40
Fluid, Electrolyte, and Acid–Base
Balances
Canadian content written by, Darlaine Jantzen RN, MA, PhD
Original chapter by, Linda Felver RN, PhD
OBJECTIVES
Mastery of content in this chapter will enable you to:
• Define the key terms listed.
• Describe the distribution, composition, movement, and regulation of body fluids.
• Describe the regulation and movement of major electrolytes.
• Describe the processes involved in regulating acid–base balance.
• Describe common fluid, electrolyte, and acid–base imbalances, and identify related risk
factors.
• Choose appropriate clinical assessments for fluid, electrolyte, and acid–base balances.
• Interpret basic fluid, electrolyte, and acid–base laboratory values.
• Identify and discuss nursing interventions for patients with fluid, electrolyte, and acid–base
imbalances.
• Discuss the purpose of, and procedure for, initiating, maintaining, and discontinuing
intravenous therapy and peripheral vascular access devices.
• Discuss the purpose and nursing care related to central vascular access devices, including
preventing and recognizing associated complications.
• Discuss complications associated with intravenous therapy.
• Discuss the purpose of, and procedure for, initiating a blood transfusion and interventions to
manage transfusion reaction.
KEY TERMS
Active transport, p. 1017
Aldosterone, p. 1019
Anion gap, p. 1026
Anions, p. 1016
Antidiuretic hormone (ADH), p. 1019
Arterial blood gas (ABG), p. 1024
Autologous transfusion, p. 1065
Base excess, p. 1025
Buffer, p. 1021
Cations, p. 1016
Central vascular access devices (CVADs), p. 1038
Colloid osmotic pressure, p. 1017
Colloids, p. 1038
Concentration gradient, p. 1017
Crystalloid, p. 1038
Dehydration, p. 1019
Diffusion, p. 1017
Edema, p. 1018
Electrolytes, p. 1016
Electronic infusion devices (EIDs), p. 1053
Extracellular fluid (ECF), p. 1016
Filtration, p. 1018
Fluid volume deficit (FVD), p. 1028
Fluid volume excess (FVE), p. 1038
Hemolysis, p. 1065
Homeostasis, p. 1018
Hydrostatic pressure, p. 1018
Hypercalcemia, p. 1024
Hyperchloremia, p. 1024
Hyperkalemia, p. 1024
Hypermagnesemia, p. 1024
Hypernatremia, p. 1023
Hypertonic, p. 1052
Hypocalcemia, p. 1024
Hypochloremia, p. 1024
Hypokalemia, p. 1023
Hypomagnesemia, p. 1024
Hyponatremia, p. 1023
Hypotonic, p. 1052
Hypovolemia, p. 1019
Infiltration, p. 1064
Insensible water loss, p. 1018
Interstitial fluid, p. 1016
Intracellular fluid (ICF), p. 1016
Intravascular fluid, p. 1016
Ions, p. 1016
Isotonic, p. 1052
Metabolic acidosis, p. 1026
Metabolic alkalosis, p. 1027
Obligatory water loss, p. 1018
Osmolality, p. 1017
Osmolarity, p. 1052
Osmoreceptors, p. 1019
Osmosis, p. 1017
Osmotic pressure, p. 1017
Oxygen saturation, p. 1025
Peripheral vascular access devices (PVADs), p. 1038
Peripherally inserted central catheter (PICC), p. 1038
Phlebitis, p. 1064
Respiratory acidosis, p. 1025
Respiratory alkalosis, p. 1025
Sensible water loss, p. 1018
Solutes, p. 1016
Solution, p. 1017
Solvent, p. 1017
Total parental nutrition (TPN), p. 1038
Transcellular fluid, p. 1016
Transfusion reaction, p. 1065
Vascular access devices (VADs), p. 1038
Fluid, electrolyte, and acid–base balances within the body are essential for
normal body function (Box 40-1). These balances are maintained by ingestion,
distribution, and excretion of water and electrolytes and by respiration.
Within the body, these balances are maintained by the renal, pulmonary, and
buffer systems. Imbalances may be caused by many factors, including altered
intake, illness, or excessive losses, such as exercise-induced diaphoresis.
These imbalances affect physiological processes at the cellular, tissue, and
system levels of the body; therefore, understanding the mechanisms that
contribute to fluid, electrolyte, and acid–base balances is essential to nursing
practice.
Box 40-1
Case Study
Sidney Runs
Sidney is a nursing student who is active in sports and exercise. Sidney has
become aware that fluid, electrolyte, and acid–base balance is critical to
healthy exercise. In the midst of studying for a biology exam, Sidney decides
to go for a long run. The weather is warm, with a brisk breeze. Sidney
decides to study while running. Sidney remembers that fluid, electrolyte,
and acid–base balance in the human body is the result of feedback loops and
concentration gradients. After a few minutes, Sidney starts to sweat, a great
deal. This water needs to be replaced, either before or after the run, or both.
It is possible that Sidney will need to drink an extra 3–4 litres, based on
increased loss of fluid through breathing and sweating. Sodium also needs
to be replaced, because sweat contains salt. Awareness that replacing water
is not enough in the context of strenuous exercise, particularly when the
environment is hot, has led to a market full of sports drinks. Amazingly,
though, most of the time Sidney's body maintains homeostasis through
normal physiology and diet, with the addition of some water. The muscles
need calcium to work effectively. The exercising muscles increase the acids in
the blood. Sidney remembers that acid–base balance is constantly being
maintained by buffers, lungs, and kidneys. By the time Sidney returns from
the run, normal physiology has responded with necessary changes, in order
to provide the muscles and cardiovascular system with the fluid and
electrolytes necessary, and to excrete excess hydrogen ions.
Scientific Knowledge Base
This section provides a foundation for nurses' critical thinking and nursing
practice. This is intended as a brief overview; anatomy and physiology
textbooks expand on this information.
Water is the largest single component of the body. The average adult male
weight is 60% water; however, this amount varies with age, gender, and body
weight. A healthy, mobile, well-oriented adult can usually maintain normal
fluid, electrolyte, and acid–base balances with renal, hormonal, and neural
functions.
Distribution of Body Fluids
Body fluids are distributed in two distinct compartments, one containing
intracellular fluid and the other containing extracellular fluid. Intracellular
fluid (ICF), or cytosol, includes all fluid within body cells, accounting for
approximately 60% of the body's fluids (Amerman, 2016, p. 986).
Extracellular fluid (ECF), all the fluid outside cells, is divided into three
compartments: interstitial fluid, intravascular fluid, and transcellular fluids.
Interstitial fluid, including lymph, is the fluid between the cells and outside
the blood vessels. Intravascular fluid is blood plasma. Transcellular fluid,
separated from other fluid by epithelium, includes cerebrospinal, pleural,
peritoneal, and synovial fluids and the fluids in the gastrointestinal tract
(Figure 40-1).
FIGURE 40-1
Body fluid distribution.
Composition of Body Fluids
Electrolytes are important solutes in all body fluids. An electrolyte, when
dissolved in an aqueous solution, separates into ions and is able to carry an
electrical current (Amerman, 2016, p. 986). Positively charged electrolytes are
cations (e.g., sodium [Na+], potassium [K+], calcium [Ca2+]). Negatively
charged electrolytes are anions (e.g., chloride [Cl–], bicarbonate [HCO3−],
sulphate [SO4−]). Electrolytes are vital to many body functions.
The body carefully regulates electrolyte concentration (Amerman, 2016, p.
986). The value millimoles per litre (mmol/L) represents the amount of the
specific electrolyte (solute) dissolved in a litre of fluid (solution). The
solution in which a solute is dissolved is called a solvent. Electrolyte
concentration within fluid compartments is influenced by electrical charge.
During normal physiological processes, ions are exchanged for other ions
with the same electrical charge.
Electrolytes are ingested, often in the form of bulk and trace minerals or
salts, and then utilized for basic physiological processes, stored for future
use, or excreted. These electrolytes are important for maintaining osmotic
concentrations in body fluids. They are also necessary for enzyme reactions,
nerve impulses, muscle contraction, and metabolism. In addition, some
minerals contribute to the regulation of hormone production and
strengthening of skeletal structures.
Movement of Water and Electrolytes
Fluids and electrolytes constantly shift between compartments, often across
plasma membranes, to facilitate body processes such as tissue oxygenation,
acid–base balance, and urine formation. The passage of molecules across the
plasma membrane occurs through passive and active transport processes.
Because cell membranes separating the body fluid compartments are
selectively permeable, water can pass through them easily. However, most
ions and others molecules pass through them more slowly. Passive transport
processes include osmosis, diffusion, and filtration.
Osmosis.
Osmosis is the movement of water through a semipermeable membrane
from an area of lesser solute concentration to an area of greater solute
concentration in an attempt to equalize concentrations on both sides of the
membrane (Figure 40-2). A semipermeable membrane allows water to pass
through while remaining impermeable to most solutes. The rate of osmosis
depends on the concentration of the solutes in the solution, temperature of
the solution, electrical charges of the solutes, and differences between the
osmotic pressures exerted by the solutions. The concentration of a solution is
measured in osmols, which reflect the amount of a substance in solution in
the form of molecules, ions, or both. Osmosis is an important concept when
administering intravenous solutions, as their osmolality influences the
potential benefits and risks. Another application of understanding osmosis
is when considering the action of osmotic laxatives. These laxative salts are
poorly absorbed through the intestinal lining and thus draw water into the
intestinal lumen, causing an accumulation of water and softened stool. The
swelling also stretches the intestine, stimulating peristalsis (Burchum &
Rosenthal, 2016, p. 967).
FIGURE 40-2
Osmosis.
Osmotic pressure is the pressure needed to counter the movement of
water (solvent) across a semipermeable membrane from a low concentration
to high concentration of solutes. A solution with a high solute concentration
has a high osmotic pressure and draws water into itself. If the concentration
of the solute is greater on one side of the semipermeable membrane, the rate
of osmosis is faster, and solvent rapidly transfers across the membrane. This
continues until equilibrium is reached.
Plasma proteins affect the blood's osmotic pressure. The three main
classes of plasma proteins are albumins, globulins, and fibrinogen
(Amerman, 2016, p. 725). Because albumin, produced in the liver, makes up
the greatest proportion of plasma proteins, it exerts colloid osmotic pressure
or oncotic pressure. This oncotic pressure tends to keep fluid in the
intravascular compartment by pulling water from the interstitial space back
into the capillaries (see Figure 40-2).
Diffusion.
Diffusion is the movement of ions and molecules in a solution across a
semipermeable membrane from an area of higher concentration to an area of
lower concentration (Figure 40-3). The result is an even distribution of the
solute in a solution. The rate of diffusion is affected by the molecule size,
concentration, and temperature of a solution. The larger the molecule is and
the cooler the solution is, the slower the rate of diffusion is. The difference
between the two concentrations is known as a concentration gradient.
Perfume permeating a room and a drop of food colouring moving through a
glass of water are common examples of diffusion. A physiological example is
the movement of oxygen (O2) and carbon dioxide (CO2) between the alveoli
and blood vessels in the lungs, or the movement of lipids across the cell
membrane. Some diffusion, still a passive transport process, is facilitated
through a channel in the cell membrane (e.g., sodium, potassium, calcium) or
with a carrier (Amerman, 2016, p. 76).
FIGURE 40-3
Diffusion.
Active Transport.
Active transport processes facilitate the movement of molecules (solutes)
across the plasma membrane across a concentration gradient, using chemical
energy (adenosine triphosphate [ATP]). There are two types of active
transport, primary and secondary. In primary active transport, a protein
binds with a solute to carry it against a concentration gradient. There are
three types of pumps: uniport, symport, and antiport (Amerman, 2016, p. 79).
The most commonly discussed primary active transport example, the
sodium-potassium pump (Na+/K+ ATPase), is an antiport pump, as it
transports solutes in opposite directions across the plasma membrane.
Secondary active transport is more complex, as the sodium-potassium pump
uses chemical energy to create a concentration gradient of sodium ions.
Then, using the potential energy and a carrier protein, a sodium ion and a
glucose molecule are transported back into the cell together (Figure 40-4).
FIGURE 40-4 Secondary active transport. A, A Na+/K+ (sodium/potassium) pump creates a
concentration gradient of sodium ions. Left, Na+ ion binds to the Na+/K+ pump. Right, Adenosine
triphosphate (ATP) hydrolysis fuels the transport of Na+ into the extracellular fluid (ECF), against
their concentration gradient. B, A carrier protein uses the potential energy of the sodium ion
gradient to power the transport of glucose. Left, from the ECF, an Na+ and a glucose molecule
bind to another carrier protein. Right, The carrier protein transports the Na+ and glucose
molecule into the cell—the Na+ with its concentration gradient, and the glucose against its
concentration gradient. ADP, Adenosine diphosphate; P, protein. (Redrawn from Amerman, E. C. [2016]. Human
anatomy and physiology [p. 81, Fig. 3.11]. Upper Saddle River, NJ: Pearson Education Inc.)
Filtration.
Filtration, the result of hydrostatic and colloid osmotic pressures, is a passive
process whereby water moves into and out of the capillaries (Amerman, 2016,
p. 690). Hydrostatic pressure is the force exerted by fluids within a
compartment. Hydrostatic pressure in the capillaries is higher at the
arteriolar end (35 mm Hg) than at the venular end (15 mm Hg). While the
colloid osmotic or oncotic pressure remains stable within the capillaries, the
changing hydrostatic pressures in the capillaries result in a pressure
gradient. The combined pressures and the pressure gradient result in a net
filtration pressure (NFP), filtering up to 2 to 4 litres of water per day into the
interstitial fluid (Figure 40-5). Problems occur when hydrostatic pressure is
increased on the venous side of the capillary bed, as occurs in heart failure.
The normal movement of water from the interstitial space into the
intravascular space by filtration is then reversed. This results in an
accumulation of excess fluid in the interstitial space, known as edema.
Filtration is also very important for urine formation as water and solutes are
carried across the wall of the glomerular capillaries by hydrostatic or blood
pressure. Falling blood pressure affects this process.
FIGURE 40-5
Capillary filtration. (From Copstead, L. C., & Banasik, J. L. [2013]. Pathophysiology [5th ed.]. St. Louis: Saunders.)
Fluid Homeostasis
Body fluids are regulated by fluid intake, hormonal controls, and fluid output
in order to maintain homeostasis. Homeostasis is essential for survival. The
primary hormones that regulate fluid are antidiuretic hormone, angiotensin
II, aldosterone, and natriuretic peptides (Amerman, 2016, p. 992).
Fluid Output Regulation.
Fluid output occurs through four organs of water loss: the kidneys, the skin,
the lungs, and the gastrointestinal tract. The kidneys are the major regulatory
organs of fluid balance. They receive approximately 180 L of plasma to filter
each day and produce 1 200 to 1 500 mL of urine (Table 40-1). Each day an
obligatory water loss of approximately 500 mL is essential, regardless of
intake. This is why a person with no fluid intake will die of dehydration
within a matter of days. Sensible water loss includes water loss through
urine and feces.
TABLE 40-1
Healthy Adult Average Fluid Intake and Output
Fluid Intake
Fluids Ingested
Oral
Foods
Metabolism
TOTAL
Fluid Output
S kin (insensible and
sweat)
Insensible lungs
Gastrointestinal
Urine
TOTAL
Normal (per
Day)
Prolonged Heavy Exercise (per Hour)
1 100–1 400 mL
800–1 000 mL
300 mL
2 200–2 700 mL
280–1 100 mL/hr
Highly variable
16–50 mL/hr
300–1 150 mL/hr
500–600 mL
300–2 100 mL/hour
400 mL
100–200 mL
1 200–1 500 mL
2 200–2 700 mL
20 mL/hr
Negligible, unless diarrhea during exerc ise
20–1 000 mL/hr, depending on hydration status
340–3 120 mL/hr
Rehydration with Na+-c ontaining fluid nec essary after prolonged vigorous
exerc ise
Data from Hall, J. E. (2016). Guyton and Hall textbook of medical physiology (13th ed.). Philadelphia:
Saunders; American College of Sports Medicine (ACSM). (2016). Position stand on exercise and fluid
replacement. Medicine & Science in Sports Exercise, 39(2), 377.
Insensible water loss is continuous, gradual loss of water from the
respiratory and skin epitheliums (Amerman, 2016, p. 990). This insensible
water loss may increase in response to changes in respiratory rate and depth.
Water loss from the skin is regulated by the sympathetic nervous system,
which activates sweat glands. Fever may increase insensible water loss.
The gastrointestinal tract plays a vital role in fluid regulation. Every day,
approximately 9 L of fluid is ingested or secreted into the small intestine and
then absorbed into the enterocytes of the small intestine and from the large
intestine. Only approximately 100 mL is lost through the feces, under normal
conditions (Amerman, 2016, p. 889). However, in the presence of a disease
process, for example, diarrhea, the gastrointestinal tract may become the site
of a large amount of fluid loss. This loss may have a significant impact on
maintaining normal fluid homeostasis.
Fluid Intake Regulation.
Fluid intake is regulated primarily through the thirst mechanism. The thirst
control centre is located within the brain's hypothalamus. Osmoreceptors
continually monitor the serum osmotic pressure, and when osmolality
increases, even slightly (2% – 3%), the thirst centre is stimulated (Amerman,
2016, p. 990). An increase in plasma sodium increases the osmotic pressure
and stimulates the thirst mechanism. Increased plasma osmolality can occur
with any condition that interferes with the oral ingestion of fluids or with the
intake of hypertonic fluids. The thirst centre will also be stimulated if plasma
volume decreases, and hypovolemia occurs, as in excessive vomiting and
hemorrhage. In addition, stimulation of the renin–angiotensin–aldosterone
mechanism, potassium depletion, psychological factors, and oropharyngeal
dryness initiate the sensation of thirst.
The average adult's fluid intake is about 2 200 to 2 700 mL per day; oral
intake accounts for 1 100 to 1 400 mL, solid foods for about 800 to 1 000 mL,
and oxidative metabolism for 300 mL daily. Patients must be in an alert state
to maintain their fluid intake independently. Infants, patients with
neurological or psychological problems, and some older persons who are
unable to perceive or respond to the thirst mechanism are at risk for
dehydration.
Hormonal Regulation of Fluid
Antidiuretic hormone (ADH) is stored in the posterior pituitary gland and is
released in response to changes in blood osmolality. The osmoreceptors in
the hypothalamus are stimulated to release ADH when the osmolality
increases. ADH promotes water conservation by acting directly on the renal
tubules and collecting ducts to make them more permeable to water. This, in
turn, causes water to return to the systemic circulation, which dilutes the
blood and decreases its osmolality. As the body attempts to compensate, the
patient will experience a temporary decrease in urinary output. When the
blood has been sufficiently diluted, the osmoreceptors stop the release of
ADH and urinary output is restored. ADH also stimulates the thirst centre to
promote fluid intake (Figure 40-6).
FIGURE 40-6 Hormone-influenced fluid excretion. ADH, Antidiuretic hormone; ANP, atrial
natriuretic peptide; Cl–, chloride; H+, hydrogen ions; H2O, water; K+, potassium; Na+, sodium.
Aldosterone is released by the adrenal cortex in response to increased
plasma potassium or falling sodium levels or as part of the renin–
angiotensin–aldosterone system (RAAS) to counteract hypovolemia. To
resolve hypovolemia, renin is released from the kidney in response to
sympathetic nervous system stimulation and decreased renal blood flow,
initiating a cascade of physiological and endocrine processes, one of which is
the release of aldosterone. Aldosterone acts on the distal portion of the renal
tubule to increase the reabsorption (saving) of sodium and the secretion and
excretion of potassium and hydrogen.
Natriuretic peptides respond to increases in circulating blood volume.
They are released from cardiac muscle cells and act on the peripheral
vasculature, other hormones, and the kidney to facilitate diuresis. Natriuretic
peptides increase sodium excretion and fluid loss while reducing thirst and
blocking the release of ADH and aldosterone.
Regulation of Electrolytes
For normal cell function and human well-being, the body maintains a normal
balance of electrolytes in the ECF and ICF, in spite of changes in intake and
loss. This is accomplished primarily through electrolyte intake, absorption in
the gastrointestinal tract, distribution, and excretion through the kidneys,
feces, and sweat. Distribution is significant to overall electrolyte
homeostasis, as some electrolytes, such as potassium, sodium, calcium, and
phosphate, have very low plasma concentrations compared with cell and
bone concentrations (Hall, 2016). Although fluid and electrolyte balances are
inextricably linked, it is important to explore electrolyte balance separately.
Cations.
Major cations within the body fluids are sodium, potassium, calcium, and
magnesium (Mg2+). Cations interchange when one cation leaves the cell and
is replaced by another. This occurs because cells tend to maintain electrical
neutrality.
Sodium Regulation.
Sodium is the most abundant cation (90%) in ECF and thus exerts the
greatest influence on the ECF osmotic concentration and water balance.
Sodium ions are also major contributors to nerve impulse transmission,
regulation of acid–base balance, and cellular chemical reactions. Normally,
the intake and output of sodium is between 1.2 g and 3.3 g daily. With an
increase in sodium intake and, therefore, an increase in ECF sodium content,
water enters the ECF by osmosis. Therefore, increased sodium intake results
in increased blood volume rather than significant changes in ECF sodium
concentration.
The body continually responds to small changes in sodium content. A
decrease in sodium in the ECF passing through the nephrons stimulates the
RAAS to increase sodium reabsorption in the nephron. These actions
indirectly increase water reabsorption as well (Amerman, 2016, 995). The
normal extracellular sodium concentration is 135 to 145 mmol/L. Sustained or
severe problems with sodium concentration result in high sodium, above 145
mmol/L (hypernatremia), or low sodium, below 135 mmol/L (hyponatremia).
Potassium Regulation.
Potassium is the major electrolyte and principal cation in the intracellular
compartment. The majority (98%) of potassium content is in the ICF. Because
the potassium concentration of ECF is relatively low, the cells expend energy
to maintain the potassium content of ICF. Potassium is regulated by dietary
intake and strongly affected by aldosterone, insulin, and epinephrine.
Extracellular potassium concentration is affected by many complex
mechanisms, including those of dietary intake and renal excretion. Renal
excretion is regulated by changes in potassium concentration, changes in the
acidity or alkalinity of a fluid (pH measurements), sodium reabsorption, and
aldosterone levels. Aldosterone secretion is triggered by many factors;
therefore, potassium balance is influenced by other factors, including
changes in fluid volume, blood pressure, and acidosis (Amerman, 2016, p.
997).
Potassium regulates many metabolic activities and is necessary for
glycogen deposits in the liver and skeletal muscle, transmission and
conduction of nerve impulses, normal cardiac conduction, and skeletal and
smooth muscle contraction. The normal range for serum potassium
concentrations is 3.5 to 5 mmol/L.
Calcium Regulation.
Calcium is stored in bone, plasma, and body cells. Ninety-nine percent of
calcium is located in bone, and only 1% is located in ECF. Approximately 50%
of calcium in the plasma is bound to protein, primarily albumin, and 40% is
free ionized calcium. The remaining small percentage is combined with
nonprotein anions such as phosphate (PO43−), citrate, and carbonate. Normal
serum ionized calcium is 1.0 to 1.2 mmol/L. Normal total calcium is 2.25 to
2.75 mmol/L. Calcium is necessary for bone and teeth formation, blood
clotting, hormone secretion, cell membrane integrity, cardiac conduction,
transmission of nerve impulses, and muscle contraction.
Magnesium Regulation.
Magnesium, the second most abundant intracellular cation, is essential for
many intracellular activities, such as enzyme reactions. Magnesium, with a
plasma concentration of 0.65 to 1.05 mmol/L, is important for bone structure
and neuromuscular function, including skeletal and cardiac muscle
excitability. Serum magnesium is regulated by dietary intake, renal
mechanisms, and actions of the parathyroid hormone.
Anions.
The three major anions of body fluids are chloride, bicarbonate, and
phosphate ions.
Chloride Regulation.
Chloride is the major anion in ECF. The transport of chloride follows sodium.
Normal concentrations of chloride range from 97 to 107 mmol/L. Serum
chloride is regulated by dietary intake and the kidneys. A person with normal
renal function who has a high chloride intake will excrete a higher amount of
urine chloride.
Bicarbonate Regulation.
Bicarbonate is the major chemical base buffer within the body. The
bicarbonate ion is found in ECF and ICF. The bicarbonate ion is an essential
component of the carbonic acid–bicarbonate buffering system, which is
essential to acid–base balance. The kidneys regulate bicarbonate. Normal
arterial bicarbonate levels range between 22 and 26 mmol/L; venous
bicarbonate is measured as carbon dioxide content, and the normal value is
24 to 30 mmol/L (Table 40-2).
TABLE 40-2
Laboratory Normal Values for Adults
Item Measured
Normal Value in Serum or Blood
Osmolality
Electrolytes
S odium (Na+)
Potassium (K+)
Chloride (Cl−)
Total CO 2 (CO 2 total c ontent)
Bic arbonate (HCO 3–)
280–300 mOsm/kg H2O (S I units)
Total c alc ium (Ca2+)
Ionized c alc ium (Ca2+)
Magnesium (Mg 2+)
Phosphate
Anion gap
Arterial Blood Gases
pH
PaCO 2
PaO 2
O 2 saturation
Base exc ess
136–145 mmol/L (S I units)
3.5–5 mmol/L (S I units)
98–106 mmol/L (S I units)
22–30 mmol/L (S I units)
Arterial: 22–26 mmol/L (S I units)
Venous: 24–30 mmol/L (S I units)
2.25–2.75 mmol/L (S I units)
1.05–1.30 mmol/L (S I units)
0.65–1.05 mmol/L (S I units)
0.97–1.45 mmol/L (S I units)
5–11 mmol/L (S I units)
7.35–7.45
35–45 mm Hg (4.7–6 kPa)
80–100 mm Hg (10.7–133.3 kPa)
95–100% (0.95–1.00)
−2 to +2 mmol/L (S I units)
Phosphate Regulation.
Phosphorus is the major anion in the ICF; however, nearly all the phosphorus
in the body exists in the form of phosphate. Phosphate's most important role
is within the ICF, where it assists in the formation of high-energy
compounds, such as ATP and nucleic acids, and in enzyme activity. Similar to
magnesium and calcium, phosphate is used and stored in the skeleton. It
also functions with calcium to develop and maintain teeth. Calcium and
phosphate are inversely proportional; if one rises, the other falls. Phosphate
also assists in acid–base regulation, promotes normal neuromuscular action,
and participates in carbohydrate metabolism. Phosphate is normally
absorbed through the gastrointestinal tract and is regulated by dietary
intake, renal and intestinal excretion, and parathyroid hormone. The normal
serum phosphorus level is 0.9 to 1.45 mmol/L.
Regulation of Acid–Base Balance
Acid–base balance exists when the rate at which the body produces and gains
acids or bases, through cellular metabolism and gastrointestinal absorption,
equals the rate at which acids or bases are excreted.
This balance results in a stable concentration of hydrogen ions (H+) in body
fluids that is expressed as the pH value. Hydrogen ions are primarily excreted
by the kidneys. A normal hydrogen ion level is necessary to maintain cell
membrane integrity and the speed of cellular enzymatic actions.
Arterial blood pH is inversely proportional to the hydrogen ion
concentration (i.e., the greater the concentration, the more acidic the solution
is and the lower the pH is; the lower the concentration, the more alkaline the
solution is and the higher the pH is). The pH is also a reflection of the
balance between carbon dioxide, which is regulated by the lungs, and
bicarbonate, a base regulated by the kidneys. Normal pH is maintained by
chemical buffers, and buffer systems and regulatory mechanisms in the
kidneys and lungs. A buffer is a substance or group of substances that can
absorb or release hydrogen ions to stabilize pH, such as bicarbonate,
phosphate, and proteins. The respiratory system, which controls the amount
of carbon dioxide in the body, the hydrogen and bicarbonate ions, and
therefore pH in the ECF, and the kidney are physiological buffer systems.
Buffers.
Buffer systems are combinations of a weak acid and a weak base and are the
short-term regulators of acid–base balance. The four main types of buffer
systems are protein (amino acids, plasma proteins), hemoglobin (also a
protein but unique in its buffering role), carbonic acid (H2CO3) and
bicarbonate, and phosphate. Other types are the ammonia buffer system, a
complex system that occurs in ICF, and the tubular system in the kidneys. All
these buffers bind hydrogen ions until they can be permanently removed
through the regulatory mechanisms in the lungs and the kidneys.
The carbonic acid–bicarbonate buffer system is used to evaluate acid–base
balance, using the arterial blood gas (ABG) test. This system can be
expressed as the following:
The carbonic acid–bicarbonate buffer system is the principal buffering
system to react to change in the pH of ECF, and it reacts within seconds.
Whenever carbon dioxide increases, an increase in hydrogen ions results, and
whenever hydrogen ions are produced, more carbon dioxide results
(Amerman, 2016, p. 1000). The lungs control the excretion of carbon dioxide,
and the kidneys control the excretion of hydrogen and bicarbonate ions.
Another buffer system is the hemoglobin–oxyhemoglobin system within
red blood cells (RBCs). This buffer system can have an immediate effect on
pH because carbon dioxide diffuses readily into the RBCs and forms carbonic
acid. The carbonic acid dissociates into hydrogen and bicarbonate ions, the
latter of which diffuse into the plasma in exchange for chloride. The
hydrogen ions attach to hemoglobin, whereas the carbon dioxide is carried to
the lungs, where the reaction is reversed.
Regulatory Mechanisms.
When the ability of buffer systems is exceeded, acid–base homeostasis is
regulated by the lungs and the kidneys. The lungs adapt rapidly to an acid–
base imbalance. Ordinarily, increased levels of hydrogen ions and carbon
dioxide provide the stimulus for respiration. When the concentration of
hydrogen ions is altered, the lungs react to correct the imbalance by altering
the rate and depth of respiration. For example, when metabolic acidosis is
present, respirations are increased, resulting in a greater amount of carbon
dioxide being exhaled, which results in a decrease in the acidic level; when
metabolic alkalosis is present, the lungs retain carbon dioxide by decreasing
the respirations, thereby increasing the acidic level (Amerman, 2016, pp.
1004–1006).
The kidneys take from a few hours to several days to regulate acid–base
imbalance. They regenerate or reabsorb bicarbonate in cases of acid excess
and excrete it in cases of acid deficit. In addition, the kidneys use a
phosphate ion to excrete hydrogen ions by forming phosphoric acid (H3PO4).
Finally, the kidneys use the ammonia mechanism to regulate acid–base
balance. In this mechanism, certain amino acids are chemically changed
within the renal tubules into ammonia, which, in the presence of hydrogen
ions, forms ammonium, which is excreted in the urine, thereby releasing
hydrogen ions from the body (Amerman, 2016, pp. 1002–1004).
Disturbances in Electrolyte, Fluid, and Acid–Base
Balances
Disturbances in electrolyte, fluid, or acid–base balance seldom occur alone
and can disrupt normal body processes. For example, when body fluids are
lost because of burns, illness, or trauma, the patient is also at risk for
electrolyte imbalances. In addition, some untreated electrolyte imbalances
(e.g., potassium loss) contribute to acid–base disturbances.
Fluid Disturbances.
Fluid imbalances include volume imbalances, or disturbances in the amount
of ECF, and osmolality imbalances, or disturbances in the concentration of
body fluids (hyper- or hypo-osmolar imbalance). Isotonic deficit and excess
exist when water and electrolytes are gained or lost in equal proportion. In
contrast, osmolar imbalances are losses or excesses of only water, so the
concentration (osmolality) of the serum is affected. It is important to
recognize that maintaining fluid homeostasis is primarily related to
circulatory volume. Hemodynamics respond quickly to changes in the
intravascular compartment, followed more slowly by sodium and water
balance mechanisms. Table 40-3 lists the common fluid isotonic and
osmolality imbalances, the causes and signs, and related symptoms.
