Health Assessment Exam 3 Module 8—Nursing Process 1, SBAR, Documentation: Be able to identify each step of the nursing process, what is unique about each step? Assessment Focuses on the patient’s response to the health problem Systematic and continuous collection, analysis, validation, communication of patient data ○ Data reflect how health functioning is enhanced by health promotion or compromised by illness/injury Distinguishing normal from abnormal findings and identifying the risks for abnormal findings Primary source of information is the patient Characteristics of Assessments Purposeful Prioritized (If someone is having difficulty breathing, respiratory assessment will be priority over them being sad) Complete Systematic Factual, accurate Relevant Recorded in standard manner Health Assessment Exam 3 Types of Assessments Comprehensive Initial Assessment Performed shortly after patient is admitted to facility Purpose: establish complete database for problem identification and care planning Focused Assessment Nurse gathers data about specific problem that has already been identified Routinely part of ongoing data collection Purpose: identify new or overlooked problems Quick Priority Assessments (QPA): short, focused, prioritized, “Flag” existing problems and risks Emergency Assessment Patient in physiological/psychological crisis Purpose: identify life-threatening problems Time-Lapsed Compares patient’s current status to the baseline data obtained earlier Purpose: reassess health status, make necessary revisions in plan Patient-Centered Assessment Method (PCAM) Used to assess patient complexity using social determinants of health Purpose: discover factors that are affecting person’s ability to manage health Be able to identify the difference between subjective and objective data. Understand how to plan assessments based on identification of priorities Objective Data Subjective Data Observable and measurable data Can be seen, heard, or felt by someone other than the person experiencing them Information perceived only by the affected person Elevated temperature, skin moisture, vomiting Pain experience, feeling dizzy, feeling anxious Health Assessment Exam 3 Establishing Assessment Priorities Are there any aspects of this person to their life/needs that are going to affect how we proceed with our assessment and with our plan of care? ❏ Health orientation ❏ Developmental stage ❏ Culture ❏ Need for nursing Be aware of the importance and relevance of nursing diagnosis. How does it differ from medical diagnosis? Nursing Assessments Focuses on patient’s response to health problem Take what was done from medical assessment and continue to assess to see how patient is doing, do we need to make any changes/are there any problems Medical Assessments Look at the patient as a “problem”/as a disease, what labs/tests need to be ordered Target data pointing to pathologic conditions Health Assessment Exam 3 What are different types of nursing diagnoses, actual, risk, etc.? Types of Nursing Diagnoses Problem-Focused Actual nursing diagnosis Ex: Acute pain Something that is actually happening Most of the time this is the priority because it’s an actual problem Risk Ex: Risk for Falls Health Promotion Readiness for enhanced coping or readiness for enhanced breastfeeding **Actual problems take priority over risk for potential problems Be able to correctly write all types of nursing diagnoses Additional Nursing Diagnoses 1-Part Nursing Diagnosis 2-Part Nursing Diagnosis “Health promotion” nursing diagnosis “Risk for” nursing diagnosis ALWAYS A 2 PART because we don’t have the evidence yet Includes: One part statement Includes: Diagnostic Label + Validation for Risk (Why is this a risk?) Examples: Readiness for enhanced breastfeeding Rape trauma syndrome” Readiness for enhanced coping Examples: Risk for infection RELATED TO compromised post-defenses Just a statement - NO EVIDENCE Risk for falls RELATED TO patient’s confusion (or patient’s dizziness) Risk for injury RELATED TO abnormal blood profile Don’t put medical diagnosis 3-Part Nursing Diagnosis ACTUAL nursing diagnosis Includes: Diagnostic label + contributing factor (related to) signs & symptoms + objective/subjective data (as evidenced by) PES FORMAT: - Problem - Etiology - Signs/symptoms