharides, amino acids and dipeptides, and fatty acids, glycerides,

and glycerol from lipids.

 Absorption

o SMALL INTESTINE is primary site

o Villi increase surface area

o Carbs, proteins, minerals, and water soluble vitamins absorbed in small intestine,
processed in liver, and released into the portal vein circulation

o Fatty acids absorbed in lymph system

o 85-90 percent of water absorbed in small intestine

o Electrolytes and minerals are absorbed in the colon

o Bacteria synthesize vitamin K and some B-complex vitamins

o Then lastly feces are formed for elimination

 Metabolism and storage of nutrients

o Anabolic or Catabolic reactions occur during metabolism

 Anabolism occurs when lean muscle is added through diet and exercise

 Amino acids are made into tissues, hormones, and enzymes

 Starvation can cause wasting which is a form of catabolism

o Metabolism is used to convert nutrients into a number of required substances

o Carbs, proteins , and fat are metabolized to produce chemical energy and

maintain a balance between anabolism and catabolism

o All body cells except RBCs and neurons oxidize fatty acids into ketones for energy

when carbs are not adequate

o Nutrient metabolism consists of 3 main processes:

 Catabolism of glycogen into glucose, carbon dioxide, and water


 Anabolism of glucose into glycogen for storage (glycogenesis)

 Catabolism of amino acids and glycerol into glucose for energy


 Elimination

o Chyme is moved through peristalsis and is changed into feces

o The longer the material stays in the colon, the more water is absorbed

o Exercise and fiber stimulate peristalsis, and water maintains consistency

o Feces contains cellulose and other indigestible materials, sloughed epithelial

cells from the GI tract, digestive secretions, water, and microbes

 Dietary Guidelines

o Dietary reference intakes (DRIs)

 Acceptable range of quantities of vitamins and minerals for each gender

and age group

 4 components of DRIs

 The estimated average requirement (EAR)- recommended amount

of a nutrient that appears sufficient to maintain a specific body

function for 50% of the population based on age and gender

 Recommended dietary allowance (RDA)- average needs of 98% of

the population, not the exact needs of the individual

 The adequate intake (AI)- suggested intake for individuals based

on observed or experimentally determined estimates of nutrient

intakes and is used when there is not enough evidence to set the


 Tolerable upper limit (UI) - highest level that likely poses no risk of

adverse health events. This is not a recommended intake

o Food guidelines

 Average daily consumption guidelines for grains, vegetables, fruits, dairy

products, and meats.

 For people over 2

 Use my plate

o Daily values

 Needed protein, vitamins, fats, cholesterol, carbs, fiber, sodium, and


 Based on percentages of a diet consisting of 2,000 calories

 Nursing knowledge base

o Sociological, cultural, psychological, and emotional factors are associated with

eating and drinking

o Nutritional requirements vary based on developmental stage, body composition,

activity levels, pregnancy and lactation, and the presence of disease

o Predictive equates that take into account some of these factors are used to

figu e out a patie t’s ut itional requirements

 Factors influencing nutrition

o Environmental factors

 Sedentary lifestyle and lack of safe places to play

 Work schedules

 Poor meal choices

 Lack of access to full-service grocery stores

 High cost of healthy food

 Widespread fast food restaurants

o Developmental Needs

 Infants through school age

 Rapid growth

 Need for high protein, vitamin, mineral, and energy requirements

 Infants need about 90-110 Kcal/kg of body weight

 Premature infants- 105-130 kcal/kg of body weight

 Breast milk and formula both provide 20kcal/oz

 Infants also need 100-200 ml/kg/day of fluid

 Breast feeding

o Recommended for the first 6 months of life and with

complementary food from 6-12 months

o Fewer allergies and intolerances, fewer infections, easier

digestion, convenience, availability, freshness, correct

temperature, economical, and increased mother child

interactions are all advantages

 Formula
o Soy used for allergies to cow milk

o Infants should ’t ha e egula o ’s ilk du i g the fi st


o Should not have honey and corn syrup because they are

sources of botulism potentially

 This toxin is fatal in children under 1 year

 Introduction to solid foods

o Iron-fortified cereals first (4-11 months)

 Most important nonmilk source of protein

o Can be added once

 Physical mobility allows

 Allergies can be detected and controlled

o Chocolate, wheat, egg white, nuts, and citrus juice should

all be added later because allergies can occur

 A toddler needs fewer calories but more protein

o Toddlers unfortunately have a lower appetite due to

strong food preferences

o Should drink whole milk until age 2

 Fatty acids for brain development

 Preschoolers (3-5)

o Similar to toddler requirements

o Consume slightly more and nutrient density is more

important than quantity

 School-aged (6-12)

o Grow at a slower, steadier rate

o Gradual decline in energy requirements

o Adequate protein, vitamin A and C needed

o Breakfast is important
o Prevention of childhood obesity is important

o Family education needed

o Promote healthy food choices and eating in moderation

o Encourage physical activities

 Adolescents

o Physiological age not chronological age is a better guide to

nutritional needs

o Calcium essential for bone growth

o Increased protein needed

o Boys need iron for muscle development and girls need it

because they lose it in the menstrual cycle

o Iodine supports increased thyroid activity

o B-complex vitamins are necessary to support heightened

metabolic activity

o Concern for body image, desire for independence, eating

fast-food, peer pressure, and fad diets all influence the

adolescent diet

o Adolescent girls as a result of dieting and oral

contraceptives can have nutritional deficiencies

o Bo ’s diet is ofte i ade uate i total kilo alo ies, p otein,

iron, folic acid, B vitamins, and iodine

o Snacks should be fruits or vegetables

o Anorexia nervosa and bulimia nervosa are an issue

o Sports are good exercise

o Carbs are main source of energy providing 55-60 % of

calories per day

o Early pregnancy (4 years after onset of menarche) puts

fetus and mother at risk due to anatomical and

physiological immaturity
 Young and Middle aged adults

o Reduction in nutrient needs as growth period ends

o Obesity an issue due to decreased exercise, dining out

more, increased ability to afford more luxury foods

o Iron and Calcium still important

o Pregnancy

 Poor nutrition can lead to low birth weight and

decreases chance of survival

 During first trimester balanced portions of essential

nutrients with emphasis on quality

 Protein should increase to 60g daily

 Calcium critical during third trimester

 Iron needed for increased maternal blood volume

 Folic acid intake important for DNA and the growth

of red blood cells

 Inadequate intake can lead to fetal neural

tube defects, anencephaly, or maternal

megaloblastic anemia

 Women of childbearing age need 400 mcg

per day and 600 mcg while actually


 Prenatal care usually includes vitamin and mineral


o Lactation

 500 kcal/ day above usual allowance for lactating


 Protein requirements greater than those of

 Increased Vitamin A and C

 Daily intake of water soluble vitamins necessary for

adequate levels in breast milk

 Adequate fluid intake but not excessive

 Avoid caffeine, alcohol, and drugs

 Older adults (65 years and older)

o Decreased need for energy because metabolic rate slows

o Vitamin and mineral requirements unchanged from

middle adulthood

o Changes in appetite, taste, smell, and the digestive system

affect nutrition

 Decreased taste cells alter food flavor

o Income can become an issue

o Lack of transportation also a problem and can lead to food


o Good oral health should be encouraged

 Poor oral hygiene and periodontal disease are

potential risk factors for systemic diseases such as

joint infections, ischemic stroke, cardiovascular

disease, DM, and aspiration pneumonia

o Grapefruit should be cautioned because it can alter


o Diminished thirst sensation

 Dehydration s/s include confusion, weakness, hot,

dry skin, furrowed tongue, rapid pulse, and high

urinary sodium

o Creams soups and meat based vegetable soups ae nutrient

dense sources of protein

o Cheese, eggs, and peanut butter are also useful high-

protein alternatives

o Milk important to avoid osteoporosis

o Vitamin D supplement for strength and balance,

strengthening bone health and preventing bone fractures

and falls

o Nutritional screening services must be provided by state

 Meals on wheels!

o Undernourishment of older adults often results in health


o See BOX 44-4 on page 1004

 Alternative Food Patterns

o Based on religion, cultural background, ethics, health beliefs, and preferences

o Vegetarian dietary pattern is the consumption of primarily plant foods

 Ovolactovegetarian- avoids meat, fish, and poultry, but eats eggs and


 Lactovegetarian- drinks milk but avoids eggs

 Vegan- consumes only plant foods

 Fruitarian- consumes fruit, nuts, honey, and olive oil

 Vegetarians can meet recommendations for proteins and essential

nutrients if selection are careful

o Zen macrobiotic (brown rice, other grains, and herb teas) and fruitarian diets are

nutrient poor

o Children who follow vegetarian diet at risk for protein and vitamin deficiencies

such as vitamin b12

o Religious dietary restrictions

 Muslim- pork, alcohol, caffeine, Ramadan fasting sunrise to sunset for

month, ritualized method of animal slaughter required for meat ingestion

 Christianity- some faith such as Baptists have minimal or no alcohol,

some meatless days may be observed during the calendar year,

commonly during Lent

 Hinduism- all meats, fish, shellfish with some restrictions, alcohol

 Judaism- pork, predatory fowl, shellfish (eat only fish with scales), rare

meats, blood, mixing of milk or dairy products with meat dishes, must

adhere to kosher food prep methods, 24 hours of fasting on Yom Kippur,

a day of atonement, no leavened bread eaten during Passover (8 days),

no cooking on the Sabbath from sundown Friday to sundown Saturday

 Church of Jesus Christ of Latter Day Saints (Mormons)- alcohol, tobacco,

caffeine such as tea coffee, and soda

 Seventh-day Adventists church- pork, shellfish, fish, alcohol, caffeine,

vegetarian or ovalactovegetarian diets encouraged

o SEE BOX 44-5

 The nursing process

o Assessment

 Patients who are malnourished are at a greater risk of life-threatening

complications such as arrhythmia, sepsis, or hemorrhage

 Th ough the patie t’s e es

 Ask about food preferences

 Observe for changes

 Ask what they expect from nutritional therapy

 U de sta d patie t’s alue, eliefs, a d ut itio al eeds

 Assess family rituals and traditions

 Screening

 Screening a patient is a quick method of identifying malnutrition

or risk of malnutrition using sample tools

 Gather data on current condition, how stable it is, assessment of

whether or not it will worsen, and if the disease process


 Tools include:

o Height

o Weight

o Weight change (decrease or increase unintentionally)

o Primary diagnosis

o Comorbidities

 Identify risk factors

o Nausea

o Vomiting

o Diarrhea or constipation

 Types

o Subjective Global Assessment (SGA)- patient history,

weight, and physical assessment data to evaluate

nutritional status

 Predicts nutrition- related complications

o Mini Nutritional Assessment (MNA)- developed to use for

screening older adults in home care programs, nursing

homes, and the hospitals

 18 items divided into screening and assessment

 If a patient scores 11 or less on the screening

portion the assessment portion is completed

 A total of less 17 indicates protein-energy


o Malnutrition Screening Tool (MST)