TABLE 40-3
Fluid Imbalances
Imbalance and Related Causes
Signs and Symptoms
Isotonic Imbalances—Water and Sodium Lost or Gained in Equal or Isotonic P roportions
Extracellular Fluid Volume Deficit—Body Fluids Have Decreased Volume but Normal Osmolality
Sodium a nd Wa ter Inta ke Less Tha n Output, Ca using
Physica l exa mina tion: S udden weight loss (overnight), postural hypotension,
Isotonic Loss:
tac hyc ardia, thready pulse, dry muc ous membranes, poor skin turgor, slow
S everely dec reased oral intake of water and salt
vein filling, flat nec k veins when supine, dark yellow urine
Inc reased GI output: vomiting, diarrhea, laxative
If severe: thirst, restlessness, c onfusion, hypotension; oliguria (urine output
overuse, drainage from fistulas or tubes
below 30 mL/hr); c old, c lammy skin; hypovolemic shoc k
Inc reased renal output: use of diuretic s, adrenal
La bora tory findings: Inc reased hematoc rit; inc reased BUN a bove 8.9 mmol/L
insuffic ienc y (defic it of c ortisol and aldosterone)
(hemoc onc entration); urine spec ific gravity usually a bove 1.030, unless renal
Loss of blood or plasma: hemorrhage, burns
c ause
Massive sweating without water and salt intake
Extracellular Fluid Volume Excess—Body Fluids Have Increased Volume but Normal Osmolality
Sodium a nd Wa ter Inta ke Grea ter Tha n Output,
Physica l exa mina tion: S udden weight gain (overnight), edema (espec ially in
Ca using Isotonic Ga in:
dependent areas), full nec k veins when upright or semi-upright, c rac kles in
lungs
Exc essive administration of Na+-c ontaining isotonic
If severe: c onfusion, pulmonary edema
IV fluids or oral intake of salty foods and water
La bora tory findings: Dec reased hematoc rit, dec reased BUN below 3.6 mmol/L
Renal retention of Na+ and water: heart failure,
(hemodilution)
c irrhosis, aldosterone or gluc oc ortic oid exc ess,
ac ute or c hronic oliguric renal disease
Osmolality Imbalances
Hypernatremia (Water Deficit; Hyperosmolar Imbalance)—Body Fluids Too Concentrated
Loss of Rela tively More Wa ter Tha n Sa lt:
Physica l exa mina tion: Dec reased level of c onsc iousness (c onfusion, lethargy,
Diabetes insipidus (ADH defic ienc y)
c oma), perhaps thirst, seizures if develops rapidly or is very severe
Osmotic diuresis
La bora tory findings: S erum Na+ level a bove 145 mmol/L, serum osmolality
Large insensible perspiration and respiratory water
a bove 300 mmol/kg
output without inc reased water intake
Ga in of Rela tively More Sa lt Tha n Wa ter:
Administration of tube feedings, hypertonic
parenteral fluids, or salt tablets
Lac k of ac c ess to water, deliberate water
deprivation, inability to respond to thirst (e.g.,
immobility, aphasia)
Dysfunc tion of osmorec eptor-driven thirst drive
Hyponatremia (Water Excess; Water Intoxication; Hypo-osmolar Imbalance)—Body Fluids Too Dilute
Ga in of Rela tively More Wa ter Tha n Sa lt:
Physica l exa mina tion: Dec reased level of c onsc iousness (c onfusion, lethargy,
Exc essive ADH (S IADH)
c oma), seizures if develops rapidly or is very severe
Psyc hogenic polydipsia or forc ed exc essive water
La bora tory findings: S erum Na+ level below 135 mmol/L, serum osmolality below
intake
280 mmol/kg
Exc essive IV administration of D 5W
Use of hypotonic irrigating solutions
Tap-water enemas
Loss of Rela tively More Sa lt Tha n Wa ter:
Replac ement of large body fluid output (e.g.,
diarrhea, vomiting) with water but no salt
Combined Volume and Osmolality Imbalance
Clinical Dehydration (Extracellular Fluid Volume Deficit plus Hypernatremia)—Body Fluids Have Decreased Volume and Are Too
Concentrated
Sodium a nd Wa ter Inta ke Less Tha n Output, With Loss Physica l exa mina tion a nd la bora tory findings: Combination of those for ECV defic it
of Rela tively More Wa ter Tha n Sa lt:
plus those for hypernatremia (see previous signs)
All of the c auses of ECV defic it (see previous
c auses) plus poor or no water intake, often with
fever c ausing inc reased insensible water output
ADH, Antidiuretic hormone; BUN, blood urea nitrogen; ECV, extracellular fluid volume; GI, gastrointestinal;
D5W, 5% dextrose in water; IV, intravenous; SIADH, syndrome of inappropriate secretion of antidiuretic
hormone.
Fluid volume deficit is insufficient isotonic fluid in the extracellular
compartment. Because this involves both intravascular and interstitial
compartments, symptoms also relate to both compartments. Fluid volume
excess is too much isotonic fluid in the extracellular compartment, and so
symptoms also relate to intravascular and interstitial compartments, such as
swollen fingers or ankles. Osmolar fluid imbalances involve a fluid
imbalance accompanied by either elevated sodium (hypernatremia) or lower
sodium (hyponatremia). Clinical dehydration, caused by reduced sodium and
water intake, or loss of more water proportionately than salt, is a combined
volume and osmolality imbalance. Serum sodium and osmolality values are
required to diagnose hypertonic and hypotonic fluid volume deficits.
Physical examination and lab values are important for diagnosing and
treating these complex imbalances.
Electrolyte Imbalances.
Many factors can disrupt electrolyte homeostasis, including acute infections
causing diarrhea, metabolic disorders, altered electrolyte intake, sudden loss
of electrolytes in the case of burns or acute vomiting, medications, and shifts
in the distribution of electrolytes from cells or bones into the ECF. Table 40-4
provides a list of the causes, signs, and symptoms of electrolyte imbalances.
TABLE 40-4
Electrolyte Imbalances
Imbalance and Related Causes
Signs and Symptoms
Hypokalemia—Low Serum P otassium (K+) Concentration
Physica l exa mina tion: Bilateral musc le weakness that begins in quadric eps and may
Decrea sed K+ Inta ke:
asc end to respiratory musc les, abdominal distension, dec reased bowel sounds,
Exc essive use of K+-free IV solutions
c onstipation, dysrhythmias
Shift of K+ Into Cells:
La bora tory findings: S erum K+ level below 3.5 mmol/L; ECG abnormalities: U waves,
Alkalosis; treatment of diabetic ketoac idosis
flattened or inverted T waves; S T segment depression
with insulin
Increa sed K+ Output:
Ac ute or c hronic diarrhea; vomiting; other GI
losses (e.g., nasogastric or fistula drainage);
use of potassium-wasting diuretic s;
aldosterone exc ess; polyuria; gluc oc ortic oid
therapy
Hyperkalemia—High Serum P otassium (K+) Concentration
Physica l exa mina tion: Bilateral musc le weakness in quadric eps, transient abdominal
Increa sed K+ Inta ke:
Iatrogenic administration of large amounts of
c ramps, diarrhea, dysrhythmias, c ardiac arrest if severe
IV K+; rapid infusion of stored blood; exc ess
La bora tory findings: S erum K+ level a bove 5 mmol/L; ECG abnormalities: peaked T
waves; widened QRS c omplex; PR prolongation; terminal sine-wave pattern
ingestion of K+ salt substitutes
Shift of K+ Out of Cells:
Massive c ellular damage (e.g., c rushing
trauma, c ytotoxic c hemotherapy); insuffic ient
insulin (e.g., diabetic ketoac idosis); some
types of ac idosis
Decrea sed K+ Output:
Ac ute or c hronic oliguria (e.g., severe ECV
defic it, end-stage renal disease); use of
potassium-sparing diuretic s; adrenal
insuffic ienc y (defic it of c ortisol and
aldosterone)
Hypocalcemia—Low Serum Calcium (Ca 2+) Concentration
Physica l exa mina tion: Numbness and tingling of fingers, toes, and c irc umoral
Decrea sed Ca 2+ Inta ke a nd Absorption:
Calc ium-defic ient diet; vitamin D defic ienc y
(around mouth) region; positive Chvostek's sign (c ontrac tion of fac ial musc les
(inc ludes end-stage renal disease); c hronic
when fac ial nerve is tapped); hyperac tive reflexes; musc le twitc hing and c ramping;
diarrhea; laxative misuse; steatorrhea
c arpal and pedal spasms; tetany; seizures; laryngospasm; dysrhythmias
Shift of Ca 2+ Into Bone or Ina ctive Form:
La bora tory findings: Total serum Ca2+ level below 2.25 mmol/L or serum ionized Ca2+
Hypoparathyroidism; rapid administration of
level below 1.05 mmol/L; ECG abnormalities: prolonged S T segments
c itrated blood; hypoalbuminemia; alkalosis;
panc reatitis; hyperphosphatemia (inc ludes endstage renal disease)
Increa sed Ca 2+ Output:
Chronic diarrhea; steatorrhea
Hypercalcemia—High Serum Calcium (Ca 2+) Concentration
Physica l exa mina tion: Anorexia, nausea and vomiting, c onstipation, fatigue,
Increa sed Ca 2+ Inta ke a nd Absorption:
Milk-alkali syndrome
diminished reflexes, lethargy, dec reased level of c onsc iousness, c onfusion,
personality c hange, c ardiac arrest if severe
Shift of Ca 2+ Out of Bone:
Prolonged immobilization;
La bora tory findings: Total serum Ca2+ level a bove 2.75 mmol/L or serum ionized Ca2+
hyperparathyroidism; bone tumours;
level a bove 1.3 mmol/L; ECG abnormalities: heart bloc k, shortened S T segments
nonosseous c anc ers that sec rete boneresorbing fac tors
Decrea sed Ca 2+ Output:
Use of thiazide diuretic s
Hypomagnesemia—Low Serum Magnesium (Mg2+) Concentration
Physica l exa mina tion: Positive Chvostek's sign, hyperac tive deep tendon reflexes,
Decrea sed Mg 2+ Inta ke a nd Absorption:
Malnutrition; c hronic alc oholism; c hronic
musc le c ramps and twitc hing, grimac ing, dysphagia, tetany, seizures, insomnia,
diarrhea; laxative misuse; steatorrhea
tac hyc ardia, hypertension, dysrhythmias
Shift of Mg 2+ Into Ina ctive Form:
La bora tory findings: S erum Mg 2+ level below 0.65 mmol/L; ECG abnormalities:
Rapid administration of c itrated blood
prolonged QT interval
Increa sed Mg 2+ Output:
Chronic diarrhea; steatorrhea; other GI losses
(e.g., vomiting, nasogastric or fistula
drainage); use of thiazide or loop diuretic s;
aldosterone exc ess
Hypermagnesemia—High Serum Magnesium (Mg2+) Concentration
Physica l exa mina tion: Lethargy, hypoac tive deep tendon reflexes, bradyc ardia,
Increa sed Mg 2+ Inta ke a nd Absorption:
hypotension
Exc essive use of Mg 2+-c ontaining laxatives
and antac ids; parenteral overload of
Ac ute elevation in Mg 2+ levels: Flushing, sensation of warmth
magnesium
S evere ac ute hypermagnesemia: Dec reased rate and depth of respirations,
dysrhythmias, c ardiac arrest
Decrea sed Mg 2+ Output:
Oliguric end-stage renal disease; adrenal
La bora tory findings: S erum Mg 2+ level a bove 1.05 mmol/L; ECG abnormalities:
insuffic ienc y
prolonged PR interval
ECG, Electrocardiogram, ECV, extracellular fluid volume, GI, gastrointestinal, IV, intravenous.
Data from Felver, L. (2013). Fluid and electrolyte homeostasis and imbalances. In L. C. Copstead & J. L.
Banasik (Eds.), Pathophysiology (5th ed.). St. Louis: Saunders.
Sodium Imbalances.
Hyponatremia is a lower-than-normal concentration of sodium in the blood
(serum), which can occur with a net sodium loss or net water excess (see
Table 40-3). It occurs frequently in seriously ill patients and is the most
common electrolyte disturbance among older persons (El-Sharkawy, Sahota,
& Lobo, 2015). Clinical indicators and treatment depend on the cause of
hyponatremia and whether it is associated with a normal, decreased, or
increased ECF volume. The usual situation is a loss of sodium without a loss
of fluid, which results in a decrease in the osmolality of ECF. Sodium and
chloride are not stored in the body; therefore, they must be consumed daily
or provided through intravenous solutions in the ill.
Hypernatremia is a greater-than-normal concentration of sodium in ECF
that can be caused by excess water loss or overall sodium excess (see Table
40-3). When hypernatremia occurs, the body attempts to conserve as much
water as possible through renal reabsorption.
Potassium Imbalances.
Hypokalemia is one of the most common electrolyte imbalances (see Table
40-4). Hypokalemia, with potassium levels less than 3.5 mmol/L, results in
cardiac arrhythmias, fatigue, and altered muscle activity throughout the body
(Paul, Day, & Williams, 2016, p. 301). Because the normal amount of serum
potassium is so small, little tolerance for fluctuations exists. The most
common cause of hypokalemia is the use of potassium-wasting diuretics such
as thiazide and loop diuretics.
Hyperkalemia is a greater-than-normal amount of potassium in the blood.
Lethal cardiac arrhythmias result from potassium levels over 5.0 mmol/L, as
well as skeletal muscle weakness and paralysis (see Table 40-4). The primary
cause of hyperkalemia is renal failure, because any decrease in renal function
diminishes the amount of potassium the kidney can excrete.
Calcium Imbalances.
Hypocalcemia represents a drop in serum or ionized calcium. It can result
from several illnesses, some of which directly affect the thyroid and
parathyroid glands (see Table 40-4). Other causes include prolonged bed rest
and renal insufficiency (in which the kidneys' inability to excrete phosphorus
causes the phosphorus level to rise and the calcium level to decline). Signs
and symptoms can be related to diminished functioning of the
neuromuscular, cardiac, and renal systems.
Hypercalcemia is an increase in the total serum concentration of calcium
or ionized calcium (see Table 40-4). Hypercalcemia is frequently a symptom
of an underlying disease, such as malignancy or hyperparathyroidism,
resulting in excess bone reabsorption with release of calcium (McCance &
Huether, 2010).
Magnesium Imbalances.
Disturbances in magnesium levels are summarized in Table 40-4. Symptoms
are the result of changes in neuromuscular excitability. Hypomagnesemia, a
drop in serum magnesium below 0.65 mmol/L, occurs with malnutrition,
malabsorption disorders, diarrhea, and alcohol withdrawal. This may cause
neuromuscular symptoms, seizures, or cardiac arrhythmias.
Hypermagnesemia, an increase in serum magnesium levels more than 1.05
mmol/L, depresses skeletal muscles and nerve function. Magnesium may
inhibit acetylcholine, thereby causing a sedative effect.
Chloride Imbalances.
Hypochloremia occurs when the serum chloride level falls below normal.
Vomiting or prolonged and excessive nasogastric or fistula drainage can
result in hypochloremia because of the loss of hydrochloric acid. The use of
loop and thiazide diuretics also results in increased chloride loss as sodium
is excreted. When serum chloride levels fall, metabolic alkalosis results as the
body adapts by increasing reabsorption of the bicarbonate ion to maintain
electrical neutrality.
Hyperchloremia occurs when the serum chloride level rises above normal,
which usually occurs when the serum bicarbonate value falls or the sodium
level rises. Hypochloremia and hyperchloremia rarely occur as single disease
processes but are commonly associated with acid–base imbalance. No single
set of symptoms is associated with these two alterations.
Acid–Base Balance.
Arterial blood gas (ABG) analysis is the best way to evaluate acid–base
balance and is based on the carbonic acid–bicarbonate buffer system.
Measurement of ABGs involves analysis of six components: pH, PaCO2, PaO2,
oxygen saturation, base excess, and bicarbonate (see Table 40-2). Deviation
from a normal value will indicate that the patient is experiencing an acid–
base imbalance.
Measurements of Acidity or Alkalinity of Fluids.
The pH reflects hydrogen ion concentration in the body fluids. Even a slight
change can be potentially life-threatening. An increase in concentration of
hydrogen ion makes a solution more acidic; a decrease makes the solution
more alkaline. Normal pH value is 7.35 to 7.45; therefore, a pH value below
7.35 is acidic, and above 7.45 is alkalotic (Table 40-5).
TABLE 40-5
Arterial Blood Gas Measures
Normal
Range in
Laboratory
Adult
Measure
Arterial
Blood
Definition and Interpretation
pH
7.35–7.45
PaCO 2
35–45 mm Hg
(4.7–6 kPa)
HCO 3–
22–26 mmol/L
PaO 2
80–100 mm Hg PaO 2 is partial pressure of oxygen (O 2), a measure of how well gas exc hange is oc c urring in the alveoli of
(10–13.3 kPa)
the lungs. Values below normal indic ate poor oxygenation of the blood.
95%–100%
S aO 2 is oxygen saturation, the perc entage of hemoglobin that is c arrying as muc h O 2 as possible. It is
influenc ed by pH, PaCO 2, and body temperature. It drops rapidly when PaO 2 falls below 60 mm Hg (8 kPa).
−2 to +2
Base exc ess is observed buffering c apac ity minus the normal buffering c apac ity, a measure of how well the
mmol/L
blood buffers are managing metabolic ac ids. Values below −2 (negative base exc ess) indic ate exc essive
metabolic ac ids; values above +2 indic ate exc essive amounts of bic arbonate.
S aO 2
Base exc ess
pH is a negative logarithm of the free H+ c onc entration, a measure of how ac id or alkaline the blood is.
Values below 7.35 indic ate abnormally ac id; above 7.45 they indic ate abnormally alkaline. S mall c hanges
in pH denote large c hanges in H+ c onc entration and are c linic ally important.
PaCO 2 is partial pressure of c arbon dioxide (CO 2), a measure of how well the lungs are exc reting CO 2
produc ed by c ells. Inc reased PaCO 2 indic ates CO 2 ac c umulation in blood (more c arbonic ac id) c aused by
hypoventilation; dec reased PaCO 2 indic ates exc essive CO 2 exc retion (less c arbonic ac id) through
hyperventilation.
HCO 3– is c onc entration of the base (alkaline substanc e) bic arbonate, a measure of how well the kidneys
are exc reting metabolic ac ids. Inc reased HCO 3– indic ates that the blood has too few metabolic ac ids;
dec reased HCO 3– indic ates that the blood has too many metabolic ac ids.
Paco2.
PaCO2 is the partial pressure of carbon dioxide in arterial blood and is a
reflection of the depth of pulmonary ventilation. The normal range is 35 to 45
mm Hg. A PaCO2 less than 35 mm Hg is an indication that hyperventilation
has occurred. As the rate and depth of respiration increase, more carbon
dioxide is exhaled, and the carbon dioxide concentration decreases. When the
PaCO2 is more than 45 mm Hg, hypoventilation has occurred. As the rate and
the depth of respiration decrease, less carbon dioxide is exhaled and more is
retained, increasing the concentration of carbon dioxide.
PaO2.
PaO2 is the partial pressure of oxygen in arterial blood. It has no primary role
in acid–base regulation if it is within normal limits. A PaO2 less than 60 mm
Hg can lead to anaerobic metabolism, resulting in lactic acid production and
metabolic acidosis. The normal range is 80 to 100 mm Hg.
Oxygen Saturation.
Oxygen saturation is the point at which hemoglobin is saturated by oxygen.
Decreasing PaO2 causes an increase in oxygen dissociation from hemoglobin.
Oxygen saturation can be affected by changes in temperature, pH, and PaCO2.
The normal range is 95% to 99%.
Base Excess.
Base excess refers to the buffering systems discussed previously, with a
normal range of +2 to −2. Base excess reflects deviations from a serum pH of
7.4 (neutral). Higher values of base excess indicate alkalosis. Negative values
of base excess indicate acidosis, usually the result of the elimination of too
many bicarbonate ions.
Bicarbonate.
Serum bicarbonate is excreted or retained by the kidneys to maintain a
normal acid–base environment. It is also the principal buffer of the ECFs of
the body. A normal pH is maintained with a bicarbonate ratio 20 times that of
the fluid concentration of carbonic acid (McCance & Huether, 2010). The
normal range is 22 to 26 mmol/L. Less than 22 mmol/L of bicarbonate usually
indicates metabolic acidosis, whereas more than 26 mmol/L indicates
metabolic alkalosis.
Types of Acid–Base Imbalances
The four primary types of acid–base imbalance are respiratory acidosis,
respiratory alkalosis, metabolic acidosis, and metabolic alkalosis (Table 40-6).
TABLE 40-6
Acid–Base Imbalances
Imbalance and Related Causes
Signs and Symptoms
Respiratory Acidosis—Excessive Carbonic Acid Caused by Alveolar Hypoventilation
Impa ired Ga s Excha nge:
Physica l exa mina tion: Headac he, light-headedness, dec reased level of c onsc iousness
Type B COPD (c hronic bronc hitis) or
(c onfusion, lethargy, c oma), dysrhythmias
end-stage type A COPD
La bora tory findings: Arterial blood gas alterations: pH below 7.35, PaCO 2 a bove 45 mm Hg (6
(emphysema)
kPa), HCO 3– level normal if unc ompensated or a bove 26 mmol/L if c ompensated
Bac terial pneumonia
Airway obstruc tion
Extensive atelec tasis (c ollapsed
alveoli)
S evere ac ute asthma episode
Impa ired Neuromuscula r Function:
Respiratory musc le weakness or
paralysis from hypokalemia or
neurologic al dysfunc tion
Respiratory musc le fatigue,
respiratory failure
respiratory failure
Chest wall injury or surgery c ausing
pain with respiration
Dysfunction of Bra instem Respira tory
Control:
Drug overdose with a respiratory
depressant
S ome types of head injury
Respiratory Alkalosis—Deficient Carbonic Acid Caused by Alveolar Hyperventilation
Hypoxemia from any c ause (e.g.,
Physica l exa mina tion: Light-headedness, numbness and tingling of fingers, toes, and
initial part of asthma episode,
c irc umoral region, inc reased rate and depth of respirations, exc itement and c onfusion
pneumonia)
possibly followed by dec reased level of c onsc iousness, dysrhythmias
Ac ute pain
La bora tory findings: Arterial blood gas alterations: pH a bove 7.45, PaCO 2 below 35 mm Hg (4.7
Anxiety, psyc hologic al distress,
kPa), HCO 3– level normal if short lived or unc ompensated or below 22 mmol/L if
sobbing
c ompensated
Inappropriate mec hanic al ventilator
settings
S timulation of brainstem respiratory
c ontrol (e.g., meningitis, gramnegative sepsis, head injury, aspirin
overdose)
Metabolic Acidosis—Excessive Metabolic Acids
Increa se of Meta bolic Acids (High Anion
Physica l exa mina tion: Dec reased level of c onsc iousness (lethargy, c onfusion, c oma),
Ga p):
abdominal pain, dysrhythmias, inc reased rate and depth of respirations (c ompensatory
Ketoac idosis (diabetes, starvation,
hyperventilation)
alc oholism)
La bora tory findings: Arterial blood gas alterations: pH below 7.35, PaCO 2 normal if
Hypermetabolic state (severe
unc ompensated or below 35 mm Hg (4.7 kPa) if c ompensated, HCO 3– level below 22 mmol/L
hyperthyroidism, burns, severe
infec tion)
Oliguric renal disease (ac ute kidney
injury, end-stage renal disease)
Circ ulatory shoc k (lac tic ac idosis)
Ingestion of ac id or ac id prec ursors
(e.g., methanol, ethylene glyc ol,
boric ac id, aspirin overdose)
Loss of Bica rbona te (Norma l Anion
Ga p):
Diarrhea
Panc reatic fistula or intestinal
dec ompression
Renal tubular ac idosis
Metabolic Alkalosis—Deficient Metabolic Acids
Increa se of Bica rbona te:
Physica l exa mina tion: Light-headedness, numbness and tingling of fingers, toes, and
Exc essive administration of sodium
c irc umoral region; musc le c ramps; possible exc itement and c onfusion followed by
bic arbonate
dec reased level of c onsc iousness, dysrhythmias (may be c aused by c onc urrent
Massive blood transfusion (liver
hypokalemia)
c onverts c itrate to HCO 3–)
La bora tory findings: Arterial blood gas alterations: pH a bove 7.45, PaCO 2 normal if
Mild or moderate ECV defic it
unc ompensated or a bove 45 mm Hg (6.0 kPa) if c ompensated, HCO 3– a bove 26 mmol/L
(c ontrac tion alkalosis)
Loss of Meta bolic Acid:
Exc essive vomiting or gastric
suc tioning
Hypokalemia
Exc ess aldosterone
COPD, Chronic obstructive pulmonary disease, ECV, extracellular fluid volume.
Data from Felver, L. (2013). Acid-base homeostasis and imbalances. In L. C. Copstead & J. L. Banasik
(Eds.), Pathophysiology (5th ed.). St. Louis: Saunders.
Respiratory Acidosis.
Respiratory acidosis is marked by an increased PaCO2, excess carbonic acid,
and an increased hydrogen ion concentration (decreased pH). This occurs
when respirations are not effective in excreting carbon dioxide, resulting in
an increase in hydrogen concentration. With respiratory acidosis, carbon
dioxide crosses the blood–brain barrier, causing neurological changes, such
as headaches, irritability, and, ultimately, impaired consciousness.
Hypoxemia occurs simultaneously because of respiratory depression,
resulting in further neurological impairment. Electrolyte changes such as
hyperkalemia and hypercalcemia may accompany the acidosis. The renal
system compensates by increasing bicarbonate and eliminating hydrogen
ion.
An example is the following: Mr. Butler comes to the emergency
department short of breath. The first set of ABGs shows the following: pH =
7.26, PaCO2 = 55 mm Hg, and bicarbonate = 23 mmol/L. His body has not yet
compensated for his respiratory insufficiency. A person with chronic lung
disease may present with greater compensation and a pH that is closer to
normal.
Respiratory Alkalosis.
Respiratory alkalosis is marked by decreased PaCO2 and increased pH.
Respiratory alkalosis can begin outside the respiratory system (e.g., anxiety
with hyperventilation) or within the respiratory system (e.g., the initial phase
of an asthma attack). Usually, the respiratory system corrects imbalances
before compensatory changes are required.
An example is the following: Ms. Chang is hyperventilating when she
comes into the emergency department. Her ABGs are as follows: pH = 7.52,
PaCO2 = 30 mm Hg, bicarbonate = 24 mmol/L, and base excess = 2.5 mmol/L.
Her kidneys have not had time to compensate and lower the bicarbonate
level.
Metabolic Acidosis.
Metabolic acidosis results from a decrease in serum bicarbonate or the
production of organic or fixed acids. An analysis of serum electrolytes to
detect an anion gap may be helpful in attempting to identify the cause of the
metabolic acidosis. An anion gap reflects unmeasurable anions present in
plasma and is calculated by subtracting the sum of chloride and bicarbonate
from the amount of plasma sodium concentration. Compensation for
metabolic acidosis initially involves an increase in respiratory rate and depth
to eliminate carbon dioxide. If not quickly resolved, renal mechanisms are
stimulated to increase hydrogen ion excretion, and to generate and release
bicarbonate into the ECF.
An example is the following: Ms. Smith is admitted to hospital after having
run her first marathon. Her electrolytes are as follows: sodium = 131 mmol/L,
bicarbonate = 9 mmol/L, and chloride = 86 mmol/L. The anion gap is
calculated as follows: Na − (HCO3− + Cl−) = 131 − (9 + 86) = 36 mmol/L. The
normal anion gap is less than 16 mmol/L (so her anion gap is high). Ms.
Smith receives a diagnosis of lactic acidosis related to tissue hypoxia.
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, high
ketones, and metabolic acidosis. This diabetic emergency is caused by a total
lack of insulin, in type 1 diabetes, causing severely elevated glucose levels.
The body responds to the glucose deficit inside the cells by mobilizing fats, a
process that results in increased ketone bodies. Together, these metabolic
processes cause osmotic diuresis, acidosis, and hyperkalemia. Patients with
type 2 diabetes are also at risk of developing metabolic acidosis from severe
hyperglycemia, although the acidosis develops more slowly and is not
associated with ketosis. The clinical response to these hyperglycemic
emergencies is to administer insulin and intravenous fluids. It is critical to
correct water and electrolyte imbalances and restore intravascular volume,
based on individual assessments and diagnostics; however, an isotonic
solution such as 0.9% saline is recommended over the initial 24 to 48 hours
(de Beer, Michael, Thacker, et al., 2008, p. 7; Kisiel & Marsons, 2009, p. 1097).
Frequent monitoring of electrolytes, fluid balance, glucose, and ABGs is
important in the treatment of DKA.
Metabolic Alkalosis.
Metabolic alkalosis is marked by the heavy loss of acid from the body or by
increased levels of bicarbonate. The most common causes are vomiting and
gastric suction, as well as potassium deficiency, hyperaldosteronism, and
diuretic therapy (Amerman, 2016, p. 1006). The body attempts to compensate
by increasing the excretion of bicarbonate and decreasing the rate and the
depth of respirations. Symptoms associated with metabolic alkalosis are
depressed respirations and tingling of the fingers and dizziness related to
secondary low calcium (Paul et al., 2016, p. 316). In serious metabolic
alkalosis, cardiac arrhythmias can occur.
An example is the following: Mr. Jones comes into the clinic with persistent
vomiting. His ABGs are as follows: pH = 7.63, bicarbonate = 45 mmol/L, PaCO2
= 48 mm Hg, and base excess = 16 mmol/L. He is in metabolic alkalosis.
Knowledge Base of Nursing Practice
The essential functions of fluid, electrolyte, and acid–base balances are
important aspects of the scientific knowledge base of nursing practice. In all
areas of nursing practice, nurses attend to the relationship between healthy
water and human health (Allgood, 2009; Davidhizar, Dunn, & Hart, 2004).
Regardless of the area of practice, all nurses will be involved in assessment,
planning, and interventions in relation to water, electrolytes, and factors that
influence acid–base balance. Identifying those most at risk for imbalances is
important for promoting health and well-being (Table 40-7). Certain patients
are particularly vulnerable to imbalances, including infants, older persons,
and the severely ill. Patients who are disoriented or immobile are also
vulnerable to imbalances because they cannot respond independently to
early symptoms. If untreated, over time, the body can no longer maintain
fluid and electrolyte or acid–base balances adequately, and the patient's
health becomes compromised. Prolonged or severe compromises may lead to
irreversible chronic health problems.
TABLE 40-7
Risk Factors for Fluid, Electrolyte, and Acid–Base Imbalances
Age
Environment
Gastrointestinal
output
Chronic
diseases
Trauma
Therapies
Very young: ECV defic it, osmolality imbalanc es, c linic al dehydration
Very old: ECV exc ess or defic it, osmolality imbalanc es
Sodium-rich diet: ECV exc ess
Electrolyte-poor diet: Elec trolyte defic its
Hot wea ther: Clinic al dehydration
Dia rrhea : ECV defic it, c linic al dehydration, hypokalemia, hypoc alc emia (if c hronic ), hypomagnesemia (if c hronic ),
metabolic ac idosis
Dra ina ge (e.g., na soga stric suctioning, fistula s): ECV defic it, hypokalemia; metabolic ac idosis if intestinal or panc reatic
drainage
Vomiting: ECV defic it, c linic al dehydration, hypokalemia, hypomagnesemia, metabolic alkalosis
Ca ncer: Hyperc alc emia; with tumour lysis syndrome: hyperkalemia, hypoc alc emia, hyperphosphatemia; other
imbalanc es, depending on side effec ts of therapy
Chronic obstructive pulmona ry disea se: Respiratory ac idosis
Cirrhosis: ECV exc ess, hypokalemia
Hea rt fa ilure: ECV exc ess; other imbalanc es, depending on therapy
Oliguric rena l disea se: ECV exc ess, hyperkalemia, hypermagnesemia, hyperphosphatemia, metabolic ac idosis
Burns: ECV defic it, metabolic ac idosis
Crush injuries: Hyperkalemia
Hea d injuries: Hyponatremia or hypernatremia, depending on ADH response
Hemorrha ge: ECV defic it, hyperkalemia if c irc ulatory shoc k
Diuretic s and other medic ations (see Box 40-5)
IV thera py: ECV exc ess, osmolality imbalanc es, elec trolyte exc esses
Pa rentera l nutrition: Any fluid or elec trolyte imbalanc e, depending on c omponents of solution
ADH, Antidiuretic hormone; ECV, extracellular fluid volume; IV, intravenous.