Examples: Acute pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest” Impaired physical mobility related to dec muscle control AEB inability to control lower extremities Be able to make a goal for a patient based on the nursing diagnosis. What is included in the goal, how is it written and how is it evaluated? Health Assessment Exam 3 Making a Goal Based on Nursing Diagnosis 1st Part of the Nursing Diagnosis (Problem Statement) - Identifies the unhealthy response or problem - Indicates what should change → suggests patient goals/outcomes - What are expectations for change? - If patient is at risk for infection, we don’t want infection 2nd Part of Nursing Diagnosis (Etiology) - Identifies factors causing or contributing to undesirable response and preventing desired change → Suggests nursing interventions Writing Patient-Centered Measurable Outcomes Outcomes should include: ● Subject: the patient or some part of the patient ● Verb: action the patient will perform ○ Examples: demonstrate, identify, describe, apply ● Conditions: particular circumstances by which outcome should be achieved ● Performance criteria: expected patient behavior or other manifestation described in observable, measurable terms ● Target time: when the patient is expected to be able to achieve the outcome ○ Realistic, actual date, or other statement indicating time ○ Before discharge, after viewing film, whenever observed Mnemonic for writing goals/outcomes: S - specific M - measurable A - attainable R - realistic T - time-bound Health Assessment Exam 3 Be able to identify well written vs incorrectly written patient goals Well-Written Patient Goals Incorrectly Written Patient Goals “Mr. Myer will drink 60 mL fluid every 2 hours while awake, beginning 2/24/20.” “Offer Mr. Myer 60-mL fluid every 2 hours while awake” “After attending the infant care class, Mrs. Gaston will correctly demonstrate the procedure for bathing her newborn.” “Mrs. Gaston will know how to bathe her newborn.” “During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL.” “At the next visit 12/23/20, the patient will correctly demonstrate relaxation exercises” Know when to report significant patient data, SBAR S - Situation B - Background A - Assessment R - Recommendation Know how to determine interventions for patients. ● Act in partnership with patient/family ● Before implementing, reassess if action is still needed ● Modify interventions according to patient’s ○ Developmental/psychosocial background ○ Ability and willingness to participate in care plan ○ Responses to previous nursing measures Health Assessment Exam 3 Be aware of how to identify assessment vs planning vs interventions, vs an other part of nursing process Know how and why to evaluate an intervention. Why is this important? ● The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions ● Nurse and patient measure how well the patient has achieved outcomes specified in the care plan ● Identifies factors that contribute to patient’s ability to achieve expected outcome, modifies the care plan if needed Elements of Evaluation ● Identifying evaluative criteria & standards ○ Criteria: measurable qualities, attributes or characteristics that specify skills, knowledge, health status ■ Describe acceptable levels of performance by stating expected behaviors of nurse or patient ○ Standards: levels of performance accepted and expected by nursing staff ■ Established by authority, custom, or consent ● Collecting data to determine if criteria and standards are met ● Interpreting and summarizing findings ● Documenting judgment ● Terminating, continuing, modifying the plan Be aware of Maslow’s hierarchy of needs 1. Physiologic needs (COME FIRST) a. Highest priority problem IS A PHYSIOLOGIC ONE 2. Safety needs 3. Love and belonging needs 4. Self-esteem needs 5. Self-actualization needs Health Assessment Exam 3 Module 10--Respiratory Assessment, Oxygen therapy, Respiratory medications: Be able to to describe the respiratory anatomy and physiology and the roles of the respiratory system to oxygenation. ● The diaphragm is the primary muscle of the respiratory system ○ Sternocleidomastoid, scalenes, intercostal muscles assist with breathing but are not the primary muscle Inhalation Chest EXPANDS Diaphragm CONTRACTS Alveolar System