Laboratory
Results:
Lab
WBC
RBC
Hgb
Hct
MCV
Platelets
Glucose
BUN
Creatinine
Sodium
Potassium
Client Value Normal Value H/L
4.8-10.8
4.7-6.1
14-18
42-52%
82-92
130-400
70-109
8-25
0.7-1.3
135-145
3.5-5
Interpretation
Bowel Obstruction
Causes:
* Hernia, Strangulation, fistula
* Perforated Bowel, complete
blockage
* Peritonitis, cancer, IBD, Crohn’s
*Hemorrhage, PUD,
ileostomy, colostomy
* Ileus. Impaction, necrosis,
Surgical Procedure/Treatments:
NG tube for Suctioning/decompression to prevent aspiration, Fluid resuscitation, Enemas, Surgical interventions
(Stents to open blockages, Ileostomy/colostomy, Resection)
Pathophysiology/Clinical Manifestations:
A bowel obstruction happens when the small or large intestine is
partly or completely blocked. The blockage prevents food, fluids,
and gas from moving through the intestines in the normal way
possibly from a blockage caused by tumors, scar tissue, or
twisting or narrowing of the intestines. In the small intestine, scar
tissue is most often the cause.
Other causes include hernias and Crohn's disease, which can twist
or narrow the intestine, and tumors, which can block the intestine.
A blockage also can happen if one part of the intestine folds like a
telescope into another part, which is called intussusception. In the
large intestine, cancer is most often the cause. Other causes are
severe constipation from a hard mass of stool,and narrowing of the
intestine caused by diverticulitis or inflammatory bowel disease.
Medications:
- IV Resuscitation: NS or LR
- ABx: gram (-) or anaerobic
Cefazolin (Ancef)-cephalosporin
- Analgesic:
Morphine Sulfate (MS Contin)
- Antiemetic:
Promethazine (Phenergan)
Ondansetron (Zofran)
Diagnostics/Labs:
V/S & Nursing Physical Assessment, ABGs-Acid/Base balance (R/T: N/V/D), CBC, CMP, WBC w/ DIFF, Chem Panel, UA, BUN,
Serum, Creatinine, Lactate dehydrogenase tests (tissues damage), Abd. X-Ray (may show blockages in sm or lrg intestines),
CT Scan to detect blockages, Ultrasound, Type & Cross match for surgical intervention, R/O hepatic obstruction with AST, ALT,
Occult blood- stool sample, Stool culture, 12 Lead ECG R/T arrhythmias Secondary to Electrolyte imbalances.
ND 1: Deficient Fluid Volume
R/T vomiting and decreased
fluid absorption in colon
secondary to Bowel Obstruction
AEB low blood pressure,
increased HR, decreased
urinary output, decreased skin
turgor, dry mucous membranes,
and change in LOC.
ND#1 Goals:
STG: Client will be A&Ox4 by noon.
LTG: Client will be increasing
urinary output to at least 30ml/hr
by end of shift.
ND 2: Risk for Aspiration R/T
entry of secretions from gastric
acid into lungs secondary to
Bowel Obstruction.
ND 3: Nausea R/T wavelike
sensation in back of throat,
epigastrium, or throughout the
abdomen with or without
vomiting secondary to Bowel
Obstruction AE sour taste in
mouth, reports of being “sick to
stomach”, aversion to food, and
increased salivation.
ND#2 Goals:
STG: Client will state 2 ways to
ND#3 Goals:
STG: Client will verbalize1 way to
prevent aspiration by noon.
decrease noxious stimuli that cause
nausea by noon.
LTG: Client will maintain a
patent airway by end of shift.
LTG: Client will report elimination of
nausea by end of shift.
Interventions
STG:
Interventions
STG:
Interventions
STG:
* Obtain a patient history to ascertain
the probable cause of the fluid
disturbance. R: Such information can
help guide interventions. Causes may
include acute trauma and bleeding,
reduced fluid intake from changes in
cognition, large amount of drainage
after surgery, or persistent
diarrhea/vomiting.