Critical Thinking
Successful critical thinking requires a synthesis of knowledge, experience,
information gathered from patients, critical thinking qualities, and
intellectual and professional standards. Nurses must use clinical judgements
to anticipate the information necessary, analyze the data, and make decisions
regarding patient care.
Nursing Process
Assessment
Patient care begins with informed assessment. This includes assessing each
patient's fluid, electrolyte, and acid–base status. Using a systematic approach
to collecting data and analyzing findings enables nurses to provide patientcentred care. Nurses' clinical decisions are based on the quality of their
assessments and critical thinking. By gathering data through a health history
and physical examination, nurses can identify patients at risk of or
experiencing imbalances. During assessment (Figure 40-7), nurses must
consider all elements that contribute to making appropriate nursing
diagnoses.
FIGURE 40-7
Critical thinking model for assessment of fluid, electrolyte, and acid–base
balances.
Patient Expectations.
Assessment begins with eliciting the patient's needs, values, and preferences
for a patient-centred assessment. At times this may not be possible because
of the severity of the patient's illness and imbalances. When able, however, it
is good to begin with a focus on the patient's experience and perceptions of
the illness. Has the patient experienced this before? How does the patient
interpret the signs and symptoms experienced? How does the patient
manage the related risks or contributing factors in his or her environment?
What are the patient's concerns about the symptoms, diagnostics, or
potential treatment?
Health History.
The nursing assessment continues with a nursing health history, which is
designed to reveal any risk factors or pre-existing conditions that may cause
or contribute to a disturbance of fluid, electrolyte, and acid–base balances.
Asking specific, focused questions will elicit the most useful data (Box 40-2).
Box 40-2
Nursing Assessment Questions
Nature of the Problem
• Are you currently under the care of a health care provider for
management of any ongoing health problems, such as kidney or heart
disease, diabetes, or blood pressure problems?
• Describe any new problems, such as vomiting, diarrhea, or a surgical
procedure.
Signs and Symptoms
• In the past several weeks, have you lost or gained any weight?
• Do you feel thirsty, have a dry mouth or skin, or notice a lack of tears?
• Have you noticed a change in your urine output—decreased volume,
dark colour, or concentrated appearance?
• Have you had any recent problems with vomiting or diarrhea? If so, for
how long?
• Are you experiencing any problems with swelling of your hands, feet,
ankles, or lower legs?
• Do you have problems breathing when you lie down at night?
• Have you noticed any dizziness, weakness, cramps, or unusual
sensations, such as tingling?
Severity
• How many times a day do you urinate?
• Do you continue to feel thirsty no matter how much fluid you drink?
• Are you experiencing these symptoms more at night than in the
morning?
• Are you having difficulty concentrating or do you feel confused?
• How does this compare with what is normal or usual for you?
Predisposing Factors
• Do you work or exercise in a hot environment?
• How much do you usually drink every day? What type of fluids do you
drink? How much alcohol do you drink in a typical week?
• Describe your normal diet. Are you following a weight loss program? Do
you use supplements for weight loss, or a salt substitute? What kind of
snacks do you eat?
• Have you had any recent changes in your appetite? Have you noticed any
changes in the taste of your food? Do you have any difficulty swallowing
or chewing?
• Do you take any over-the-counter or prescription medications or herbal
remedies?
Effect on the Patient
• How have these symptoms affected you?
• Are you losing sleep, feeling irritable, or having difficulty performing
your usual daily tasks?
• What treatments or solutions have you tried to resolve these symptoms?
Age.
First, the patient's age is considered. An infant's proportion of total body
water, approximately 75%, is greater than that of children or adults. Infants
are at a greater risk for fluid volume deficit (FVD) and hyperosmolar
imbalance because body water loss is proportionately greater per kilogram of
weight, and therefore, they have smaller reserves.
Children ages 2 through 12 years have less stable regulatory responses to
imbalance and in childhood illnesses tend to have less tolerance for large
changes. Children frequently respond to illnesses with fevers of higher
temperatures and longer duration than those of adults, increasing their
insensible water loss. Adolescents have increased metabolic processes and
water production because of the major rapid changes that occur during
puberty. Adolescent girls experience changes in fluid balance with the
hormonal changes associated with the menstrual cycle.
Aging has a significant impact on fluid, electrolyte, and acid–base balances
and on older persons' capacity to compensate; therefore, nurses need to be
able to identify the risk factors and work to prevent them (Box 40-3). With
normal aging, the glomerular filtration rate is reduced, along with the
number and functional capacity of nephrons. Older persons have a decreased
thirst sensation. The reduction in taste may limit the amount of oral fluids
consumed. Older persons have reduced aldosterone, which increases sodium
excretion and may result in hyponatremia. Because older persons are more
susceptible to dehydration and have a higher rate of mortality from
dehydration, early detection of infection and disorders in fluid balance is
very important (Shepherd, 2013). Box 40-4 outlines evidence-informed
nursing practice guidelines synthesized from recent research (Arai, Butzlaff,
Stotts, et al., 2014; Bunn, Jimoh, Wilsher, et al., 2015; El-Sharkawy et al., 2015;
Schub & Obiamaka, 2016; Shepherd, 2013; Wotton, Crannitch, & Munt, 2008).
Box 40-3
Focus on Older Persons
Factors Affecting Fluid, Electrolyte, and Acid–Base Balance
• Body composition changes, causing a decreased percentage of body
weight as water (50%), which increases risk of extracellular fluid volume
(ECV) deficit and dehydration (Felver, 2013a).
• Some older people restrict fluid intake because of impaired mobility or
concerns about bladder control; this increases their risk of
hypernatremia and ECV deficit.
• Decreased elasticity of skin alters skin turgor even with normal fluid
balance; do not rely on skin turgor to assess ECV deficit or dehydration
in older persons.
• Decreased thirst sensation increases risk of hypernatremia and
dehydration; do not rely on thirst to assess hypernatremia, ECV deficit,
or dehydration in older persons (Touhy & Jett, 2014).
• Baroreceptors become sluggish with age, often causing brief postural
hypotension; have older persons arise slowly when taking orthostatic
blood pressure measurements.
• Cardiovascular changes with aging often decrease the ability to adapt to
a sudden increase in vascular volume, increasing risk of pulmonary
edema with rapid infusion of isotonic intravenous fluids.
• Kidneys of older persons are less able to concentrate urine, making them
less able to conserve fluid when needed; this increases the risk of
hypernatremia, ECV deficit, and dehydration (Touhy & Jett, 2014).
• Kidney changes of normal aging make it more difficult to excrete a large
acid load, increasing the risk of metabolic acidosis.
• Increased sensitivity to anticholinergic effects of medications causes dry
mouth; use several different assessments for ECV deficit and
dehydration rather than relying solely on dry mouth (Burchum &
Rosenthal, 2016).
• The combined effects of normal aging, chronic diseases, and multiple
medications often pose challenges to maintaining fluid and electrolyte
balance.
Box 40-4
Evidence-Informed Practice
Preventing and Responding to Dehydration* in Older Persons
Evidence Summary
• Older persons are at increased risk of illness and death from
dehydration, overhydration, and salt overload.
• Reduced thirst sensation and diminished appetite contribute to
dehydration in older persons. Older people also have diminished
capacity to correct volume losses.
• Chronic dehydration contributes to constipation in older persons.
• Adequate hydration in older persons is recommended for the prevention
of falls, possibly related to hypotension or postural hypotension.
• Dehydration is a risk factor for delirium. The risk for delirium can be
reduced as much as 33% with each additional glass of water consumed
(El-Sharkawy et al., 2015).
• Signs and symptoms of dehydration can be easily confused with normal
aging processes; therefore, assessment requires knowledge, skill, and
commitment to acting on signs and symptoms.
Nursing Practice Guidelines
• Calculating fluid requirements should take into consideration individual
characteristics including weight, gender, environmental factors, physical
activity, and comorbidities, such as renal and cardiac disease.
• Identify risk factors for each older person from the following: age over 70
years, female, high or low body mass index, recent hospitalization, new
admission to residential care, situations causing increased insensible
loss (pyrexia), decreased access or ability to request fluids, and
situations causing decreased intake, such as swallowing disorder
(dysphagia), physical frailty, and decreased sentience. Diarrhea and
vomiting are key causes of dehydration in older persons. Previous
malnutrition, dehydration, polypharmacy, and having more than three
medical conditions are significant risk factors.
• Establish an assessment, monitoring, and evaluation tool for identifying
risk factors for older persons when initiating a caregiving relationship
(e.g., on admission to residential care; with home assessment of older
persons; routine health care visits)
• Assessment of hydration status should include physiological measures
(urine specific gravity, urine colour, blood pressure, pulse, and
respiration), as well as observed intake patterns and treatments.
Recommend blood testing to determine cause and severity in suspected
dehydration.
• Maintain fluid intake through documented planning using the nursing
process in home, residential care, and hospital settings.
• Educate older persons and their family and friends on the importance of
hydration.
• Evaluate acute losses such as diarrhea and vomiting.
• Attend more diligently to fluid balance in the context of medical issues
such as diabetes, with the use of diuretics, with decreased cognitive level
or functional status, and with reduced level of consciousness.
• Ensure availability of adequate fluids, including water, tea, coffee, milk,
and other beverages, throughout the day and assist persons who are
unable to access their own fluids. Replenish and refresh fluids through
the day.
• Advocate for adequate staffing levels in residential and acute care, as
inadequate staffing is closely linked to increased mortality (Shepherd,
2013).
• Promote audits of hydration practices and barriers or obstacles in health
care settings and identify benchmarks for improved practice.
• Ongoing management consists of daily fluid goals, comparing current
intake with physiological needs, and monitoring actual consumption of
fluids and fluid-rich foods.
• Incorporate the offer of fluids, hot or cold, into regular rounds,
socializing, and aspects of care using the “little and often” approach.
Offer assistive devices, such as drinking straws or feeder cups, as
necessary.
• Fluid status documentation should include hydration, eating habits,
weight, vital signs, and fluid preferences.
*
Dehydration is defined variably. Shepherd (2013) defines dehydration as equal to or greater than 1% loss
of body mass through fluid loss. See text and Tables 40-3 and 40-4 for exploration of dehydration and
tonicity.
Reduced respiratory lung capacity impairs the ability of older persons to
compensate for acid–base imbalances and maintain oxygen requirements.
With increased age, patients are at risk for disorders of other body systems,
including the cardiovascular, renal, and endocrine systems. In addition, older
persons have a decreased ability to excrete medications.
Environmental Factors.
Nurses also need to include certain environmental factors in the health
history. Patients who have participated in vigorous exercise or are exposed to
temperature extremes may have clinical signs of fluid and electrolyte
alterations. Exposure to environmental temperatures exceeding 28°C to 30°C
results in excessive sweating with weight loss. Excessive sweating with
extreme exercise or exposure to high environmental temperatures can result
in fluid deficits, hypernatremia, or clinical dehydration, because sweat is a
hypotonic sodium-containing fluid.
Diet.
The nurse should assess dietary intake (see Box 40-2) and recent changes in
appetite or the ability to chew and swallow. It is good to explore if patients
follow weight loss diets or gastrointestinal cleansing regimes. When
nutritional intake is inadequate, the body tries to preserve its protein stores
by breaking down glycogen and fat stores. When excess free fatty acids are
released, metabolic acidosis can occur because the liver converts free fatty
acids to ketones, which are strong acids. With high-protein diets, ketosis can
also occur. After fat and carbohydrate resources are depleted, the body
begins to destroy protein stores. Hypoalbuminemia occurs with lack of
amino acids in the diet and with liver dysfunction. In hypoalbuminemia, the
serum colloid osmotic pressure is decreased, allowing fluid to shift from the
circulating plasma to the interstitial fluid spaces. The nurse should also ask
about complementary or alternative medicine (CAM) diet supplements or
restrictions.
Lifestyle.
Patients' history of smoking or alcohol consumption and of recreational drug
use should be explored. These factors can alter the patient's fluid, electrolyte,
and acid–base balance. Damage to the liver, kidneys, or lungs can alter
compensatory mechanisms. For example, the excessive use of alcohol can
ultimately cause respiratory depression, which can result in respiratory
acidosis.
Medication.
The nurse should obtain a complete list of current medications, including
over-the-counter and herbal preparations (see Box 40-2 and Box 40-5). The
nurse should evaluate the potential effects of medications to determine if
specific laboratory values need to be assessed, using knowledge of
physiology and pharmacology, and pharmacology references. The patient's
knowledge of adverse effects and adherence to medication schedules should
also be assessed.
Box 40-5
Medications That Cause Fluid, Electrolyte, and
Acid–Base Disturbances
• ACE inhibitors (e.g., captopril [Capoten]) and angiotensin II receptor
blockers (e.g., Losartan [Cozaar]): Hyperkalemia
• Antidepressants, SSRIs (e.g., fluoxetine [Prozac]): Hyponatremia
• Calcium carbonate antacids: Hypercalcemia, mild metabolic alkalosis
• Corticosteroids (e.g., prednisone): Hypokalemia, metabolic alkalosis
• Diuretics, potassium-wasting (e.g., furosemide [Lasix], thiazides): ECV
deficit, hyponatremia (thiazides), hypokalemia, hypomagnesemia, mild
metabolic alkalosis
• Diuretics, potassium-sparing (e.g., spironolactone [Aldactone]):
Hyperkalemia, mild metabolic acidosis
• Effervescent (fizzy) antacids and cold medications (high Na+ content):
ECV excess
• Laxatives: ECV deficit, hypokalemia, hypocalcemia, hypomagnesemia,
metabolic acidosis
• Magnesium hydroxide (e.g., Milk of Magnesia): Hypermagnesemia
• Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen [Advil]): Mild
ECV excess, hyponatremia
• Penicillins, high-dose (e.g., carbenicillin): Hypokalemia, metabolic
alkalosis; hyperkalemia with penicillin G (contains K+)
ACE, Angiotensin-converting enzyme; ECV, extracellular fluid volume;
SSRI, selective serotonin reuptake inhibitor.
Data from Burchum, J. R., & Rosenthal, L. D. (2016). Lehne's pharmacology for nursing care (9th ed.). St.
Louis: Elsevier.
Medical History
Acute Illness.
Head and chest trauma, gastrointestinal disturbances, sepsis, shock, and
second- or third-degree burns are conditions that place patients at high risk
for fluid, electrolyte, and acid–base alterations. When obtaining a medical
history, it is important to review any allergies. Treatment for fluid, electrolyte,
and acid–base imbalances may involve exposure to latex in equipment and
supplies. With neonates and infants, the nurse needs to assess the mother for
known latex allergy to prevent inadvertent exposure to latex sensitization.
Burns.
The burned patient can lose body fluids by many routes. The greater the
body surface burned, the greater the fluid loss. Burns can result in a plasmato-interstitial fluid shift. Plasma and interstitial fluids are also lost as burn
exudate. Water vapour and heat are lost in proportion to the amount of skin
that is burned away, increasing insensible losses. Blood leaks from damaged
capillaries, adding to the loss of intravascular fluid volume. Sodium and
water shift into the cells, further compromising ECF volume (Paul et al., 2016,
p. 1844). Cell damage is accompanied by a loss of serum proteins, and a
release of potassium into the intravascular fluid.
Respiratory disorders.
Many alterations in respiratory function predispose the patient to respiratory
acidosis. For example, pneumonia or sedative overdose interferes with the
elimination of carbon dioxide due to hypoventilation. As the carbon dioxide
continues to build up in the bloodstream, the body's compensatory
mechanisms can no longer adapt, and the pH decreases. Likewise,
hyperventilation that occurs with conditions such as fever or anxiety can
cause respiratory alkalosis when too much carbon dioxide is expelled with
the increased respiratory rate.
Gastrointestinal disturbances.
Gastroenteritis and naso​gastric suctioning result in a loss of fluid, potassium,
and chloride ions. Hydrogen ions are also lost, resulting in metabolic
alkalosis. In contrast, loss of bicarbonate-rich intestinal or pancreatic fluids
(diarrhea, fistulas) can cause metabolic acidosis and also hypokalemia.
Timely education of infant and child caregivers is necessary to prevent
clinical dehydration when the infant or child is experiencing diarrhea.
Trauma.
Trauma resulting in hemorrhage causes FVD or hypovolemia. In addition,
crush injuries causing cellular damage bring about a massive release of
potassium into the intravascular fluid, causing hyperkalemia.
Head injury.
Head injury can result in cerebral edema. Occasionally, this edema creates
pressure on the pituitary gland and, as a result, ADH secretion is changed.
Diabetes insipidus occurs when too little ADH is secreted and the patient
excretes large volumes of diluted urine with a low specific gravity. Syndrome
of inappropriate antidiuretic hormone (SIADH) results in water intoxication
characterized by fluid volume expansion and hyponatremia, as well as
hypotonicity of fluids as a result of high urine osmolality and low serum
osmolality (Amerman, 2016, p. 974).
Recent surgery.
After surgery patients can exhibit many acid–base changes. The more
extensive the surgery and fluid loss are during the surgical procedure, the
greater the body's response is to the surgical trauma. The patient who is
reluctant to breathe deeply and cough may develop respiratory acidosis as a
result of retained PaCO2. The patient with nasogastric suction may develop
metabolic alkalosis as a result of the loss of gastric acid, fluids, and
electrolytes. In addition, the stress response of surgery may cause fluid shifts
postoperatively when aldosterone, glucocorticoids, and ADH are increasingly
secreted, causing sodium and chloride retention, potassium excretion, and
decreased urinary output.
Chronic Illness.
Chronic disease (e.g., cancer, heart failure, or renal disease) can create fluid,
electrolyte, and acid–base imbalances. The normal course of the patient's
chronic disease is important to know in order to anticipate how fluid,
electrolyte, and acid–base status may be affected.
Cancer.
The types of fluid and electrolyte imbalances that are observed in a patient
with cancer depend on the type and progression of the cancer, and the
related treatment. The potential electrolyte imbalances result from
anatomical distortion and functional impairment from tumour growth, or
tumour-related metabolic and endocrine abnormalities. Hypercalcemia can
result when cancer cells secrete chemicals that prompt the release of calcium
from the bone. Anorexia, stomatitis, and diarrhea, side effects of some
chemotherapy or radiation, create risks for many imbalances.
Cardiovascular disease.
In the patient with cardiovascular disease, diminished cardiac output reduces
kidney perfusion, causing the patient to experience a decrease in urinary
output. The patient will retain sodium and water, resulting in circulatory
overload, and is at risk of developing pulmonary edema. Fluid and electrolyte
imbalances associated with heart disease can be controlled with medications
and with fluid and sodium restrictions.
Renal disorders.
Kidney disease alters fluid and electrolyte balances by the abnormal
retention of sodium, chloride, potassium, and water in the extracellular
compartment. The plasma levels of metabolic waste products such as urea
and creatinine are elevated because the kidneys are unable to filter and
excrete the waste products of cellular metabolism. This elevation is toxic to
cellular processes. Metabolic acidosis results when hydrogen ions are
retained because of decreased renal function. Because of the renal disorder,
the usual renal compensatory mechanisms, such as bicarbonate
reabsorption, are not available; therefore, the body's ability to restore normal
acid–base balance is limited.
The severity of fluid and electrolyte imbalance is proportional to the
degree of renal failure. Acute renal failure is reversible. Although chronic
kidney disease is progressive, the patient may be treated successfully with
dietary control of protein and salt intake, diuretic medications, and fluid
restrictions. In later stages, treatment with dialysis, transplantation, or both
may be required.
Gastrointestinal disorders.
Chronic gastrointestinal disorders can have a serious impact on fluid,
electrolyte, and acid–base balances. Inflammatory bowel diseases, such as
ulcerative colitis, regional enteritis, and celiac disease, are relatively common
(Paul et al., 2016). Patients with liver failure may have a number of
imbalances, including metabolic acidosis, ECF shifts in the case of ascites,
and electrolyte disturbances. Key gastrointestinal assessments include the
length of the illness, the presence of exacerbations in the case of
inflammatory bowel disease, and the type of treatment currently being
administered. It is important to determine whether the patient has a history
of acute illnesses such as diarrhea or vomiting. Any condition that results in
the loss of gastrointestinal fluids predisposes the patient to the development
of dehydration and a variety of electrolyte disturbances.
Physical Assessment.
A thorough physical examination (see Chapter 31) is necessary because fluid
and electrolyte imbalances or acid–base disturbances can affect all body
systems. When conducting a physical examination, nurses need to
incorporate knowledge regarding the signs and symptoms of fluid,
electrolyte, and acid–base imbalances; disease processes that may affect
these balances; developmental considerations; and common risk factors (see
Table 40-7). For example, an examination of the oral cavity may reveal signs of
dehydration. Table 40-8 outlines nursing assessment findings and links these
to fluid, electrolyte, and acid–base imbalances.
TABLE 40-8
Focused Nursing Assessments and Relevant Imbalances
Assessment
Body Weight Changes From P revious Day
Loss of 1 kg (2.2 lbs) or more in 24 hours for adults
Gain of 1 kg (2.2 lbs) or more in 24 hours for adults
Clinical Markers of Vascular Volume
Blood pressure:
Hypotension or orthostatic hypotension
Light-headedness on sitting upright or standing
Pulse ra te a nd cha ra cter:
Rapid, thready
Bounding
Fullness of neck veins:
Flat or c ollapsing with inhalation when supine
Full or distended when upright or semi-upright
Other a ssessments of va scula r volume:
Capillary refill: S luggish
Lung ausc ultation, dependent lobe: Crac kles or rhonc hi with progressive
dyspnea
Urine output: S mall volume of dark yellow urine
Clinical Markers of Interstitial Volume
Presence of edema : Present in dependent areas (ankles or sac rum) and possibly
fingers or around eyes
Mucous membra nes: Dry between c heek and gum, dec reased or absent tearing
Skin turgor: Pinc hed skin fails to return to normal position within 3 sec onds
Presence of thirst: Thirst present
Beha viour a nd level of consciousness:
Restlessness and mild c onfusion
Dec reased level of c onsc iousness (lethargy, c onfusion, c oma)
Cardiac and Respiratory Signs of Electrolyte or Acid–Base Imbalances
Pulse rhythm a nd ECG: Irregular pulse and ECG c hanges
Ra te a nd depth of respira tions:
Inc reased rate and depth
Dec reased rate and depth
Neuromuscular Markers of Electrolyte or Acid–Base Imbalances
Muscle strength bila tera lly, especia lly qua driceps muscles:
Musc le weakness
Reflexes a nd sensa tions:
Dec reased deep tendon reflexes
Hyperac tive reflexes, musc le twitc hing and c ramps, tetany
Numbness, tingling in fingertips, around mouth
Musc le c ramps, tetany
Tremors
Gastrointestinal Signs of Electrolyte Imbalances
Inspection a nd a usculta tion:
Abdominal distension
Dec reased bowel sounds
Motility: Constipation
Imbalances
ECV defic it
ECV exc ess
ECV defic it
ECV defic it
ECV defic it
ECV exc ess
ECV defic it
ECV exc ess
ECV defic it
ECV exc ess
ECV defic it
ECV exc ess
ECV defic it
ECV defic it
Hypernatremia, severe ECV defic it
S evere ECV defic it
Hyponatremia, hypernatremia, hyperc alc emia, ac id–base
imbalanc es
K+, Ca2+, Mg 2+, and/or ac id–base imbalanc es
Metabolic ac idosis (c ompensatory mec hanism); respiratory
alkalosis (c ause)
Metabolic alkalosis (c ompensatory mec hanism); respiratory
ac idosis (c ause)
Hypokalemia, hyperkalemia
Hyperc alc emia, hypermagnesemia
Hypoc alc emia, hypomagnesemia
Hypoc alc emia, hypomagnesemia, respiratory alkalosis
Hypoc alc emia, hypomagnesemia, respiratory alkalosis
Hypomagnesemia
Hypokalemia, third-spac ing of fluid
Hypokalemia
Hypokalemia, hyperc alc emia
ECG, Electrocardiogram; ECV, extracellular fluid volume.
Assessing Fluid Intake and Output.
Assessing fluid balance involves knowledge of normal fluid requirements
and accurate measurement techniques and is critical to patient-centred care
in the acute care setting (McGloin, 2015). Inadequate fluid management,
including inaccurate calculations of fluid balance, is considered a common
barrier to safety, according to many reports (McGloin, 2015). Measuring and
recording fluid intake and output over a 24-hour period is a fundamental
aspect of fluid balance assessment. A fluid balance chart (FBC) includes all
intake (e.g., by mouth, intravenous solutions) and output (e.g., urine,
nasogastric drainage) and the 24-hour balance (deficit or excess) or summary.
An FBC, used in conjunction with physical assessment, is an essential
component of fluid monitoring across health care settings. Recognition of
trends in intake and output is also important to recognizing and responding
to problems, such as fluid volume excess or clinical dehydration, promptly.
Nurses can play a leadership role on the interprofessional team to promote,
complete, and report accurate fluid status.
Daily weight is considered the most accurate means to evaluate fluid
balance and guide the interprofessional team (Paul et al., 2016). The patient
should be weighed at the same time each day with the same scale after the
patient voids. The scale needs to be routinely calibrated. The patient should
wear the same clothes (or clothes that weigh the same); if a bed scale is being
used to weigh the patient, there should be the same number of sheets on the
bed with each weighing. Patients with chronic health issues can learn to
monitor their own fluid balance through weighing themselves daily,
recording their weights, and reporting changes. Health care providers may
direct patients with parameters and preferred action.
Intake includes all liquids taken by mouth (e.g., gelatin, ice cream, soup,
juice, and water) or through nasogastric or jejunostomy feeding tubes,
intravenous fluids (including both continuous and intermittent intravenous
fluids), and blood or its components. A patient receiving tube feedings may
receive numerous liquid medications and water may be used to flush the
tube. Over a 24-hour period, these liquids can amount to significant intake
and should always be recorded on the intake and output record. Output
includes urine, diarrhea, vomitus, gastric suction, and drainage from
postsurgical wounds or other tubes (see Chapter 48). Daily intake should
equal output plus 500 mL (to cover for insensible fluid losses).
To measure output, ambulatory patients are instructed to save their urine
in a calibrated receptacle that attaches to the rim of the toilet bowl. When a
patient has an in-dwelling Foley catheter, drainage tube, or suction, output is
recorded at predetermined times depending on the patient's condition and
prescribers' orders. Patient and family cooperation is essential for accurate
intake and output measurements. The patient and the family must be taught
the purpose of the measurements, including oral intake.
Recording intake and output is essential for obtaining an accurate
database to evaluate hydration status. This information helps maintain an
ongoing evaluation of the patient's hydration status to prevent severe
imbalances. Electronic or paper forms are used to ensure consistent
recording of intake and output by nurses or unregulated care providers. This
recording must be accurate, and estimation is not acceptable for safe
provision of care.
Laboratory Studies.
Nurses need to review laboratory data, including serum and urinary
electrolyte levels, hematocrit, blood creatinine level, blood urea nitrogen
(BUN) levels, urine specific gravity, and ABG readings. Serum electrolyte
levels are measured to determine the hydration status, the electrolyte
concentration of the blood plasma, and acid–base balance. The frequency
with which these electrolyte levels are measured depends on the severity of
the patient's illness. Serum electrolyte tests are routinely performed on any
patient entering a hospital to screen for alterations and to serve as a baseline
for future comparisons. Serum and urine osmolality are also used to assess
fluid balance (Arai et al., 2014, p. 464). The normal range for serum
osmolality is 285 to 295 mmol/kg. With dehydration, the serum osmolality
will be higher than normal.
Arterial Blood Gases.
To determine ABG levels, a sample of blood from an artery is taken to assess
the patient's acid–base status and the adequacy of ventilation and
oxygenation. Arterial blood is drawn from a peripheral artery (usually the
radial artery) or from an arterial line inserted by a physician. In some
agencies, nurses are responsible for radial artery punctures. Nurses may also
need to assist in the sampling process and care for the patient after the
procedure. After the specimen is obtained, care is taken to prevent air from
entering the syringe because this will affect the ABG analysis. The syringe
should be transported to the laboratory immediately. In the event of a delay
of more than 20 minutes, the syringe is submerged in crushed ice for
transport to the laboratory to reduce the metabolism of cells. Pressure is
applied to the puncture site for at least 5 minutes to reduce the risk of
hematoma formation. The nurse can reassess the pulse after pressure has
been removed.
Patient Expectations.
Often the patient's fluid, electrolyte, or acid–base disturbance is so serious
that it prevents a review of patient expectations. However, if a patient is alert
enough to discuss care, the nurse should explore with the patient his or her
short-term needs (e.g., provision of comfort from nausea) and long-term
needs (e.g., understanding how to prevent alterations from occurring in the
future). The nurse may also explore patient expectations with family and
supportive friends. The patient's trust is strengthened through a competent
response to sudden changes in condition and through clear communication
with the patient, family members, or both.
Nursing Diagnosis
When caring for patients with suspected fluid, electrolyte, and acid–base
imbalances, it is particularly important to use critical thinking to formulate
nursing diagnoses. The assessment data that establish the risk for or the
actual presence of a nursing diagnosis in these areas may be subtle, and
patterns and trends emerge only when nurses conscientiously assess for
them. Nurses must keep in mind that many body systems may be involved.
Clustering of defining characteristics will lead nurses to select the
appropriate diagnoses. For example, the nursing diagnosis deficient fluid
volume is developed to demonstrate the nursing diagnostic process in Box 406.
Box 40-6
Nursing Diagnostic Process
Deficient Fluid Volume
Assessment Activities
Defining Characteristics
Assess blood pressure and pulse
Obtain daily weight measurements
Observe volume of urine output and measure intake and
spec ific gravity
Assess skin turgor
Ask if patient is thirsty or weak
Inspec t muc ous membranes for degree of moisture
Patient is hypotensive, with inc reased heart rate
Patient experienc es sudden weight loss of up to 1 kg or more in 24 hours.
Dec reased volume of output in c omparison to intake; inc reased urine spec ific
gravity is present
Inelastic skin turgor noted
Patient verbalizes thirst and weakness
Dry muc ous membranes are noted
An important part of formulating nursing diagnoses is identifying the
relevant causative or related factor. Nursing interventions are chosen to treat
or modify the related factor. Deficient fluid volume related to loss of
gastrointestinal fluids via vomiting requires therapies different from those
needed for deficient fluid volume related to elevated body temperature.
Possible nursing diagnoses for patients with fluid, electrolyte, and acid–
base alterations include the following:
• Actual or risk of deficient fluid volume
• Actual or risk of excess fluid volume
• Decreased cardiac output
• Impaired gas exchange
• Acute confusion
• Impaired oral mucous membrane
• Actual or risk of impaired skin integrity
• Impaired mobility
• Ineffective therapeutic regimen management
• Deficient knowledge regarding disease management
Planning
During the planning process, nurses use critical thinking to synthesize
information from multiple sources and to ensure that the patient's care plan
integrates both scientific and nursing knowledge, the nurse's knowledge of
the individual, and the patient's expectations (Figure 40-8).
FIGURE 40-8
Critical thinking model for fluid, electrolyte, and acid–base balances planning.
CDC, Centers for Disease Control and Prevention.
Goals and Outcomes.
The nurse develops an individual care plan for the nursing diagnoses (see
Box 40-6 and Box 40-7). Goals or expectations for care set by the nurse and the
patient should be individualized and realistic, with measurable outcomes,
and developed in a patient-centred manner. For example, if the goal is to
achieve and maintain homeostasis, the following related outcomes might be
established:
Box 40-7
Nursing Care Plan
Fluid Volume Deficit
Assessment
Mrs. Hilda Beck is a 72-year-old seen by her health care provider this
morning after falling at home and telephoning a neighbour for assistance.
She lives alone in an apartment and has no chronic disease except for
osteoarthritis of her hands. She has had diarrhea and vomiting for over 24
hours and has not eaten anything. Despite feeling slightly nauseated, she
tried to drink a little water, because she knew she needed fluid. Mrs. Beck is
admitted for intravenous (IV) fluid therapy. X-ray films indicate that she has
no broken bones. Review of laboratory findings: hematocrit 55%
(hemoconcentration caused by hypovolemia); sodium 148 mmol/L, and
potassium 3 mmol/L. (Note: Mrs. Beck has hypokalemia in addition to
extracellular fluid volume [ECV] deficit and hypernatremia [clinical
dehydration].)