 Measures of nutritional problems for patient in a

variety of health care settings

 Whe to assess patie t’s fo al ut itio

 Conditions that interfere with their ability to ingest, digest, or

absorb adequate nutrients

 Patients who are fed only by IV infusion of 5% or 10% dextrose are

at risk

 Chronic diseases or increased metabolic requirements are risk

factors for development of nutritional problems

 Infants and older adults are at a greater risk

 Anthropometry- a measurement system of the size and makeup of the


 Nurse obtains height and weight

 Should obtain serial weights over time to observe for patterns

o Should be weighed at the same time, on the same scale,

with the same clothing

 Ideal body weight (IBW)- estimate of what a person should weigh

 Body mass index (BMI)- measures weight corrected for height and

serves as an alternative to traditional height-weight relationships

o 25-30 overweight

o 30+ obesity

 These patients are at risk of coronary heart disease,

some cancers, DM, and hypertension

 Laboratory and biochemical tests

 No single test is diagnostic for malnutrition

 Things that alter labs:

o Fluid balance

o Liver function

o Kidney function

o Presence of disease

 Should study
o Albumin

o Transferrin

o Prealbumin

o Retinol binding protein

o Total iron-binding capacity

o Hemoglobin and Hematocrit

 Factors that affect serum albumin levels

o Hydration

o Hemorrhage

o Renal or hepatic disease

o Large amounts of drainage from wounds, drains, burns, or

the GI tract

o Steroid administration

o Exogenous albumin infusions

o Age

o Trauma

o Burns

o Stress

o Surgery

 Albumin level is a better indicator for chronic illness

 Prealbumin is preferred for acute conditions

 Nitrogen balance is important to determining serum protein


 Look at urinary urea nitrogen for 24 hours to determine nitrogen


 Diet history and health history

 Fo uses o a patie t’s ha itual i take of foods a d li uids

 Gather info about- health status, age, cultural background,

religious food patterns, socioeconomic status, personal food

preferences, psychological factors, use of alcohol or illegal drugs,

use of vitamin, mineral, or herbal supplements, prescription or

OTC d ugs, a d the patie t’s ge e al ut itio k o ledge

 Physical examination

 SEE TABLE 44-4 pg 1011

 Dysphagia (difficulty swallowing)- Make sure to look at page 1026 for

aspiration precautions!

 Complications of dysphagia:

o Aspiration pneumonia

o Dehydration

o Decreased nutritional status

o Weight loss

 Warning signs:

o Cough during eating

o Change invoice tone or quality after swallowing

o Abnormal movements of the mouth, tongue, or lips

o Slow, weak, imprecise, or uncoordinated speech

o Abnormal gag

o Delayed pharyngeal pooling

o Delayed or absent trigger of swallow

o Inability to speak consistently

 Silent aspiration- aspiration that occurs in patients with

neurological problems that lead to decreased sensation

 Can lead to inadequate food intake

 Changes in skin fold thickness and albumin

 The acute stroke dysphagia screen is an easily administered and

reliable tool for health care professionals who are not speech-

language pathologists
o Nursing Diagnosis

 Risk for aspiration

 Diarrhea

 Deficient knowledge

 Imbalanced nutrition less than body requirements (1013-1014 good


 Imbalanced nutrition more than body requirements

 Risk for imbalanced nutrition: more than body requirements

 Readiness for enhanced nutrition

 Feeding self-care deficit

 Impaired swallowing

o Planning

 Nutritional education and counseling are important for all patients to

prevent disease and promote health

 Meeting goal requires input from the patients

 Refer to professional standards for nutrition

 Collaboration with a registered dietitian (RD) helps develop appropriate

nutrition treatment plans

 Setting priorities

 Setting proper priorities is important to sustain nutrition

 Patient and family must collaborate with the nurse in planning

care and setting priorities

 Teamwork and Collaboration

 Discharge planning include nutritional interventions as patients

return to their homes or extended care facilities

 Communicate goals to all team members

 Consult SLP, RD, pharmacist, and/or occupational therapist for

patient with dysphagia or wo need ongoing nutritional

assessment and interventions to meet their nutritional needs

 Enteral tube feedings administer food into stomach or intestines

via a tube inserted into the nose or a percutaneous access

o RDs are experts in deciding which feeding to use

 Patie ts ho a ’t tole ate food th ough the GI t a t e ei e

parenteral nutrition

o A solution of glucose, amino acids, lipids, minerals,

electrolytes, trace elements, and vitamins

o Pharmacist will assess for drug/medication interactions

 Occupational therapist help with swallowing issues

o Implementation

 Educate patients and family caregivers about balanced nutrition and to

assist them in obtaining resources to eat high-quality meals

 I a ute a e, a age a ute o ditio s that alte patie ts’ ut itio al

status and assist in ways to promote their appetite and ability to take in


 Anorexia can be caused by pain, fatigue, and the effects of medications

 In restorative care, assist patients in learning how to follow the

therapeutic diets necessary for recovery

 Health promotion:

 Education!!

o Prevent development of disease

o Educate families and provide info about community


 Meal planning

o Re e e patie t’s udget

o Preparation modifications (Bake vs. Fried)

o Plan menus a week in advance to ensure better


o Support those patients who want to lose weight if it is


 Help develop a weight loss plan

 Food safety is important due to food-borne pathogens

o Occurs due to improper cooking, cleaning, or poor hygiene

o Educate patients on how to avoid this

 SEE boxes 44-9, 44-10, and 44-12

 Acute Care

 Diagnostic tests and procedures disrupt food intake

o Patients can be NPO

 It is i po ta t to o ti uousl assess a patie t’s ut itio al status

and adopt interventions that promote normal intake, digestion,

and metabolism

 Advancing diets

 Patients with decreased immune system require special diets that

decrease their exposure to microorganisms and have high


 Table 44-6

 Promoting appetite

 Keep environment free of unpleasant odors

 Provide oral hygiene to remove unpleasant tastes

 Maintain comfort

 Offer small more frequent meals

 Medications can affect diet

o Nurse and RD will help select foods to decrease altered

taste sensation and nausea

o Consult with RD on seasoning that may improve taste

o May need pharmacological agents to promote appetite

 Encourage visitors to eat with the patient if appropriate

 Also use mealtime for patient education

 Assisting patients with oral feedings

 I po ta t to p ote t patie t’s dig it , independence, and safety

 Assess for risk of aspiration

 Provide 30 minute rest period before eating

 Seat them upright at a 90 degree angle if possible

 Have patient flex head to a chin-down position to help prevent


 Place food on stronger side of mouth

 Try different consistency of foods to determine which will be best

o thicker are typically easier to swallow

 Patients with dysphagia have specific diets:

o 4 levels of food

 Dysphagia puree

 Dysphagia mechanically altered

 Dysphagia advanced

 Regular

o 4 levels of liquids

 Thin liquids (low-viscosity)

 Nectar-like liquids (medium-viscosity)

 Honey-like liquids (viscosity of honey)

 Spoon-thick liquids (viscosity of pudding)

o Feed them slowly, providing small bites

o Make sure they thoroughly chew and swallow

o Match speed of feedi g to patie t’s eadi ess

o Oral suction equipment may be necessary

o If patient begins to choke remove food immediately

o Allow patient to pick order they want to eat the food

o Ask patient if food is correct temperature

 Patients with visual deficits will also need assistance

o Give them adequate information to feed themselves using

a clock description

o Give them large handle adaptive utensils

 Enteral tube feeding

 Provides nutrients into the GI tract

 Physiological, safe, and economical nutritional support

 P efe ed ethod if patie t a ’t s allo

 Receive formula via nasogastric, jejunal, or gastric tubes

o Patients with low risk of reflux get gastric feedings

o Jejunal is preferred when the risk is high

 See box 44-11

 Go back to page 594 to review giving meds through tubes

 After an enteral tube is inserted get an x-ray for placement


 Usually started at full strength at slow rates and then increase

hourly rate every 8-12 hours

 Signs of intolerance:

o High gastric residuals, nausea, cramping, vomiting, and


 Feeding in the enteral route reduces sepsis, minimizes the

hypermetabolic response to trauma, decreases hospital mortality,

and maintains intestinal structure and function

 Gastric ileus prevents nasogastric feedings

o Naso-intestinal or jejunal tubes allows successful feeding

because it is past pyloric sphincter

 Aspiration is a serious complication of enteral feedings

o Can lead to pneumonia or acute respiratory distress


 Keep head of bed minimum of 30 degrees but preferably 45

 Measure residual volumes every 4-6 hours

o Delayed gastric emptying concerned if 250 mL or more

e ai i patie t’s sto a h o t o o se uti e

assessments 1 hour apart or 1 GRV that exceeds 500 mL

 Enteral access tubes

 Feeding tubes inserted through the nose (nasogastric or


 Surgically inserted (gastrostomy or jejunostomy)

o PEG- percutaneous endoscopic gastrostomy

o PEJ- percutaneous endoscopic jejunostomy

 Su gi al should e used if it’s goi g to last fo o e tha weeks

 Patients with gastroparesis (decreased or absent innervation to

the stomach that results in delayed gastric emptying or

esophageal reflux or with a history of aspiration pneumonia

require placement of tubes beyond the stomach into the intestine

 Most healthcare facilities use small bore feeding tubes

o They create less discomfort

o St let used du i g i se tio to stiffe it a d it’s e o ed

once correctly positioned

o Auscultation has been relatively ineffective in detecting

tube accidents

o Measurement of pH of residuals is used to determine

whether tube is placed in stomach or intestines

o X-ray is the most reliable verification of placement

 Patients who are severely malnourished are at risk for electrolyte

disturbances from re-feeding syndrome

o Potassium, magnesium, and phosphate move

intracellularly, resulting in low serum levels and edema

 Can cause cardiac dysrhythmias, heart failure,

respiratory distress, convulsion, coma, or death

 Parenteral Nutrition- form of specialized nutrition support in which

nutrients are provided intravenously

 Combination of crystalline amino acids, hypertonic dextrose,

electrolytes, vitamins, and trace elements

 Central line- formula with fat emulsions administered separately

from protein and dextrose solution

 Asepsis critical as well as infusion management

 PN is good fo patie ts ho a ’t do EN

o Patients with sepsis, head injury, or burns are possible


 Need for PN is consistently reevaluated because it is a goal to

move towards GI tract use

 Disuse of GI can lead to villus atrophy and generalized cell

shrinkage. Also bacteria can move to blood causing septicemia

 Intravenous fat emulsions

 Provide supplemental kilocalories and prevent fatty acid


 Help control hyperglycemia during periods of stress

 Must be given through separate peripheral tube

 If oil droplets or an oily creamy layer on the surface of the

admixture you do not administer

o Emulsion has broken and can cause fat emboli

 Initiating parental nutrition

 PN with greater than 10% dextrose require a CVC

o Use the port that is dedicated specifically to TPN- label it

 Make sure position is confirmed with radiograph before flushing

and using the catheter

 Always verify orders and check for particulate matter or a break in

fat emulsion prior to infusion

 Always us an infusion pump to ensure a constant rate

 No more than 50% of need is given in first 24-48 hours and rate is

gradually increased

 Home PN can redu e ualit of life e ause it’s ti e o su i g

 Preventing complications

 Pneumothorax results from puncture to pulmonary system which

can occur during CVC placement. Monitor for first 24 hours for s/s

 Air embolus possibly occurs during insertion or when changing the

tubing or cap- have patient perform Valsalva maneuver to

decrease risk

 Catheter occlusion present when there is sluggish or no flow

through catheter- stop infusion and flush with saline or heparin

a d if this does ’t o k t aspi ati g the lot. If that still does ’t

work follow protocol for thrombolytic agent use

 Catheter sepsis- change TPN infusion tubing every 24 hours

o Do ’t ha e a si gle PN o tai e ha gi g fo o e tha


o Do ’t ha e lipids fo o e tha hou s

o Change administration system every 72 hours when using

a 2-1 solution and every 24 hours when using a 3-1


o Follow proper protocols for dressing changes and asses for

infection- change dressing if it becomes soiled

o Use a 1.2- micron filter for 3-1 solutions and a .22 for

those that do ’t ha e lipids

 PN solutions

 have most electrolytes and some also need vitamin K because it is

ot s thesized he GI t a t is ’t used

 Monitor blood glucose levels every 6 hours to assess for


 If a i fusio falls ehi d s hedule do ’t speed up rate in an

attempt to catch

 Hypoglycemia sometimes occurs when patients are suddenly

taken off PN- diabetic patients especially at risk

 After 75% of need is being met by normal feeding PN or EN is

discontinued typically

 Restoring and continuing care

 Medical Nutrition Therapy- the use of specific nutritional

therapies to treat an illness, injury, or condition

o Help the body metabolize certain nutrients, correct

nutritional deficiencies related to the disease, and

eliminate foods that may exacerbate disease symptoms

o Most effective with collaborative health care team and


 Gastrointestinal Diseases

o Peptic ulcers

 Helicobactor pylori is a bacterium that causes 85%

 Stress and overproduction of HCl also irritate a

preexisting ulcer

 Avoid:

 Caffeine

 Decaffeinated coffee

 Frequent milk intake

 Citric acid juices

 Certain seasonings- spicy

 Smoking

 Alcohol

 Aspirin


 Large meals and snacks especially at


 Teach

 Well balanced diet

 Consume small, frequent meals

 Family members with H. pylori infection needs to

be treated

o Ch o ’s Disease a d idiopathi ul e ati e olitis

 Elemental diets- nutrients in their simplest form

ready for absorption

 Parenteral nutrition when diarrhea and weight loss

are prevalent

 In chronic stage of disease a regular highly-

nourished diet is appropriate

 Vitamins and iron supplements often required to

correct or prevent anemia

 IBS:
 Increase fiber

 Reduce fat

 Avoid large meals

 Avoid lactose or sorbitol containing foods

o Malabsorption syndromes

 Celiac disease- gluten-free diet

 Short bowel syndrome:

 Extensive resection of vowel, after patient

suffers from malabsorption

 Lifetime elemental enteral formulas or PN

 Diverticulitis:

 Inflammation of diverticula

 Moderate or low residue diet for until

infection subsides

 After high-fiber diet prescribed for chronic

diverticula conditions

o Diabetes mellitus

 Type 1: insulin and dietary restrictions

 Type 2:

 Exercise and diet therapy initially, then oral

meds, then insulin injection

 Individualized diet based on:

o Age

o Build

o Weight

o Activity level

 Maintain prescribed carb intake

o Carbs from fruit, vegetables, whole

grains, legumes, and low-fat milk

o Monitor carb inake

 Limit saturated fat intake to less than 7%

 Recommend foods with fiber

 Sugar alcohols and non-nutritive

sweeteners are able to be eaten as long as

recommended daily intake levels are


 Those with normal renal function should

continue to consume normal amounts of

proteins (15-20% of diet)

 Cholesterol intake less than 200 mg/dL

 Goal is to keep glycemic levels that are normal or

as close to normal as possible , less than 100 mg/DL

LDLs, BP less than 130/85, and avoidance of


o Cardiovascular diseases

 Reduce risk factors for the development of

hypertension and coronary artery disease

 Balance caloric intake and exercise

 Maintain healthy body weight

 Eat a diet high in fruits, vegetables, and whole grain

high-fiber foods, complex carbs

 Eat fish at least twice a week

 Limit foods and beverages high in sugar and salt

 Limit saturated fat to less than 7% and trans fat to

less than 1%

 Cholesterol less than 300 mg/day

 Patients should choose lean meats and vegetables,

use fat-free dairy products, and limit intake of fats

and sodium

o Cancer and cancer treatment

 Malignant cells compete with normal cells for


 Need to meet increasing metabolic needs

 Malignant cells compete with normal cells for


 Nausea, vomiting, and taste distortions common

 Malnutrition associated with cancer increases

morbidity and mortality

 Radiation causes anorexia, stomatitis, severe

diarrhea, intestinal strictures, and pain

 Maximize intake of nutrients and fluid

 I di idualize diet hoi es to a patie t’s eeds,

symptoms, and situation

 Encourage small, frequent meals and snacks that

are easy to digest


 Body wasting and severe weight loss occur r/t

anorexia, stomatitis, oral thrush infection, nausea,

or recurrent vomiting all result in inadequate


 Severe diarrhea, GI malabsorption, altered nutrient

metabolism of nutrients

 Hypermetabolism as a result of cytokine elevation

can cause systemic infections

 Medications used to treat HIV infection cause side

effects that alter nutritional status

 Maximize kilocalories and nutrients

 Encourage small, frequent, nutrient-dense meals

with fluid in between limit fatty and overly sweet


 Individually tailored nutrition support progresses in

stages from oral, to enteral, and finally to


 Good hand hygiene and food safety essential

o Evaluation

 Alte pla if it did ’t o k

 Know what the patient expects and figure out if those expectations were


 Co side li its of patie t’s o ditio

 Multidisciplinary collaboration remains essential in providing nutritional


 Changes in condition indicate a need to change the nutritional plan of


 Co side the li its of patie ts’ o ditio s a d t eat e ts, thei dieta

preferences, and cultural beliefs when evaluating outcomes

Urinary Elimination- Chapter 45

 Scientific knowledge base:

o Kidneys

 Remove waste from the blood to form urine

 Approximately 20-25% of CO circulates each kidney per minute

 Urinary formation begins in capillaries of glomerulus

 Permit filtration of water, glucose, amino acids, urea, creatinine,

and major electrolytes

 Large proteins and blood usually do not go through

 Normal filtration rate: 125 mL of filtrate per minute

 Most filtrate reabsorbed into plasma and the rest excreted as


 Normal adult urine output averages 1200-1500 mL per day

 Output <30 mL/hour is problem

 Kidneys produce erythropoietin

 Those with kidney issues at risk for anemia

 Renal hormones affect BP regulation

 Renin is released from juxtamedullary cells

 Renin converts angiotensinogen into angiotensin I which becomes

angiotensin II in lungs which stimulates aldosterone which causes

water retention which increases BP

 Patients with chronic alterations of kidney function do not make

sufficient amounts of vitamin D which impairs calcium absorption and

affects bones

 Produces prostaglandin E2 and prostacyclin, which also affect BP

 Vasodilators

 Kidneys affect calcium and phosphate regulation

o Ureters

 Transport urine from the kidneys to the bladder

 Peristaltic waves move urine through ureters

 If obstruction such as kidney stone, strong peristalsis attempts to move

urine and causes pain

o Bladder

 Reservoir for urine until the urge to urinate develops

 In pregnant women, fetus pushes on bladder and causes feeling of


o Urethra

 Urine travels from the bladder and exits through the urethral meatus

 Normally turbulent flow of urine through urethra washes it free of


 Shorter in women, which exposes them to infection

 4-6.5 cm in female

 20 cm in male

 Act of urination

o Brain structures influence bladder function

 Cerebral cortex

 Thalamus

 Hypothalamus

 Brainstem

o Bladder capacity varies, but is typically between 600-1000 mL of urine

 Normal adult voids every 2-4 hours

 Children do not have mental capacity until 24 months, some not until 36


 Voiding: Bladder contraction + Urethral sphincter and pelvic floor muscle


 1. Stretching of bladder wall signals the micturition center in the

sacral spinal cord.

 2. Impulses from the micturition center in the brain respond to or

ignore this urge, thus making urination under voluntary control.

 3. When a person is ready to void, the external sphincter relaxes,

the micturition reflex stimulates the detrusor muscle to contract,

and the bladder empties.

 Damage to spinal cord can cause reflex incontinence

 Overflow incontinence occurs when bladder overly full and bladder

pressure exceeds sphincter pressure

 Head injury

 Spinal injury

 MS

 Diabetes

 Trauma to urinary system

 Postanesthesia

 Tricyclices

 Analgesia

 Hyperreflexia is a life threatening problem affecting heart rate and BP

caused by an overly full bladder

 Typically neurogenic in nature but can be cause by a functional


o Factors influencing urination

 Disease conditions

 Conditions can affect renal function, urine elimination, or both

 Prerenal: decreased blood flow through kidney

 Renal: disease conditions of renal tissue

 Postrenal: obstruction of lower urinary tract

 Diabetes & MS are neuromuscular disease that change nerve


o Reduced bladder tone

o Reduced sensation of bladder fullness

o Inability to inhibit bladder contractions

 Benign prostatic hyperplasia makes men prone to urinary

retention and incontinence

 Cog iti e i pai e t su h as Alzhei e ’s lose a ilit to se se full

bladder and unable to recall procedure for voiding

 Degenerative joi t disease & Pa ki so ’s ake it diffi ult fo

patients to reach the toilet

 End stage renal disease

o Symptoms resulting from uremic syndrome

 Increase in nitrogenous waste in blood

 Fluid and electrolyte abnormalities

 N/V

 Headache

 Coma

 Convulsions

o Renal replacement therapies to treat these conditions as

they worsen

 Dialysis

 Peritoneal

o Indirect method of cleaning blood

o Peritoneum used as semipermeable


 Hemodialysis

o Requires machine equipped with

semipermeable filtering membrane

that removes wastes and excess


 Organ transplant

 Can use living or cadaver of compatible

tissue type

 Immunosuppressives for life

 Successful organ transplant offers return to

normal kidney function

 Socioeconomic factors

 Degree of privacy for urination varies with cultural norms

 Social expectations influence the time of urinations

 Psychological factors

 Anxiety and emotional stress causes sense of urgency

 Anxiety also prevents person to be unable to urinate completely

 Emotional tension makes it difficult to relax muscles

 Privacy and adequate time to urinate are usually important to

most people

 Fluid balance

 Amount of urine formed at night is about half of what is formed

during the day due to less intake and metabolism

 Nocturia is a sign of renal alteration

 Polyuria is excessive output

 Oliguria is decreased output despite normal intake

 Anuria is a lack of urine and occurs during severe kidney disease

 Caffeine promotes increased urine formation (diuresis)