* Monitor and document BP & HR.
R: Reduction in blood volume can
cause hypotension/tachycardia.
*Monitor for changes in mental status.
R: Dehydration may alter mental status,
esp in older adults. May include:
restlessness, anxiety, lethargy, and
confusion.
*Monitor active fluid loss from wound
drainage, tubes, diarrhea, bleeding,
vomiting, insensible loss and maintain an
accurate I & O record. R: Fluid loss can
cause decreased fluid volume and
dehydration.
*Monitor V/S and temp. R: Febrile states
decrease body fluids through perspiration
and increased respirations.
* Monitor LOC. R: A decreased LOC is a
prime risk factor for aspiration.
*Assess the presence of cough and gag
reflexes. R: The lungs are normally
protected against aspiration by reflexes
such as cough and gag.
*Evaluate swallowing ability by assessing
for the following: Coughing, choking,
throat clearing, gurgling or “wet” voice
during or after swallowing. If there is
residual food after eating. Regurgitation of
flood/fluid through nares. R: Impaired
swallowing increases r/f aspiration.
*Auscultate bowel sounds to evaluate
bowel motility, and assess for and
distention and firmness. R: Decreased GI
motility increase r/f aspiration.
*Assess for presence of N/V. R: N/V
increases risk, pt should get antiemetics to
prevent gastric regurg.
* Assess the cause of the Nausea. R:
Determining the cause will guide the choice
of interventions, such as removing stimulus.
*Assess the nausea characteristics: Hx,
duration, Freq, Severity, Precipitating factors,
Medications, Measures to alleviate the
problem. R: A comprehensive assess. Of the
nausea can help determine interventions or
alleviate problems.
*Keep an emesis basin within easy reach of
the Pt. R: N is often associated with V.
*Offer or assist with oral hygiene Q2-hrs. R:
N is often related to anorexia and increased
salivation. Oral hygiene helps promote
comfort
*Remove noxious odors from the room. R:
Strong or noxious odors can promote nausea.
LTG:
* Assess skin turgor and mucous
membranes for signs of dehydration. R:
Loss of interstitial fluid causes loss of
skin turgor. Skin turgor assessed over
the sternum or forehead is best.
*Assess the color and amount of urine.
Report urine output of less than 30mls/hr
for 2 consecutive hours. R: Concentrated
Urine denotes fluid deficits.
*Monitor serum electrolytes and urine
osmolality, and report abnormal values.
R: Elevated BUN suggest fluid deficit.
Urine specific gravity is likewise
increased.
*Insert IV catheter and maintain IV access.
R: Parental fluid replacement is indicated
to prevent or treat hypovolemic
complications.
*Administer parental Fluids as ordered.
R: Fluids are needed to maintain
hydration states.
LTG:
* Assess for S/S of aspiration by
auscultation of breath sounds for
development of wheezes or crackles.
Monitor CXR as ordered. R: Aspiration
can occurs with sm amounts. CXR will
show infiltrates.
*Pts with NG Tubes or gastronomy tubes:
check placement before feeding, using
tube markings, x-ray study, pH of gastric
contents, and color of aspirate as guides.
R: A displaced tube can tube feeding into
airway.
*Keep suction available and use as
needed. R: Tracheal suction may be
needed to maintain an airway.
*Position Pts with decreased LOC
supine on side. R: Rescue positioning
decreases r/f aspiration.
*Elevated HOB 30-45 degrees. R:
Upright positioning reduces r/f
aspiration by decreasing gastric reflux.
LTG:
* Maintain fluid balance for pts at risk for
nausea. R: Adequate hydration before surgery
or Chemo reduces nausea.
*Teach pt to use nonpharmacological nausea
control techniques: relaxation, guided
imagery, music therapy, distraction, deep
breathing. R: helps patient manage their
nausea.
*Administer Antiemetic’s as ordered. R:
Antiemetic’s raise threshold of
chemoreceptor trigger zones to stimulation.