Assessment Activities
Findings/Defining Characteristics*
Ask Mrs. Bec k to desc ribe when her
vomiting and diarrhea began and any
ac c ompanying signs and symptoms.
S he states that her gastrointestinal problems began suddenly yesterday and that she gets wea k a nd
light-hea ded when she sta nds or sits upright, whic h is why she fell. S he feels wea k and has a dry
mouth .
S he says she was still vomiting earlier this morning. S he has not done so for the past 3 hours.
S he feels slightly nauseated. S he had three episodes of watery diarrhea this morning and more
than six yesterday.
Hea rt ra te is 110 bea ts/min with regular rhythm and a wea k pulse; supine blood pressure (BP) is 90/58 .
Temperature and respirations are within normal limits. Postural BP measurement is not taken
sinc e patient says that she gets light-hea ded when she sits upright.
Nec k veins are flat when she is supine; 100 mL of da rk yellow urine in past 4 hours; dry muc ous
membranes between c heek and gum; prolonged c apillary refill time of 5 sec onds.
Weight is 55.5 kg. S he states that usual weight at home is 58.5 kg ( 3 kg weight loss).
Ask her about the c urrent status of
vomiting and diarrhea.
Assess Mrs. Bec k's vital signs.
Evaluate physic al signs of ECV.
Weigh Mrs. Bec k using a bed sc ale.
*
Defining characteristics are shown in italics.
Nursing Diagnosis:
Deficient fluid volume related to increased output of GI fluids from
vomiting and diarrhea
Planning
Goals (Nursing Outcomes Classification)†
Fluid Ba la nce
Patient's fluid volume will return to normal by hospital disc harge.
Patient will desc ribe how to manage fluid balanc e at home before
hospital disc harge.
Expected Outcomes
Heart rate and BP return to normal within 24 hours.
Within 24 hours, Mrs. Bec k does not report light-headedness when
sitting or standing.
Urine c olour bec omes light yellow within 24 hours.
Daily urine output equals intake of at least 1 500 mL by disc harge.
Mrs. Bec k desc ribes how to replac e GI fluid loss with fluids that
c ontain sodium.
S he desc ribes signs and symptoms indic ating need to inc rease fluid
and sodium intake.
†
Outcome classification labels from Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2012).
Nursing outcomes classification (NOC) (5th ed.). St. Louis: Mosby.
Interventions
Interventions (Nursing Interventions
Rationale
Classification)‡
Fluid/Electrolyte Ma na gement
Provide Mrs. Bec k with her favourite fluids at her
preferred temperature.
Patient-c entred c are takes individual preferenc es into ac c ount. Offer c ultural
preferenc es regarding temperature of oral fluid intake (Giger, 2013). In c ontrast to
popular belief, moderate amounts of c affeinated beverages are not likely to have
exc essive diuretic effec t (S hepherd, 2013).
Provide a pitc her and glass of water at Mrs. Bec k's Weakness or c hronic disease suc h as osteoarthritis of hands may make it diffic ult to
preferred temperature at her bedside; ensure that
manipulate a full water pitc her. Make fluid available in form that is easy for patient to
she c an ac c ess and pour from it easily; provide
ac c ess (Felver, 2013b).
straw if she wishes.
Administer IV therapy as presc ribed, monitoring
IV fluid replac ement augments oral replac ement when ECV defic it exists. Agec losely for early adverse effec ts of c omplic ations. appropriate c are is needed bec ause of older persons' anatomic al and physiologic al
c hanges that affec t volume delivery (INS , 2016).
Disc uss different ways to prevent and treat
Patient educ ation is enhanc ed in older persons when the nurse uses multiple senses
dehydration at home. Provide written handout of
during teac hing sessions (Touhy & Jett, 2014).
information.
‡
Intervention classification labels from Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C.
(2013). Nursing interventions classification (NIC) (6th ed.). St. Louis: Mosby.
Evaluation
Nursing Actions
Monitor vital signs, intake and
output (I&O), daily weight,
and postural BP when no
longer light-headed.
Assess nec k vein fullness
when supine, muc ous
membranes.
Patient Response and Finding
T 37°C, RR 10, HR 72 beats/min, BP 120/78 sitting, 122/78 standing,
denies light-headedness
Intake 2 000 mL, output 2 000 mL of light yellow urine
Today's weight: 58.5 kg
Nec k veins full when supine; muc ous membranes moist
Achievement of
Outcome
Vital signs have
returned to normal
range. There is no
postural hypotension.
I&O measurements
are balanc ed, urine is
light yellow.
Daily weight has
returned to Mrs.
Bec k's normal
weight.
Additional markers of
ECV are normal.
Evaluate effec tiveness of teac hing Mrs. Bec k identified salty broth and c ommerc ial elec trolyte replac ement
Mrs. Bec k desc ribes
regarding maintaining fluid balanc e fluids for replac ing GI fluid loss and indic ated the need to inc rease her intake effec tive home
at home.
if her urine bec omes dark yellow or she bec omes light-headed when sitting management of fluid
upright.
balanc e.
• The patient will have normal fluid and electrolyte
balance at discharge.
• The patient will be free of complications associated
with the intravenous therapy.
• The patient will demonstrate fluid balance by moist,
mucous membranes and good skin turgor.
• The patient will have serum electrolytes within the
normal range within 48 hours.
Setting Priorities.
The patient's clinical condition will determine which diagnosis takes priority.
Many nursing diagnoses in the area of fluid, electrolyte, and acid–base
balances are of highest priority because the consequences for the patient can
be serious or even life-threatening. For example, in the concept map for a
patient with gastroenteritis and dehydration (Figure 40-9), nausea and
diarrhea caused a fluid volume deficit and electrolyte imbalances. Without
treating the cause, the fluid, electrolyte, and acid–base imbalances will
continue and progress.
FIGURE 40-9
Concept map for Mrs. Beck.
Teamwork and Collaboration.
Consultation with the patient's physician or primary health care provider
may assist in setting realistic time frames for the goals of care, particularly
when the patient's physiological status is unstable. During planning, it is
important to collaborate as much as possible with the patient, family, and
other members of the interdisciplinary health care team. Family can be
particularly helpful in identifying subtle changes in a patient's behaviour
associated with imbalances (e.g., anxiety, confusion, or irritability).
Depending on the composition of the health care team, some therapies can
be delegated, such as taking of daily weights or recording of fluid intake and
output.
Infusion Therapy Team.
Managing fluid, electrolyte, and acid–base imbalances often involves
infusion therapy. The Infusion Nurses Society (INS) has developed standards
of practice based on systematic review of the current evidence. These
standards, reviewed and published regularly, are a key source for standards
to inform decision making (see Figure 40-8). Vascular access device (VAD)
insertion, maintenance, and surveillance for quality improvement are
conducted by individuals and teams with infusion therapy education,
training, and validated competency (Coram, 2015; INS, 2016, p. S17). Having a
designated team for VADs, including peripheral catheters, improves patient
outcomes (e.g., reduced infections), comfort (e.g., reduced number of
unsuccessful attempts to initiate a VAD), and satisfaction (INS, 2016, p. S17).
For patients with acute disturbances, discharge planning must begin early.
The nurse must ensure that care can continue in the home or long-term care
setting with few disruptions. For example, when a patient is discharged on
intravenous therapy, the nurse must determine the knowledge and skills of
the person who is to assume caregiving responsibilities and make a referral
for home intravenous therapy as soon as possible (Box 40-8). The nurse must
also collaborate closely with other members of the health care team, such as
the dietitian, pharmacist, and physician. In consultation with a dietitian, the
nurse can recommend foods to increase intake of certain electrolytes or
reduce intake as necessary (see Chapter 42). The pharmacist can help identify
medications likely to cause electrolyte or acid–base disturbances and
describe possible adverse effects of the patient's prescribed drugs. The
physician directs the treatment of any fluid, electrolyte, or acid–base
alteration.
Box 40-8
Patient Teaching
Home Intravenous Therapy
Objective
• The patient, family caregiver, or both will demonstrate competence with
administering intravenous (IV) therapy safely in the home.
Teaching Strategies
• Explain the importance of IV therapy in maintaining hydration and
access for the delivery of medications.
• Emphasize the risks involved when the IV system is not kept sterile.
• Be sure that the patient or family caregiver is able to manipulate the
required equipment.
• Instruct them in aseptic technique and hand hygiene in the handling of
all IV equipment.
• Teach them how to change IV solutions, tubing, and dressing when they
become soiled or dislodged (Alexander et al., 2014). (Note: As the home
care nurse, you may be able to visit frequently enough to perform
scheduled tubing changes.)
• Teach procedures for safe disposal in appropriate containers of all
sharps and IV materials exposed to blood. Keep sharps containers away
from children (see Chapter 34).
• Instruct patient and caregiver to apply pressure with sterile gauze if the
catheter falls out and, if the patient is on anticoagulants, to tape pieces
of sterile gauze in place for at least 20 minutes with pressure or until
bleeding stops.
• Instruct patient and caregiver about signs and symptoms of infiltration,
phlebitis, and infection and reporting symptoms immediately.
• Instruct patient and family caregiver to report if the infusion slows or
stops or if blood is seen in the tubing.
• Teach patient with family caregiver's assistance how to ambulate,
perform hygiene, and participate in other activities of daily living
without dislodging or disconnecting catheter and tubing:
• For showering, protect the IV site and dressing from getting wet
by covering it completely with plastic. If using an electronic
infusion device, unplug around water.
• Wear clothes that avoid pressure on the IV site and avoid
trauma to the site when changing clothes.
• Have patient avoid strenuous exercise of the arm with the IV
line.
Evaluation
• Ask patient and family caregiver why it is necessary to maintain
hydration and IV access for the delivery of medications.
• Ask what to do if the IV infusion stops.
• Ask patient and family caregiver to describe signs and symptoms of
complications and the action they should take.
• Observe patient or family caregiver changing the IV container, tubing,
and dressing.
• Observe the patient ambulating and participating in activities of daily
living to see how he or she protects and manipulates the IV catheter and
apparatus.
Implementation
Health Promotion.
Health promotion activities in the area of fluid, electrolyte, and acid–base
imbalances include patient education regarding fluid and electrolyte
requirements, promotion of healthy environments affecting hydration, and
advocating for secure access to safe water as a universal need and human
right (International Council of Nurses [ICN], 2008; see also Pike-Macdonald,
Best, Twomey, et al., 2007).
Patients and caregivers need to recognize risk factors for imbalances and
implement appropriate preventive measures. Clear communication and use
of plain language are important in health education. Parents of infants need
to understand that gastrointestinal losses can quickly lead to serious
imbalances. When an infant is vomiting or has diarrhea, the parent must
recognize the risk and promptly seek health care to restore the infant's
normal balance. Even a healthy adult is at risk for developing imbalances
when subjected to high temperatures. Patients should be advised to increase
water intake, maintain adequate ventilation, and refrain from excessive
activity during heat waves. Box 40-4 provides guidelines for preventing
dehydration in older persons. All patients with a chronic health alteration are
at risk for developing changes in their fluid, electrolyte, and acid–base
balances. They need to understand their own risk factors and the measures to
be taken to avoid imbalances. For example, patients with chronic kidney
disease must avoid excess intake of fluid, sodium, potassium, magnesium,
and phosphorus. Through diet education, these patients learn the types of
foods to avoid and the suitable volume of fluid they are permitted daily (see
Chapter 42). Patients with chronic health conditions need to be made aware
of early signs and symptoms of fluid, electrolyte, and acid–base imbalances.
A patient with heart disease should be instructed to obtain an accurate body
weight each day at approximately the same time and to inform the health
care provider of significant changes in weight from one day to another.
Increase in weight, shortness of breath, orthopnea, and dependent edema are
all associated with fluid retention.
Nurses engaged in health promotion can attend to environmental factors
that influence the health of communities. For example, community health
nurses in Newfoundland and Labrador (Pike-MacDonald et al., 2007)
conducted a comprehensive community health needs study. The research was
used to increase awareness of drinking water pollution, through monitoring
of water quality and reporting of results to both the community and health
policymakers. Globally, improved water quality and access to safe drinking
water, though largely ignored, would have a significant impact on health,
saving millions of lives (Allgood, 2009). While there have been successes in
improving access to safe drinking water and reducing water contamination,
household water treatment could bring about further advances in community
health. Efforts of nurses in the developing world to provide education
regarding safe drinking water and to implement safe drinking practices are
saving lives. Community needs assessments and quality improvement
initiatives in relation to environmental determinants of health involve
attention to safe drinking and access to safe water (see Chapter 4). These
efforts relate strongly to nurses' advocacy role in health promotion of healthy
fluid and electrolyte levels.
Acute Care.
While fluid, electrolyte, and acid–base imbalances can occur in all settings,
many patients are cared for in acute care settings. Today, management of a
patient's complex medical care is completed in a shorter span of time and
involves expectations to perform increasingly difficult technological skills.
Enteral Replacement of Fluids.
Oral replacement of fluids and electrolytes is appropriate as long as the
patient is not so physiologically compromised that oral fluids cannot be
replaced rapidly. Patients unable to tolerate solid foods may still be able to
ingest fluids. Nurses may use strategies to encourage fluid intake, such as
frequently offering small sips of fluid, ice pops, and ice chips. Ice chips
should be included in the intake and output measurements, at one-half the
volume of the chips (i.e., 250 mL of ice chips = 125 mL). For children with
mild gastroenteritis, diluted apple juice followed by preferred fluids is an
effective alternative to electrolyte maintenance fluids, with fewer treatment
failures (Freedman, Willan, Boutis, et al., 2016).
Use of oral rehydration solutions (ORS) has reduced mortality related to
diarrhea around the world. ORS are either glucose-electrolyte solutions or
polymer-based solutions (e.g., made from rice, wheat, or maize). Evidence
suggests that polymer-based solutions may be more effective in rehydration
(Gregorio, Gonzales, Dans, et al., 2009). Hartling, Bellemare, Wiebe, and
colleagues (2006) conducted a systematic review and concluded that oral
hydration is effective and safe in treating dehydration in children with
gastroenteritis, particularly with low-osmolarity solutions. A key nursing role
is to encourage children and their caregivers regarding oral rehydration.
Oral replacement of fluids is contraindicated if the patient has a
mechanical obstruction of the gastrointestinal tract, is at risk for aspiration,
or has impaired swallowing. A feeding tube may be necessary, such as when
the patient's gastrointestinal tract is healthy but the patient cannot ingest
fluids (e.g., with impaired swallowing). Fluids can also be replaced through a
gastrostomy or jejunostomy feeding tube or administered via a small-bore
nasoenteral feeding tube. Maintaining adequate hydration for patients with
enteral feeding involves an interprofessional team including dietitians,
nurses, and other health care providers (Dunn, 2015). In caring for these
patients, nurses need to assess for signs of dehydration and overhydration.
Restriction of Fluids.
Patients who retain fluids and have fluid volume excess (FVE) require
restricted fluid intake. Fluid restriction is often difficult for patients,
particularly if they take medications that dry the oral mucous membranes or
if they breathe through the mouth. The nurse should provide the rationale
for fluid restrictions and the amount permitted. The patient and family need
to understand that ice chips, gelatin, and ice cream are considered fluid. The
patient should be involved in decisions regarding the amount of fluid and
the distribution of fluids over the day. Patients on fluid restriction can
swallow a number of pills with as little as 30 mL of liquid. Patients on fluid
restriction require mouth care frequently to moisten mucous membranes,
decrease the chance of mucosal drying and cracking, and maintain comfort.
In experiments, patients under fluid restrictions can lose 1% to 2% body
mass within 13 to 24 hours and will experience thirst strongly, except for
older persons who often do not experience thirst (Arai et al., 2014; Shepherd,
2013).
Interventions for Acid–Base Imbalances.
Nursing interventions to promote acid–base balance support prescribed
medical therapies and are aimed at reversing the acid–base imbalance. Such
imbalances can be life-threatening and require rapid correction. In
collaboration with the interdisciplinary team, the nurse must maintain a
functional intravenous line and provide prescribed medications, such as
insulin or sodium bicarbonate, and fluid and electrolyte replacement
promptly. Patients with acute acid–base disturbances often require repeated
ABG analysis and close monitoring.
Parenteral Replacement of Fluids and Electrolytes.
Fluid and electrolytes may be replaced through infusion directly into the
circulatory system or intravenously, rather than via the digestive system. This
is often referred to as infusion therapy (INS, 2016). Parenteral replacement
includes administration of crystalloids, colloids, and total parenteral
nutrition (TPN). TPN is a nutritionally adequate hypertonic solution
consisting of glucose, other nutrients, and electrolytes. This solution is
formulated to meet individual patient needs through interdisciplinary
collaboration (e.g., dietitian, pharmacist, physician, nurse). See Chapter 42
for a full discussion of TPN and nutritional support.
The goal of intravenous fluid administration is to maintain fluid,
electrolyte, and energy demands when patients are limited in their intake
and to prevent or correct fluid and electrolyte disturbances from excess
losses. Intravenous fluid administration enables direct access to the vascular
system, permitting the continuous infusion of fluids over a period of time.
Intravenous fluid therapy must be continuously regulated to assess for
changes in the patient's fluid and electrolyte balances. Knowledge of the
correct ordered solution, the equipment needed, the procedures required to
initiate an infusion, how to regulate the infusion rate and maintain the
system, how to identify and correct problems, and how to discontinue the
infusion is necessary for safe and appropriate therapy. Because of the risk of
transmission of infectious diseases, standard precautions must be followed
when preparing to administer parenteral fluids (see Chapter 33). Patient
safety and quality improvement are continuously attended to in all infusion
therapy–related care (INS, 2016, p. S11). When providing infusion therapy to
special populations such as infants and older persons, special competency is
required. Consideration is given to anatomical and physiological differences,
growth and development stage, and family preferences (INS, 2016, p. S11).
Safe administration of intravenous fluids includes an evidence-informed
knowledge base related to the solution prescribed, the patient-centred
rationale, equipment selection based on best practice, and potential risks and
complications (Table 40-9). Safe administration of intravenous fluids also
includes skills related to intravenous initiation, regulation of rate,
assessment of the site and equipment, necessary techniques for maintenance
of the site and prevention of infection, and, finally, discontinuation of the
intravenous catheter. Consideration of the patient's unique preferences and
perspectives is important throughout the intervention.
TABLE 40-9
Intravenous Solutions
Solution
Concentration Comments
Dextrose in Water Solutions
Dextrose 5% in water (D 5W)
Isotonic
Dextrose 10% in water (D 10W)
Hypertonic
Saline Solutions
0.225% sodium c hloride (quarter normal
saline;
NS ; 0.225% NaCl)
Hypotonic
Dextrose is the name used for gluc ose in intravenous solutions.
Isotonic when first enters vein; dextrose enters c ells rapidly, leaving free
water, whic h dilutes ECF; most of water then enters c ells by osmosis.
Hypertonic when first enters vein, dextrose enters c ells rapidly, leaving free
water, whic h dilutes ECF; most of water then enters c ells by osmosis.
S aline is sodium c hloride in water.
Expands ECV (vasc ular and interstitial) and rehydrates c ells.
0.45% sodium c hloride (half normal saline; Hypotonic
NS ; 0.45% NaCl)
Expands ECV (vasc ular and interstitial) and rehydrates c ells.
0.9% sodium c hloride (normal saline; NS ; Isotonic
0.9% NaCl)
3% or 5% sodium c hloride (hypertonic
Hypertonic
saline; 3% or 5% NaCl)
Dextrose in Saline Solutions
Dextrose 5% in 0.45% NaCl sodium
Hypertonic
c hloride (D
NS ; D 0.45% NaCl)
Expands ECV (vasc ular and interstitial); does not enter c ells.
5
Draws water from c ells into ECF by osmosis.
Dextrose enters c ells rapidly, leaving 0.45% sodium c hloride.
5
Dextrose 5% in 0.9% sodium c hloride
(D 5NS ; D 50.9% NaCl)
Balanced Electrolyte Solutions
Lac tated Ringer's (LR)
Hypertonic
Dextrose enters c ells rapidly, leaving 0.9% sodium c hloride.
Isotonic
Dextrose 5% in lac tated Ringer's (D 5LR)
Hypertonic
Contains Na+, K+, Ca2+, Cl−, and lac tate, whic h liver metabolizes to HCO 3–.
Expands ECV (vasc ular and interstitial); does not enter c ells.
Dextrose enters c ells rapidly, leaving lac tated Ringer's.
ECF, Extracellular fluid; ECV, extracellular fluid volume.
Types of solutions.
The two main categories of intravenous fluids are crystalloids and colloids.
Crystalloids are used most commonly and include dextrose, sodium chloride,
and lactated Ringer's solutions (see Table 40-9). These solutions contain
solutes that mix, dissolve, and cross semipermeable membranes. They vary in
their tonicity (Figure 40-10). Colloids contain protein or starch, which does
not cross semipermeable membranes and therefore remains suspended and
distributed in the extracellular space, primarily the intravascular space, for
up to several days. Colloids have been used to increase the osmotic pressure
in the intravascular space to increase vascular volume in critical situations.
Colloids are either semi-synthetic, such as dextran, pentastarch, or
hetastarch, or human plasma derivatives, such as albumin, plasma proteins,
or blood. Recent evidence suggests that crystalloids are as effective as
colloids in many situations and are less costly (Perel & Roberts, 2012).
FIGURE 40-10
Effects of isotonic (A), and hypertonic (B), and hypotonic (C) solutions. (From Hall, J. E.
[2016]. Guyton and Hall textbook of medical physiology [13th ed.]. Philadelphia: Saunders.)
Vascular Access Devices.
Vascular access devices (VADs) are catheters, cannulas, or infusion ports
designed for repeated access to the vascular system. These devices include
peripheral vascular access devices (PVADs) and central vascular access
devices (CVADs) (Figure 40-11) and allow for parenteral fluid and electrolyte
replacement, parenteral nutrition, and administration of medications.
Peripheral cannulas are selected for short-term use, whereas central venous
catheters (CVCs), peripherally inserted central catheters (PICCs), tunnelled
catheters (e.g., Hickman), and implanted ports (Figure 40-12) are for longterm use or for administration of medications or solutions that are irritating
to veins. A midline catheter, a catheter inserted into the upper arm and
terminating distal to the shoulder, is recommended for intermediate use (1–4
weeks) or when peripheral or central access is difficult or contraindicated
(Ogston-Tuck, 2012, p. 476). Other reasons for using CVADs are presence of
limited or poor peripheral veins, the need for good access to administer large
volumes of fluid, and the need for reliable measurement of fluids. CVADs
have become an essential tool in contemporary nursing practice in acute care
and in community settings (INS, 2016). PICCs are quite common across
settings (Figure 40-13). Correct dressing and labelling are critical to the
prevention of infection and effective monitoring of the PICC site and line
(Figure 40-14). Nurses play an important role in the education of patients and
families regarding VADs and in decisions regarding device selection (INS,
2016; Registered Nurses' Association of Ontario [RNAO] 2004/2008). See
Figure 40-15 for a comparison of midline and peripheral catheters.
FIGURE 40-11
Central venous access devices (CVADs) deliver fluid into the superior vena cava
near the heart.
FIGURE 40-12 A, Implanted port. B, Accessing an implanted port. (Courtesy Darlaine
Jantzen, RN, MA, PhD. Photo by Burl Jantzen.)
FIGURE 40-13
Peripherally inserted central catheter (PICC) model. (Courtesy Darlaine Jantzen, RN, MA, PhD.
Photo by Burl Jantzen.)
FIGURE 40-14
Peripherally inserted central catheter (PICC) dressing and label. (Courtesy Darlaine
Jantzen, RN, MA, PhD. Photo by Burl Jantzen.)
FIGURE 40-15
Midline (top) and peripheral (bottom) intravenous catheters. (Courtesy Darlaine Jantzen, RN,
MA, PhD. Photo by Burl Jantzen.)
Informed consent is required when providing care to patients with health
challenges, and patients have the right to refuse treatment. Education
regarding parenteral replacement of fluid and electrolytes or administration
of treatments includes knowledge of the patient's preferred learning
methods, health literacy level, and cultural preferences; organizational
policy; and legislation (INS, 2016, p. S27). Nurses also play a role in the
continual evaluation of the need and appropriateness of a VAD, as prompt
removal of unnecessary lines is key to preventing catheter-related
bloodstream infections (INS, 2016) (Box 40-9). The recommendations and
discussion that follow here are general guidelines; nurses should be aware of,
and follow, specific institutional and manufacturer's policy.
Box 40-9
Evidence-Informed Practice
Preventing Central Line-Associated Bloodstream Infections
(CLABSI)
PICO Question: In hospitalized adult patients, which interventions for
central intravenous (IV) site care are best to prevent central line–associated
bloodstream infections (CLABSI)?
Evidence Summary
CLABSI is a serious complication of IV therapy that increases morbidity,
hospital length of stay, and health care costs. Research shows that effective
strategies for prevention of CLABSI include the use of several evidenceinformed practices together as a “bundle” or “checklist” (Chopra, Krein,
Olmsted, et al., 2013). Such bundles are effective in reducing CLABSIs at the
time of insertion of central lines and also during their maintenance (The
Joint Commission, 2017). For example, a recommended bundle at insertion of
a central line is hand hygiene before catheter insertion; use of maximum
sterile barrier precautions on insertion; chlorhexidine skin antisepsis before
insertion and during dressing changes; avoidance of the femoral vein for
central venous access for adults; and daily evaluation of line necessity, with
prompt removal of nonessential lines (Chopra et al., 2013). Maintenance
bundles are similar, with attention to hand hygiene, catheter hub asepsis,
dressing and line change, and continued daily evaluation of line necessity.
For the most effective reduction in CLABSIs, research demonstrates the
need for organized educational strategies and attention to institutional
support and culture in addition to the use of bundled central line insertion
and maintenance practices. One hospital had instituted the central line
insertion bundle but still had not achieved zero CLABSI rate in the Critical
Care Unit (CCU); however, with addition of a collaborative program
involving staff education, daily surveillance, single-use line insertion kits,
and updated policies and protocols, a zero CLABSI rate was achieved
(Matocha, 2013). Dumyati, Concannon, van Wijngaarden, and colleagues
(2014) reduced the CLABSI rate by 50% with a multimodal intervention that
included involvement of nursing leadership and staff, education on the
central line maintenance bundle components, competency evaluation, and
line care audits. Zingg, Cartier, Inan, and colleagues (2014) achieved a
hospital-wide clinically relevant reduction in CLABSIs with an
interdisciplinary multimodal program that included educational
components, single-use insertion kits, a catheter insertion checklist, and a
catheter maintenance bundle.
Application to Nursing Practice
• If CLABSI prevention bundles are not used for central line insertion and
maintenance at your agency, review the current research in a nursing
practice committee or with your IV therapy team to influence policy and
procedures and implement these bundles.
• Extend use of central line maintenance bundles to hospital units outside
the CCU where patients have central lines.
• Work with infection control personnel and medical and nursing
administration to establish a multidisciplinary CLABSI prevention
program that includes institutional support for education, competency
demonstration, use of insertion and maintenance bundles, and daily line
audits.
Peripheral vascular access devices: Nursing considerations.
Comprehensive assessment is the first step in initiating any intravenous
therapy (Ogston-Tuck, 2012); (Skill 40-1, Steps 2 to 6; Box 40-10). Many factors
are involved in device selection, including safety concerns, treatment goals
and duration, access to services such as home intravenous programs, and
physical limitations. Effective communication, allowing time for questions,
and education regarding the signs of complications are important to
preventing and managing risks (Scales, 2011).
SKILL 40-1
INITIATING A PERIPHERAL INTRAVENOUS INFUSION
Delegation Considerations
In many provinc es, monitoring intravenous therapy is inc luded within the sc ope of
prac tic e for lic ensed and registered prac tic al nurses. In some loc ations, the
delegating nurse is ultimately responsible for assessment and monitoring of the
intravenous devic e. The skill of initia ting intra venous thera py should not be delega ted to
unregula ted ca re providers (UCPs) or to those who ha ve not demonstra ted competence in
initia ting intra venous thera py (INS , 2016, S 18). Other aspec ts of the patient's c are
may be delegated to UCPs. Instruc t the UCP about the following:
• To inform the nurse if the patient c omplains of burning sensation or appears to have
disc omfort, bleeding, swelling, or c oolness at the c atheter insertion site
• The presc ribed flow rate and to report if the rate has slowed or inc reased
• To inform the nurse if the intravenous dressing bec omes wet or c ompromised
• To inform the nurse if an elec tronic infusion devic e (EID) sounds or appears to be
malfunc tioning
• To inform the nurse if the volume of fluid in the intravenous bag is low
Equipment
• Correc t intravenous solution
• Proper c atheter for venipunc ture (the gauge will
vary with the patient's body size and the reason
for intravenous fluid administration). S elec t the
smallest gauge and shortest length possible.
• Intravenous start kit (if available): May c ontain a
sterile drape to plac e under the patient's arm, a
tourniquet, c leaning and antiseptic preparations,
dressings, and a small roll of sterile tape
• Loc al anaesthetic (optional)
For intravenous fluid infusion
• Administration set (the c hoic e depends on the
type of solution and rate of administration; infants
and c hildren, patients with c ardiac or renal
disease, and patients taking c ertain medic ations
require mic rodrip tubing, whic h provides 60
gtt/mL)
• Extension tubing (used when a longer
intravenous line is nec essary or to avoid
manipulation of the c atheter insertion site with
frequent tubing c hanges)
• Antiseptic swabs or stic ks (c hlorhexidine,
povidone–iodine, alc ohol)
• Disposable gloves
• Tourniquet (Determine the type of tourniquet on
the basis of the patient assessment, e.g., a blood
pressure [BP] c uff [older person] or a rubber
band [infants]. Tourniquets c an be a sourc e of
c ontamination; use a single-use produc t.)
• Nonallergenic tape
• Waterproof pad (to plac e under patient's hand or
arm)
• Intravenous pole or EID, for prec ise flowc ontrol, or flow-c ontrol devic e, determined by
patient age, patient's presenting c ondition,
spec ific infusion therapy, and setting
• S pec ial patient gown with snaps at shoulder
seams, if available (makes removal with
intravenous tubing easier)
• Needle disposal c ontainer (also c alled sharps
c ontainer)
• Intravenous site protec tion devic e (optional)
For Normal Saline Lock
• Needleless c onnec tors
• Injec tion c ap (also c alled intravenous plug,
adapter, CAP)
• 1 to 3 mL of sterile normal saline
Gauze Dressing Only
• 2 × 2 (5 c m × 5 c m) or 4 × 4 (10 c m × 10 c m)
sterile gauze sponge
• S terile tape
Transparent Dressing Only (P referred)
• Transparent dressing
P ROCEDURE
STEP S
ASSESSMENT
1. Review presc riber's order for type and amount of intravenous fluid, rate of fluid
administration, and purpose of infusion. Follow 10 rights for administration of
medic ations (see Chapter 34).
2. Identify patient ac c ording to agenc y polic y.
RATIONALE
• An order requesting the initiation of a peripheral
intravenous ac c ess and administration of an
intravenous solution must be made by a
physic ian before implementation of this
proc edure. Nurses assist in dec ision making for
selec tion of appropriate ac c ess devic e.
• Ensures c orrec t patient and c omplies with quality
and safety guidelines.
Critical Decision P oint: Hea lth ca re providers or prescribers do not write orders to “initia te periphera l a ccess” or “perform venipuncture.” “Sta rt IV”
ma y be written, followed by the exa ct intra venous thera py order. The order to perform venipuncture is implied. If the order is confusing or in question,
cla rify it with the hea lth ca re provider before proceeding.
3. Assess for c linic al variables that respond to or are affec ted by intravenous fluid
• Provides baseline data for later evaluation of
administration. Assess for c hronic illness and presc ribed and over-the-c ounter
c hange in fluid and elec trolyte status.
medic ations.
• Analysis of data may lead to rec ommendations
regarding slower infusion rate or
c ontraindic ations to therapy.
A. Peripheral edema
• Indic ates expanded interstitial fluid volume,
evident in dependent body parts (e.g., feet and
ankles). Exc ess intravenous fluids will worsen
this c ondition.