Alveoli is the site of gas exchange Oxygenates venous blood Removes carbon dioxide from blood Exhalation Chest CONTRACTS Diaphragm RELAXES Cardiovascular System Vital for gas exchange Carry nutrients/wastes to/from body cells Heart & Blood vessels Upper Chambers (atria) RECEIVE blood from the VEINS (superior/inferior vena cava & L/R pulmonary veins) Lower Chambers (Ventricles) force blood OUT of the heart through the ARTERIES (L/R pulmonary arteries and the aorta) Health Assessment Exam 3 Upper Airway Function: warm, filter, humidify inspired air Components: Nose, Pharynx, Larynx, Epiglottis Lower Airway Function: conduction of air, mucociliary clearance, production of pulmonary surfactant Components: Trachea, R/L mainstem bronchi, segmental bronchi, terminal bronchioles Lungs Lungs are the main organs of respiration Extend from the base of the diaphragm to the apex above the first rib Right lung has 3 lobes Left lung has 2 lobes (because the heart is on the left side) Composed of elastic tissue (alveoli, surfactant, pleura) Alveoli → site of GAS EXCHANGE Pulmonary Ventilation (Breathing) Movement of air into and out of the lungs Inspiration (Inhale) Expiration (Exhale) ACTIVE phase of ventilation PASSIVE phase of ventilation Movement of muscles/thorax to bring air into Movement of air OUT of the lungs the lungs Health Assessment Exam 3 Process of Ventilation (Breathing) 1. 2. 3. 4. Diaphragm contracts and descends, lengthening thoracic cavity External intercostal muscles contract, lifting the ribs upward and outward Sternum is pushed forward, enlarging the chest from front to back Increased lung volume + decreased intrapulmonic pressure allow air to move from an area of greater pressure (outside lungs) to lesser pressure (inside lungs) 5. Relaxation of structures results in expiration Gas Exchange (Respiration) Refers to intake of oxygen & release of carbon dioxide Made possible by respiration and perfusion Occurs via diffusion (movement of oxygen and carbon dioxide between the air and blood) Be knowledgeable of nursing strategies to promote adequate oxygenation and identify rationale Promoting Proper Breathing Deep breathing → keeps the air going into the lungs, keeps alveoli expanded, prevents alveolar collapse (use for patients who just had surgery or someone who is not ambulating) Using incentive spirometry → keeps the air going into lungs, keeps alveoli expanded, prevents alveoli from collapsing (use for patients who just had surgery or someone who is not ambulating) Pursed-lip breathing → can settle down an exacerbation Diaphragmatic breathing → provides optimal lung expansion Health Assessment Exam 3 Be knowledgeable of age related differences and changes that influence the care of patients with respiratory disorders. Normal Age-Related Variations Infant/Child ● LOUDER breath sounds on auscultation ● More RAPID RESPIRATORY RATE (until 8-10 years old) ● Use of abdominal muscles during respiration INFANT: Crackles heard at end of deep respiration are NORMAL Older Adult ● Increased anteroposterior chest diameter ● Increase in dorsal spinal curve (kyphosis) ● Decreased thoracic expansion ● Use of accessory muscles to exhale **Older adults have an INCREASED risk for disease ESPECIALLY PNEUMONIA** Health Assessment Exam 3 Know respiratory assessment and what tools are used to assess patients. Know the how’s, what’s and the why’s of respiratory assessment and techniques Respiratory Assessment Inspection → Palpation → Percussion → Auscultation Health History Data - May elicit a health problem (dyspnea, chest pain, sleeping patterns, cough, sputum) - Hx of smoking indicates need to stop smoking in care plan - Environmental exposures (smoke, paint, pollution) increase r/o cancer Physical Examination - Provides data on structures of thorax, respiratory effort, chest expansion, breath sounds - Requires stethoscope & watch - Observe chest for color, shape/contour, breathing patterns - Palpation detects areas of sensitivity, vibrations - Auscultation detects airflow within respiratory tract Normal Breath Sounds Bronchial or Tubular - Blowing, hollow sounds, auscultated over larynx & trachea Bronchovesicular - Medium-pitched, medium intensity, blowing sounds, auscultated over first and 2nd interspaces anteriorly & scapula posteriorly