*Teach pt to change positions slowly.
Sudden or gross movement can increase
nausea.
*Teach patient to avoid greasy, fried, or spicy
foods. R: These foods exacerbate nausea.
DIABETES
Pathophysiology
Diabetes mellitus is a syndrome with
disordered metabolism and inappropriate
hyperglycemia due to either a deficiency of
insulin secretion or a combination of
insulin resistance and inadequate insulin
secretion to compensate. Type I diabetes
is due to pancreatic islet B cell destruction
predominantly by an autoimmune process,
and these persons are prone to
ketoacidosis, while type 2 diabetes is the
more prevalent form and results from
insulin resistance with defect in
compensatory insulin secretion.
Treatments and Medication:
Glimepiride, metformin, repaglinide,
Nateglinide, Acarbose, Actos, Avandia,
Javia, Humalog. Lantas Insulin Therapy,
diet changes and exercise.
Diagnostics and Labs
Hemoglobin AIC test, Glycated
hemoglobin tests. Fasting plasma
glucose (FPG), Random plasma
glucose (RPG)
Nursing Interventions
Assess for signs of hyperglycemia, Assess blood
glucose level before meals and at bedtime. Assess
for signs of avoidance to learn. Identify client's
support person that may need information about the
planned diabetes regimen Set up patient witch a
dietician to promote healthier diet. Patient Education
Patient Education
Teach Pt proper way to give and store insulin.
Provide written information or guidelines and selfleaning modules, especially about the proper diet
essential for diabetic patients
Provide positive reinforcements and evaluate the
learning of skills
Educate about nearby community resources or
support groups
Expected Outcomes
Improved nutritional status, maintenance of integrity
Ability to perform basic diabetes self-care skills
Patient maintains normal glucose levels
RISK FACTOR
URINARY CATHETER
USAGE PREGNANCY
PREMATURE
NOWBORNS
DM
NEUROGENIC
BLADDER
SEXUAL INTERROUSE
LOWER URINARY TRACK INFECTION
Bacteria is introduced. Pathogens ascends
through the urethra toward bladder colonizing in
the urethra (urethritis), Bladder (cystitis), or
prostate (prostatis)
Bacteria multiply and overwhelms the hosts defense system
reproducing rapidly by uropathic bacteria attracting to the
uroepithelium. These bacteria such as E. Coli have pili
adhesions that allow them to bind to mucosal cellular receptors
and enter uroepithelial cells and resist flushing during
urination.
Labs and
diagnostics:
-urine dipstick
and microscopy
Urine culture of
fresh urine
McCance, K.L,&
Huther, S.E. (2005).
Pathophysiology: the
biologic basis for
disease in adults and
children (5th ed.) St.
Louis, MO: Elsevier
Mosby.
Hasdungan, A (2019).
UTI. Retrived from
https://armandoh.org/
October 17. 2019.
Bacteria
KEEPS
Keisiella
E. coli
Enterobacteria
Proteus
Staph
Inflammatory response and Neutrophil infiltration promoting
inflammation and edema in the bladder wall, which
discharge stretch receptors.
Pathogens use enzymes to reduce nitrate to
nitrite
Pathogens ascends toward kidney and
colonizes and spreading infection.
Dissemination also occurs by way of
bloodstream.
Upper Urinary tract infection
(Pyelonephritis)
Medullary infiltration of WBC with renal
parenchyma and capsule inflammation, renal
edema, necrosis of renal papillae. Cytokines
released systemically
Bacteremia
Bacteria spread to circulation via renal
vein and leads to septic shock if left
untreated
Treatment: -3 to 4 week’s
microorganism specific Antibiotic
Lots of fluid
-Dysuria
-Frequency
-Urgency
Treatment:
3 to 7 days
Microorganism
Specific
antibiotic
Hematuria Foul
smelling urine
(+) bacterial
culture
Increase WBC
(+) Nitrites
-Malaise
Fever
vomiting
Rigors
Flank Pain