B. Greater than 20% c hange in body weight
• Daily weights assist in doc umenting fluid
retention or loss. Change in body weight of 1 kg
c orresponds to 1 L of fluid retention or loss.
C. Dry skin and muc ous membranes
• Frequently assoc iated with fluid volume defic it
(FVD).
D. Distended nec k veins
• Frequently assoc iated with fluid volume exc ess
(FVE) or c ardiovasc ular alterations.
E. BP c hanges
• Elevations in BP may indic ate volume exc ess,
and dec reased pressure may indic ate FVD.
These c hanges c an be more sudden and
pronounc ed in patients with underlying
c ardiopulmonary disease.
F. Irregular pulse rhythm; tac hyc ardia
• Rate and rhythm c hange c an oc c ur with c hanges
in intravasc ular volume, as well as c hanges in
potassium, c alc ium, or magnesium. Tac hyc ardia
may indic ate c ardiac c ompensation for reduc ed
c irc ulating volume, whereas irregular pulse may
indic ate arrhythmias sec ondary to elec trolyte
imbalanc e.
G. Ausc ultation of abnormal lung sounds
• With FVE, the c ardiovasc ular system is unable to
c ompensate for this exc ess and fluid builds up in
the lungs, c reating abnormal lung sounds, suc h
as c rac kles.
H. Dec reased skin turgor. S kin fails to return to normal position in 3 sec onds after
• With dec reased fluid volume, the skin when
pinc hing.
pinc hed remains in that state for several sec onds.
This is c alled “tenting.”
Critical Decision P oint: Cha nges in skin turgor a re a less relia ble indica tor for older pa tients beca use of the na tura l loss in skin ela sticity ca used by the
norma l a ging process.
I. Thirst
• S ymptomatic of FVD. Very young, c onfused,
and severely debilitated patients may not be able
to indic ate their thirst.
J. Anorexia, nausea, and vomiting
• May be present with FVE or FVD. These
symptoms may also be present with the patient's
underlying disease.
• During dehydration, the kidneys attempt to
restore fluid balanc e by reduc ing urine
produc tion.
L. Behavioural c hanges
• May oc c ur with FVD and ac id–base imbalanc e.
In addition, behavioural c hanges may be due to
fever, the underlying c ondition, or pre-existing
disease.
4. Assess patient's previous or perc eived experienc e with intravenous therapy and arm • Determines level of emotional support and
plac ement preferenc e (INS , 2016).
instruc tion nec essary for patient-c entred c are. If
sensitive to venipunc tures, a loc al anaesthetic
may be indic ated. The loc al anaesthetic needs to
be applied 5–10 minutes prior to insertion
(Burc hum & Rosenthal, 2016).
5. Determine whether patient is to undergo any planned surgeries or is to rec eive blood • Allows nurse to selec t c atheter gauge, and
infusion later.
avoids plac ement in an area that will interfere
with medic al proc edures.
6. Assess laboratory data.
• Determines priority assessments, establishes
baseline, and provides information that affec ts
insertion of devic es, suc h as FVD, anemia.
7. Determine patient's history of allergies.
• Equipment used or medic ation or solution
ordered may c ontain substanc es to whic h patient
is allergic , suc h as iodine, adhesive, or latex.
8. Assess for the following risk fac tors: c hild or older person, presenc e of heart failure • Fluid imbalanc es develop more rapidly in
or renal failure, previous surgeries, or low platelet c ount.
extremely young patients (infants) and older
patients bec ause suc h patients have
proportionately larger extrac ellular fluid (ECF)
volume, patients with heart failure may require
fluid restric tion and c annot adapt to sudden
inc reases in vasc ular volume, and patients with
renal failure c annot eliminate exc ess ECF. A low
platelet c ount predisposes patients to bleeding at
intravenous site.
• Vasc ular visualization may be indic ated in
patients with disease-related vessel c hanges
(e.g., diabetes), prior extended intravenous
therapy, skin alterations (e.g., burns, sc ars), very
young or advanc ed age, or obesity.
K. Dec reased urine output
P LANNING
9. Prepare patient and family by explaining the proc edure, its purpose, and what is
expec ted of the patient.
10. Obtain informed c onsent.
• Dec reases anxiety and promotes c ooperation.
• Initiation of a vasc ular ac c ess devic e (VAD) c an
be ac c epted or refused. Follow organizational
polic y and legislation regarding c onsent
proc edures.
• Verbal c onsent and implied c onsent are types of
c onsent in keeping with patient-c entred c are.
11. Assist patient to c omfortable sitting or supine position.
• Enables patient to extend arm.
12. Collec t and organize equipment on c lean, c lutter-free bedside stand or overbed table. • Reduc es risk of c ontamination and ac c idents and
c ontributes to patient safety.
13. Change patient's gown to the more easily removed gown with snaps at the shoulder, • Use of a spec ial intravenous gown fac ilitates safe
if available.
removal of the gown.
14. Chec k intravenous solution, using the 10 rights of drug administration (see Chapter
• Intravenous solutions are medic ations and
34). Make sure presc ribed additives, suc h as potassium and vitamins, have been
should be c arefully c hec ked to reduc e the risk of
added. Chec k solution for c olour, c larity, and expiration date. Chec k bag for leaks,
error.
whic h is best if done before reac hing the bedside (see S tep 14 illustration).
• As with medic ation administration, use agenc yapproved resourc es (e.g., drug referenc e) for
c omposition of intravenous fluids,
inc ompatibilities, adverse effec ts, and spec ial
c onsiderations.
• S olutions that are disc oloured, c ontain partic les,
or are expired are not to be used. (S ome
solutions may have slight disc oloration [e.g., be
pink-tinged] and still be suitable for use.) Leaky
bags present an opportunity for infec tion and
must not be used.
STEP 14
Check intravenous solution. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo by
Burl Jantzen.)
IMP LEMENTATION
15. Perform hand hygiene.
For continuous infusion:
16. Open the infusion set and other supplies, maintaining aseptic tec hnique. When
preparing the infusion set, do not touc h point of entry for c onnec tions, and avoid
removing end c ap.
17. Plac e roller c lamp about 2 to 5 c m below drip c hamber and move roller c lamp to
c losed position. For EIDs, plac e roller c lamp proximal to the patient.
• Reduc es spread of mic roorganisms, thereby
helping to prevent infec tion.
• Maintains sterility of equipment and reduc es
spread of mic roorganisms. Prevents bac teria
from entering infusion equipment and
bloodstream, and reduc es transmission of
infec tion.
• EIDs may have spec ial administration sets, in
whic h c ase, follow manufac turer's instruc tions.
• If c ontamination oc c urs, disc ard intravenous
tubing.
• Close proximity of roller c lamp to drip c hamber
allows more ac c urate regulation of flow rate.
Moving c lamp to c losed position prevents
ac c idental spillage of fluid.
• Provides ac c ess for insertion of infusion tubing
into solution.
18. Remove protec tive sheath over intravenous bag port. For bottled intravenous
solution, remove metal c ap and metal and rubber disc s beneath c ap. Use c aution to
avoid touc hing exposed opening.
19. Insert infusion set into fluid bag or bottle by removing protec tor c ap from tubing
• Prevents c ontamination of solution from
insertion spike (keeping spike sterile) and inserting spike into opening of intravenous c ontaminated insertion spike.
bag (see S tep 19 illustration). Clean rubber stopper on glass-bottled solution with
• Container heights of approximately 1 m are
antiseptic and insert spike into blac k rubber stopper of intravenous bottle. Hang
usually suffic ient to overc ome venous pressure
solution c ontainer on intravenous pole at a minimum height of 90 c m above planned
and other resistanc e from tubing and c atheter.
insertion site.
• If c ontamination oc c urs, disc ard intravenous
tubing and obtain a new set.
STEP 19
Inserting spike into intravenous bag. (Courtesy Darlaine Jantzen, RN, MA, PhD.
Photo by Burl Jantzen.)
20. Compress drip c hamber and release, allowing it to fill one-third to one-half full. Open • Creates vac uum effec ts; fluid enters drip c hamber
c lamp and prime infusion tubing by filling with intravenous solution, c arefully
to prevent air from entering tubing. By inverting
inverting valves and ports in sequenc e as the solution moves through the tubing (see valves and ports, you allow them to fill with
S tep 20 illustration).
fluid, minimizing air bubbles.
STEP 20
Priming intravenous tubing. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo
by Burl Jantzen.)
21. S lowly release roller c lamp to allow fluid to travel from drip c hamber through tubing • S low filling of tubing dec reases turbulenc e and
to needle adapter. (S ee S tep 20, Priming intravenous tubing.) Return roller c lamp to
c hanc e of bubble formation. Removes air from
c losed position after tubing is primed (filled with intravenous fluid).
tubing and permits tubing to fill with solution.
Closing the c lamp prevents ac c idental loss of
fluid.
• Most tubing sets c an be primed without
removing the end c ap. If the tubing protec tor c ap
is removed, replac e it promptly onc e the tubing
is primed.
22. Be c ertain tubing is c lear of air and air bubbles. To remove small air bubbles, firmly
• Air bubbles may c ontribute to anxiety related to
tap intravenous tubing where air bubbles are loc ated. Chec k entire length of tubing to intravenous therapy and may c ause EID to set off
ensure that all air bubbles are removed. If using multiple-port tubing, turn ports upside alarm, inc reasing anxiety further.
down and tap to fill and remove air.
23. Insert primed tubing into EID set to “off” (see S tep 23 illustration).
• Fac ilitates starting infusion as soon as
intravenous site is ready.
STEP 23
Primed line with EID. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo by Burl
Jantzen.)
For intermittent intravenous catheter use:
• Priming the extension tubing and needleless
24. Prepare needleless c onnec tor and extension set. Use sterile tec hnique to c onnec t the
c onnec tor prevents introduc tion of air into the
needleless c onnec tor to the loop or short extension tubing. Prime with normal saline. vein.
• Extension sets are not rec ommended for
c ontinuous intravenous fluid administration, as
they are potential sites of mic robial
c ontamination (INS , 2016, p. S 68).
• Remove needleless c onnec tor when rapid flow
rates are required, or when administering red
blood c ells (INS , 2016, p. S 68).
25. Apply disposable gloves. Eye protec tion and mask may be worn (see agenc y
• Reduc es transmission of mic roorganisms.
Dec reases exposure to bloodborne organisms
polic y) if splash or spray of blood is possible. Note: Gloves c an be left off to loc ate
(INS , 2016).
vein but must be applied before preparing site.
Critical Decision P oint: Gloves ca n be a pplied before or a fter a ssessing veins. Gloves must be a pplied before VAD insertion. Use disposa ble, nonsterile
gloves a nd no-touch technique for intra venous insertion (INS, 2016, p. S65).
26. Apply tourniquet 10 to 15 c m above the proposed insertion site or above antec ubital • Tourniquet should be tight enough to impede
fossa (see S tep 26 illustration) to begin vein selec tion. Position tourniquet so that
venous return but not oc c lude arterial flow.
ends are away from proposed venipunc ture site. Chec k for presenc e of radial pulse. • If patient has fragile veins, apply tourniquet
loosely or not at all.
Option: Apply BP c uff instead of tourniquet. Inflate to a level just below patient's
• Avoid antec ubital fossa for intravenous insertion,
normal diastolic pressure. Maintain inflation at that pressure until venipunc ture is
exc ept in extreme emergenc ies.
c ompleted.
STEP 26
Apply tourniquet. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo by Burl
Jantzen.)
27. S elec t the vein. Common intravenous sites for the adult inc lude c ephalic , basilic , and
median c ubital veins (see Figures 40-17 and 40-18).
A. Use the most distal site in the nondominant arm, if possible.
• Venipunc ture should be performed distal to
proximal, whic h inc reases the availability of
other sites for future intravenous therapy.
B. Avoid areas that are painful to palpation.
• May indic ate inflamed vein.
C. S elec t a vein large enough for c atheter plac ement.
• Prevents interruption of venous flow while
allowing adequate blood flow around the
c atheter.
D. Choose a site that will not interfere with patient's ac tivities of daily living or planned • S elec tion of an appropriate site will minimize
proc edures.
risk of injury and loss of the intravenous line.
E. Use the fingertips to palpate the vein by pressing downward and noting the resilient, • Fingertips are more sensitive and are better to
soft, bounc y feeling as the pressure is released (see S tep 27E illustration).
assess vein c ondition.
STEP 27E
Palpate vein for resilience. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo
by Burl Jantzen.)
F. If needed, promote venous distension by instruc ting the patient to open and c lose the • These ac tivities inc rease blood flow to the area
fist several times, lowering the patient's arm in a dependent position, applying warmth
of insertion. When these tec hniques are properly
to the arm for several minutes, and rubbing or stroking the patient's arm from distal to
used, they foster venous dilation and ac c ess to
proximal below proposed site.
the vein.
Critical Decision P oint: Avoid vigorous rubbing a nd multiple ta pping of pa tient's veins. These techniques ma y ca use injury to the vein, such a s a
hema toma , or ca use venous constriction.
G. Avoid sites distal to previous venipunc ture site, sc lerosed or hardened c ordlike
• S uc h sites inc rease the risk of infiltration of a
veins, infiltrated site or phlebotic vessels, bruised areas, and areas of venous valves or newly plac ed intravenous line and of exc essive
bifurc ation. Avoid veins in antec ubital fossa and ventral surfac e of the wrist.
vessel damage.
• Veins in the antec ubital fossa are used for blood
draws, and plac ement in this area limits mobility.
The inner wrist c ontains numerous tendons that
c ould be damaged.
H. Avoid fragile dorsal veins in older persons and vessels in an extremity with
• Venous alterations c an inc rease risk of
c ompromised c irc ulation (e.g., in c ases of mastec tomy, dialysis graft, or paralysis).
c omplic ations (e.g., infiltration and dec reased
c atheter dwelling time).
28. Release tourniquet temporarily and c arefully. Clip arm hair with sc issors (if
nec essary).
• Hair impedes venipunc ture and adherenc e of
dressing. S having c an c ause mic roabrasions and
predispose patient to infec tion.
Critical Decision P oint: Do not sha ve a rea with a ra zor. Sha ving ma y ca use microa bra sions a nd predispose pa tient to infection. Use single-pa tient-use
scissors or disposa ble-hea d surgica l clippers (INS, 2016, p. S64).
29. (If area of insertion appears to need c leaning, use soap and water first.) Clean
• Air-drying prevents c hemic al reac tions between
insertion site using firm, c irc ular motion (c entre to outward) in c onc entric c irc les 5–
agents and allows time for maximum mic robic idal
7.5 c m from insertion site. Use antiseptic preparation as a single agent or in
ac tivity of agents (INS , 2016).
c ombination, ac c ording to agenc y polic y. Chlorhexidine (>0.5%) in alc ohol solution • Touc hing the c leaned area would introduc e
is rec ommended. If this solution is c ontraindic ated, povidone-iodine is a topic al antiorganisms from the nurse's hand to the site.
infec tive agent that reduc es skin surfac e bac teria; 70% alc ohol is another antiseptic
• The use of c hlorhexidine for insertion and with
c leaning agent. Povidone-iodine must dry to be effec tive in reduc ing mic robial
the use of ports is c onsidered best prac tic e (INS ,
c ounts. Avoid touc hing the c leaned site. Allow the site to dry for at least 2 minutes. If 2016; S c ales, 2011).
skin is touc hed after c leaning, repeat c leaning proc edure (INS , 2016).
30. Reapply tourniquet or BP c uff above insertion site.
• BP c uff should be inflated <50 mm Hg, as
diminished arterial flow prevents venous filling.
Critical Decision P oint: Do not pa lpa te the insertion site a fter skin a ntisepsis (INS, 2016, p. S65).
31. Perform venipunc ture. Anc hor vein by plac ing thumb over vein beneath insertion
• The VAD selec ted should be the smallest gauge
site and by stretc hing the skin against the direc tion of insertion 5 to 7.5 c m distal to
and shortest length that will ac c ommodate the
the site. Warn patient of a sharp stic k. Punc ture skin and vein, holding c atheter at 10therapy (INS , 2016).
to 30-degree angle with the bevel pointed upward slightly distal to ac tual site in the
• Plac es needle parallel to vein. When vein is
direc tion of vein (see S tep 31 illustrations).
punc tured, risk of punc turing posterior vein wall
is reduc ed.
• S uperfic ial veins require a smaller angle; deeper
veins require a greater angle.
STEP 31
Stabilize vein below insertion site with skin taut and puncture vein (Courtesy
Darlaine Jantzen, RN, MA, PhD. Photo by Burl Jantzen.)
Critical Decision P oint: No more tha n two a ttempts a t inserting a n intra venous line should be ma de by a single nurse (INS, 2016, p. S64).
32. Look for blood return through tubing of butterfly needle or flashbac k c hamber of
• Inc reased venous pressure from tourniquet
over-the-needle c atheter, indic ating that needle has entered vein (see S tep 32
inc reases bac kflow of blood into c atheter or
illustration). Lower c atheter or needle until almost flush with skin. Advanc e until hub
tubing.
is near the insertion site. Do not reinsert the stylet onc e it is loosened. Follow
• Lowering the angle and advanc ing the c annula
manufac turer's guidelines for spec ific safety c atheter use and for tec hniques for
slightly allow for full penetration of vein wall,
retrac ting stylus.
STEP 32
plac ement of c atheter within vein's inner lumen,
and easy advanc ement of c atheter off stylet.
• Threading c atheter up to hub reduc es the risk of
introduc ing infec tious organisms along the
c atheter length. Reinsertion of the stylet c an
c ause c atheter damage and potential c atheter
embolization.
• Advanc ing stylet into vein may penetrate
posterior vein wall.
• Reinsertion of stylet c an c ause c atheter shearing
and potential c atheter embolization.
Blood return in flashback chamber, catheter lowered flush with skin. (Courtesy
Darlaine Jantzen, RN, MA, PhD. Photo by Burl Jantzen.)
33. S tabilize the c atheter. Apply gentle but firm pressure with the index finger of
• Permits venous flow, reduc es bac kflow of blood,
nondominant hand 3 c m above insertion site. Release tourniquet or BP c uff with
and prevents ac c idental withdrawal or
dominant hand. Apply gentle but firm pressure above insertion site and keep c atheter
dislodgement.
stable.
34. Quic kly c onnec t distal end of tubing, extension set, or needleless c onnec tor. Be sure • Prompt c onnec tion of infusion set maintains
c onnec tion is sec ure. Do not touc h point of entry of c onnec tion. S ec ure c onnec tion patenc y of vein.
(see S tep 34 illustration).
• Maintains sterility.
STEP 34
Secure connection, maintaining asepsis. (Courtesy Darlaine Jantzen, RN, MA,
PhD. Photo by Burl Jantzen.)
For Continuous Infusion:
• Permits venous flow and prevents c lotting of
35A. Release roller c lamp slowly to begin infusion at a rate to maintain patenc y of
vein and obstruc tion of flow of intravenous
intravenous line, or turn on EID, program it, and begin infusion at c orrec t rate (see
solution.
S kill 40-2).
For intermittent infusion:
• Positive pressure in the c atheter prevents reflux
35B. Continue to stabilize c atheter with nondominant hand and attac h injec tion c ap of
of blood into the c atheter lumen.
adapter. Insert prefilled flush solution into injec tion c ap. Flush slowly. Maintain thumb
• Use volume equal to twic e the internal volume
pressure on syringe during withdrawal or c lose c lamp on extension tubing of injec tion of the c atheter system.
c ap while still flushing last 0.2–0.4 mL of flush solution.
Critical Decision P oint: Be sure to ca lcula te ra te so a s not to infuse intra venous solution too ra pidly or too slowly.
36. S tabilize c atheter with an engineered stabilization devic e (ES D) (see S tep 36
• S ec uring the c atheter and tubing prevents
illustration), either alone or in c ombination with a sec urement dressing.
movement and tension on the devic e, reduc ing
mec hanic al irritation and possible phlebitis or
infec tion (Higgingson, 2015). Proc edures for
sec uring c atheter vary with devic es and with
agenc y polic y. Manufac turer-provided c atheter
stabilization devic es reduc e the risk of
c omplic ations from peripheral VAD (INS , 2016,
S 73).
• Joint stabilization, through use of a padded
armboard, is ac c eptable, although sites c lose to
joints (e.g., antec ubital fossa) are not
rec ommended (INS , 2016, S 75).
STEP 36
Catheter stabilization device. (C.R. Bard, Inc. Used with permission.)
A. If applying transparent dressing, sec ure c atheter with nondominant hand while
preparing to apply dressing.
37. Observe site for swelling.
38. Apply sterile dressing over site.
A. Transparent dressing
Carefully remove adherent bac king. Apply one edge of dressing and then gently
smooth remaining dressing over site (see S tep 38A illustration).
STEP 38A
Apply transparent dressing. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo
by Burl Jantzen.)
39. S ec ure tubing (see S tep 39 illustration).
• Transparent dressings are preferred (Bernatc hez,
2014) as gauze does not provide the same
barrier, needs to be c hanged more often (every 2
days), and does not provide stabilization of the
c atheter, all c ontributing to an inc reased risk of
infec tion with gauze dressings.
• Additional c ost of transparent dressing is offset
by inc reased labour c osts and frequenc y of
dressing c hange.
• Any swelling suggests the c atheter has been
dislodged or was unsuc c essfully inserted and
must be removed.
• Transparent dressings are oc c lusive to moisture
and mic roorganisms. Transparent dressings allow
c ontinuous inspec tion of the intravenous site, are
more c omfortable, and enable patients to bathe
and shower without saturating the dressing.
• Transparent dressings are oc c lusive to moisture
and mic roorganisms between c atheter and tubing
or c ap, allowing for both c ontinuous and
intermittent intravenous use.
STEP 39
Secure tubing. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo by Burl
Jantzen.)
40. Prepare the equipment ac c ording to expec ted frequenc y of use.
A. For intra venous fluid a dministra tion: Adjust flow rate to c orrec t drops per minute or
c onnec t to EID (see S kill 40-2, S teps 9 to 15).
B. For intermittent use: S aline loc k. Flush with 3 mL of sterile normal saline at presc ribed
frequenc y or ac c ording to agenc y polic y.
41. Label dressing with date, time, gauge size and length of c atheter, and your initials
(see S tep 41 illustration).
STEP 41
• Maintains c orrec t rate of flow for intravenous
solution. Flow c an fluc tuate; therefore, it must be
c hec ked at intervals.
• Maintains patenc y of intravenous c atheter. While
some authors rec ommend heparin loc k, the
RNAO (2004/2008) rec ommends use of saline
for flushing and loc king peripheral short
c atheters, after eac h use and daily if not in use.
• Allows for easy rec ognition of type of devic e
and time interval for site rotation.
Label intravenous dressing. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo
by Burl Jantzen.)
42. Dispose of used needles in appropriate sharps c ontainer. Disc ard supplies. Remove
gloves and perform hand hygiene.
• Reduc es transmission of mic roorganisms and
protec ts staff from injury.
43. Observe patient every hour to determine whether fluid is infusing c orrec tly:
• Correc t administration of fluid volume prevents
fluid imbalanc e.
A. Chec k whether c orrec t amount of solution is infused as presc ribed, by looking at
time tape.
B. Count flow rate or c hec k rate on infusion pump.
• Ac c urate monitoring of rate further ensures
c orrec t volume administration.
C. Chec k patenc y of intravenous c atheter or needle.
D. Observe patient for signs of disc omfort.
E. Inspec t insertion site for absenc e of phlebitis (see Table 40-10), infiltration (see Table
40-11), or inflammation.
44. Doc ument intravenous insertion, inc luding date, time, devic e selec ted (size, type,
length, brand), site, number of attempts, name of prac titioner, and professional
designation. A spec ial parenteral therapy flow sheet may be used. Rec ord patient's
• Prec ise desc ription of insertion site is important
for future c onsideration of sites.
• Evaluation of parenteral therapy is an important
response to intravenous fluid, amount infused, and integrity and patenc y of system
every 4 hours or ac c ording to agenc y polic y.
45. Observe patient every hour to determine response to therapy (i.e., measure vital
signs, c onduc t postproc edure assessments).
UNEXP ECTED OUTCOMES
FVD, a s ma nifested by decrea sed urine output, dry mucous membra nes, hypotension, a nd
ta chyca rdia
FVE, a s ma nifested by cra ckles in lungs, shortness of brea th, a nd edema
Electrolyte imba la nces, a s ma nifested by a bnorma l serum electrolyte levels; cha nges in menta l
sta tus, neuromuscula r function, a nd vita l signs; a nd other signs a nd symptoms
Infiltra tion, a s indica ted by swelling a nd possible pitting edema , pa llor, coolness, pa in a t
insertion site, a nd possible decrea se in flow ra te
part of the nursing proc ess.
• Provides c ontinuous evaluation of type and
amount of fluid delivered to patient. Hourly
inspec tion prevents ac c idental fluid overload or
inadequate infusion rate and identifies early
inc idenc e of vein inflammation or tissue damage.
Intravenous fluids and additives are given to
maintain or restore fluid and elec trolyte balanc e.
They c an also c ause unexpec ted effec ts, whic h
c an be serious.
RELATED INTERVENTIONS
• Notify physic ian; may require readjustment of
infusion rate.
• Reduc e intravenous flow rate if symptoms
appear and notify physic ian.
• Notify physic ian. Additives in intravenous or
type of intravenous fluid may be adjusted.
• S top infusion and disc ontinue intravenous
therapy. Elevate affec ted extremity. Restart new
intravenous line if c ontinued therapy is
nec essary.
Phlebitis, a s indica ted by pa in, increa sed skin tempera ture, a nd erythema a long pa th of vein
• Cause of phlebitis (c hemic al, mec hanic al,
bac terial, postinfusion) will inform interventions.
• S top infusion or slow infusion, depending on the
determined c ause.
• Mec hanic al irritation may be treated by
stabilizing c atheter, elevating limb, and
monitoring.
• If phlebitis worsens or is c ausing patient distress,
disc ontinue intravenous therapy. Restart new
intravenous line if c ontinued therapy is
nec essary.
• Plac e moist, warm c ompress over area of
phlebitis and elevate limb if possible.
Bleeding a t venipuncture site
• Bleeding from vein is usually slow, c ontinuous
seepage. Common in patients who have
rec eived heparin or have a bleeding disorder or
if the intravenous site is over a bend in the arm
or hand.
• If bleeding oc c urs around venipunc ture site and
c atheter is within vein, antisepsis and dressing
c hanges are performed. Eventually, intravenous
therapy may need to be disc ontinued.
• Blood on the dressing c an result when the
administration set bec omes disc onnec ted from
the c atheter's hub. When blood appears on the
dressing, verify that the system is intac t and
c onduc t site c are, skin antisepsis, and dressing
c hange.
REP ORTING
• Report the following to inc oming nursing staff: type of fluid, flow rate, status of venipunc ture site, amount of fluid remaining in present
solution, expec ted time to hang next intravenous bag or bottle, and any adverse effec ts.
HOME CARE CONSIDERATIONS
• Teac h patient and family about hand hygiene and aseptic tec hnique for all c are related to the intravenous site and equipment.
• Teac h c aregiver to apply pressure with sterile gauze if c atheter falls out and, if patient is on antic oagulant therapy, to tape several piec es of
sterile gauze in plac e for at least 20 minutes with pressure or until bleeding stops.
• Teac h patient and c aregiver to perform tub bath without getting intravenous tubing wet and to unplug pump first if one is used. For
showering, the patient must protec t the intravenous site and dressing from getting wet by c overing them c ompletely with plastic .
• Teac h patient and family to monitor intake and output using measuring devic es, as nec essary.
• Teac h patient and family to dispose of open and sheathed needles into sharps c ontainer. All sharps c ontainers must be stored in a safe area
away from c hildren.
Box 40-10
Safety Guidelines for Infusion Therapy
Ensuring patient safety is an essential role of the professional nurse. To
ensure patient safety, communicate clearly with members of the health care
team, assess and incorporate the patient's priorities of care and preferences,
and use the best evidence when making decisions about a patient's care.
When performing the skills in this chapter, remember the following points
to ensure safe, individualized patient care:
• Check that you have the necessary information, a prescriber's order if
required, and equipment available for the procedure before beginning.
• Before initiation of therapy, check patient identification using two
patient identifiers and assess the appropriate route and rate of infusion
and potential incompatibilities between infusing fluids and medications
(INS, 2016).
• Determine if the patient has a latex allergy or latex sensitivity and use
latex-free equipment and supplies if allergy or sensitivity is present
(INS, 2016, p. S35).
• Use special designated tubing for the brand of electronic infusion device
(EID) and for blood transfusions and some medications.
• Review the steps of the procedure mentally before entering a patient's
room (i.e., consider modifications that you may need to make for this
specific patient and verify that the type of IV solution is appropriate for
this patient).
• Maintain strict aseptic and sterile techniques, when required, and
sterility and integrity of the IV system to prevent bloodstream infections
(INS, 2016).
• If you contaminate a sterile object during the procedure, do not use it.
Use a new sterile one.
• Use standard body fluid precautions during procedures and place all
disposable blood-contaminated items and sharp items in designated
puncture-resistant biohazard containers (INS, 2016).
Insertion and management of a PVAD are now considered a routine
nursing responsibility and skill. Competency assessment and validation on
an ongoing basis are required. This should be documented according to
organizational policy (INS, 2016, p. S18). Vascular visualization technology is
used with difficult access, in special populations, or after failed attempts to
insert a PVAD and thus to avoid the need for CVAD related to successful
cannulation of the PVAD (INS, 2016, p. S44). The management of PVADs
requires careful monitoring of the site, patency, and dressing. The site should
be assessed for phlebitis and infiltration (Table 40-10 and Table 40-11). Scales
to assess for phlebitis and infiltration are important tools for nurses
initiating and managing PVADs (Box 40-11) (Groll, Davies, MacDonald, et al.,
2010). Although a recent systematic review of phlebitis scales recommends
further study and standardization of definitions, the INS phlebitis scale is
one of the most commonly used scales (see Table 40-10) (Ray-Barruel, Polit,
Murfield, et al., 2014).
TABLE 40-10
Phlebitis Scale
Grade Clinical Criteria
0
1
2
3
4
No symptoms
Erythema at ac c ess site with or without pain
Pain at ac c ess site with erythema and/or edema
Pain at ac c ess site with erythema and/or edema; streak formation; palpable venous c ord
Pain at ac c ess site with erythema and/or edema; streak formation; palpable venous c ord >2.54 c m (1 in) in length; purulent
drainage
From Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing,
34(1S), S1.
TABLE 40-11
Infiltration Scale
Grade
Clinical Criteria
0
1
No symptoms
S kin blanc hed
Edema <2.54 c m (1 in) in any direc tion
Cool to touc h
With or without pain
S kin blanc hed
Edema 2.54–15.2 c m (1–6 in) in any direc tion
Cool to touc h
With or without pain
S kin blanc hed, transluc ent
Gross edema >15.2 c m (6 in) in any direc tion
Cool to touc h
Mild–moderate pain
Possible numbness
S kin blanc hed, transluc ent
S kin tight, leaking
S kin disc oloured, bruised, swollen
Gross edema >15.2 c m (6 in) in any direc tion
Deep pitting tissue edema
Circ ulatory impairment
Moderate-to-severe pain
Infiltration of any amount of blood produc t, irritant, or vesic ant
2
3
4
From Groll, D., Davies, B., MacDonald, J., et al. (2010). Evaluation of the psychometric properties of the
phlebitis and infiltration scales for the assessment of complications of peripheral vascular access devices.
Journal of Infusion Nursing, 33(6), 385.
Box 40-11
Research Highlight
Using Phlebitis and Infiltration Scales for Assessing Peripheral
Vascular Access Devices (PVADs)
Research Focus
Phlebitis and infiltration are common complications related to intravenous
therapy. Two scales, developed by the Infusion Nurses Society (INS), are
used to assess the extent of these complications. A study was done by a team
of Canadian researchers to evaluate the scales' reliability, validity, and ease of
use (Groll et al., 2010).