Vesicular - Soft, low-pitched, whispering sounds, heard over most of lung fields Health Assessment Exam 3 Know the difference between normal respiration and when a patient is experiencing changes in respiratory status. Inspiration/Expiration evenly spread out Height of each curve is the same throughout Anything smaller → shallow Anything higher → deep breathing Tall peak because someone took a DEEP breath Brady → slow breathing Height within normal range but long space in between each breath Tachy → fast breathing Height within normal range but short space between each breath Seen prior to someone’s passing Times of rapid/deep breathing followed by short time of apnea (not breathing at all) Seen with COPD/Emphysema patients Inspiration is normal but expiration is prolonged Health Assessment Exam 3 What causes different lung sounds, what is peak flow, what is oxygen saturation, how do we deliver oxygen therapy to patients- nebs, metered dose inhalers, oxygen therapy etc Be aware of breath sounds, normal and abnormal Abnormal Breath Sounds Wheeze (Sibilant) Musical or squeaking High-pitched continuous sounds Auscultated during inspiration and expiration Cause: air passing through narrowed airways Rhonchi (Sonorous Wheeze) Sonorous/course, snoring quality Low-pitched, continuous sounds Auscultated during inspiration and expiration Coughing may clear the sound somewhat Cause: air passing through or around secretions Crackles Bubbling, crackling, popping Low to high pitched, discontinuous sounds Auscultated during inspiration and expiration Cause: opening of deflated small airways and alveoli; air passing through fluid in the airways Stridor Harsh, loud, high pitched Auscultated on INSPIRATION Cause: narrowing of upper airway (larynx or trachea); presence of foreign body in airway; obstruction Friction Rub Rubbing or grating Loudest over lateral anterior surface Auscultated on inspiration and expiration Cause: Inflamed pleura rubbing against chest wall Health Assessment Exam 3 Peak Expiratory Flow Rate Point of HIGHEST flow during FORCED expiration Reflexed changes in the size of pulmonary airways Measured using a flow meter Used for patients with asthma to measure severity of the disease Oxygen Saturation (SpO2) is a measurement of the percentage of hemoglobin molecules carrying a full load of oxygen Useful for monitoring patients receiving oxygen therapy, monitoring those at risk of hypoxia, monitoring postoperative patients Desaturation indicates gas exchange abnormalities (considered a late sign of respiratory compromise in patients w/ reduced rate & depth of breathing) Bronchodilators Open narrowed airways Nebulizers Disperse fine particles of liquid medication into the deeper passages of the respiratory tract Metered-Dose Inhalers Deliver a controlled dose of medication with each compression of canister Dry powder inhalers Breath-activated delivery of medications Oxygen Delivery Systems Nasal Cannula Most commonly used oxygen delivery device Does not affect eating, easily used at home 1-6 L/min Simple Mask 5-8 L/min Monitor pt to check mask placement NRB Mask 10-15 L/min Make sure reservoir bag collapses only slightly during inspiration Check valves/flaps functioning properly Venturi Mask 4-6 L/min Check that intake valves are not blocked Health Assessment Exam 3 Module 11—Elimination, Nutrition, Enteral Feeding: 1. Review your abdominal assessment, know the order of assessment. Be aware of why the order of this assessment is different that other body systems Abdominal Assessment Inspection → auscultation → percussion → palpation Percussion and palpation are done AFTER auscultation because they stimulate bowel sounds ALWAYS AUSCULTATE BEFORE PALPATING Auscultation: Warm stethoscope Light pressure Diaphragm on RLQ → RUQ → LUQ → LLQ Bowel sounds occur every 5-34 seconds Normoactive (normal), Hypoactive, hyperactive, absent, infrequent BEFORE DOCUMENTING BOWEL SOUNDS AS ABSENT → LISTEN FOR 2 MIN EACH QUADRANT Health Assessment Exam 3 2. Be familiar with different types of diets and when each type is appropriate. Be aware of how diets progress Therapeutic Diets DIABETIC Consistent Carbohydrate Diet INDICATIONS: Type 1 & Type 2 diabetes, gestational diabetes, impaired glucose tolerance Total daily carbohydrate content is consistent