 Alcohol inhibits ADH which can result in water loss

 Persons with fever lose fluids through perspiration so urine

output decreases

o Indications for dialysis

 Renal failure that can no longer be controlled by conservative


 Worsening of uremic syndrome associated with ESRD

 Severe electrolyte and/or fluid abnormalities that cannot be controlled

by simpler measures

o Surgical procedures
 After surgery the general adaptation syndrome (GAS) is initiated and

decreases output

 Increase in ADH which causes increased water resorption

 Increase in aldosterone which causes sodium and water retention

 Anesthetics and analgesics slow glomerular filtration rate

o Medications

 Some cause urinary retention and/or overflow incontinence

 Some cause urgency and incontinence

 Some change the color of urine such as Pyridium which causes urine to

be orange

 Always consider medications as new onset urinary incontinence

especially in elderly

 Patients with impaired kidney function often require modified

medication doses

o Diagnostic examinations

 Restriction of fluid intake lowers urine output

 Direct visualization causes localized trauma and edema; patients may

have difficulty voiding

 IVP (intravenous pylogram) requires limitations

 Cystoscopy can cause edema of urethral passage and spasm of bladder

sphincter which can cause difficulty voiding or pink/red urine

 Alterations in urinary elimination

o See Box 45-2 on pg. 1048

 Provide frequent opportunities to void. Older adults have a smaller

bladder capacity than younger adults

 Encourage older adults to empty the bladder completely before and after

meals and at bedtime

 Encourage patients to increase fluid intake to at least six to eight glasses

a day unless medically contraindicated

o Urinary retention is an accumulation of urine due to the inability of the bladder

to empty

 Bladder is unable to respond to micturition reflex

 Overflow develops allowing small amounts of urine to escape

 Assess abdomen for bladder distention

 Acute retention

 S/S

o Absence of urine output over several hours

o Bladder distention

 Severe urinary retention

 Bladder holds as much as 2000-3000 mL of urine

 Retention occurs because of obstruction, surgical, or childbirth trauma,

and alterations in motor and sensory innervations of the bladder

(diabetic neuropathy)

 Can also occur with removal of catheter

 Medications

 Residual urine (AKA Post Void Residual or PVR) is urine left in bladder

after voiding

 When patient experiences retention a catheter is necessary

o Urinary tract infection

 Most common hospital acquired infection (HAI)

 80% are due to catheter use

 Every day a catheter is in the bacteria in the urine increases by 5%

 Hospitals are not compensated for CAUTI infections

 E. Coli is typically the causative pathogen

 Bacteriuria can lead to bacteremia or urosepsis (bacteria in the blood)

 Women are more susceptible to infections

 Urinary retention causes the urine to be more alkaline so it supports

bacterial growth

 Lower UTI

 Pain or burning during urination (dysuria)

 Fever, chills, nausea, vomiting, and malaise

 Cystitis causes a frequent and urgent sensation of blood-tinged

urine (hematuria)

 Upper UTI

 Pyelonephritis- flank pain, tenderness, fever, and chills

o Urinary incontinence

 Involuntary leakage of urine

 Urge incontinence- se se u ge to u i ate ut a ’t ea h toilet efo e

having to urinate

 More common in younger women

 May be caused by a UTI

 Stress incontinence

 More common in older women

 Muscles around the urethra become weak and even a small

amount of urine is capable of leaking out

 Hyperactive or overactive bladder (OAB)

 Associated with all ages but elderly are most likely to have

incontinence with it

 Sudden involuntary contraction of the muscles of the urinary

bladder lead to urge incontinence

 Cerebrovascular accident and other head injuries, spinal cord

injuries, or diabetic neuropathy can cause it

 Some people are embarrassed to talk about this issue with

 Continued episodes put patients at risk for impaired skin integrity

 Immobilized patients are at risk for pressure ulcers

o Urinary Diversion

 Diversion of urine to external source (not seen too much)

 Bladder cancer, radiation injury to bladder, or chronic urinary infections

may necessitate a urinary diversion to drain urine

 Continent urinary reservoir

 Created form distal portion of ilium and proximal portion of the


o Ureters embedded in reservoir which is located under

abdominal wall to form a small stoma

o Patients catheterize this pouch 4-6 times per day

 Orthotropic neobladder uses an ileal pouch to replace bladder

o Positioned in same place as bladder allowing patients to

void normally

 Some patients need a nephrostomy to drain one or both kidneys

A u i a di e sio is a th eat to a patie t’s od i age

 Care must be taken to not pull out tubing especially in a nephrostomy

 Most are sutured into kidney

 Nursing knowledge base

o Infection control and hygiene

 Use medical and surgical asepsis when providing care involving the

urinary tract or external genitalia

 Perineal care- medical asepsis (clean gloves, etc.)

 Catheterization- surgical asepsis

 Factors influencing urination

o Age, environment, medication history, psychological factors, muscle tone, fluid

balance, current surgical or diagnostic procedures, and the presence of disease


o Dehydration

o Constipation

o Environmental factors- elevated toilet seats, grab bars, or portable commode

might be helpful

 Growth and development

o Infants and young children cannot effectively concentrate urine

o Neurologic system not well developed until 2-3 years of age and until this age a

child cannot fully control the bladder

o So e hild e do ’t gai full o t ol u til age -5

 Can have daytime accidents or nocturnal enuresis

o Pregnancy leads to frequency and increased risk of UTIs

o Changes in bladder and kidneys occur in an older adult

 Bladde a ’t effe ti el o t a t

 More susceptible to UTIs

 Bladder loses muscle tone and capacity decreases which can result in

increased urinary frequency

 Muscle tone

o Weak abdominal and pelvic floor muscles impair the ability of the urinary

sphincter to maintain tone during increased abdominal pressure

o Poor control of micturition can be caused by:

 Prolonged immobility

 Muscle damage during vaginal childbirth

 Being overweight

 Caffeine use

 Muscle atrophy secondary to menopause

 Other traumatic damage to pelvic nerves and muscles

 Psychosocial Considerations
 Cultural Considerations

 Nursing process: Assessment

o Box 45-4 and Table 45-1

o Identifying Urinary alterations

 Co du t a u si g histo , ph si al, assess patie t’s u i e, a d e ie

information from diagnostic tests and examinations

o Nursing history

 Pattern of urination

 Daily voiding patterns, including frequency and times of day

 Normal volume at each voiding

 Any recent changes

 Common times of urination- on awakening, after meals, and

before bedtime

o Other times vary from patient to patient

 Most people void around 5 times a day

o Some people who void frequently at night have renal

disease, prostate enlargement, or cardiac disease

 Symptoms of urinary alterations

 Ask patient about any symptoms related to urinary alterations

 Assess whether the patient is aware of conditions or factors that

precipitate or aggravate symptoms and determine what the

patient does when these occur

 Monitor fluid balance (I&O)

 Assess characteristics of urine

 Assess the patie t’s pe eptio of u i a p o le s as it affe ts self-

concept and sexuality

 Gather relevant lab and diagnostic test data

o Physical Assessment
 Provides data to determine the presence and severity of urinary


 Skin and mucosal membranes

 Assess hydration

 Asses skin turgor and oral mucosa

 Increased risk for skin breakdown with incontinence

 Observe the perineum for rashes, blistering, irritation, and


 Kidneys

 Flank pain may occur with infection or inflammation

 Position, shape, and size of kidney reveal problems such as


 Auscultate for renal artery bruit

 Bladder

 Distended bladder rises above symphysis pubis

 You may notice a swelling or convex curvature of the lower


 Urethral meatus

 Observe for discharge, inflammation, and lesions

 Female should be observed in dorsal recumbent position

 If candida is found in urine- important to inspect vagina, in the

groin area, under the breasts, and in the mouth for the source

 Older women can have vaginitis as a result of estrogen deficiency

o Inspect vaginal orifice for signs of inflammation and

describe any drainage

 Inspect male for discharge, inflammation, and lesions

o Retract foreskin

o Assessment of Urine
 Measu i g patie ts’ fluid i take a d output

 Change in urine volume is an indicator of fluid alterations or

kidney disease

 Any extreme increase or decrease must be reported

 Daily output should range from 1200-1500 mL of urine

 An hourly output of less than 30 mL for more than 2 consecutive

hours is concerning

 Polyuria (2000-2500 mL daily) is also concerning

 Characteristics of urine

 Color

o Normal urine ranges from a pale, straw color to amber

depending on concentration

o Urine will be less concentrated with more fluids

o Bleeding from kidneys or ureters causes dark red urine

 Bleeding from urethra or bladder is bright red

o Phenazopryidine- bright orange

o Eating beets, rhubarb, or blackberries- can make urine red

o Dyes used in studies can also change the color

o Dark amber is due to bilirubin caused by liver dysfunction

 Clarity

o Transparent unless pathology is present

o Urine that stands too long in a container can become


o Patients with renal disease have cloudy urine due to


o Bacteria and WBCs can also cloud urine

 Odor

o More concentrated the stronger the odor

o Stagnant urine has ammonia odor- people with repeated


o Sweet or fruity odor is acetone which can occur in diabetes

mellitus or starvation due to incomplete fat metabolism

o Food and medication can play a role (asparagus and


 Urine testing

 La el all spe i e s ith patie t’s a e, date, a d ti e of


 Specimen collection

o Collect random, clean-voided or midstream, sterile and

timed specimens

o Table 45-2

 Urine collection in children

o Specimen collection from infants and children is often


o Adolescents and school-aged children usually are able to


o Preschool children and toddlers have difficulty voiding on


o Children often have trouble urinating in the presence of

people other than their parents

o Give fluids 30 minutes before if possible

o Do not get urine from diaper

o Urine tests and diagnostic examinations

 Know the normal values on table 45-3

pH (4.6-8.0)

pH of urine indicates acid-base balance. An acid pH helps protect

against bacterial growth. Urine that stands for several hours becomes

Protein (none or

up to

8 mg/100 mL)

Normally protein is not present in urine. It is common in renal disease

because damage to glomeruli or tubules allows it to enter urine.

Glucose (none)

Patients with diabetes mellitus often have glucose in urine as a result

of inability of tubules to resorb high glucose concentrations

(>180 mg/100 mL). Ingestion of high concentrations of glucose

causes some glucose to appear in urine of healthy persons.

Ketones (none)

Patients whose diabetes mellitus is poorly controlled experience

breakdown of fatty acids. End products of fat metabolism are ketones.

Some patients with dehydration, starvation, or excessive aspirin usage

also have ketonuria.


A positive test for occult blood occurs when intact erythrocytes,

hemoglobin, or myoglobin is present. Blood in a routine urine

specimen in a woman may be a result of contamination with

menstrual fluid.

Specific gravity


Specific gravity measures concentration of particles in urine. High

specific gravity reflects concentrated urine, and low specific gravity

reflects diluted urine. Dehydration, reduced renal blood flow, and

increased ADH secretion elevate specific gravity. Overhydration,

early renal disease, and inadequate ADH secretion reduce specific

Microscopic Examination

RBCs (up to 2)

Damage to glomeruli or tubules allows RBCs to enter the urine.

Trauma, disease, or surgery of the lower urinary tract also causes

blood to be present.

WBCs (0-4 per

low-power field)

Greater numbers indicate urinary tract infection.

Bacteria (none)

Bacteria indicate urinary tract infection. (Patients do not always have


Casts (none)

Casts are cylindrical bodies the shapes of which take on likeness of

objects within the renal tubule. Types include hyaline, WBCs, RBCs,

granular cells, and epithelial cells. Their increased presence is always

an abnormal finding and indicates renal alterations.

Crystals (none)

Crystals are the result of food metabolism. Excess crystals such as

uric acid or calcium phosphate result in renal stone formation.