Research Abstract
The study used observation in a hospital setting and with a home nursing
agency, for a total of 182 participants and 416 observations. Each participant
was observed up to four times by two observers. The participants' charts
were also audited. The research nurses used a data collection tool and
observation form for each participant. The study evaluated the phlebitis and
infiltration scales for four properties: acceptability, feasibility, reliability, and
validity. The researchers concluded that the scales are easy to use and did not
take long to complete. The scales were reliable and valid in both settings.
The researchers also found that nurses who used the tools identified more
cases of phlebitis and infiltration than were recorded in the participants'
charts. These findings support the use of the INS phlebitis and infiltration
scales in a variety of settings.
Evidence-Informed Practice
• Nurses in all settings are positioned to assess for complications related
to PVADs.
• Scales to assess for phlebitis and infiltration are important tools for
nurses initiating and managing PVADs.
Groll, D., Davies, B., Mac Donald, J., Nelson, S., & Virani, T. (2010). Evaluation of the psychometric
properties of the phlebitis and infiltration scales for the assessment of complications of peripheral
vascular access devices. Journal of Infusion Nursing, 33(6), 385–390.
Central vascular access devices: Nursing considerations.
A CVAD is a venous access device with a tip that terminates in a great vessel,
preferably in the lower third of the superior vena cava; however, the upper
right atrium is an acceptable site. The catheters are available in a variety of
lengths, sizes, and numbers of lumens and are often made of silicone or
polyurethane. The most common insertion sites are the internal jugular and
subclavian veins; the right internal jugular vein is considered the best option
(Casey & Elliot, 2010, p. 80). Skin-tunnelled catheters (STC) are tunnelled
from the entry site, subcutaneously, to the preferred vein, where the catheter
is inserted and advanced into the superior vena cava (Green, 2008, p. 44).
PICCs are inserted through a peripheral vein, such as the basilic, median
cubital, or cephalic vein, and terminate in the superior vena cava (Hamilton,
2006).
Nurses need to be able to recognize the following complications associated
with CVADs: pneumothorax, arterial puncture, hemorrhage, cardiac
tamponade, air embolus, hemothorax, nerve injury, hydrothorax, infection,
catheter occlusion, and phlebitis. Nurses also need to be aware of strategies
to prevent these complications when caring for patients with a CVAD.
Evidence-informed and vigilant nursing care is important for insertion and in
the maintenance of all CVADs. Nursing responsibilities for CVADs include
careful monitoring, flushing, site care, and dressing changes to prevent
central line–associated bloodstream infection (CLABSI). See Box 40-9 for
evidence-informed practice for preventing CLABSI. Aseptic technique and
diligent hand hygiene are essential for all aspects of care. Prior to insertion,
chlorhexidine gluconate 2% in 70% isopropyl alcohol should be applied
properly and allowed to dry. Maximal barrier precautions (including gown,
mask, cap, and full drape) and ultrasound-guided procedure are key
recommendations for insertion (Casey & Elliot, 2010, p. 82). Nurses must
ensure that the tip placement or location has been verified and documented
before the CVAD is used. Finally, the date of insertion must be documented.
Maintenance recommendations are aimed at maintaining patency and
preventing complications, specifically catheter-related bloodstream infection
(CR-BSI) or CLABSI. The manufacturer's stabilization device is preferred for
PICCs and CVCs. Sterile, transparent, semipermeable membrane dressings
are recommended (INS, 2016). Dressings are assessed daily or when they
become wet, soiled, or loose. The new dressing is labelled with the site, type
of CVAD, length, date, time, and nurse's initials. Transparent dressing may
be left intact for up to 5 to 7 days. No dressing is required for an STC once
the wound has healed, unless the patient prefers one (Green, 2008, p. 45).
The external catheter should be measured and results documented daily to
ensure that the catheter remains in the correct placement. The insertion site
should be inspected daily for tenderness, signs of infection, erythema,
warmth, and edema, and assessment should include palpation. The chest and
neck should be assessed for engorged veins and for difficulty with
movement. The nurse should also assess the patient for signs of systemic
infection, such as fever, chills, and hypotension (Casey & Elliot, 2010, p. 78;
Scales, 2011).
Prior to accessing a CVAD, the nurse conducts a 15-second rub with 70%
isopropyl alcohol, povidone-iodine, or >0.5% chlorhexidine in alcohol
solution (INS, 2016). New antimicrobial devices and approaches to
preventing CR-BSI are being developed and include antimicrobial catheters,
needleless access devices, dressings, and lock solutions (Casey & Elliot, 2010,
p. 84). To prevent occlusion of the CVAD, the device is flushed and assessed
for patency according to institutional policy. The use of heparin for flushing
and locking is currently an area for further study and future
recommendations (e.g., Mitchell, Anderson, Williams, et al., 2009; RNAO,
2008). Totally implanted ports, used for long-term treatment such as
chemotherapy, are inserted surgically and are accessed by inserting a needle
through the skin into the device. They can be used up to 2 000 times (Kelly,
2009, p. s11) and have the lowest incidence of infection (Casey & Elliot, 2010,
p. 80).
Patient and family education is required for all patients with a CVAD. This
should include care requirements and patient restrictions.
Administration of Intravenous Therapy
Types of solutions.
Many prepared intravenous solutions are available for use (Table 40-9).
Solutions are classified as hypertonic, isotonic, or hypotonic (see Figure 4010, earlier in chapter). Osmolarity, reflecting the osmolar concentration in 1 L
of solution (mOsm/L), is most often used to describe fluids outside the body
(Hannon, Pooler, & Porth, 2010). A solution with the same osmolarity as
blood plasma is called isotonic. A hypertonic solution, with a higher osmotic
pressure, such as 3% sodium chloride, pulls fluid from cells, causing them to
shrink. An isotonic solution, with the same osmotic pressure as plasma, such
as 0.9% sodium chloride, expands the body's fluid volume without causing a
fluid shift from one compartment to another. A hypotonic solution, with an
osmotic pressure lower than plasma, such as 0.45% sodium chloride, moves
fluid into the cells, causing them to enlarge. Each of these actions occurs
through osmosis.
In general, isotonic fluids are used most commonly for extracellular
volume replacement (e.g., FVD after prolonged vomiting). The decision to
use a hypotonic or hypertonic solution is based on the specific fluid and
electrolyte imbalances. For example, the patient with a hypertonic fluid
imbalance will in general receive a hypotonic intravenous solution to dilute
the ECF and rehydrate the cells. All intravenous fluids should be given
carefully, especially hypertonic solutions, because these pull fluid into the
vascular space by osmosis, resulting in an increased vascular volume that can
lead to pulmonary edema, particularly in patients with heart or renal failure.
Certain additives, most commonly vitamins and potassium chloride, are
frequently added to intravenous solutions.
Safety Alert
Under no circumstances should potassium chloride (KCl) be given by
intravenous push. Direct intravenous infusion of KCl may cause death. If an
intravenous fluid requires additives, a prescriber's order must specify the
required additives—for example, “1 000 mL D51/2 NS with 20 mmol/L KCl at
125 mL/hour.”
Patients with normal renal function who are receiving nothing by mouth
should have potassium added to intravenous solutions. The body cannot
conserve potassium, and even when the serum level falls, the kidneys
continue to excrete potassium. Without oral or parenteral potassium intake,
hypokalemia can develop quickly. Conversely, the nurse should verify that the
patient has adequate renal function before administering an intravenous
solution containing potassium, because hyperkalemia can develop quickly.
Equipment.
Correct selection and preparation of intravenous equipment are necessary for
safe and quick placement of an intravenous line (Figure 40-16). Because fluids
are instilled into the bloodstream, sterile technique is necessary; the nurse
should have all equipment organized for efficient insertion (see Skill 40-1).
Intravenous cannulas are available in a variety of gauges. The larger the
gauge, the smaller the diameter of the cannula. These cannulas are plastic
tubing threaded over a needle. Once the cannula is inserted into the vein, the
needle is withdrawn, leaving the cannula in place. Intravenous tubing or an
intermittent infusion device, such as a needleless port, is then connected.
FIGURE 40-16
Options for intravenous access device.
Safety Alert
Intravenous pumps or volume-control (flow-control) devices ensure a
prescribed rate of infusion. A prescribed rate of infusion is vital for children,
patients with renal or cardiac failure, and critically ill patients. Electronic
infusion devices must be used for medications that require precise rates of
administration.
Initiating an intravenous line.
A venipuncture is a technique in which a vein is punctured through the skin
by a sharp, rigid stylet (e.g., butterfly needle or metal needle), a partially
covered plastic catheter (over-the-needle catheter), or a needle attached to a
syringe. When veins are fragile or collapse, venipuncture may become
extremely difficult. For these difficult cases, venipuncture should be
performed by an experienced, skilled practitioner. Skill 40-1 describes
venipuncture for intravenous fluid infusion.
Venipuncture site.
After the equipment is collected at the bedside, the nurse prepares to place
the intravenous line by assessing the patient for a venipuncture site (see Skill
40-1, Step 27A). Common intravenous puncture sites are the hand and the
arm (Figures 40-17 and 40-18). The use of the foot for an intravenous site is
common with children but is avoided in the adult because of the danger of
thrombophlebitis (INS, 2016). According to a review of the literature,
replacing a PVAD every 72 hours is not supported; instead this is done when
clinically indicated. However, nurses need to follow agency policy (Webster,
Osborne, Rickard, et al., 2010).
FIGURE 40-17 Common intravenous sites.
FIGURE 40-18 A, Vein finder. B, Veins illuminated. (Courtesy Darlaine Jantzen, RN, MA,
PhD. Photo by Burl Jantzen.)
When assessing the patient for potential venipuncture sites for
intravenous infusion, nurses should consider conditions and
contraindications that exclude certain sites. Because children and older
persons have fragile veins, nurses should avoid sites that are easily moved or
bumped, such as those on the dorsal surface of the hand. Venipuncture is
contraindicated in a site that has signs of infection, infiltration, or
thrombosis. An infected site is red, tender, swollen, and possibly warm to the
touch, and exudate may be present. An infected site is not used because of
the danger of introducing bacteria from the skin surface into the
bloodstream. Arms on the side of a mastectomy, and extremities with an
arteriovenous graft or fistula for dialysis should be avoided. It is important to
place intravenous devices at the most distal point, when possible, as this
allows for the use of proximal sites later if the patient needs a venipuncture
site change. See Box 40-12 for guidelines concerning older persons.
Box 40-12
Focus on Older Persons
Protection of Skin and Veins
• Use the smallest gauge cannula or needle possible (e.g., 22 to 24 gauge).
Veins are very fragile, and a smaller gauge allows better blood flow to
provide increased hemodilution of the intravenous fluids or
medications.
• Avoid using the back of the hand for needle insertion, which may
compromise the patient's need for independence and mobility.
• Impaired skin integrity may lead to susceptibility for tearing, venous
sclerosis, and difficulty detecting complications.
• Avoid placement of an intravenous line in veins that are easily bumped
because less subcutaneous support tissue is present.
• If the patient has fragile skin and veins, use minimal or no tourniquet
pressure.
• After applying a tourniquet, venous pressure rises rapidly, the vein is
overstretched, and puncture with even a thin needle can rupture the wall
of the vein.
• If using a tourniquet, place it over the patient's sleeve to decrease
shearing of fragile skin.
• With loss of supportive tissue, veins tend to lie more superficially; lower
the insertion angle for venipuncture to 5 to 15 degrees (INS, 2016).
• If the patient has lost subcutaneous tissue, the veins lose stability and
will roll away from the needle. To stabilize the vein, apply traction to the
skin below the projected insertion site.
• Secure the device with a securement device for protection (Higgingson,
2015).
• Nutritional deficiencies promote fluid to migrate into tissues
surrounding vessels, making intravenous access more difficult.
• Multiple medication usage (e.g., anticoagulants, antibiotics, and
steroids) increases the likelihood of fragile, transparent skin that bruises
and bleeds easily.
• Dehydration related to a lower percentage of body weight as water and
diminished thirst mechanism contribute to difficult intravenous access.
Regulating the infusion flow rate.
After the intravenous infusion is secured and the line is patent, the nurse
must regulate the rate of infusion according to the prescriber's orders (Skill
40-2). An infusion rate that is too slow can lead to further cardiovascular and
circulatory collapse in a critically ill patient. An intravenous fluid that is
running too slowly can also clot more easily. An infusion rate that is too rapid
can result in FVE. Fluids that run by gravity are adjusted through use of a
flow control or regulator clamp. Fluids infused by an electronic infusion
device or rate controller are regulated by a mechanical mechanism set at the
prescribed rate. Regardless of the device in use, the patient requires close
monitoring to verify the correct infusion of the intravenous solution and to
detect the occurrence of any complication.
SKILL 40-2
REGULATING INTRAVENOUS FLOW RATES
Delegation Considerations
Equipment
In many provinc es, regulating and monitoring intravenous therapy is
• Watc h or c loc k with a sec ond hand
inc luded within the sc ope of prac tic e for lic ensed and registered prac tic al
• Paper and penc il or c alc ulator
nurses. The skill of regulating intravenous therapy should not be delegated • Intravenous elec tronic infusion c ontroller or pump (optional)
to unregulated c are providers (UCPs). Refer to S kill 40-1 for important
• Volume c ontrol devic e (optional)
information to c onvey to the UCP.
• Time indic ator tape for gravity infusions
P ROCEDURE
STEP S
RATIONALE
1. Chec k patient's medic al rec ord for c orrec t solution, additives, and time of • Use princ iples of drug administration to ensure c orrec t fluids
infusion. Usual order inc ludes solution for 24 hours, usually divided into
are given to c orrec t patient.
2 or 3 L. Oc c asionally, intravenous order c ontains only 1 L to keep vein
open (KVO). Order also indic ates time over whic h eac h litre is to infuse.
Critical Decision P oint: It is common for hea lth ca re providers to write a n a bbrevia ted intra venous order, such a s “D5W with 20 mmol KCl 125 mL/hr
continuous.” This order implies tha t the intra venous fluid should be ma inta ined a t this ra te until the order ha s been written for the intra venous line to be
discontinued.
2. Perform hand hygiene. Observe for patenc y of intravenous line and
• For fluid to infuse at a proper rate, intravenous line and
needle or c atheter.
needle must be free of kinks, knots, and c lots.
A. Open drip regulator and observe for rapid flow of fluid from solution into • Rapid flow of fluid into drip c hamber indic ates patenc y of
drip c hamber and then c lose drip regulator to presc ribed rate.
intravenous line. Closing drip c hamber to presc ribed rate
prevents fluid overload.
3. Chec k patient's knowledge of how positioning of the intravenous site
• Fosters patient partic ipation in maintaining most effec tive
affec ts flow rate.
position of arm with intravenous equipment.
4. Verify with patient how venipunc ture site feels (e.g., determine whether • Inc ludes patient in dec ision making. Pain or burning
the patient is experienc ing pain or burning sensation).
sensation may be early indic ation of phlebitis.
5. Have paper and penc il or use c alc ulator to c alc ulate flow rate.
• The beginning student is unfamiliar with intravenous fluid
rates and should use mathematic al c alc ulations to obtain the
c orrec t rate.
6. Know c alibration (drop fac tor) in drops per millilitre (gtt/mL) of infusion
set:
A. Microdrip: 60 gtt/mL
B. Macrodrip: 15 gtt/mL or 10 gtt/mL depending on manufac turer (will state
on pac kage)
Critical Decision P oint: Know which compa ny's infusion set your a gency uses.
7. Calc ulate flow rate (hourly volume) of presc ribed infusion. Flow rate
mL/hr = total infusion (volume in mL)/hours of infusion (time to be
infused).
Example: 1 000 mL/8 hr = 125 mL/1 hr
8. Read presc riber's orders and follow 10 rights for c orrec t solution and
proper additives.
9. Intravenous fluids are usually ordered by rate, suc h as 100 mL/hr.
However, oc c asionally, intravenous fluids are ordered over a period of
time, suc h as 1 000 mL D5W with 20 mmol KCl over 8 hr.
10. Plac e adhesive or fluid indic ator tape on intravenous bottle or bag next to
volume markings.
• Mic rodrip tubing, also c alled pediatric tubing, universally
delivers 60 gtt/mL and is used when small or very prec ise
volumes are to be infused. However, different c ommerc ial
parenteral administration sets for mac rodrip tubing are
available. Mac rodrip tubing should be used when large
quantities or fast rates are nec essary.
• Onc e hourly rate has been determined, these formulas give
c orrec t flow rate.
• Intravenous fluids are medic ations; following 10 rights
dec reases c hanc e of medic ation error.
• Determines volume of fluid that should infuse hourly.
• Time taping intravenous bag gives visual c ue as to whether
fluids are being administered over c orrec t period of time.
Time tapes may be required for all intravenous infusions,
inc luding those on therapies infused via elec tronic infusion
devic es (EIDs). Chec k agenc y polic y.
Critical Decision P oint: Do not use felt-tipped pens or perma nent ma rkers on intra venous ba gs ma de of polyvinyl chloride beca use the ink could
conta mina te the solution (Milla m & Ha da wa y, 2003).
11. S elec t one of the following formulas to c alc ulate minute flow rate
• Formulas c ompute c orrec t flow rate over a minute.
(drops/min) on the basis of the drop fac tor of infusion set:
A. mL/hr/60 min = mL/min and
• Total volume × drop fac tor/infusion time in minutes.
Drop fac tor × mL/min = drops/min
• Volume is multiplied by drop fac tor, and the produc t is
divided by time (in min).
B. Alternative: mL/hr × drop fac tor/60 min = drops/min
• When using mic rodrip, mL/hr always equals gtt/min.
Using formula B above, c alc ulate minute flow rate for bottle
1 : 1 000 mL with 20 mmol KCl
Microdrip:
125 mL/hr × 60 gtt/mL = 7 500 gtt/hr
7 500 gtt ÷ 60 minutes = 125 gtt/min
Ma crodrip:
125 mL/hr × 15 gtt/mL = 1 875 gtt/hr
1 875 gtt ÷ 60 minutes = 31 gtt/min
12. Establish flow rate by c ounting drops in drip c hamber for 1 minute by
• Determines whether fluids are administered too slowly or
watc h; then adjust roller c lamp to inc rease or dec rease rate of infusion.
too quic kly.
13. Follow manufac turer's proc edure for EIDs.
• Infusion devic es are rec ommended for minimizing risks
assoc iated with infusion therapy.
Most pumps require the user to begin by plac ing the intravenous
• Infusion pumps move fluid by c ompressing and milking
infusion tubing within ridges of c ontrol box in direc tion of flow (i.e.,
intravenous tubing, thus propelling fluid through tubing.
portion of tubing nearest intravenous bag at top and portion of tubing
• Rate c ontrol c lamp should be open c ompletely while
nearest patient at bottom). Required drops per minute or volume per
infusion c ontroller or pump is in use.
hour and volume to be infused are selec ted (see S tep 13 illustration).
Open rate c ontrol c lamp and press start button.
STEP 13
Program EID. (Courtesy Darlaine Jantzen, RN, MA, PhD.
Photo by Burl Jantzen.)
Critical Decision P oint: Specia l infusion tubing is required for some pumps (check ma nufa cturer's directions).
A. Monitor infusion rates and intravenous site for c omplic ations ac c ording • Infusion c ontrollers or pumps are not infallible and do not
to agenc y polic y.
replac e frequent, ac c urate nursing assessments. Infusion
pumps may c ontinue to infuse intravenous fluids after an
infiltration has begun. All EIDs must have a free-flow
protec tor devic e.
B. Assess patenc y and integrity of system when alarm sounds.
• Alarm indic ates that elec tronic eye has not noted prec ise
number of drops from drip c hamber, the solution bag or
bottle is empty, or flow is obstruc ted (e.g., kink in tubing,
c losed drip regulator, infiltrated or c lotted needle, or air in
the tubing).
14. Follow this proc edure for volume c ontrol devic e:
A. Plac e volume c ontrol devic e (see S tep 14A illustration) between
• Reduc es risk of sudden inc rease in fluid volume.
intravenous bag and insertion spike of infusion set using sterile tec hnique.
STEP 14A Volume control device. (From Perry, A. G., Potter, P. A., &
Ostendorf, W. [2018]. Clinical nursing skills and techniques [9th ed., p. 618].
St. Louis: Mosby.)
B. Plac e 2 hours of fluid allotment into c hamber devic e.
C. Assess system at least hourly; add fluid to volume c ontrol devic e.
Regulate flow rate.
15. Rec ord name of solution, rate of infusion, drops/minute, and mL/hour in
nurses' notes or flow sheet every 4 hours or ac c ording to patient's
c ondition and to agenc y polic y. Immediately rec ord in nurses' notes or
flow sheet any new intravenous fluid rates. Doc ument use of any EID or
c ontrolling devic e.
16. Observe patient for response to therapy. Refer to S kill 40-1, S teps 42 and
44.
17. Evaluate infusion site for signs of infiltration, inflammation, c lot in
c atheter, or kink or knot in infusion tubing.
UNEXP ECTED OUTCOMES
Sudden infusion of la rge volume of solution, with symptoms of dyspnea , cra ckles in
lungs, a nd increa sed urine output, indica ting fluid overloa d
Intra venous fluid ba g runs empty, with subsequent loss of intra venous line pa tency
• Prevents intravenous line from running dry if nurse does not
return in exac tly 60 minutes. In addition, if an ac c idental
inc rease in flow rate oc c urs, patient rec eives at most only a
2-hour allotment of fluid.
• Maintains patenc y of system.
• Prompt and ac c urate doc umentation informs interdisc iplinary
c ollaboration.
• S igns and symptoms of dehydration or overhydration
warrant c hanging rate of fluid infused.
• Prevents dec rease in or c essation of flow rate.
RELATED INTERVENTIONS
• S low infusion to KVO rate and notify physic ian immediately.
New intravenous orders will be required. Patient may require
diuretic s.
• Intravenous therapy will be restarted.
• The intravenous infusion is slower than ordered.
• Chec k patient for positional c hange that might affec t infusion
rate, height of intravenous bag, and for kinking of tubing.
• An infiltration may be developing at intravenous site. Chec k
c ondition of site.
• If volume infused is defic ient, c onsult physic ian for new
order to provide nec essary fluid volume.
REP ORTING
• At c hange of shift or when leaving on break, report rate of infusion to nurse in c harge or next nurse assigned to c are for patient.
HOME CARE CONSIDERATIONS
• Ensure that patient is able and willing to operate the EID (if applic able) and administer intravenous therapy or that a reliable c aregiver or
nursing support personnel is at home to provide this intravenous therapy c are.
• Teac h patient and primary c aregiver to time drops per minute using watc h with sec ond hand.
• Ensure proper EID func tion and that elec tric al outlets are func tioning properly and grounded and infusion devic e has bac kup power, if
required by type of infusate.
• Teac h patient and c aregiver alarms and how to troubleshoot them.
• Provide patient and c aregiver with a phone number that c an be ac c essed 24 hours a day.
Electronic infusion devices (EIDs) or infusion pumps are necessary when
administering low hourly volumes (e.g., less than 20 mL/hour) and for
patients who are at risk for volume overload, such as neonatal, pediatric, and
geriatric patients. In addition, when infusing high volumes of intravenous
fluids (more than 150 mL/hour) to patients with impaired renal clearance,
older persons, or children, or when infusing drugs or intravenous fluids that
require specific hourly volumes, EIDs permit accurate infusion. EIDs deliver
the infusion via positive pressure and have become standard in most
settings. Recent advances in infusion technology have resulted in a variety of
devices available for use to ensure accurate delivery.
Many devices have operating and programming capabilities that allow for
single- and multiple-solution infusions at different rates. A variety of
detectors and alarms respond to air in intravenous lines, completion of
infusion, high and low pressure, low battery power, occlusion, and the
inability to deliver at a preset rate.
Safety Alert
An anti–free-flow safeguard (preventing bolus infusion in the event of
machine malfunction) is an important element of an electronic infusion
device and is required. The manufacturer's recommendations for specific
device features should always be checked.
Patency of the intravenous needle or catheter means that the tip of the
needle or catheter has no clots and that the catheter or needle tip is not
against the vein wall. A blocked catheter or needle can affect the rate of
infusion of the intravenous fluids. Intravenous flow rates can also be affected
by infiltration, a knot or kink in the tubing, the height of the solution, a
restrictive intravenous dressing, and the position of the patient's extremity.
One way to assess patency is by lowering the intravenous bag below the level
of the intravenous insertion site and observing for a blood return; however,
this method does not confirm patency. If no blood return occurs and fluid
does not flow easily from the drip chamber when the roller clamp is opened,
the nurse should assess potential causes: a clot may be occluding the cannula
of the intravenous catheter, the catheter tip may be occluded against the wall
of the vein, or the intravenous dressing may be too tight, thereby impeding
the flow. The tubing and area around the insertion site should be inspected
for anything that could obstruct the flow of intravenous fluids. A knot or kink
in the tubing can decrease the flow rate. Occasionally, the tubing is kinked
under a dressing; the dressing should be removed to locate the problem. The
patient may also occlude the tubing by lying or sitting on it. The flow rate
frequently resumes after the tubing is straightened. The height of the
intravenous bag can also affect flow rates. Raising the bag usually increases
the rate because of increased hydrostatic pressure.
Flexion of an extremity, particularly at the wrist or elbow, or positioning can
decrease flow rates. Although VAD placement in areas of flexion is
discouraged, in emergencies it may be necessary. Immobilizing with an arm
board provides some protection; however, this requires vigilant assessment,
and careful positioning to enable visualization and to prevent pressure. Most
often it is preferred that an intravenous catheter be inserted in a new site
rather than relying on a site that causes problems. However, before
discontinuing the infusion hampered by an extremity position, the nurse
should start the infusion in another site, to verify that the patient has other
accessible veins.
Sudden increases in flow can occur accidentally. For example, a restless
patient may loosen the roller clamp with a sudden movement and increase
the flow rate, or the flow rate may be accidentally increased if the patient
ambulates. Some intravenous catheters are positional in the patient's vein. A
sudden increase in the intravenous infusion rate causes a rapid increase in
vascular volume, which can make the patient critically ill or even cause death.
EID and volume-control devices are designed to prevent sudden changes in
infusion rate.
Maintaining the system.
After the intravenous line is in place and the flow rate is regulated, the nurse
must maintain the system. It is important to observe agency policy regarding
maintenance of intravenous lines. Line maintenance is achieved by (1)
keeping the system sterile; (2) changing solutions, tubing, and site dressings;
and (3) assisting the patient with self-care activities so as not to disrupt the
system.
Nurses play an important role in maintaining the integrity of both PVAD
and CVAD systems to prevent infection from developing. Knowledge of
potential sites for contamination informs nurses' practice (refer to Figures 4017 and 40-18). This begins with thorough hand hygiene before and after
handling any component of the intravenous system. Special training for
nurses who care for patients with CVADs is the first step in preventing
infections (Scales, 2011).
The integrity of the intravenous system must always be maintained. Tubing
must never be disconnected because it becomes tangled or because it might
be more convenient in positioning or moving a patient or applying a gown. If
a patient needs more room to manoeuvre, extension tubing can be added to
an intravenous line. However, the use of extension tubing should be kept to a
minimum, as each connection of tubing provides an opportunity for
contamination. Stopcocks for connecting more than one solution to a single
intravenous site are sources of contamination and should be avoided (INS,
2016). Whenever an intravenous line is disconnected from a stopcock, the
port should be plugged with a sterile cap. A port should never remain
exposed to air because of the risk of contamination. A new administration set
should be exchanged with the subsequent fluid change.
Intravenous tubing also contains injection ports through which adapters
can be inserted for medication injections. The INS (2016) recommends
intravenous tubing, when the peripheral catheter site is changed it may be
used for up to 96 hours without increasing the chance of infection if it does
not contain lipids, blood, or blood products. Needleless injection ports
reduce the risk of needle-stick injury and reduce contamination, thereby
promoting patient safety when connecting, accessing, or removing
intravenous equipment (Edwards & Johnson, 2012). This risk is further
minimized by using alcohol–chlorhexidine gluconate solution or povidone–
iodine for cleaning the port both before and after use. Patients receiving
intravenous therapy over several days will require a change of solutions. It is
important to organize tasks so that this can be done in plenty of time before
the solution empties and the cannula becomes clotted. Many agencies have
policies regarding the “hang time” of intravenous fluids. Rickard,
Vannapraseuth, McGrail, and colleagues (2009) found no need to routinely
replace intravenous fluid containers and recommend further research to
establish set time points for replacing intravenous fluid containers. Skill 40-3
reviews steps for changing intravenous solutions.
SKILL 40-3
MAINTENANCE OF INTRAVENOUS SYSTEM
Delegation Considerations
Equipment
In many provinc es, this skill is inc luded within the sc ope of prac tic e for lic ensed and
registered prac tic al nurses. The skill of c hanging intravenous solutions and tubing should not
be delegated to unregulated c are providers (UCPs). UCPs may be delegated the tasks of
c ollec ting supplies and assisting with c omfort and safety measures. UCPs are instruc ted to
ensure intravenous tubing is not kinked or pulled during c are and ambulation. UCPs are
instruc ted to report if intravenous solution is near empty or if there is leaking or patient
experienc es disc omfort related to the intravenous infusion.
P ROCEDURE
STEP S
Changing Intravenous Solution
1. Chec k presc riber's orders.
Intravenous infusion
• Bottle or bag of c orrec t type and volume
of intravenous solution as ordered by
physic ian or health c are provider
• Time tape
• Infusion tubing and tubing label
• Filter (size appropriate to solution) and
extension tubing (if nec essary)
Intermittent Saline Lock
• Injec tion or disinfec tant c ap, loop, or short
extension tubing (if nec essary)
• Antiseptic swab
Normal saline flush
• Commerc ially available prefilled syringe
filled with preservative-free normal saline
(single-patient use if using multidose vial)
• Disposable gloves
Discontinuation of intravenous line
• Disposable gloves
• S terile 2 × 2 (5 c m × 5 c m) gauze
• Tape
RATIONALE
• Ensures that c orrec t solution will be used.
Intravenous therapy requires the 10 rights
of medic ation administration.
2. If order is written for keep vein open (KVO) or to keep open (TKO), c ontac t physic ian for • Orders for KVO do not provide c omplete
c larific ation of the rate of the infusion. Note date and time when solution was last c hanged.
information and c an result in fluid overload
or defic it and elec trolyte imbalanc e. A
KVO order should c ontain a spec ific
infusion rate (INS , 2016). Refer to agenc y
polic y. Intravenous tubing and solution
should be c hanged at the same time.
3. Determine the c ompatibility of all intravenous fluids and additives by c onsulting appropriate • Inc ompatibilities may lead to prec ipitate
literature or the pharmac y.
formation and c an c ause physic al,
c hemic al, and therapeutic patient c hanges.
Prec ipitation may oc c lude patenc y of
c atheter.
4. Determine patient's understanding of need for c ontinued intravenous therapy.
• Informs need for patient instruc tion.
5. Assess patenc y of c urrent intravenous ac c ess site. VADs are flushed and aspirated prior to • If patenc y is oc c luded, a new intravenous
eac h intermittent infusion and after. VAD is loc ked after c ompleted.
ac c ess site may be needed. Notify
physic ian.
6. Have next solution prepared and ac c essible at least 1 hour before needed. Chec k that
• Adequate planning reduc es risk of c lot
solution is c orrec t and properly labelled. Chec k solution expiration date and for presenc e of formation in vein c aused by empty
intravenous bag. Chec king prevents
prec ipitate and disc oloration.
medic ation error.
7. Prepare to c hange solution when less than 50 mL of fluid remains in bottle or bag or when a • Prevents air from entering tubing and vein
new type of solution is ordered.
from c lotting from lac k of flow.
8. Prepare patient and family by explaining the proc edure, its purpose, and what is expec ted of • Dec reases anxiety and promotes
patient.
c ooperation.
9. Be sure drip c hamber is at least half full.
• Provides fluid to vein while bag is
c hanged.
10. Perform hand hygiene.
• Reduc es transmission of mic roorganisms.
11. Prepare new solution for c hanging. If using plastic bag, remove protec tive c over from
• Permits quic k, smooth, and organized
intravenous tubing port. If using glass bottle, remove metal c ap and metal and rubber disc s.
c hange from old to new solution.
12. Move roller c lamp to stop flow rate.
• Prevents solution remaining in drip
c hamber from emptying while c hanging
solutions.