Calories based on attaining/maintaining a healthy weight High-fiber, high heart healthy fats Limit sodium/saturated fats Fat-Restricted Diet INDICATIONS: CVD (prevent atherosclerosis), chronic cholecystitis (gallbladder inflammation) Low-fat diets lower patient’s total fat intake High-Fiber Diet Emphasis on increased intake of foods high in fiber (fruits, INDICATIONS:prevent/treat vegetables) constipation, IBS, diverticulosis Low-Fiber Diet INDICATIONS: before surgery, ulcerative colitis, diverticulitis, Crohn’s disease Fiber limited to < 10 g/day CARDIAC Sodium-Restricted Diet INDICATIONS: HTN, heart failure, acute/chronic renal disease, liver disease Sodium limit may be set at 500-3,000 mg/day Renal Diet INDICATIONS: nephrotic syndrome, chronic kidney disease, diabetic kidney disease Reduce workload on kidneys to delay or prevent further damage Control accumulation of uremic toxins Protein restriction, sodium restriction, potassium and fluid restrictions dependent on patient Health Assessment Exam 3 Modified Consistency Diets Clear Liquid Diet INDICATIONS: prep for bowel surgery/endoscopy, acute GI disorders, post-op diet Only clear liquids/foods (can see through the light) that become fluid at body temp Requires minimal digestion, leaves minimal residue Clear broth, coffee, tea, clear juices (apple, cranberry, grape), popsicles, Jell-O Pureed Diet INDICATIONS: after oral/facial surgery, chewing/swallowing difficulties “Blenderized liquid diet” liquids and foods blended to liquid food All food allowed Mechanically Altered Diet INDICATIONS: Chewing/swallowing difficulties, after surgery to head/neck/mouth Regular diet with modifications for texture (Excludes most raw fruits/vegetables, foods with seeds and nuts) Foods are chopped, ground, mashed, soft Health Assessment Exam 3 3. Be familiar with different types of enteral feeding and why each is appropriate – PO, NGT, Jtube, etc Nasogastric (NG) Tube Short-Term Short term use ONLY For a few days Inserted through nose → into stomach Patient at risk for aspiration Confirm NG Feeding tube placement by: Radiographic examination (with x-ray)*GOLD STANDARD* - Measurement of aspirate pH and visual assessment of aspirate (to see if they’re metabolizing food) - Measurement of tube length and marking (mark tube to make sure tube isn’t moving) Nasointestinal (NI) Tube (Short Term) Passed through nose into upper portion of small intestine INDICATION: pt w/ increased r/o aspiration due to diminished gag reflex or slow gastric motility, delayed gastric emptying, gastric tumor Gastrostomy/Jejunostomy GTUBE/JTUBE (Long Term) Long-period use Tube placed through an opening into the stomach GTUBE Preferred route to deliver enteral nutrition to comatose patient 4. Be aware of nursing considerations for each type of feeding Feeding Nursing Considerations N-Tube Administer oral hygiene frequently (2-4 hrs), have patient rinse mouth Keep nares clean, use lubricant Throat lozenges to prevent irritation from tube in throat Enteral Feeding Pumps Check tube placement Check gastric residual before each feeding or every 4-6 hours during continuous feeding Make sure patient is upright as possible Keep head of bed elevated at all times during administration Elevate 1 hour after to prevent reflux Health Assessment Exam 3 5. Be aware of how to troubleshoot feeding tubes- what steps can nurses take Potential Complication Interventions Pt complains of nausea after feeding Ensure head of bed remains elevated & suction is at bedside Consider notifying PCP for an antiemetic Clogged tube Use warm water/gentle pressure to remove clog To prevent clogs: ensure adequate flushing for each feeding GTUBE leaking large amount of drainage Apply gentle pressure to tube Ensure balloon is inflated properly Skin irritation on insertion site Can indicate gastric fluids may be leaking from site causing skin breakdown Stop the leakage, apply a skin barrier Ensure skin is kept dry Nasal erosion w/N-TUBE Check nostrils every shift for signs of pressure Clean/moisten nares every 4-8 hours Aspiration Give small, frequent feedings Elevate HOB at least 30-45 degrees during feeding, 1 hour after Avoid oversedation of patient Check residual 6. Be aware of difference between continuous vs intermittent feedings- what are recommendations