 Urinalysis

 Should be examined within 2 hours

 First voided specimen in the morning

 Specific Gravity

 Weight or degree of concentration of a substance compared with

an equal volume of water

 Weighted urinometer is suspended in the cylinder of urine

 If questions come up osmolarity test should be run

 Culture
 Sterile or clean voided sample of urine

 While awaiting results broad-spectrum antibiotics are sometimes

used and then they are switched to more specific ones

 Diagnostic Examinations

 Direct or indirect

 Common responsibilities before study:

o Obtain a signed consent

o Asses patient for history of allergies and whether or not

the ’ e e e had a ea tio to a o t ast age t

 Allergic individuals in general are at mildly

increased risk for developing adverse reactions to

radio-contrast media

o Administer bowel-cleaning medications as ordered

o Ensure the patient receives appropriate pretest diet or

NPO as needed

 Common responsibilities post procedure

o Assess I&O

o Observing characteristics of urine

o Encouraging fluid intake, especially if using radiopaque dye

 Nursing Diagnosis and planning

o Common diagnoses

 Social isolation (acute, chronic)

 Disturbed body image

 Urinary incontinence (functional, stress, urge, overflow)

 Pain (acute, chronic)

 Risk for infection

 Toileting self-care deficit

 Impaired skin integrity

 Impaired urinary elimination

 Constipation

 Urinary retention

o Planning

 General goal is urinary elimination

 Goals are short or long term depending on the situation

 Psychological needs like self-esteem and sexuality are sometimes a huge

priority for the patient

 Co side a patie t’s ho e e i o e ta d o al eli i atio outi es

when planning therapies

 Explore the need for home care services and make appropriate referrals

 Implementation

o Health promotion

 Assist patient in understanding and participating in self-care practices to

preserve and protect healthy urinary system

 Patient education

 Teach patient on their specific elimination problem

 Teach hand hygiene and proper perineal care

 Incorporate teaching into nursing care

 Promoting normal micturition

 Help prevent urination difficulties

o Stimulating micturition reflex

 Help patient learn to relax and stimulate the reflex to void by helping

them assume the normal position for voiding

 Women in a squatting position

 Men in a standing position

 Sensory stimuli promotes relaxation- running water

 Stroking the inner aspect of the thigh

 Pou a ate o e the patie t’s pe i eu

 Be sure to measure the volume you poor over so output is not

messed up

 Maintaining elimination habits

 I teg ate patie t’s ho e habits into care plan to foster normal


 Maintaining adequate fluid intake

 Patient who does not have a heart or kidney disease needs to

drink 2200-2700 mL of fluid daily

o Minimal daily intake 1200-1500 mL of fluids is usually

adequate unless the patient has a history of UTI

 Most patie t’s o t d i k that u h pu e ate so e ou age

fluids they like and encourage fruits and vegetables

 Promoting complete bladder emptying

 Only a small amount should remain in the bladder

 Encourage patients to wait until urine stops flowing or attempt to

void again

 C ede’s ethod of a ual o p essio of the ladde alls ith

each attempted void may be used

o Press down on bladder to promote sphincter opening and

bladder emptying

 Preventing infection

 Perineal hygiene

 Clean urethral meatus after each voiding or bowel movement

 Dilute urine with at least 1500 mL of fluid intake

 Void after sex

 Do ’t use e essi e soap o take u le aths

 Wear cotton underwear

 Drink apple or cranberry juice

o Acute care- Table 45-5 also good nursing care plan on 1057

 Maintaining elimination habits

 Allow time and provide privacy

o At least 30 minutes to provide privacy

 Offer patients opportunities to void to avoid falls

 Keep the curtain closed

 Offer reading materials or music if it helps a patient

 Medications

 Parasympathetic stimulation of the detrusor muscle aids


 Cholinergic drugs increase bladder contraction and improve


 Catheterization

 Provides continuous flow of urine

 Carries the risk of UTI, blockage, and trauma to the urethra

 Types:

o Intermittent

 Introduce a straight single-use catheter

 Immediately withdrawal after emptying

 Repeat as necessary but each catheter insertion

increases risk of trauma and infection

 Common for people with spinal cord injury and MS

o Indwelling

 Inflated balloon rests against bladder outlet to

anchor it in place

 Often has two or three lumens

 One drains urine through the catheter to a

collecting tube

 Second carries sterile water to and from the


 Third is sometimes used to instill fluids or

medications into the bladder

o Coude catheter is used on male patients who may have

enlarged prostates that partly obstruct the urethra

 Cathete s o e i a dia ete s to fit size of patie t’s u eth al


 Catheter insertion

o Strict asepsis

o See skill on 1061

 Closed drainage system

o Maintain a closed urinary drainage system to minimize the

risk of infection

o Bag should never touch floor but needs to hang below

level of bladder

o When ambulating continue to hold bag below waist

o Empty the bag regularly to prevent backflow

o Keep system patent

 Perineal hygiene

o Buildup of secretions at insertion site is a source of

irritation and potential infection

o Perineal hygiene at least 3 times daily or as needed by


o Must be careful not to advance catheter further

 Catheter care

o Catheters should receive care 3 times a day and after

defecation or bowel incontinence

 Fluid intake

o Daily intake of 2000-2500 mL if permitted

o Oral intake and IV infusion both sources

o Large volumes of fluid keep sediment out of catheter

o Use citrus juices sparingly because they can create an

environment in the bladder more prone to infection

 Catheter irrigations and instillations

o If a catheter becomes plugged with pus or sediment it is

best to change it rather than irrigate

o Use irrigation after surgery for blood clots and short term

catheter use

o Antiseptic or antibiotic flush may be used in an infection


o Follow sterile technique

o Before irrigating assess for blockage

 Removal of indwelling catheter

o Perform hand hygiene and put on clean gloves

o Position patient

o Place towel et ee a fe ale’s thighs o o e a ale’s


o Deflate balloon

 Make sure the it deflates completely or trauma can


o Dysuria may occur

o Assess urinary function after removal for next 24 hours

 If 4 hours elapse without voiding or patient

experiences discomfort it is often necessary to

reinsert the catheter

 Alternative to urethral catheterization

o Suprapubic catheterization

 Surgical placement through the abdominal wall

above pubic symphysis

 Maintenance of the tubing and drainage bag is the

same as the indwelling catheter

 Infections rates slightly lower but long-term

complications are similar

 Sediments, clots, or the abdominal wall can block

the catheter

 Monitor I&O, urine characteristics, and signs of


 Skin care around insertion sight

o Condom catheter

 Suitable for incontinent or comatose men who

have complete and spontaneous bladder emptying

 Three methods of securing

 Strip of elastic tape or rubber that encircles

the top to secure it in place

 Self-adhesive condom sheath

 Inflatable ring within the condom to secure


 Never use standard adhesive tape

 Little risk of infection

 Observe the skin- try to use transparent catheter

 Change daily and clean with each change

 Pads and protective clothing can be used for

o e ut do ’t efe to the as p ote ti e

clothing or adult diapers

o Restorative Care

 Strengthening pelvic floor muscles

 Kegal exercises improve the strength of pelvic floor muscles and

consist of repetitive contractions of muscle groups

 Begins these exercises during voiding to learn the technique then

they are practiced at non-voiding times

 Slow improvement over time

 Bladder retraining

 Goal is to reduce frequency and perhaps bladder capacity

 Return to a normal pattern of voiding by teaching a patient

 Keep a bladder diary to establish a baseline for comparison

 Assess patie t’s u e t patte

 Patient will suppress urination for each voiding and increase time

by increments of 15 minutes

 Goal is voiding every 3-4 hours in volumes of 240-500 mL

 Stress urinary incontinence: gaining control

o Learning exercise to strengthen pelvic floor

o Initiating a toileting schedule on awakening, at least every

2 hours during the day and evening, before getting into

bed, and every 4 hours at night

o Avoiding an overfilled bladder because this increases

chances of incontinence related to increased bladder


o Minimizing tea, coffee, other caffeine drinks, and alcohol

o Taking prescribed diuretic medication early in the morning

o Following a weight-control program if obesity is a problem

that is causing increased abdominal pressure

 Habit training
o Patient with functional incontinence benefits

o Flexible toilet pattern developed based on individual


o Help patient to bathroom before urge

o Keep patient dry

o Time fluids and medications to prevent interference with

the toileting schedule

o When combined with positive reinforcement this is called

prompted voiding

 Self-catheterization

o Teach structures of urinary tract, clean versus sterile

technique, promote fluids, and the frequency of self-


o Goal is 4-6 times per day with volumes of 400-500 mL

 Maintenance of skin integrity

o Wash with mild soap and warm water

o Body lotion keeps skin moisturized

 Promotion of comfort

o Incontinent patient- clean, dry clothing

o Urinary analgesics that act on the urethral and bladder

mucosa relieve dysuria

o Iced sitz bath may provide plain relief if the patient has

local discomfort from an inflamed urethra

o Interventions that stimulate micturition or intermittent

catheterization are the only way to relieve pain from


 Nursing Process: Evaluation

o Evaluate whether the patient has met outcomes and goals

o Check how the patient reports progress made

o Help the patient redefine goals if necessary

o Revise nursing interventions as indicated

 Safety guidelines

o Follow principles of surgical and medical asepsis as indicated when performing

catheterizations, handling urine specimens, or helping patients with their

toileting needs.

o Identify patients at risk for latex allergy (i.e., patients with history of hay fever;

asthma; and allergies to certain foods such as bananas, grapes, apricots, kiwi

fruit, and hazelnuts).

o Identify patients with allergies to povidone-iodine (Betadine). Provide

alternatives such as chlorhexidine

Bowel Elimination- Chapter 46

 Organs of the GI tract

o These organs absorb fluid and nutrients, prepare food for absorption and use by

body cells, and provide for temporary storage of feces.

o Incompetent lower esophageal sphincter leads to acid reflux

o Delayed gastric emptying is an issue with pyloric sphincter

o Large intestine secretes bicarb, mucous, and absorbs water

o Bright red blood in vomit is likely in esophagus or high part of stomach

o Golytly- best way to eliminate bowels (high concentration of electrolytes to clear

everything out

o Mouth

 Digestion begins here

 Teeth break down food mechanically and saliva dilutes and softens food

o Esophagus

 Food and water enter at upper esophageal sphincter

 Bolus of food travels down esophagus vis peristalsis

 Before entering stomach, food passes through lower esophageal (cardiac)

 This sphincter prevents reflux back into esophagus

o Stomach

 Storing swallowed food and liquid

 Mixing food, liquid, and digestive juices

 Emptying its contents into small intestine

 Produces HCl, mucus, pepsin, and intrinsic factor

 HCl digests protein

 Mucus protects stomach mucosa from acidity and enzyme activity

 Intrinsic factor is for absorption of B12

o Small intestine

 Segmentation and peristaltic movements facilitate both digestion and


 Duodenum

 20-28 cm

 Continues to process chyme from stomach

 Jejunum

 2.5 m

 Absorbs carbs and proteins

 Ileum

 3.7 m

 Absorbs water, fats, certain vitamins, and bile salts

 Duodenum and jejunum absorb most nutrients and electrolytes

 Substances such as plant fiber empty into cecum (start of large intestine)

 Impairment of small intestine alters digestive process

 Inflammation

 Surgical resection

 Obstruction

 Can lead to electrolyte and nutrient deficiencies

o Large intestine

 Primary organ of bowel elimination

 Divided into cecum, colon, and rectum

 Chyme enters large intestine via peristalsis through ileocecal valve

 This valve prevents regurgitation

 3 functions of colon:

 Absorption

o Absorbs water, sodium, and chloride

 Secretion

o Bicarbonate (HCO


 Elimination

o waste

 Can absorb water, sodium, and chloride

 Healthy adults should absorb a gallon of water and an oz of salt every 4


 Abnormally fast peristalsis leads to watery stool

 Abnormally slow peristalsis leads to constipation

 Secretory function aids in electrolyte balance

 Colon excretes 4-9 mEq of potassium daily

 In rectum bacteria convert fecal matter into its final form

 Normally rectum is free of waste products until defecation

o Anus

 Feces and flatus expelled from rectum through anal canal and anus

 Contraction and relaxation of internal and external sphincters aid in


 Defecation
o Factors critical for bowel elimination

 GI tract function

 Sensory awareness of rectal distention and rectal contents

 Voluntary sphincter control

 Adequate rectal capacity and compliance

o Valsalva maneuver used to assist in stool passage

o Patients with cardiovascular disease, glaucoma, increased intracranial pressure,

or new surgical wound are at greater risk for cardiac dysrhythmias and elevated

BP with Valsalva maneuver and need to avoid straining to pass stool

o Defecation should be painless

 Factors affecting bowel elimination

o Table 46-2

o GI shuts down called paralytic ileus

o Age

 Infant has small stomach capacity and less digestive enzymes so food

passes quickly

 Infant cannot control defecation until 2-3 yrs of age

 Systemic changes in function of digestion and absorption of nutrients in

older patients are due to cardiovascular and neurological systems rather

than GI system

 Peristalsis decreases

 Esophageal emptying slows

 Loss of muscle tone in perineal floor and anal sphincter therefore

often have issue with bowel evacuation and are at risk for


 Nerve impulses to anal region slow and make them less aware of

need to defecate

o Diet
 Fiber provides bulk of fecal material

 Whole grains and fresh fruits and vegetables help flush fats and waste

products from body

 Ingestion of high fiber diet improves likelihood of normal elimination


 Diets high in veggies and fruit have led to decreased risk of colorectal


 Gas-producing foods such as onions, cauliflower, and beans stimulate


 Spicy foods increase peristalsis

 Food intolerance is not allergy but does cause body stress resulting in

diarrhea, cramps, or flatulence

 Lactose intolerance

 Celiac disease is a hypersensitivity to protein in certain cereal grains and


o Fluid intake

 Fluid eases passage through colon

 Adult needs at least 1100-1400 mL daily

o Physical activity

 Promotes peristalsis

 Immobilization depresses peristalsis

 Encourage early ambulation

 Decreased muscle tone impairs ability to increase intraabdominal

pressure and control external sphincter which can increase risk for


o Psychological factors

 During emotional stress, digestive process is accelerated which can lead

to diarrhea and gaseous distention

 Ulcerative colitis

 IBS (irritable bowel syndrome)

 Certain gastric and duodenal ulcers

 C oh ’s disease

 Depression can cause constipation

o Personal habits

 Personal habits influence bowel function

 Busy work schedules can prevent individual from appropriate response

 Individuals need to recognize the best time for elimination

 Try and provide the best possible privacy for hospitalized patients

 Sharing a toilet facility or using bedpans are often embarrassing to

patients so they often ignore need to defecate causing constipation and


o Position during defecation

 Squatting is normal

 Patient immobilized in bed

 Defecation often difficult due to supine position making it

impossible to contract needed muscles

 Raise head of bed if possible to enhance ability to defecate

o Pain

 Hemorrhoids, rectal surgery, rectal fistulas, and abdominal surgeries

result in discomfort so patients try to suppress urge to defecate to avoid

pain leading to constipation

o Pregnancy

 As fetus size increases, more pressure is exerted on rectum

 Fetus can cause obstruction which impairs passage of feces

 Peristalsis slowed in 3

trimester which can lead to constipation

 P eg a t o a ’s f e ue t st ai i g du i g defe atio a d deli e a

result in hemorrhoids

o Surgery and anesthesia

 General anesthetic agents cause temporary cessation of peristalsis

 Patients with local or regional anesthetic are less at risk for elimination


 Any surgery involving direct manipulation of bowels stops peristalsis

temporarily (paralytic ileus)

 Lasts 24-48 hrs

o Medications

 Promote defecation or control diarrhea

 Prescribed medications for acute or chronic conditions often have

se o da effe ts o patie t’s o el eli i atio patte s

 Laxatives and cathartics soften stool and promote peristalsis

 Laxatives are milder in action

 When used correctly both can maintain normal elimination


 Chronic use of cathartics causes large intestine to become less

responsive to stimulation by laxatives

 Overuse of laxatives can cause serious diarrhea leading to

dehydration and electrolyte depletion

 Mineral oil decreases fat soluble vitamin absorption

 Laxatives can influence efficacy of other meds by altering transit


o Diagnostic tests

 Often require bowel preparation to ensure bowel is empty

 Patients cannot eat or drink for hours for procedures like endoscopy and

 Following diagnostic procedures change in elimination such as increased

gas or loose stool often occur

 Common bowel elimination problems

o Constipation

 A symptom, not a disease

 Infrequent stool and/or hard, dry, small stools that are difficult to


 Causes are improper diet, reduced fluid intake, lack of exercise, and

certain meds

 Signs of constipation are infrequent BMs less than every 3 days, difficulty

passing stools, excessive straining, inability to defecate at will, and hard


 Can cause rectal pain

 Too much straining can cause sutures to open

o Impaction

 Results from unrelieved constipation

 A collection of hardened feces wedged in rectum that a person cannot


 If not resolved or removed can lead to intestinal obstruction

 Patients who are debilitated, confused, or unconscious are most at risk

 Obvious sign is inability to pass a stool for several days despite repeated

urge to defecate

 Suspect impaction when a continuous oozing of diarrhea stool occurs

 Loss of appetite, N/V, abdominal distention and cramping, and rectal pain

accompany the condition

 Gently palpate for the impacted mass

o Diarrhea
 An increase in the number of stools and the passage of liquid, unformed


 Contents passed too fast through the small and large intestines

diminishing absorption of fluids and nutrients

 Irritation within colon results in mucus secretion making feces watery

and patient is unable to control urge to defecate

 Excess loss of colonic fluid results in serious fluid and electrolyte or acid-

base imbalance

 Infants and older adults are particularly susceptible

 Meticulous skin care is necessary to avoid breakdown

 Antibiotic use can alter normal flora

 Patients receiving enteral nutrition also at risk for diarrhea

 Food allergies and intolerances increase peristalsis and cause diarrhea

 Surgeries or diagnostic testing of lower GI tract can cause diarrhea

 To treat, remove precipitating condition and slow peristalsis

 Foodborne pathogens also cause diarrhea

 When diarrhea is result of foodborne pathogen, get rid of pathogen

rather than slow peristalsis

o Incontinence

 Inability to control passage of feces and gas from anus

 Can harm body image

 Can lead to social isolation

 Physical conditions impairing anal sphincter function or control cause


 Using anal bag or bowel management system aids in preventing skin


o Flatulence

 Accumulation of gas in the intestines causing walls to stretch

 Common cause of abdominal fullness, pain, and cramping

 Escapes through mouth or anus

 If intestinal mobility is reduced, it causes abdominal distention and

severe sharp pain

 Some causes:

 Opiates

 General anesthetics

 Abdominal surgery

 Immobilization

 Hemorrhoids

 Dilated, engorged veins in the lining of the rectum

 External or internal

 External are protrusions of skin

 If underlying vein is hardened, there is purplish discoloration


 Causes increased pain and often needs to be excised

 Internal hemorrhoids have outer mucous membrane

 Increased venous pressure from straining at defecation,

pregnancy, heart failure, and liver disease cause hemorrhoids

 Bowel diversions

o Temporary or permanent artificial openings in abdominal wall known as stomas

o Created in ileum (ileostomy) or colon (colostomy)

o The standard bowel diversion creates a stoma or patient has reconstructive

bowel surgery using native sphincter for bowel continence

o Ostomies

 Location determines consistency of stool

 Ileostomies have liquid

 Colostomies of ascending colon also liquid

 Transverse colostomy has more solid and more formed stool

 Sigmoid colostomy has near normal stool

 3 types of colostomy construction

o Loop colostomy

 Performed in medical emergency when HCPs

anticipate closure

 Temporary large stoma in transverse colon

 2 openings through 1 stoma

 Proximal end drains stool

 Distal end drains mucus

 External supporting device temporarily placed to

keep loop colostomy from slipping back

 Within 7-10 days supporting device removed by


o End colostomy

 Consists of 1 stoma formed from proximal end of

bowel with distal portion of GI tract removed or

sewn closed

 Usually result of surgical treatment of colorectal


 Rectum usually removed

 Patients with diverticulitis who are treated

surgically often have temporary end stoma with

Ha t a ’s pou h

o Double-barrel colostomy

 Surgeon divides intestine and brings both proximal

and distal ends through abdominal incision

 Small incision made in proximal stoma for fecal


 Distal stoma leads to inactive intestine and left


 When intestinal injury has healed, colostomy is

reversed and divided ends are anastomosed to

restore intestinal integrity

o Alternative approaches

 Ileoanal pouch anastomosis

 Used in patients who need colectomy for treatment of ulcerative

colitis or familial polyps

 Surgeon removes colon and creates pouch from end of small

intestine and attaches pouch to anus

 Pouch provides for collection of waste material

 Patient is continent because stool is evacuated via anus

 Patient will have temporary ileostomy to allow anastomosis to


 Kock continent ileostomy

 Continent ileostomy created usi g patie t’s s all i testi e,

changing its cylindrical shape into spherical reservoir

 Pouch has continent stoma drained with external catheter which

the patient places intermittently in stoma

 Macedo-Malone antegrade continence enema (MACE)

 Improves continence in patients with fecal soiling associated with

neuropathic or structural abnormalities of anal sphincter

 Procedure isolates 3 cm flap on left colon

 Foley catheter placed on surface of flap creating tubular passage

which produces continence valve mechanism

 Surgeon takes distal end of tube and makes v-shape to skin flap
 Enema administration begins 7-10 days after surgery and patients

receive enemas daily

o Psychological considerations

 Stoma can cause serious body image changes

 Provide emotional support before and after surgery

 A well-pla ed sto a should ot i te fe e ith patie t’s a ti ities a d

should be able to conceal it with clothing

 Many patients have difficulty maintaining or initiating sexual relations

 Foul odors, or spillage or leakage of liquid stools and inability to regulate

BMs cause patients to lose self-esteem

 Aging process often affects ability to manage stomas

 Refer patients to ostomy support groups

 Nursing process: Assessment

o Patients expect nurse to answer questions regarding diagnostic tests and

preparation for these tests

o Some elderly patients who fail to recognize their own elimination needs may

need monitoring for elimination patterns

o Co side patie t’s ultu al p efe e es a d p a ti es

o Nursing history

 What a patient describes as normal or abnormal is often different from

factors and conditions that tend to promote normal elimination

 Ide tif i g o al a d a o al patte s, ha its, a d the patie t’s

perception of normal and abnormal with regard to bowel elimination

allows you to a u atel dete i e a patie t’s p o le s

 Determine usual elimination pattern

 Frequency and time of day

 Patie t’s des iptio of usual stool ha a te isti s

 Stool is normally watery or formed, soft or hard

 Typical color

 Presence of blood

 Have patient describe shape of stool

 Number of stools per day

 Identification of routines followed to promote normal elimination

 Drinking hot liquids

 Eating specific foods

 Taking time to defecate during certain part of the day

 Assessment of use of artificial aids at home

 Enemas

 Laxatives

 Bulk-forming food additives

 Presence and status of bowel diversions

 Frequency of fecal drainage

 Character of feces

 Appearance and condition of stoma

 Type of fecal collection device

 Methods used to maintain function of ostomy

 Changes in appetite

 Eating patterns

 Weight change

o Planned or unplanned

 Diet history

 Preferences

 Intake of fruits, veggies, cereals, and breads

 Irregular or regular meal times

 Description of daily fluid intake

 Amount and type of fluid

 History of surgery or illness affecting GI tract

 Medication history

 Laxatives, antacids, iron, or analgesics

 Emotional state

 History of exercise

 History of pain or discomfort

 Type, frequency, and location

 Social history

 Living arrangements

 Shared bathroom?