13. Remove old intravenous fluid c ontainer from intravenous pole.
• Brings work to nurse's eye level.
14. Quic kly remove spike from old solution bag or bottle and, without touc hing tip, insert
• Reduc es risk of solution in drip c hamber
spike into new bag or bottle.
running dry and maintains sterility.
Critical Decision P oint: If spike is conta mina ted, a new intra venous tubing set is required.
15. Hang new bag or bottle of solution on intravenous pole.
• Gravity assists with delivery of fluid into
drip c hamber.
16. Chec k for air in tubing. If bubbles form, they c an be removed by c losing the roller c lamp,
• Reduc es risk of air embolus. Use of an airstretc hing the tubing downward, and tapping the tubing with the finger. For larger amounts
eliminating filter also reduc es this risk.
of air, swab injec tion port below the air with alc ohol and allow to dry. Connec t a syringe to
this port and aspirate the air into the syringe. Reduc e air in tubing by priming slowly instead
of allowing a wide-open flow.
17. Make sure drip c hamber is one-third to one-half full. If the drip c hamber is too full, pinc h off • Reduc es risk of air entering tubing.
tubing below the drip c hamber, invert the c ontainer, squeeze the drip c hamber (see S tep 17
illustration), hang up the bag, and release the tubing.
STEP 17
Pinch tubing, invert chamber, and squeeze drip chamber to remove a portion of fluid.
(Courtesy Darlaine Jantzen, RN, MA, PhD. Photo by Burl Jantzen.)
18. Regulate flow to presc ribed rate.
• Maintains measures to restore fluid
balanc e and deliver intravenous fluid as
ordered.
19. Mark time on label tape and plac e on bag. Do not use felt-tipped pens or permanent markers • Ink from markers may leac h through
on intravenous bags.
polyvinyl c hloride c ontainers.
20. Observe patient for signs of overhydration or dehydration to determine response to
intravenous fluid therapy.
• Provides ongoing evaluation of patient's
fluid and elec trolyte status.
21. Observe intravenous system for patenc y and development of c omplic ations (e.g.,
infiltration or phlebitis).
Changing Intravenous Tubing
22. Determine when new infusion set is needed:
• Provides ongoing evaluation of
intravenous system.
• Note that usually the tubing and the bag,
and even the site, are c hanged at the same
time. (Refer to S teps 13–22, 33, and 34, to
c hange bag a nd tubing.)
A. Agenc y polic y will indic ate frequenc y of routine c hange for intravenous administration
• Evidenc e (Gillies, Wallen, Morrison, et al.,
sets and saline flush tubing.
2005) rec ommends up to 96 hours for
tubing c hanges.
B. Punc ture of infusion tubing requires immediate c hange.
• Punc tured tubing results in fluid leakage
and bac terial c ontamination.
C. Contamination of tubing requires immediate c hange.
• Contamination of tubing allows entry of
bac teria into patient's bloodstream.
D. Oc c lusions in existing tubing c an oc c ur after infusion of pac ked red blood c ells, whole
• Whole blood or blood c omponent
blood, albumin, or other blood c omponents.
produc ts c an oc c lude or partially oc c lude
tubing bec ause visc ous solutions adhere
to walls of tubing and dec rease the size of
the lumen.
23. Prepare patient and family by explaining the proc edure, its purpose, and what is expec ted of • Dec reases anxiety, promotes c ooperation,
patient.
and prevents sudden movement of
extremity, whic h c ould dislodge
intravenous needle or c atheter.
24. Perform hand hygiene.
• Reduc es transmission of mic roorganisms.
25. Open new infusion set, keeping protec tive c overings over infusion spike and distal adapter. • Provides nurse with ready ac c ess to new
S ec ure all junc tions with Luer-Loc ks, c lasping devic es, or threaded devic es.
infusion set and maintains sterility of
infusion set.
26. Apply nonsterile, disposable gloves.
• Reduc es risk of exposure to HIV, hepatitis,
and other bloodborne pathogens.
27. If c atheter hub is not visible, remove intravenous dressing while maintaining stability of
• Hub must be ac c essible to provide
c atheter. If transparent dressing has to be removed, anc hor c atheter during disc onnec tion.
smooth transition when removing old
tubing and inserting new tubing.
28. For intravenous c ontinuous infusion:
A. Move roller c lamp on new intravenous tubing to c losed position.
• Prevents spillage of solution after bag or
bottle is spiked.
B. S low rate of infusion by regulating drip rate on old tubing. Be sure rate is at KVO rate.
C. Compress and fill drip c hamber of old tubing.
• Prevents c omplete infusion of solution
that remains in tubing, whic h c an inc rease
risk of oc c lusion of intravenous c atheter
or needle.
• Provides surplus of fluid in drip c hamber
so enough fluid is available to maintain
intravenous patenc y while c hanging
tubing.
• Fluid in drip c hamber will run slowly to
keep c atheter patent.
D. Remove intravenous c ontainer from pole, invert c ontainer, and remove old tubing from
c ontainer. Carefully hold c ontainer while hanging or taping drip c hamber on intravenous
pole 1 m above intravenous site.
E. Plac e insertion spike of new tubing into old solution bag opening and hang solution bag on • Permits flow of fluid from solution into
intravenous pole.
new infusion tubing.
F. Compress and release drip c hamber on new tubing; fill drip c hamber one-third to one-half
• Allows drip c hamber to fill and promotes
full.
rapid, smooth flow of solution through
new tubing.
G. S lowly open roller c lamp, remove protec tive c ap from needle adapter (if nec essary), and • Removes air from tubing and replac es it
flush new tubing with solution. Replac e c ap.
with fluid.
H. Turn roller c lamp on old tubing to c losed position.
• Prevents spillage of fluid as tubing is
removed from needle hub.
29. To c onnec t to a saline loc k:
A. If a loop or short extension tubing is needed bec ause of an awkward intravenous site
plac ement, use sterile tec hnique to c onnec t the new injec tion c ap to the loop or tubing.
B. S wab injec tion c ap with rec ommended solution for 15 sec onds. Insert syringe with 1 to 3
• Removes air to prevent introduc tion into
mL saline and injec t through the injec tion c ap into the loop or short extension tubing (see
the vein.
S tep 29B illustration). Connec t tubing to injec tion c ap.
STEP 29B
Inject saline into injection cap.
30. To c hange (c ontinuous or extension set) tubing at the hub, stabilize hub of c atheter and
• It is important to maintain asepsis at the
apply pressure over vein just above c atheter tip at least 3 c m above insertion site. Gently
c atheter hub.
disc onnec t old tubing from c atheter hub and c lean c ap to c onnec t new tubing. Maintain
• Prevents ac c idental displac ement of
stability of hub and quic kly insert adapter of new tubing or saline loc k into hub (see S tep 30 c atheter or needle.
illustration).
• Prevents c lot formation in c atheter or
needle and bac kflow of blood.
STEP 30
Clean cap to connect new tubing. (Courtesy Darlaine Jantzen, RN, MA, PhD. Photo by
Burl Jantzen.)
31. Open roller c lamp on new tubing. Allow solution to run rapidly for 30 to 60 sec onds.
32. Regulate intravenous drip ac c ording to presc riber's orders and monitor rate hourly.
33. Apply new dressing, if needed.
34. Disc ard old tubing in proper c ontainer.
35. Remove and dispose of gloves. Perform hand hygiene.
36. Evaluate flow rate and observe c onnec tion site for leakage.
Discontinuing P eripheral Intravenous Access
37. Chec k physic ian's order for disc ontinuation of intravenous therapy.
• Permits intravenous solution to enter
c atheter to prevent c atheter oc c lusion.
• Maintains infusion flow at presc ribed rate.
• Reduc es risk of bac terial infec tion from
skin.
• Reduc es ac c idental transmission of
mic roorganisms.
• Reduc es transmission of mic roorganisms.
• Maintains presc ribed rate of flow of
intravenous fluid and determines if it is
sec ure.
• Order is required for disc ontinuation of
fluids or medic ation.
38. Explain proc edure to patient. Explain that affec ted extremity must be held still and how long
proc edure will take.
• Minimizes patient's anxiety and
disc omfort.
39. Perform hand hygiene and apply disposable gloves.
• Reduc es transmission of mic roorganisms.
40. Turn intravenous tubing roller c lamp to c losed position. Remove tape sec uring tubing.
41. Remove intravenous site dressing and tape while stabilizing c atheter.
• Movement of c atheter will c ause
disc omfort.
42. With dry gauze held over site, apply light pressure and withdraw the c atheter, using a slow • Changing the angle of the c atheter inside
steady movement, keeping the hub parallel to the skin.
the vein c ould c ause additional vein
irritation, inc reasing the risk of
postinfusion phlebitis.
Critical Decision P oint: If pa tient ha s received a nticoa gula nts (e.g., low-dose a spirin, wa rfa rin sodium [Couma din], hepa rin) or ha s a low pla telet
count, a pply stea dy pressure for 5 to 10 minutes a nd a ssess bleeding.
43. Apply pressure to the site for 2 to 3 minutes, or until no further bleeding is noted, using the • Dry pad c auses less irritation to the
dry, sterile gauze pad. S ec ure with tape.
punc ture site. S ubc utaneous hematoma is a
c ommon c omplic ation. When needle is
removed, vein wall c ontrac ts to stop
bleeding.
44. Inspec t the c atheter for intac tness, noting tip integrity and length.
• Tips of c atheter c an break off, c ausing an
embolus, an emergenc y situation. Notify
physic ian if tip is broken.
45. Disc ard used supplies.
46. Remove and disc ard gloves and perform hand hygiene.
47. Instruc t patient to report any redness, pain, drainage, or swelling that may oc c ur after
• Postinfusion phlebitis may oc c ur within 48
c atheter removal.
to 96 hours after c atheter removal.
UNEXP ECTED OUTCOMES
RELATED INTERVENTIONS
Incorrect flow ra te; pa tient receives too little or too much fluid
Decrea sed or a bsent flow of intra venous fluid
• Readjust infusion rate to ordered rate;
evaluate patient for adverse effec ts; notify
physic ian.
• Assess intravenous infusion system for
patenc y.
• Rec alibrate drip rate on new tubing.
• Assess intravenous site for infiltration.
RECORDING AND REP ORTING
• Rec ord c hanging of tubing and solution on patient's rec ord. A spec ial parenteral therapy flow sheet may be used.
• Attac h a piec e of tape or preprinted label with the date and time of tubing c hange to tubing below the level of drip c hamber. Labelling c an
ensure these items are c hanged at the c orrec t intervals (S c ales, 2011).
HOME CARE CONSIDERATIONS
• Emphasize to patient and family the importanc e of c hanging solutions when intravenous tubing still c ontains fluid.
The dressings over intravenous sites are applied to reduce the entrance of
bacteria into the insertion site. The two forms of dressings are transparent
and gauze. Transparent dressings reliably secure the intravenous device,
allow continuous visual inspection of the intravenous site, become less easily
soiled or moistened, and require less frequent changes than standard gauze.
Intravenous dressings should be routinely changed as per agency policy
(Skill 40-4).
SKILL 40-4
CHANGING A PERIPHERAL INTRAVENOUS DRESSING
Delegation Considerations
In many provinc es, the skill of c hanging a peripheral intravenous dressing is inc luded within
the sc ope of prac tic e for lic ensed and registered prac tic al nurses. This skill should not be
delegated to unregulated c are providers (UCPs). UCPs may be delegated the tasks of
c ollec ting supplies, assisting with c omfort measures, and distrac ting the patient during the
proc edure. UCPs are instruc ted to inform the nurse if the patient or UCP notes moistness on
the dressing or if the dressing is no longer intac t.
P ROCEDURE
STEP S
ASSESSMENT
1. Identify patient with two identifiers or ac c ording to agenc y polic y. Assess site, inc luding
expiration date of dressing, dressing integrity, and c leanliness daily, or more often. Assess
c atheter–skin junc tion for signs of infec tion or inflammation.
2. Perform hand hygiene.
3. Observe intravenous system for proper func tioning, leaking, or c omplic ations: kinks in
infusion tubing or intravenous c atheter. Palpate the c atheter site through the intac t dressing
for inflammation, noting any patient c omplaints of pain or burning sensation.
4. Inspec t exposed c atheter site for swelling or blanc hing and other signs of infiltration.
Equipment
• Antiseptic swab stic k (c hlorhexidine,
povidone-iodine, or 70% alc ohol, as
rec ommended by the agenc y)
• Adhesive remover (if needed)
• S kin barrier
• Disposable gloves
• S terile transparent dressing
RATIONALE
• Doc umentation is essential for prevention
of peripheral venous ac c ess c atheter–
related infec tions.
• Peripheral intravenous dressings should
be sc heduled when intravenous system is
c hanged; when damp, loosened, or
visibly soiled; or every 5–7 days (INS ,
2016, p. S 82).
• Follow princ iples of ANTT: Always wash
hands effec tively; Never c ontaminate key
parts; Touc h non-key parts with
c onfidenc e; Take appropriate infec tive
prec autions (Ogston-Tuc k, 2012, p. 479).
• Moisture is a medium for bac terial
growth.
• Unexplained dec rease in flow rate
requires investigation of plac ement and
patenc y of the intravenous c atheter. Pain
c an be assoc iated with both phlebitis and
infiltration.
• Indic ates fluid infusing into surrounding
tissues. Will require removal of
intravenous c atheter.
5. Assess patient's understanding of need for c ontinued intravenous infusion.
P LANNING
• Determines need for patient instruc tion.
6. Explain proc edure and purpose to patient and family. Explain that affec ted extremity must be
• Dec reases anxiety, promotes c ooperation,
held still and how long proc edure will take.
and gives patient time frame around whic h
personal ac tivities c an be planned.
7. Collec t equipment.
• Ensures organized proc edure.
8. Apply disposable gloves.
• Reduc es transmission of mic roorganisms.
9. Remove dressing. Be c autious if c atheter tubing bec omes tangled or attac hed to dressing.
• Prevents ac c idental displac ement of
When removing transparent dressing, hold c atheter hub and tubing with nondominant hand.
c atheter or needle.
• Be aware of adhesive-related skin injury.
10. Observe insertion site for signs and symptoms of infec tion (redness, swelling, and exudate). • Presenc e of infec tion or c omplic ation
If present, remove c atheter and insert a new intravenous line in another site.
indic ates need to remove vasc ular ac c ess
devic e at c urrent site.
11. If infiltration, phlebitis, or c lot oc c urs or if ordered by presc riber, stop infusion and
disc ontinue intravenous therapy. Restart new intravenous line if c ontinued therapy is
nec essary. Plac e moist, warm c ompress over area of phlebitis.
12. If intravenous fluid is infusing properly, gently remove any tape sec uring c atheter. S tabilize • Exposes venipunc ture site. S tabilization
needle or c atheter with one hand. Use adhesive remover to c lean skin and remove adhesive prevents ac c idental displac ement of
residue, if needed.
c atheter or needle. Adhesive residue
dec reases ability of new dressing to
adhere tightly to skin.
13. S tabilize c atheter at all times with one finger over c atheter until tape or dressing is replac ed. • Prevents dec annulation from vein.
14. Using c irc ular motion, c lean peripheral intravenous insertion site with antiseptic swab
• Circ ular motion prevents c rossstarting at insertion site and working outward, c reating c onc entric c irc les (see S tep 14
c ontamination from skin bac teria near
illustration). Allow swab solution to air-dry c ompletely.
venipunc ture site. Antiseptic s may
inc lude c hlorhexidine, povidone-iodine,
and alc ohol. If antiseptic agents are used
in c ombination, allow eac h to dry
separately.
STEP 14
Clean peripheral insertion site.
Critical Decision P oint: Do not ta pe over connection of a ccess tubing or port to intra venous ca theter.
15. Apply new transparent dressing (see S kill 40-1, S tep 38A).
• Ensures protec tion of intravenous site and
reduc es c hanc e of infec tion.
16. Remove and disc ard gloves.
17. Anc hor intravenous tubing with additional piec es of tape. When using transparent
polyurethane dressing, minimize the tape plac ed over dressing.
18. Plac e insertion date, date and time of dressing c hange, size and gauge of c atheter, and your
initials direc tly on dressing.
19. Disc ard used equipment and perform hand hygiene.
20. Observe func tioning and patenc y of intravenous system in response to c hanging dressing.
21. Monitor patient's body temperature.
UNEXP ECTED OUTCOMES
Infiltra tion of intra venous ca theter, a s evidenced by decrea sed flow ra te or edema , pa llor, or decrea sed
tempera ture a round insertion site
• Prevents ac c idental displac ement of
intravenous needle or c atheter or
separation of intravenous tubing from
needle adapter.
• Doc uments dressing c hange.
• Reduc es transmission of mic roorganisms.
• Validates that intravenous line is patent
and func tioning c orrec tly.
• Elevated temperature indic ates an
infec tion that may be assoc iated with
bac terial c ontamination of the
venipunc ture site.
RELATED INTERVENTIONS
• S top infusion and disc ontinue intravenous
therapy. Restart new intravenous line in
other extremity if c ontinued therapy is
nec essary.
• Elevate affec ted extremity.
• Restart intravenous infusion if c ontinued
Accidenta l remova l of intra venous ca theter or needle
therapy is needed.
• Notify physic ian. Intravenous line may be
Eleva ted body tempera ture
removed and restarted. Patient will be
evaluated for sourc e of infec tion.
Red, edema tous, or pa inful insertion site or presence of exuda tes, indica ting infection a t venipuncture site • Disc ontinue intravenous infusion.
Antibiotic therapy may begin.
• Apply warm, moist c ompress to area of
inflammation.
RECORDING AND REP ORTING
• Rec ord appearanc e of intravenous site, type of dressing, and status of intravenous fluid infusion.
• A spec ial parenteral fluid flow sheet may be used for rec ording.
To prevent the accidental disruption of an intravenous system, the nurse
may need to assist the patient with hygiene, comfort measures, meals, and
ambulation. Using a gown specifically made with snaps along the top sleeve
seam helps facilitate changing the gown without disturbing the venipuncture
site. Regular gowns are changed as follows:
1. Remove the sleeve of the gown from the arm without the intravenous
line, maintaining the patient's privacy.
2. Remove the sleeve of the gown from the arm with the intravenous
line.
3. Remove the intravenous solution container from its stand and pass it
and the tubing through the sleeve. (If this involves removing the
tubing from an intravenous electronic infusion device, use the roller
clamp to slow the infusion to prevent the accidental infusion of a
large volume of solution or medication.)
4. Place the intravenous solution container and tubing through the
sleeve of the clean gown and hang it on its stand. (If the intravenous
line is connected to an electronic infusion device, open the roller
clamp. Turn on the pump.)
5. Place the arm with the intravenous line through the gown sleeve.
6. Place the arm without the intravenous line through the gown sleeve.
(Breaking the integrity of an intravenous line to change a gown leads
to contamination.)
Protective devices designed to prevent accidental dislodgement of an
intravenous catheter (Figure 40-19) are now available. The device fits
comfortably around a patient's hand or arm and provides a plastic shield to
cover the intravenous device. Protective devices extend the time a catheter
remains in the vein and minimize repeated venipuncture.
FIGURE 40-19
IV House protective device. (Courtesy IV House, St. Louis, MO.)
The patient with an arm or a hand infusion is able to walk, unless
contraindicated. A portable intravenous pole (a standard intravenous pole
with wheels) is needed. Help the patient get out of bed and place the pole
next to the involved arm. The patient should be instructed to hold on to the
pole and push it while walking. The nurse needs to assess the equipment to
make sure that the intravenous bag is at the proper height, the tubing is not
tense, the flow rate is correct, and the tubing does not get contaminated. The
patient should be instructed to report any blood in the tubing, a stoppage in
the flow, or increased discomfort. Intravenous medications, especially
antibiotics and potassium, can cause discomfort and burning sensations at
the intravenous site. Although discomfort may be relieved by repositioning
the extremity, the source of discomfort must always be carefully evaluated
and may necessitate starting a new intravenous line in a larger vein.
Complications of intravenous therapy.
An infiltration occurs when intravenous fluids enter the surrounding space
around the venipuncture site (see Table 40-11). This manifests as swelling
(from increased tissue fluid) and pallor and coolness (caused by decreased
circulation) around the venipuncture site. Fluid may be flowing through the
intravenous line at a decreased rate or may have stopped flowing. Pain may
also be present and usually results from edema. This pain increases
proportionately as the infiltration continues.
When infiltration occurs, the infusion must be discontinued, and if
intravenous therapy is still necessary, a new catheter is inserted into a vein in
another extremity. To reduce discomfort and edema, the extremity should be
raised, which promotes venous drainage. Wrapping the extremity in a warm,
moist towel for 20 minutes while keeping it elevated on a pillow also
promotes venous return, increases circulation, and reduces pain and edema.
This can be repeated three to four times per day until resolved. Infiltration of
medications that cause extravasation require specific care, outlined by
institutional policy.
Phlebitis is inflammation of the vein. Selected risk factors for phlebitis
include the type of catheter material, chemical irritation of additives and
drugs given intravenously (e.g., antibiotics), the rate of the medication
administration, the skill of the individual inserting the catheter, and the
anatomical position of the catheter. Signs and symptoms may include pain,
edema, erythema, increased skin temperature over the vein, and, in some
instances, redness travelling along the path of the vein (INS, 2016).
Dehydration may also be a contributing factor because of the increase in
blood viscosity.
When phlebitis develops, the intravenous line must be discontinued and a
new line inserted in another vein. Warm, moist heat on the site of phlebitis
can offer some relief to the patient. Phlebitis can be dangerous because
blood clots (thrombophlebitis) can occur and, in some cases, may result in
emboli. Such conditions can result in permanent damage to veins and in
prolonging the patient's hospitalization.
Bleeding can occur around the venipuncture site during the infusion or
through the catheter needle or tubing if these become inadvertently
disconnected. Bleeding is common in patients who have received heparin or
who have a bleeding disorder (e.g., leukemia or thrombocytopenia). If
bleeding occurs around the venipuncture site and the catheter is within the
vein, a pressure dressing may be applied over the site to control the bleeding.
Bleeding from a vein is usually a slow, continuous seepage and is not serious.
Discontinuing intravenous infusions.
Discontinuing an infusion is necessary after the prescribed amount of fluid
has been infused, when an infiltration occurs, if phlebitis is present, or if the
infusion catheter or needle develops a clot at its tip. Refer to Skill 40-3 for
discontinuing an intravenous infusion.
Safety and Quality Improvement.
As stated throughout this text, individual nurses and health care teams have
important roles in ensuring patient safety and quality improvement. For
individuals administering infusion therapy, competency assessment should
include psychomotor skills, such as those outlined in this chapter, as well as
application of knowledge, decision making, and ethical practice. Nurses
contribute to quality improvement through using standardized
documentation, fostering a culture of care, demonstrating accountability, and
assisting in identifying clinical quality indicators and benchmarks (INS, 2016,
p. S21). Evaluating and reporting the incidence of infusion therapy–related
infections is one very important example. Some nurses participate in
collecting data from standardized documentation and then analyzing patient
outcomes or safety for the health care team (Edwards & Johnson, 2012).
Taking a systems approach and reviewing practices and patient outcomes can
result in rapid implementation of changes (Coram, 2015).
In the quality and safety literature, a common approach to prevention of
infection is ANTT: Always wash hands effectively; Never contaminate key
parts; Touch non-key parts with confidence; Take appropriate infective
precautions (Ogston-Tuck, 2012, p. 479). Bloodstream infections in both
peripheral and central intravenous lines have been significantly reduced by
using a disinfection cap, as a way of addressing noncompliance and variation
in techniques of disinfecting the hubs of needleless connectors (DeVries,
Mancos, & Valentine, 2014).
Blood Transfusion.
Blood replacement or transfusion, or blood component therapy, is the
intravenous administration of whole blood or a component, such as plasma,
packed red blood cells (RBCs), platelets, or cryoprecipitate. Other blood
products, manufactured from human plasma, include albumin (5% or 25%),
intravenous immune globulin (IVIG), Rh immune globulin (RHIG), and
prothrombin complex concentrate (PCC). The primary objectives for blood
transfusions include the following: (1) to increase circulating blood volume
after surgery, trauma, or hemorrhage; (2) to increase the number of RBCs and
to maintain hemoglobin levels in patients with severe anemia; and (3) to
provide selected cellular components as replacement therapy (e.g., clotting
factors, platelets, albumin). Caring for patients receiving blood or blood
products is a significant nursing responsibility. Thorough assessment,
meticulous identification of the patient and transfusion, and careful
monitoring is critical, as error could lead to dangerous and life-threatening
events.
Blood Groups and Types.
The most important grouping for transfusion purposes is the ABO system,
which includes A, B, O, and AB blood types. The determination of blood
groups is based on the presence or absence of A and B RBC antigens.
Individuals with A antigens, B antigens, or no antigens belong to groups A,
B, and O, respectively. The person with A and B antigens has AB blood.
Individuals with type A blood naturally produce anti-B antibodies in their
plasma. Similarly, individuals with type B blood naturally produce anti-A
antibodies. An individual with type O blood has neither type A nor type B
antigen and thus is considered a universal blood donor. Individuals with type
AB blood produce neither antibody, which is why they can be universal
recipients and receive any type of blood (Table 40-12). Rhesus, or Rh, factor is
the second important consideration in blood typing. The Rh factor is an
antigenic substance in the erythrocytes. A person with the factor is Rh
positive, and a person without it is Rh negative. Blood must be matched for
Rh factor as well as ABO grouping. Rh-negative people must receive only Rhnegative blood, whereas Rh-positive people can receive either Rh-negative or
Rh-positive blood.
TABLE 40-12
ABO Compatibilities for Transfusion Therapy
Component
Compatibilities
Whole Blood
Pac ked red c ells (stored, washed, or frozen/washed)
Give Type-Specific Blood Only
Donor
Recipient
O
O, A, B, AB
A
A, AB
B
B, AB
AB
AB
Donor
Recipient
O
O
A
A, O
B
B, O
AB
AB, B, A, O
RBC: ABO and Rh c ompatible preferred
Donor
Recipient
O
O, A, B, AB
A
A, AB
B
B, AB
AB
AB
Fresh-frozen plasma
Platelets
ABO, Blood group consisting of groups A, AB, B, and O.
Data from Alexander, M., Corrigan, A. M., Gorski, L. A., et al. (2014). Core curriculum for infusion nursing
(4th ed.). Philadelphia: Lippincott.
If incompatible or mismatched blood is transfused, a transfusion reactions
occurs. The patient's, or recipient's, antibodies trigger RBC destruction. This
response ranges from a mild response (e.g., faintness, dizziness) to severe
anaphylactic shock or acute intravascular hemolysis, both of which can be
life-threatening. Prompt intervention is required, including immediately
stopping the transfusion, removing the tubing, and replacing the line with a
normal saline infusion to maintain intravenous access.
Autologous Transfusion.
Autologous transfusion, or auto-transfusion, is the collection of a patient's
own blood. The blood for an autologous transfusion can be obtained by
preoperative donation up to 5 weeks before the planned surgery (e.g., heart,
orthopedic, plastic, or gynecological). Patients can donate several units of
their own blood, depending on the type of surgery and the ability of the
patient to maintain an acceptable hematocrit. Another way to collect blood
for an autologous transfusion is during perioperative blood salvage (e.g.,
during vascular and orthopedic surgery, organ transplant surgery, and
traumatic injuries). The blood that has been salvaged is then reinfused
during the surgery. Blood can also be salvaged postoperatively from
mediastinal and chest tube drainage and after joint and spinal surgery.
Autologous transfusions decrease the risk of complications such as
mismatched blood and exposure to bloodborne infectious agents (Alexander,
Corrigan, Gorski, et al., 2014).
Blood Transfusions.
When transfusing blood or blood components, assessment is required
before, during, and after the transfusion and for regulation of the
transfusion, because of the risk of reactions and complications. Prior to
transfusion the primary health care provider must obtain consent for
transfusion, except in emergencies. The nurse then verifies that consent has
been obtained, that it is current, and that the patient understands the reason
for the blood transfusion. Patients with certain cultural backgrounds may
abstain from blood transfusions (Box 40-13). The nurse should ask the patient
if he or she has had a previous transfusion or a transfusion reaction. Before
giving a transfusion, the nurse needs to explain the procedure and instruct
the patient to report any side effects (e.g., chills, dizziness, or fever) once the
transfusion begins. The nurse checks that the patient is properly identified,
based on agency policy. This is critical to ensure that the patient is given the
correct blood component, based on blood typing. Certain diagnostic tests are
used to determine the need for blood component and the effectiveness of
treatment, such as hemoglobin, platelet count, or tests related to clotting.
Box 40-13
Cultural Aspects of Care
Preinfusion Assessments
When a patient's natural skin contains more melanin, it becomes more
difficult to identify colour changes. Intravenous complications such as
phlebitis and infiltration may not be easily detected. Patients from some
cultural backgrounds experience fear related to the donor process for blood.
Patients with certain religious (e.g., Jehovah's Witness) or personal beliefs
may abstain from receiving blood transfusions or medications.
Implications for Practice
• Establish communication. Understand the values of family elders and
know whom to speak with about intravenous procedures.
• Assess patients individually to determine their acceptance of or
abstinence from therapeutic regimens.
• Appreciate patients' choice related to their therapy.
• Although some patients will abstain from receiving whole blood or
packed red blood cells, they will accept other blood products or
alternatives.
Adapted from Rudnicke, C. (2003). Transfusion alternatives. Journal of Infusion Nursing, 26(3), 29.
Infusion of blood components or blood products requires an order from
the primary health care provider. The nurse checks patient identification,
component or product to be administered, the amount or volume, the rate of
administration, and any other requirements, such as premedication (e.g.,
intravenous diuretic). If the patient has an intravenous line in place, the
nurse needs to assess the venipuncture site and determine the appropriate
gauge of the intravenous catheter. A large catheter, such as 18 to 22 gauge, is
recommended for adults unless rapid infusion is required (16–18 gauge).
Blood administration tubing with a 70- to 260-micron filter is used, and the
nurse needs to determine if the tubing is appropriate for the EID when using
one. When priming blood administration tubing, 0.9% normal saline must be
used to prevent hemolysis, or breakdown of RBCs. Timing of blood
transfusion is extremely important. The infusion is begun within 30 minutes
of accessing the blood component from the transfusion medical laboratory
(TML) and is stopped after 4 hours. Bags and tubing are discarded in the
biohazardous waste, according to agency policy.
Because of the danger of transfusion reactions, it is very important to use
specific precautions and the ten rights of medication administration (see
Chapter 34) in administering blood or blood products. The nurse should first
obtain the patient's baseline vital signs (temperature, blood pressure, pulse,
respirations, and oxygen saturation) before the transfusion begins. This
allows the nurse to determine when changes in vital signs occur, which can
indicate that a transfusion reaction is developing. A thorough check of the
blood product, the patient, the reason for the transfusion, the volume or
dose, the rate, and site ensures safe administration and that the patient is
receiving the correct type of blood component or product. The rate of
transfusion is usually specified in the health care provider's orders. Although
the nurse is not involved in the blood labelling process, he or she is
responsible for determining that the blood delivered to the patient
corresponds to the blood type listed in the patient's medical record. Two
registered nurses or one registered nurse and a licensed practical nurse (see
agency policy) must together check the label on the blood product against
the patient's identification number, blood group, and complete name. If even
a minor discrepancy exists, the blood should not be given and the TML
should be notified immediately. The nurse documents vital signs, time, and
transfusion details on initiation, and throughout the transfusion, as the
seventh right. On completion of the transfusion, the eighth right involves
monitoring and documenting the patient response.
Initiation of a transfusion begins slowly, to allow for the early detection of
a transfusion reaction. The nurse needs to maintain the infusion rate,
monitor for side effects, assess vital signs, and promptly record all findings.
The nurse continues to monitor the patient and obtain vital signs periodically
during the transfusion, as directed by agency policy. The nurse should
observe for hives, fever or rigors, dyspnea, cough, or back or infusion site
pain and note patient complaints of unusual feelings. Upon completion, the
administration tubing used for RBCs should be discarded at 4 hours or after
two units; it should be discarded immediately following infusion of blood
products, such as IVIG, clotting factors, and albumin. If blood components
or products are contraindicated, plasma expanders may be required in cases
of sudden or extreme hypovolemia.