for each type CONTINUOUS Check residual, confirm placement of tube every 4-6 hours, document volume on intake/output, patient’s response Hang a water bag A continuous tube automatically provides a 25 mL flush every hour & removes the need to do it by hand Elevate head at least 30 degrees INTERMITTENT Use this if the pump isn’t working, will take about 1 hour Adjust the feed about 12 inches above patient’s stomach Flush with 30 mL water before/after feed Have patient sit upright 30-60 min Health Assessment Exam 3 7. Know how to check for initial placement of feeding tube vs before each subsequent feeding ● Check initial placement of feeding tube by x-ray ● Before each subsequent feeding: ○ Measure length of exposed tube & document measurement ○ Mark the exit site of feeding tube and observe for a change in tube length ○ Observe for a change in volume of fluid aspirated ■ Sharp increase in volume may indicate displacement of tube ■ Consistent inability to withdraw fluid may indicate displacement ○ Test pH and appearance of aspiration if feedings have been off for at least 1 hour ■ pH less helpful for continuous feedings because nutritional formula buffers pH of GI secretion 9. Be able to assess urinary and bowel elimination Bowel Elimination Assessing - Collect data on hx current/past problems, stool patterns - Pertinent patient history, physical assessment, diagnostic studies - Stool Characteristics - Volume, color, odor, consistency, shape, constituents Urinary Elimination Assessing - Collect data on voiding patterns, habits, difficulties, hx of current/past urinary problems - Assess bladder and urethral meatus, assess skin integrity/hydration, examine the urine - Correlate findings with results of diagnostic tests/procedures for examining urine and urinary tract Urine Characteristics - Color, odor, turbidity (should be clear), pH, specific gravity (density of particles in urine), constituents (urea, creatine, sodium, potassium) Health Assessment Exam 3 10. Be knowledgeable of I&O’s Intake/Output Desirable amount of fluid intake/loss ranges from 1,500-3,500 mL each 24 hours Most people average 2,500-2,600 mL per day 60-80 oz (1.8-2.4 L) of fluid daily prevents constipation Intake should normally be approximately balanced by output or fluid loss If the intake is less than output or if the output is MORE than the intake → think DEHYDRATION. The patient is losing too much fluids compared to what they are taking in. If the intake is more than output or if the output is LESS than the intake → think that the patient may be retaining fluid and is in FLUID OVERLOAD! 11. What is normal urinary output, what is normal bowel elimination? Mass Peristalsis (contractions of digestive system) - occur 1-4 times every 24 hours 12. What can you teach patients with regard to urinary elimination, incontinence, diarrhea and constipation in your patients Incontinence ● Incontinence is the inability of anal sphincter to control the discharge of fecal material ● Can be related to dementia, confusion, neurologic conditions, depression, aging, childbirth ● Regular toileting and cleaning ● Keep skin dry and use skin barriers ○ Patients are at risk for skin breakdown due to pH of stool ○ Use skin barrier cream so you don’t have to scrub stool off skin ■ Should never have to scrub the area if you’re using cream ● Change bed linens as often as necessary ● Avoid use of briefs ○ Patient’s tend to be in them longer than they should be ■ R/o further skin breakdown and infection/UTI Health Assessment Exam 3 Urinary Elimination ● Promote fluid intake ● Assist patient to void when patient first feels urge to void ○ Routinely delaying urination may result in difficulty initiating a stream and/or urinary stasis → UTIs ● Seek medical assistance for any change in urine characteristics or pain upon urination Diarrhea ● Diarrhea is the passage of more than 3 loose stools a day ● Acute diarrhea ○ May result from viral/bacterial infection, reaction to medication, alterations in diet ○ Sudden onset ● Chronic Diarrhea ○ Lasts more than 3-4 weeks ○ Crohn’s disease, IBS, tumor, infection, surgery, laxative abuse ● Focus on nursing care is to eliminate the causes of diarrhea and replacing lost fluids and treating the symptoms ○ Water, bouillon, clear soup, gelatin ○ Adults at increased risk of dehydration ● Avoid highly spiced foods/foods with laxative effects ○ Fruits/vegetables ○ Dairy ● Alterations in fluid/electrolyte imbalance occur faster and more often in infants and children compared to adults Health Assessment Exam 3 13. Be aware of different types of urinary incontinence Types of Urinary incontinence Transient Mixed Appears suddenly Lasts 6 months or less Urine loss with features of two or more types of incontinence Overflow Overdistention and overflow of bladder Functional Caused by factors outside the urinary tract (caused by impaired mobility, impaired cognition, inability to communicate; loss of control b/c toilet is not accessible) Reflex Emptying of the bladder without sensation of need to void (caused by damage to motor and sensory tracts in lower spinal cord secondary to trauma) Total Continuous, unpredictable loss of urine Stress** Involuntary loss of urine related to an increase in intra-abdominal pressure (peeing when you laugh → happens to women who just gave birth due to weakening of perineal and sphincter muscles) 14. Know how to collect urine samples ● Measuring urine output in patients who are continent ○ Ask patient to void into bedpan, urinal, container ○ Put on gloves, pour urine from collection device into appropriate measuring device ○ Place a calibrated container on a flat surface for an accurate reading, note the amount of urine voided and record it in the patient's record. ○ Discard urine in toilet unless specimen is required 15. What is 24 hour urine, when and how is it collected? 24-Hour Urine Specimens** Collect all urine voided in a 24-hour period Health Assessment Exam 3 16. What can cause diarrhea or constipation, are there age related changes? Risk factors for each Developmental Considerations Infants Characteristics of stool/frequency depend on formula or breast feedings Toddler Physiological maturity is the first priority for bowel training Child/Adolescent/Adult Defecation patterns vary in quantity, frequency, rhythmicity Older Adult Constipation often chronic problem; diarrhea and fecal incontinence may result from physiologic or lifestyle changes Factors Affecting Bowel Elimination Constipating Foods - Cheese, lean meat, eggs, pasta Foods with laxative effect - Fruits/Veggies, bran, chocolate, alcohol, coffee Gas-Producing Foods - Onions, cabbage, beans, cauliflower Individuals at High Risk for Constipation Patients on bedrest taking constipating medicines (opioid/pain meds, post-surg patients) → encourage ambulation, fluids, fiber in diet, administer stool softener Patients with reduced fluids or bulk in their diet Patients who are depressed Patients with CNS disease or local lesions that cause pain while defecating Nursing Measures for Patients with Diarrhea Answer call bells immediately Remove cause of diarrhea whenever possible (medication/antibiotic that is causing diarrhea → call prescriber) If there is impaction, notify physician Hold medication dose if patient has diarrhea and is prescribed a laxative Health Assessment Exam 3 17. Be knowledgeable of all types of enemas, why they are used and how they work Cleansing Enemas *Insert tube 3-4 in. and angle toward the navel Used to remove feces & relieve constipation MOST COMMON SOLUTIONS: - Tap water (hypotonic) → distends intestine, increases peristalsis, softens stool - Normal saline (isotonic) → distends intestine, increases peristalsis, softens stool - Soap → Distends intestine, irritates intestines which stimulates peristalsis & softens - Hypertonic → draws fluid out of interstitial space → leads to distention, stimulates peristalsis (small volume) - Oil → lubricates stool & intestinal mucosa, patient may need to hold solution for 30-60 min (small volume) Retention Enemas Oil: Lubricate the stool and intestinal mucosa, easing defecation Carminative: help expel flatus from rectum Medicated: provide medications absorbed through rectal mucosa Anthelmintic: destroy intestinal parasites Enema Considerations When administering an enema, assess for cramping, dizziness, or pain. Enema may stimulate a vagal response which increases parasympathetic stimulation which causes a decrease in HR. Dizziness and bradycardia take priority. *Noninvasive procedures take precedence over invasive procedures