 Safe ambulation to toilet?

 If not independent, who helps?

 Mobility and dexterity

 Need for assistive devices?

o Physical assessment

 Mouth

 Poor dentition can influence ability to chew

 Sores in mouth can make eating painful

 Abdomen

 Assess all 4 quadrants for contour, shape, symmetry, and skin


 Observable peristalsis is sign of intestinal obstruction

 Assess for abdominal distention

 Auscultate abdomen

o Normal bowel sounds occur every 5-15 secs

o Note character and frequency of bowel sounds

o Hear increase or tinkling sound with abdominal distention

o No sounds with paralytic ileus

o Hyperactive bowel sounds occur with small intestine

obstruction and inflammatory disorders

 More than 35 in 1 min

 Percuss abdomen

o Masses, tumors, or fluid make flat sound

 Palpate abdomen

o Assess for tenderness

o Make sure patient relaxes

 Rectum

 Inspect for lesions, discoloration, inflammation, and hemorrhoids

o Laboratory tests

 Fecal specimens

 Nurse needs to make sure labeled correctly in appropriate

containers and transferred to lab on time

 Use medical aseptic technique

 Wear clean gloves

 If patient can obtain specimens, let them do it themselves

 Teach patient to avoid mixing it with urine or water

 Only need small amount of stool for occult blood tests

 Tests for measuring fecal fat output requires 35 day stool


 Some tests need stool to be warm such as those for ova or


 Fecal occult blood tests

o Can be performed at home by patient or at bedside by


o Measures microscopic amount of blood in feces

o Useful screening for colon cancer

o 3 types

 Most common is GUAIAC fecal occult blood test

 Immunochemical fecal occult test

 Stool deoxyribonucleic acid test

o Repeat tests 3 times while patient refrains from ingesting

foods and medications because they cause false positives

 Fecal characteristics

 Reveals info about elimination alterations

 Color

o Normal for infant is yellow

o Normal for adult is brown

 Odor

o Pungent affected by food type

 Consistency

o Soft formed

 Frequency

o Infant is 4-6 times daily if breastfed

o Infant is 1-3 times daily if bottle fed

o Adult is daily or 2-3 a week

 Amount

o 150 g/day

 Shape

o Should resemble diameter of rectum

 Constituents

o Undigested food

o Dead bacteria

o Fat

o Bile pigment
o Cells lining intestinal mucosa

o Water

o Diagnostic examinations

 Moderate sedation used by many facilities

 Most common type are benzodiazepines and opiates

 Crash cart must be present if these are used

 Vitals are taken usually every 15 minutes

 See Box 46-6

 Nursing Diagnosis and planning

o Bowel incontinence

o Constipation

o Risk for constipation

o Perceived constipation

o Diarrhea

o Toileting self-care deficit

o The Agency for Healthcare Research and Quality (AHRQ) provides guidelines on

reduction of pressure ulcers that can also help you develop a plan of care for

patients with bowel incontinence

o Associated problems such as age, body image changes, or skin breakdown

require interventions unrelated to bowel function

o When planning care, synthesize info from multiple sources

o P ote t patie t’s ski , p o ote o ti e e, a d edu e e a ass e t

o Help patients establish goals by incorporating own elimination habits or routines

as much as possible

o Overall goals

 Patient to set regular defecation habits

 Patient is able to list proper fluid and food intake needed to achieve

bowel elimination
 Patient implements regular exercise program

 Patient reports daily passage of soft-formed, brown stool

 Patient does not report discomfort associated with defecation

o Include family in plan of care if patient debilitated

o Can delegate assisting patients onto bedpan or bedside commode to NAP

o Make sure NAP reports any abnormalities or difficulties during defecation

 Implementation

o Teach patient and family about proper diet, adequate fluid intake, and factors

stimulating or slowing peristalsis such as emotional stress

o Health promotion

 Promotion of normal defecation

 Establish routine an hou afte a eal o ai tai patie t’s outi e

 Patient needs to know when urge to defecate normally occurs

 Offer bedpan or help to bathroom in timely manner

 Provide privacy

 Patients more able to relax if they know interruptions will not occur

 Always place all light a d toilet tissue ithi patie t’s ea h

 When patients are at risk for fall, stand near them or open door slightly

to see them at all times

o Promotion of normal defecation

 Sitting position

 Assist patients who have difficulty sitting

 Place elevated seat on toilet when patients are unable to lower


 Positioning on bedpan

 Shallow end of pan goes under buttocks toward sacrum

 Deeper end with handle goes under thighs

 Prevent muscle strain and discomfort

 Never try to lift patient onto bedpan

 Be sure patient is positioned high in bed

 Raise patie t’s ed a out deg ees

 Always wear gloves

 Immobilized patients

o Lower head of bed flat and help patient roll onto one side

o Apply small amount of powder to back and buttocks or

cover bedpan edge with tissue to prevent skin from

sticking to bedpan

o Place bedpan firmly against buttocks

o Keeping one hand against bedpan place other hand on

patie t’s fo ehip a d ask patie t to oll a k o to edpa

o Raise head of bed 30 degrees

o Place rolled towel or pillow under lumbar curve

o Ask patient to bend knees if possible

o Privacy

 Maintain patient privacy

 When patient finishes respond to call light immediately

 Provide assistance wiping if necessary

 Clean perineum front to back

 Assess stool and immediately empty contents

 Offer bedpan often

 Warn patients of risk of falls or accidents

o Acute Care

 Cha ges i patie t’s fluid status, o ilit status, ut itio , a d sleep

cycle affect regular bowel habits

 Re ai se siti e to patie t’s eli i atio eeds a d i te e e to help

them maintain as normal bowel elimination habits as possible

 Medications

 Cathartics, laxatives, and occasionally an enema are used to

resolve constipation

 Antidiarrheal preparations help patient resolve diarrhea

 Caution patients not to use OTC medications on prolonged basis

without consulting HCP

 Cathartics and laxatives

o Prescribed for bowel evacuation for patients undergoing

GI tests and abdominal surgery

o Cathartics are stronger

o Oral tablets, powder, and suppository forms

 Oral route is most common

 Suppository is more effective

o Cathartic suppositories work within 30 minutes

o Older adults often get strong urge to defecate with


o Excessive use increases risk for diarrhea and abnormal

bowel elimination

 Antidiarrheal agents

o Imodium is OTC agent commonly used to relieve diarrhea

o Most effective are prescribed opiates such as codeine

phosphate, opium tincture, and diphenoxylate (Lomotil)

 Decrease intestinal muscle tone to slow passage of


 Inhibit peristaltic waves

 Increase segmental contractions that mix intestinal

contents which results in more water absorption

 Use with caution because opiates are habit forming

 Enemas

o Instillation of solution into sigmoid colon

o Stimulates peristalsis to promote defecation

o Volume of fluid instilled breaks up fecal mass, stretches

rectal wall, and initiates defecation reflex

o Enemas also vehicle for medications that exert local effect

on rectal mucosa

o Indications

 Temporary relief of constipation

 Removing impacted feces

 Emptying bowel before diagnostic tests or surgery

 Beginning a program of bowel training

o Cleansing enema

 Promote complete evacuation of feces from colon

 Stimulate peristalsis through infusion of large

volumes of fluid or local irritation of mucosa

 Infants and children receive only normal saline

 Tap water

 Hypotonic and exerts osmotic pressure

lower than fluid in interstitial places

 Infused volume stimulates defecation

before large amounts of water leave bowel

 Do not repeat tap water enemas because

water toxicity or circulatory overload occurs

if body absorbs large amounts of water

 Normal Saline

 Safest solution

 Stimulates peristalsis
 Does not create danger of excess fluid


 Hypertonic solutions

 Pulls fluid out of intestinal spaces which

causes distention and promotes defecation

 Patients unable to tolerate large amounts of

fluid benefit most from this enema

 Contraindicated for patients who are


 Should use hypertonic solution of 120-180


 Commercially prepared Fleet enema is most


 Soap suds enema

 Add soap suds to tap water or saline to

create effect of intestinal irritation which

promotes peristalsis

 Use only pure castile soap that comes in

liquid form

 Use with caution in pregnant women and

older adults because they cause electrolyte

imbalance or damage to intestinal mucosa

 HCP orders either high or low cleansing enema

referring to height of which it is hung

 High enemas cleanse entire colon

 After infusion ask patient to turn from left lateral

to dorsal recumbent position and then over to right

lateral positon to ensure enema reaches large


 Low enemas only cleanse rectum and sigmoid


o Oil retention

 Lubricate rectum and colon

 Feces absorb oil and become softer

 Patient retains enema for several hours if possible

o Other types of enemas

 Carminative

 Provide relief form gaseous distention

 Medicated

 Contain drugs

 Kayexalate

o used to treat patients with

dangerously high serum potassium


 Neomycin solution

o Reduces bacteria in colon before

bowel surgery

o Enema administration

 Sterile technique unnecessary

 Explain procedure

 Precautions to avoid discomfort

 Length of time necessary to retain solution before


 E e as u til lea ea s e e a ad i iste ed

until fluid comes out without feces

 If it takes more than 3 times, check agency


 Giving enema to patient unable to control external

sphincter poses difficulty

 Give this enema while patient on bedpan

o Digital removal of stool

 Cannot be delegated

 Must e pe ph si ia ’s o de

 Only used if enemas fail

 Break it up with fingers and pull it out in sections

 Last resort for constipation

 HCP order required to remove impaction

 Very uncomfortable and can cause bleeding and

stimulation of vagus nerve which results in reflex

slowing heart rate

o Inserting and maintaining a nasogastric tube

 NG tube is pliable, hollow tube inserted into stomach

 Purposes

 Decompression

 Enteral feeding

 Compression

 Lavage

 Large bore tubes

 12 French and above

 Usually for gastric decompression or removal of gastric secretions

 Small bore tubes

 For medication administration and enteral feeding

 Salem sump tube

 Used for stomach decompression

 2 lumena

o One for removal of gastric contents

o The other used for irrigant

 Never clamp off air vent, connect it to suction, or use it for


 No sterile technique

 Procedure uncomfortable

 Help patient relax

 Consistently assess condition of naris and mucosa for


 Change tape daily

 Patient must breathe through mouth so frequent mouth care

helps prevent dehydration and should be done every 2 hours

 Can provide ice bag to external throat if irritated

 Maintain patency

o Regular irrigation

o Flush with NS to clear blockages

o Any change in position requires verification of placement

in GI tract

 Can cause distention

o Turning patient frequently can help

o Continuing and restorative care

 Care of ostomies

 Individual with ostomy wears pouch to collect effluent which is

stool discharge from stoma

 Meticulous skin care is needed

 Irrigating colostomy

o Never use enema set to irrigate colostomy

o Need special cone-tipped irrigator to prevent bowel

penetration and back flow

o Before irrigating stoma, place irrigating sleeve over stoma

o End of sleeve extends into bowl of commode

o Typically use 500-700 mL of tap water for adult

o Irrigation takes 5-10 minutes and then remove lubricated

cone-tip and wait 30-45 minutes for solution and feces to

drain out of irrigation sleeve

o Once pouch stops, patient applies stoma cap or pouch

 Pouching ostomies

o An effective pouching system protects the skin, contains

fecal material, remains odor free, and is comfortable and


o Would ostomy contents nurse is specially trained to pick

out right pouch

o So e pou hi g s ste s atta h to patie t’s ski a d othe s

are non-adhesive

o Assess stoma color and normal is bright pink or brick red

 Nutritional considerations

 Consume low fiber for the first weeks, particularly patients with


o Low fiber foods

 Bread

 Noodles

 Rice

 Cream cheese

 Eggs not fried

 Strained fruit juices

 Lean meats

 Fish

 Poultry

o As ostomies heal, high fiber

 Fresh fruits and veggies to ensure more solid stool

 Eat slowly and chew food completely

 Drink 10-12 glasses of water daily

 Patient may choose to avoid gassy foods

 High fiber foods causing problems

o Stringy meats

o Mushrooms

o Popcorn

o Fruits such as cherries

o Some seafood such as crab and shrimp

 Avoid foods that cause gas and odor

o Broccoli

o Cauliflower

o Dried beans

o Brussel sprouts

 Bowel training

 Helps some patients defecate normally

 Attempts for patients to defecate at same time each day

 Successful program includes

o Assessing normal elimination pattern and record times

patient is incontinent

o Choose ti e i patie t’s patte to i itiate defe atio

control measures

o Give stool softeners orally every day or cathartic

suppository at least an hour before selected defecation


o Offer hot drink or fruit juice

o Help patient to toilet at designated time

o Avoid opioids

o Provide privacy and setting time limit for defecation

o Instruct patient to lean forward at hips while defecation,

apply manual pressure with the hands over abdomen, and

bear down but do not strain

o Do not criticize or convey frustration if patient cannot


o Maintain normal exercise

 Maintenance of proper fluid and food intake

 High fiber for patients with constipation

 Low fiber with diarrhea

 Excessively hot or cold fluids stimulate peristalsis causing

abdominal cramps and further diarrhea

 Promotion of regular exercise

 Walking, riding a stationary bike, or swimming stimulates


 Ambulate a surgery patient as soon as possible

 Exercises for patients on bedrest

o Lie supine and tighten abdominal muscles and hold them

on the count of 3. Repeat 5-10x as tolerated

o Flex and contract thigh muscles by raising one knee slowly

towards chest. Repeat for each leg at least 5x and increase

frequency as tolerated

 Hemorrhoids
 Main goal is to have soft-formed painless bowel movements

 Need proper diet, exercise, and fluids

 Ice pack or warm sitz bath provides temporary relief for swollen


 Skin integrity

 Liquid stool is acidic and contains digestive enzymes

 Repeated wiping can irritate skin

 Protect anal areas with petrolatum, zinc oxide, or other ointments

 If yeast infection develops, use antifungal agent instead of baby

powder or corn starch

 Evaluation

o Evaluate level of knowledge regarding normal elimination pattern, caring for

ostomy, and promoting skin integrity

o Ask the follo i g uestio he patie t’s out o e ot et

 Do you use medications such as laxatives or enemas to help you


 What barriers are preventing you from eating a diet high in fiber and

participating in regular exercise?

 How much fluid do you drink in a typical day? What types of fluids do you

normally drink?

 What challenges do you encounter when you change your ostomy



Nursing Process


Includes an in-depth history of a patient's normal and present cardiopulmonary function, past
impairments in circulatory or respiratory functioning, and methods that a patient uses to optimize


History includes allergies

Through the Patients Eyes

Establish realistic, short-term outcomes that build to a larger goal

Nursing History


Cardiac pain does not occur with respiratory variations

Pericardial pain results from inflammation of the pericardial sac, occurs on inspiration,

and does not usually radiate

Pleuritic chest pain is peripheral and radiates to the scapular regions; associated with




Clinical sign of hypoxia

Orthopnea is an abnormal condition in which a patient uses multiple pillows when

reclining to breathe easier or sits leaning forward with arms elevated



Productive vs. non and other characteristics (color, odor)

Hemoptysis (bloody sputum)

Determine if it is associated with coughing and bleeding from the upper

respiratory tract, sinus drainage, or gastrointestinal tract (hematemesis)


Environmental or geographical exposures

Environmental exposure to inhaled substances is closely linked with respiratory



Respiratory infections


Health risks

Familial risk factors

Infectious diseases



Physical Examination


Kussmaul respiration - increase in rate and depth of respiration

Apnea - the absence of respirations for a period of time

Cheyne-Stokes respiration - occurs when there is decreased blood flow or injury to the


Deep, shallow, and apnea breathing




Diagnostic Tests

TB test screening

Blood specimens




Activity intolerance

Decreased cardiac output


Impaired gas exchange

Impaired spontaneous ventilation

Impaired verbal communication

Ineffective airway clearance

Ineffective breathing pattern

Ineffective health maintenance

Risk for aspiration

Risk for imbalanced fluid volume

Risk for infection

Risk for suffocation


Goals and outcomes

Setting priorities

Teamwork and collaboration


Health promotion


Healthy lifestyle

Proper diet, reduce stress, exercise, maintain a body weight in proportion to their

high, eliminate tobacco, reduce pollutants, monitor air quality and adequately hydrate

Environmental pollutants

Second hand smoke

Acute care

Dyspnea management

Pharmacological measures: bronchodilators, inhaled steroids, mucolytics, and low-

dose antianxiety medications

Oxygen therapy

Physical techniques: cardiopulmonary reconditioning, relaxation techniques,

biofeedback and meditation

Psychosocial techniques

Airway maintenance

Hydration and coughing

Mobilization of pulmonary secretions

Nursing interventions promoting removal of pulmonary secretions assist in achieving

and maintaining a clear airway and help to promote lung expansion and gas exchange


The color consistency and ease of mucus expectoration determine adequacy of


Humidification - process of adding water to gas

Nebulization - adds moisture or medications to inspired air by mixing particles of varying

sizes with the air

Coughing and Deep-breathing techniques

Diaphragmatic breathing/belly breathing is a technique that encourages deep

breathing to increase air to the lower lungs

Deep breathing opens the pores of Kohn between alveoli to allow sharing of oxygen

between alveoli

Coughing techniques include deep breathing and coughing for the postoperative

patient, cascade huff, and quad coughing

Cascade cough: the patient takes a slow, deep breath and holds it for 2 seconds

while contracting expiratory muscles; then performs a series of coughs

Huff cough: stimulates a natural cough reflex and is generally effective only for

clearing central airways

Quad cough: for patients without abdominal muscle control; while the patient

breaths out the nurse pushes inward and upward on the abdomen

Chest physiotherapy - group of therapies for mobilizing pulmonary secretions

Postural drainage

Chest percussion


This is recommended for patients who produce greater than 30mL of sputum per day

or have evidence of atelectasis on chest x-ray examination

Suctioning techniques

When suctioning you apply negative pressures (not greater than 150 mm Hg) during

withdrawal of the catheter, never on insertion

Too frequent suctioning puts patients at risk for development of hypoxemia,

hypotension, arrhythmias, and possible trauma to the mucosa of the lungs

Oropharyngeal and nasopharyngeal - when the patient is able to cough effectively but

unable to clear secretions by expectorating

Orotracheal and nasotracheal - the patient is unable to manage secretions by

coughing and does not have an artificial airway present

Tracheal - performed through suctioning an artificial airway

Open - new sterile catheter for each session

Closed - closed off, used for patients who require mechanical ventilation

Artificial airways - used for patients with a decreased level of consciousness or airway

obstruction and aids in removal of tracheobronchial secretions

Oral airway - prevents obstruction of the trachea by displacement of the tongue into

the oropharynx

Endotracheal and tracheal airway

Endotracheal tube is a short-term artificial airway to administer mechanical
ventilation, relieve upper airway obstruction, protect against aspiration, or clear


Tracheostomy is a long-term assistive device

Usually cannot speak

Maintenance and promotion of lung expansion



The 45 degree semi-Fowlers is the most effective position to promote lung

expansion and reduce pressure from the abdomen on the diaphragm

In most cases, position the patient with the good lung down; in the presence of

pulmonary abscess or hemorrhage, position the patient with the affected lung

down to prevent drainage toward the healthy lung

Incentive spirometry - encourages patients to use visual feedback to maximally inflate

their lungs and sustain that inflation

Noninvasive ventilation

The purpose of noninvasive positive-pressure ventilation is to maintain a

positive airway pressure and improve alveolar ventilation

This prevents or treats atelectasis by inflating the alveoli, reducing
pulmonary edema by forcing fluid out of the lungs back into circulation,

and improving oxygenation in those with sleep apnea

Continuous positive airway pressure

Bilevel positive airway pressure

Chest tubes - a catheter inserted through the thorax to remove air and fluids from the

pleural space, to prevent air or fluid from reentering the pleural space, or to

reestablish normal intrapleural and intrapulmonic pressures

Uses collection, water seal, and suction control

A constant or intermittent bubbling in the water-seal change indicates a leak in

the drainage system

A chest tube is only clamped when replacing the chest drainage system,

assessing for an air leak, or during removal

Maintenance and promotion of oxygenation

Oxygen therapy

Use safety precautions when oxygen is in use

Supply of oxygen

Oxygen tanks

Permanent wall-pipes oxygen systems

Oxygen concentrators

Refillable cylinders

Regulators are in place

Methods of oxygen delivery

Nasal cannula

Oxygen masks

Simple face mast (35-50%)

Plastic face mask with a reservoir bag

Partial rebreather mask (40-70%)

Non-rebreather (60-80%)

Venturi mak (24-60%)

Home oxygen therapy

An arterial partial pressure of 55 mm Hg or les

An arterial saturation of 88% or less

Oxygen delivery systems: gas cylinders, liquid oxygen, and oxygen concentrators

Restoration of cardiopulmonary functioning

If a patients hypoxia is severe and prolonged, cardiac arrest results

Cardiopulmonary Resuscitation (CPR)

Chest compression, Airway, Breathing

The critical initial elements found to be essential for survival were chest

compressions and early defibrillation

Restorative and continuing care

Cardiopulmonary rehabilitation - helps patients achieve and maintain an optimal level of

health through controlled physical exercise, nutrition counseling, relaxation and stress-

management techniques, and prescribed medications and oxygenation

Respiratory muscle training

Incentive spirometer resistive breathing device

Breathing exercises

Pursed-lip breathing - prolonged expiration through pursed lips to prevent alveolar


Diaphragmatic breathing - this improved efficiency of breathing by decreasing air

trapping and reducing the WOB


Through the patients eyes

Evaluate the patient's motivation and emotional readiness to adhere to treatments


Patient outcomes