Transfusion Reactions and Complications.
Noninfectious complications from transfusions are generally more common
than infectious complications. Noninfectious complications such as allergic
reactions (minor to severe), hemolytic transfusion reactions, and ABO
transfusion reactions are a systemic response by the body to incompatible
blood or blood component (e.g., white blood cells from donor blood). Causes
may also include allergic sensitivity to the potassium or citrate preservative
in the blood. Several types of acute reactions can result from blood
transfusions (Table 40-13). Transfusion-related acute lung injury is the most
serious transfusion reaction and requires critical care. If a transfusion
reaction is anticipated or suspected, vital signs must be monitored more
frequently (see Table 40-13).
TABLE 40-13
Acute Adverse Effects of Transfusions
Adverse
Effect
Cause
Clinical Manifestations
Transfusion Reactions—Caused by Immune Response to Blood Components
Ac ute
Infusion of ABO- Chills, fever, low bac k pain, flushing,
intravasc ular
inc ompatible
tac hyc ardia, tac hypnea, hypotension,
hemolytic
whole blood,
hemoglobinuria, hemoglobinemia,
RBCs, or
sudden oliguria (ac ute kidney injury),
c omponents
c irc ulatory shoc k, c ardiac arrest, death
c ontaining 10 mL
or more of RBCs
Antibodies in
rec ipient's
plasma attac h to
antigens on
transfused RBCs,
c ausing RBC
destruc tion
Febrile
Antibodies against
nonhemolytic donor white blood
(most
c ells
c ommon)
S udden shaking c hills (rigors), fever
(rise in temperature 0.5°C [1°F] or
more from start), headac he, flushing,
anxiety, musc le pain
Management
S top transfusion and save
blood bag and
administration set for followup. Keep IV site open with
normal saline infused
through new tubing.
Maintain BP and treat shoc k
as ordered, if present.
Obtain blood samples slowly
to avoid hemolysis; send
for serologic al testing. S end
urine spec imen to
laboratory.
Give diuretic s as presc ribed
to maintain urine flow.
Insert in-dwelling urinary
c atheter or measure eac h
voiding to monitor hourly
urine output. Dialysis may
be required if ac ute kidney
injury oc c urs.
Patient safety alert: Do not
transfuse additional RBCc ontaining c omponents until
transfusion servic e provides
newly c ross-matc hed units.
S top transfusion.
Give antipyretic s as
presc ribed; avoid aspirin in
thromboc ytopenic patients.
Patient safety alert: Do not
restart transfusion.
Prevention
Metic ulously verify and
doc ument patient
identific ation from sample
c ollec tion to c omponent
infusion.
Consider leukoc ytepoor blood produc ts
(filtered, washed, or
frozen).
Pretreat with
antipyretic s if prior
Mild allergic
Antibodies against
donor plasma
proteins
Flushing, itc hing, urtic aria (hives)
Anaphylac tic
Antibodies to donor
plasma, espec ially
anti-IgA
Anxiety, urtic aria, dyspnea, wheezing
progressing to c yanosis, severe
hypotension, c irc ulatory shoc k,
possible c ardiac arrest
Other Acute Adverse Effects
Circ ulatory
Blood administered Dyspnea , c ough, c rac kles, or rales in
overload
faster than c irc ulation dependent lobes of lungs; distended
c an ac c ommodate
nec k veins when upright
S epsis
Bac terial
c ontamination of
transfused blood
c omponents
Rapid onset of c hills, high fever,
severe hypotension, and
c irc ulatory shoc k
Ma y occur: Vomiting, diarrhea,
sudden oliguria (ac ute kidney
injury), disseminated intravasc ular
c oagulation (DIC)
history.
S top transfusion temporarily. Treat prophylac tic ally with
Give antihistamine as
antihistamines.
direc ted.
If symptoms are mild and
transient, restart transfusion
slowly.
Patient safety alert: Do not
restart transfusion if fever,
pulmonary symptoms, or
hypotension develops.
S top transfusion.
Have epinephrine ready for
injec tion (0.4 mL of 1 : 1
000 solution
subc utaneously or 0.1 mL of
1 : 1 000 solution diluted to
10 mL with saline for IV
use).
Provide blood pressure
support as ordered.
Initiate CPR if indic ated.
Patient safety alert: Do not
restart transfusion.
Turn down transfusion rate
or stop transfusion.
Plac e patient upright with
feet in dependent position.
Administer presc ribed
diuretic s, oxygen,
morphine.
Phlebotomy may be
indic ated.
S top transfusion.
Obtain c ulture of patient's
blood and send bag with
remaining blood to
transfusion servic e for
further study.
Treat as ordered: antibiotic s,
IV fluids, vasopressors,
gluc oc ortic oids.
Transfuse extensively
washed RBC produc ts from
whic h all plasma has been
removed. Alternately use
blood from IgA-defic ient
donor.
Adjust transfusion
volume and flow rate
on basis of patient size
and c linic al status.
Have transfusion
servic e divide unit into
smaller aliquots for
better spac ing of fluid
input.
Collec t, proc ess, store, and
transfuse blood produc ts
ac c ording to blood-banking
standards and infuse within
4 hours of starting time.
ABO, Blood group consisting of groups A, AB, B, and O; BP, blood pressure; CPR, cardiopulmonary
resuscitation; IgA, immunoglobulin A; IV, intravenous; RBC, red blood cell.
Data from Alexander, Corrigan, A. M., Gorski, L. A., et al. (2014). Core curriculum for infusion nursing (4th
ed.). Philadelphia: Lippincott.
A second category of transfusion reactions, infectious complications,
includes diseases transmitted by infected blood donors who are
asymptomatic. Because all units of blood collected must undergo serological
testing and screening for human immunodeficiency virus (HIV) and hepatitis
B virus, the risk of acquiring bloodborne infections from blood transfusions
is reduced. Bacterial sepsis is more common in platelets.
Circulatory overload, or TACO, is a risk when a patient receives large
volumes of whole blood or packed RBC transfusions for massive
hemorrhagic shock or when a patient with normal blood volume receives
blood. Patients particularly at risk for circulatory overload are older persons
and those with cardiopulmonary diseases.
Safety Alert
If a blood reaction is suspected, stop the transfusion immediately.
Blood transfusion reactions are life-threatening, but prompt nursing
intervention can maintain the patient's physiological stability.
• Keep the intravenous line open by hanging 0.9%
normal saline directly into the intravenous line and
running the saline.
• Do not turn off the blood and simply turn on the
0.9% normal saline that is connected to the Y-tubing
infusion set. This would cause blood remaining in the
Y-tubing to infuse into the patient. Even a small
amount of mismatched blood can cause a major
reaction.
• Notify the primary health care provider
immediately.
• Remain with the patient, observing signs and
symptoms and monitoring vital signs as often as
every 5 minutes.
• Prepare to administer emergency drugs such as
antihistamines, vasopressors, fluids, and steroids as
per physician order or protocol.
• Prepare to perform cardiopulmonary resuscitation.
• Obtain a urine specimen and send it to the
laboratory to determine the presence of hemoglobin
as a result of RBC hemolysis.
• Save the blood container, tubing, attached labels,
and transfusion record, and return them to the
laboratory.
Restorative Care
After experiencing acute alterations in fluid, electrolyte, or acid–base
balance, patients often require ongoing maintenance to prevent a recurrence
of health alterations. Older persons and chronically ill patients require
special considerations to prevent complications from developing.
Home Intravenous Therapy.
Intravenous therapy is often continued in the home setting for patients who
are discharged from the hospital and have not completed their prescribed
treatment or who require long-term therapy. Ideally, a family member will be
available at home if the patient suddenly cannot manage the intravenous
system or if a problem develops. A home care nurse will work closely with
the patient and family to ensure that a sterile intravenous system is
maintained and that complications are avoided or recognized promptly. Refer
to Box 40-8 for a summary of patient education guidelines for home
intravenous therapy.
Nutritional Support.
Most patients who have had electrolyte disorders or metabolic acid–base
disturbances require ongoing nutritional support. Depending on the type of
disorder, fluid or food intake may be encouraged or restricted (see Chapter
42). If patients are still responsible for meal preparation, they should learn to
understand the nutritional content of foods and to read the labels of
commercially prepared foods.
Medication Safety.
Numerous medications and over-the-counter drugs contain components or
create potential adverse effects that can alter fluid and electrolyte balances.
Patients with chronic disease who are receiving multiple medications and
those with renal or liver disorders are at significant risk for alterations in
fluid and electrolyte status (Box 40-14). Once patients return to a restorative
care setting, whether in their home or in a residential care home, drug safety
becomes very important. Patient and family education is essential to
providing information regarding potential drug interactions and what
adverse effects they can cause. It is important to review all medications with
patients and encourage them to consult with their local pharmacist,
especially if they try a new over-the-counter medication.
Box 40-14
Research Highlight
Managing Chronic Kidney Disease
Research Focus
Prevention of complications associated with chronic kidney disease requires
attention to many biochemical parameters. In nurse-run clinics, nurses, with
the guidance of physicians, are able to successfully manage these
parameters through patient-centred care, health promotion, teaching,
dealing with problems, taking time, use of protocols, consultations or
referrals, logistics, paperwork or documentation, and nurse–physician
collaboration.
Research Abstract
The purpose of the study conducted by Molzahn, Pelletier Hibbert, Gaudet,
and colleagues (2008) was to describe the nature of the care provided to
people with chronic kidney disease in a larger study of nurse-run, physicianmonitored clinics and to describe how patients, nurses, and nephrologists
described their experience with the clinics. Seven nurses, five physicians,
and 22 patients participated in interviews, which were tape-recorded and
transcribed. In addition to interviews, data collection involved review of 40
randomly selected charts. Themes identified related to the characteristics of
the nurse, patient-centred care, health promotion, teaching, dealing with
problems, time, protocols, consultations or referrals, logistics, paperwork or
documentation, and nurse–physician collaboration. Challenges and
outcomes were also described as part of the experience with the clinic.
Patients were actively engaged in self-management and reported high levels
of satisfaction with care, as well as improvements in selected outcomes.
Overall, the perceptions about this model of care were positive, and the
approach warrants further exploration.
Evidence-Informed Practice and Primary Health Care
• Regular assessment and management by nurses can be used to prevent
cardiovascular disease and other complications of chronic kidney
disease.
• Patient-centred care, teaching, and health promotion are important
processes in caring for the patient with chronic kidney disease.
• Many people with chronic kidney disease are able and willing to selfmanage their illness.
Molzahn, A. E., Pelletier Hibbert, M., Gaudet, D., Starzomski, R., Barrett, B., & Morgan, J. (2008).
Managing chronic kidney disease in a nurse-run, physician-monitored clinic: The CanPREVENT
experience. Canadian Journal of Nursing Research, 40, 96–112.
Evaluation
Patient Expectations.
Nurses routinely review with patients how well their concerns and
expectations regarding fluid, electrolyte, or acid-base status have been
addressed. Asking questions directed at presenting signs and symptoms and
at anticipated responses to interventions is important to the nursing process.
If the patient's concerns involve having a better understanding of a chronic
problem, the nurse needs to focus the evaluation on health education
provided. Often the patient's level of satisfaction with care also depends on
the nurse's success in involving family and friends. If the patient has
concerns about returning home or to a different care setting, it will be
important to evaluate if the patient feels prepared for the transition from
acute care.
Patient Outcomes.
The evaluation of a patient's clinical status is especially important if an acute
fluid and electrolyte or acid–base imbalance exists. In some situations, the
patient's condition can change very quickly, and the nurse must be able to
recognize the signs and symptoms of impending problems by being aware of
health alterations, the effects of medications and fluids, and the patient's
presenting clinical status (see Figure 40-8). It is particularly important to
evaluate the effectiveness of the interdisciplinary team interventions, review
diagnoses, report outcomes, and remain open to revising the plan of care.
This evaluation should include risk factors, clinical status, laboratory
findings, and underlying or contributing problems.
The nurse needs to determine whether changes have occurred from the
last patient assessment and analyze such changes. For example, have the
physical signs and symptoms of the assessed condition begun to disappear
or lessen in intensity? A patient's response to treatment of hypokalemia
would be evidenced by an increasing serum potassium and a reduction in
physical symptoms associated with hypokalemia.
For patients with less acute alterations, evaluation likely occurs over a
longer period of time. In this situation, the nurse's evaluation may be focused
more on behavioural changes (e.g., the patient's ability to follow dietary
restrictions and medication schedules). The family's ability to anticipate
alterations and prevent problems from recurring may also be an important
element of the evaluation.
The patient's level of progress determines whether the nurse needs to
continue or revise the care plan. If goals are not met, the nurse may need to
consult with others on the interdisciplinary team to discuss additional
methods, such as increasing the frequency of an intervention (e.g., provide
more fluids to a dehydrated patient), introducing a new therapy (e.g., initiate
insertion of an intravenous line), or discontinuing a particular therapy. Once
outcomes have been met, the nurse can resolve the nursing diagnosis and
focus on other priorities.
Key Concepts
• Body fluids are distributed in ECF and ICF
compartments.
• A dynamic interplay of fluid and electrolyte intake
and absorption, distribution, hormonal control, and
output determines fluid and electrolyte balance.
• Volume disturbances include isotonic and osmolar
deficits and excesses.
• Acid–base imbalances are buffered by chemical,
biological, and physiological buffering, especially the
lungs and kidneys.
• Chronic and serious illnesses increase the risk of
fluid, electrolyte, and acid–base imbalances.
• Patients who are very young or very old are at
greater risk for fluid, electrolyte, and acid–base
imbalances.
• Assessment for fluid, electrolyte, and acid–base
alterations includes the nursing health history,
physical and behavioural assessments, measurements
of intake and output, daily weights, and specific
laboratory data.
• Osmolar imbalances and extracellular fluid volume
(ECV) deficit can be corrected by enteral or parenteral
administration of fluid.
• Common complications of intravenous therapy are
infiltration, phlebitis, infection, ECF excess, and
bleeding at the infusion site.
• Blood transfusions are given to replace fluid
volume loss from hemorrhage, treat anemia, or
replace coagulation factors.
• Blood transfusions can be obtained from a donor,
autologously, or through perioperative salvage.
• Administration of blood or blood products requires
the nurse to follow a specific procedure in order to
prevent and identify transfusion reactions quickly.
• In addition to transfusion reactions, the risks of
transfusion include hyperkalemia, hypocalcemia,
hypervolemia or circulatory overload, and infection.
• Treatment for electrolyte disturbances includes
dietary and pharmacological interventions.
• The body's chemical buffering system responds
first to acid–base abnormalities.
• The goals of therapy for acid–base imbalances are
to treat the underlying illness and to restore the
arterial blood pH to normal.
• With new technology emerging continually, nurses
need to stay current on evidence to inform practice,
particularly in relation to VADs.
Critical Thinking Exercises
1. Mrs. Emanuele is an 81-year-old woman admitted to the hospital with
a 3-day history of vomiting and diarrhea. She has had only ice chips
since the first episode of vomiting and is now complaining of malaise,
cramping muscles, and a temperature of 39°C. Which laboratory
findings would you expect to be abnormal on the basis of her
complaints? What interventions would you expect the physician to
order?
2. Caroline, a nurse, has just received a new patient on her unit who is to
receive one unit of RBCs within the next hour. What nursing actions
are necessary before administering blood? Can Caroline delegate the
administration of blood to a licensed practical nurse or an
unregulated care provider?
3. Carlos is caring for Mr. Rossi, a 52-year-old man who has been seen in
the emergency department following a motor vehicle accident. Mr.
Rossi is complaining of difficulty breathing and has a respiratory rate
of 40 breaths per minute. He is transferred to the Critical Care Unit,
intubated, and placed on a ventilator. A nursing student asks Carlos
to interpret Mr. Rossi's last ABG results: pH = 7.30; PaO2 = 70; PaCO2 =
50; bicarbonate = 24 mmol/L. What interpretation will Carlos give to
the student nurse? What is the relationship between the ABG results
and Mr. Rossi being intubated and ventilated?
4. Janelle is the nurse caring for Mrs. Kwan, a 59-year-old woman who
has just had a total knee replacement. The physician has ordered
cefazolin (Ancef) 1 g in 50 mL to run over 30 minutes intravenous
three times daily. Mrs. Kwan has a continuous infusion of Ringer's
lactate at 75 mL/hour in the left forearm. What type of tubing will
Janelle use to administer the intravenous medication? Calculate the
drops per minute for both microdriptubing (60 drops/mL) and
macrodriptubing (15 drops/mL).
5. Mrs. Yoe is on a surgical unit following a total abdominal
hysterectomy. She experienced postoperative bleeding and requires
blood products; however, for religious and cultural reasons, she has
refused blood products. What are the key principles in providing care
for Mrs. Yoe? How does a health promotion perspective inform your
care of Mrs. Yoe? What other options are available, and how realistic
or viable are these options?
6. A 24-year-old tennis professional was admitted to the clinic with a
temperature of 41°C. He has a history of playing 5-hour tennis
matches in 38°C heat. His coach brought him to the clinic because he
was weak and lethargic. What assessment findings would you expect
to find? What interventions would be necessary? Describe a teaching
plan for this patient upon discharge.
Review Questions
1. One of the most common electrolyte imbalances is:
1. Hypokalemia
2. Hyperkalemia
3. Hyponatremia
4. Hypocalcemia
2. The patient most at risk for fluid volume deficits is a(n):
1. Older person
2. Young to middle adult
3. Child
4. Infant
3. One reason that older persons experience fluid and electrolyte imbalance
and acid–base imbalances is that they:
1. Eat poor-quality food
2. Have a decreased thirst sensation
3. Have a more severe stress response
4. Have an overly active thirst response
4. Output recorded on an intake and output record includes:
1. Urine, vomitus, diarrhea, and drainage from wounds
2. Diarrhea, gastric suction, and drainage from wounds
3. Medications, juices, and water
4. Urine, diarrhea, vomitus, gastric suction, and drainage from wounds or
tubes
5. Health promotion activities in the area of fluid and electrolyte imbalances
focus primarily on:
1. Patient teaching
2. Dietary intake
3. Medication regimen
4. Physician involvement in care
6. The nurse is aware that the following medication is never given directly
intravenously:
1. Potassium chloride (KCl)
2. Furosemide (Lasix)
3. Dextrose
4. Calcium gluconate
7. Many factors are initially controlled for in the intravenous insertion
procedure. The nurse understands that this begins with:
1. Hand hygiene
2. Checking the sterility of supplies
3. Ensuring the ten rights of medication administration
4. Carefully checking the order for the intravenous therapy
8. Indications of intravenous fluid infiltration include:
1. Phlebitis and coolness
2. Edema and erythema
3. Pallor and coolness
4. Pain and erythema
9. A recent evidence-informed review recommends that replacing peripheral
venous catheters and rotating sites should occur:
1. Every 96 hours
2. Every 72 hours
3. When clinically indicated
4. Every 48 hours
10. Fifteen minutes after blood administration, your patient develops
dyspnea, a cough, and a rapid heart rate. You suspect:
1. Sepsis
2. Anaphylaxis
3. Acute hemolytic reaction
4. Circulatory overload
Answers: 1. 1; 2. 4; 3. 2; 4. 4; 5. 1; 6. 1; 7. 1; 8. 3; 9. 3; 10. 4
Rationales for the Review Questions appear at the end of the book.
Recommended Websites
Association for Vascular Access. http://www.avainfo.org.
The website for the Association for Vascular Access has many links to
conferences and national and international organizations regarding
vascular access.
Canadian Association of Nephrology Nurses and Technologists.
http://www.cannt.ca.
This association exists to promote excellence in the care of patients with
renal disease. They provide leadership through education, research,
and dissemination of research. Nephrology nursing standards are
available from the website and include standards for holistic patient
care across areas of practice such as prevention, assessment, and
nursing interventions.
Canadian Paediatric Society. http://cps.ca/documents/position/homeintravenoustherapy.
The Canadian Paediatric Society has a position statement on home
intravenous therapy for Canadian children and youth. The web
resource outlines indications and summarizes research related to
pediatric home intravenous therapy.
Canadian Patient Safety Institute (CPSI) (Tools and Resources).
http://www.patientsafetyinstitute.ca/en/Topic/Pages/Central-LineInfections-(CLI).aspx.
CPSI focuses on a wide range of patient safety topics. Preventing
central-line infections is one topic with resources for physicians and
nurses. The link given here is for two sets of evidence-informed steps
for insertion and care of central lines.
Canadian Vascular Access Association. http://www.cvaa.info/.
The Canadian Vascular Access Association provides leadership in
advocating for safe, quality vascular access by promoting education,
partnerships, knowledge, and research. The mission statement
highlights the role of empowering and engaging members, with a
vision for optimal patient outcomes.
Infusion Nurses Society. http://www.ins1.org/default.aspxm.
This society is a global leader in intravenous therapy, playing a key role
in synthesizing and disseminating the best evidence and publishing
standards for infusion care. The society advances best practice
through their publications, professional development opportunities,
and advocacy.
MedCalc: Acid–Base Calculator.
http://www.medcalc.com/acidbase.html.
The MedCalc acid–base program provides a calculator for acid–base
status and anion gap. Other options are calculators for creatinine
clearance, fractional excretion of sodium, free water deficit, and hypoand hypernatremia.
Ontario Regional Blood Coordinating Network.
http://www.transfusionontario.org/.
This government-funded network provides a number of services,
including an educational service for registered nurses, called Bloody
Easy Blood Administration. The online learning program requires
registration; however, anyone can register and complete the module
and an assessment test.
Registered Nurses' Association of Ontario (RNAO) Nursing Best
Practice Guidelines. http://rnao.ca/bpg/guidelines/clinical-guidelines.
RNAO has developed Best Practice Guidelines for a number of aspects
of nursing care, including intravenous therapy. RNAO Best Practice
Guidelines address assessment, device selection, care, and
maintenance of vascular access, including central vascular access
devices (CVAD). RNAO guidelines can be accessed through the
RNAO website (http://www.rnao.org) and clicking on Nursing Best
Practice Guidelines or by going to the link above. These guidelines
are based on current evidence and knowledge and constitute an
excellent resource.
References
Alexander M, Corrigan AM, Gorski LA, et al. Core curriculum for infusion
nursing. 4th ed. Lippincott, Williams, and Wilkins: Philadelphia; 2014.
Allgood G. Safe drinking water for the most vulnerable. International
Nursing Review. 2009;56(3):273–275; 10.1111/j.1466-7657.2009.00752.x.
Amerman EC. Human anatomy and physiology. Pearson Education Inc:
New York; 2016.
Arai SR, Butzlaff A, Stotts NA, et al. Quench the thirst: lessons from
clinical thirst trials. Biological Research for Nursing. 2014;16(4):456–466;
10.1177/1099800413505900.
Bernatchez SF. Care of peripheral venous catheter sites: Advantages of
transparent film dressings over tape and gauze. Journal of the
Association for Vascular Access. 2014;19(4):256–261.
Bunn D, Jimoh F, Wilsher SH, et al. Increasing fluid intake and reducing
dehydration risk in older people living in long-term care: A
systematic review. Journal of the American Medical Directors Association.
2015;16(2):101–113; 10.1016/j.jamda.2014.10.016.
Burchum JR, Rosenthal LD. Lehne's pharmacology for nursing care. 9th ed.
Elsevier: St. Louis, MO; 2016.
Casey AL, Elliott TSJ. Prevention of central venous catheter–related
infection: Update. The British Journal of Nursing. 2010;19(2):78;
10.12968/bjon.2010.19.2.46289.
Chopra V, Krein SL, Olmsted RN, et al. Prevention of central lineassociated bloodstream infections: Brief update review. Shekelle PG,
Wachter RM, Pronovost PJ, et al. Making health care safer II: An
updated critical analysis of the evidence for patient safety practices.
Agency for Healthcare Research and Quality: Rockville, MD; 2013
[(AHRQ publication no. 13-E001-EF); Retrieved from]
http://www.ncbi.nlm.nih.gov/books/NBK133364/.
Coram J. A collaborative approach: Seeking excellence in vascular
access. The British Journal of Nursing. 2015;24(8):S16–S22;
10.12968/bjon.2015.24.Sup8.S16.
Davidhizar R, Dunn CL, Hart AN. A review of the literature on how
important water is to the world's elderly population. International
Nursing Review. 2004;51(3):159–166; 10.1111/j.1466-7657.2004.00224.x.
De Beer K, Michael S, Thacker M, et al. Diabetic ketoacidosis and
hyperglycaemic hyperosmolar syndrome—clinical guidelines.
Nursing in Critical Care. 2008;13(1):5–11; 10.1111/j.14785153.2007.00259.x.
DeVries M, Mancos PS, Valentine MJ. Reducing bloodstream infection
risk in central and peripheral intravenous lines: Initial data on
passive intravenous connector disinfection. Journal of the Association
for Vascular Access. 2014;19(2):87–93; 10.1016/j.java.2014.02.002.
Dumyati G, Concannon C, van Wijngaarden E, et al. Sustained
reduction of central line-associated bloodstream infections outside
the intensive care unit with a multimodal intervention focusing on
central line maintenance. American Journal of Infection Control.
2014;42(7):723–730; 10.1016/j.ajic.2014.03.353.
Dunn S. Maintaining adequate hydration and nutrition in adult enteral
tube feeding. The British Journal of Community Nursing. 2015;20(Suppl.
7):S16–S23; 10.12968/bjcn.2015.20.Sup6a.S16.
Edwards C, Johnson C. Evaluation of a Luer-activated intravenous
administration system. Journal of the Association for Vascular Access.
2012;17(4):200–207; 10.1016/j.java.2012.10.003.
El-Sharkawy AM, Sahota O, Lobo DN. Acute and chronic effects of
hydration status on health. Nutrition Reviews. 2015;73(Suppl. 2):97–
109; 10.1093/nutrit/nuv038.
Felver L. Fluid and electrolyte homeostasis and imbalances. Copstead
LC, Banasik JL. Pathophysiology. 5th ed. Saunders: St. Louis; 2013.
Felver L. Fluid and electrolyte balance. Giddens JF. Concepts for nursing
practice. Mosby: St. Louis; 2013.
Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and
preferred fluids vs. electrolyte maintenance solution on treatment
failure among children with mild gastroenteritis: A randomized
clinical trial. JAMA. 2016;315(18):1966–1974; 10.1001/jama.2016.5352.
Giger JN. Transcultural nursing: Assessment and intervention. 6th ed.
Mosby: St. Louis; 2013.
Gillies D, Wallen MM, Morrison AL, et al. Optimal timing for
intravenous administration set replacement. Cochrane Database of
Systematic Reviews. 2005;(4); 10.1002/14651858.CD003588.pub2
[CD003588].
Green J. Care and management of patients with skin-tunnelled
catheters. Nursing Standard. 2008;22(42):41–48;
10.7748/ns2008.06.22.42.41.c6580.
Gregorio GV, Gonzales MLM, Dans LF, et al. Polymer-based oral
rehydration solution for treating acute watery diarrhoea. Cochrane
Database of Systematic Reviews. 2009;(2);
10.1002/14651858.CD006519.pub2 [CD006519].
Groll D, Davies B, MacDonald J, et al. Evaluation of the psychometric
properties of the phlebitis and infiltration scales for the assessment
of complications of peripheral vascular access devices. Journal of
Infusion Nursing. 2010;33(6):385–390; 10.1097/NAN.0b013e3181f85a73.
Hall JE. Guyton and Hall textbook of medical physiology. 13th ed.
Saunders: Philadelphia, PA; 2016.
Hamilton H. Complications associated with venous access devices: Part
one. Nursing Standard. 2006;20(26):43;
10.7748/ns2006.03.20.26.43.c4087.
Hannon R, Pooler C, Porth CM. Porth pathophysiology: Concepts of altered
health states. 1st Cdn. ed. Lippincott Williams & Wilkins:
Philadelphia, PA; 2010.
Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous
rehydration for treating dehydration due to gastroenteritis in
children. The Cochrane Database of Systematic Reviews. 2006;(3);
10.1002/14651858.CD004390.pub2 [CD004390].
Higgingson R. IV cannula securement: protecting the patient from
infection. The British Journal of Nursing. 2015;24(8):S23–S28;
10.12968/bjon/2015.24.Sup8.S23.
Infusion Nurses Society (INS). Infusion nursing standards of practice.
Journal of Infusion Nursing. 2016;39(S1):S1–S159.
International Council of Nurses. Universal access to clean water.
International Council of Nurses position statement. [Retrieved from]
http://www.icn.ch/images/stories/documents/publications/position_statemen
2008.
Kelly LJ. The family of vascular access devices. Journal of Infection
Prevention. 2009;10(1):s7–s12; 10.1177/1757177409342156.
Kisiel M, Marsons L. Recognizing and responding to hyperglycaemic
emergencies. The British Journal of Nursing. 2009;18(18):1094–1098;
10.12968/bjon.2009.18.18.44549.
Matocha D. Achieving near-zero and zero: Who said interventions and
controls don't matter? The Journal of Vascular Access. 2013;18(3):157;
10.1016/j.java.2013.03.003.
McCance KL, Huether SE. Pathophysiology: The biologic basis for disease in
adults and children. 6th ed. Mosby Elsevier: Maryland Heights, MO;
2010.
McGloin S. The ins and outs of fluid balance in the acutely ill patient.
The British Journal of Nursing. 2015;24(1):14–18;
10.12968/bjon.2015.24.1.14.
Millam DA, Hadaway LC. On the road to successful I.V. starts. Nursing.
2003;33(5):1–14.
Mitchell MD, Anderson BJ, Williams K, et al. Heparin flushing and
other interventions to maintain patency of central venous catheters:
A systematic review. Journal of Advanced Nursing. 2009;65(10):2007–
2021.
Molzahn AE, Pelletier Hibbert M, Gaudet D, et al. Managing chronic
kidney disease in a nurse-run, physician monitored clinic: The
CanPREVENT experience. The Canadian Journal of Nursing Research.
2008;40(3):96–112.
Ogston-Tuck S. Intravenous therapy: Guidance on devices, management
and care. The British Journal of Community Nursing. 2012;17(10):474–
484; 10.12968/bjcn.2012.17.10.474.
Paul P, Day RA, Williams B. Brunner & Suddarth's Canadian textbook of
medical-surgical nursing. 3rd ed. Lippincott Williams & Wilkins:
Philadelphia, PA; 2016.
Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in
critically ill patients. Cochrane Database of Systematic Reviews. 2012;(6);
10.1002/14651858.CD000657.pub5 [CD000567].
Pike-MacDonald S, Best DG, Twomey C, et al. Promoting safe drinking
water. The Canadian Nurse. 2007;103(1):14–19.
Ray-Barruel G, Polit DF, Murfield JE, et al. Infusion phlebitis
assessment measures: A systematic review. Journal of Evaluation in
Clinical Practice. 2014;20(2):191–202; 10.1111/jep.12107.
Registered Nurses' Association of Ontario. Nursing Best Practice
Guideline: Assessment and device selection with 2008 supplement.
[Toronto: Author; Retrieved from]
http://rnao.ca/bpg/guidelines/assessment-and-device-selectionvascular-access; 2004/2008.
Registered Nurses' Association of Ontario. Care and maintenance to
reduce vascular access complications: Guideline supplement. [Toronto:
Author; Retrieved from] http://rnao.ca/sites/rnaoca/files/storage/related/3380_Care_and_Maintenance_to_Reduce_Vascular_A
2008.
Rickard CM, Vannapraseuth B, McGrail MR, et al. The relationship
between intravenous infusate colonisation and fluid container hang
time. Journal of Clinical Nursing. 2009;18(21):3022–3028; 10.1111/j.13652702.2009.02870.x.
Scales K. Reducing infection associated with central venous access
devices. Nursing Standard. 2011;25(36):49–56;
10.7748/ns2011.05.25.36.49.c8517.
Schub T, Obiamaka O. Hydration: Maintaining oral hydration in older
adults. [October 28] CINAHL Nursing Guide. 2016 [Retrieved from]
http://www.cinahl.com.
Shepherd AB. Water, water, everywhere and not a drop to drink?
Nursing and Residential Care. 2013;15(8):530–537;
10.12968/nrec.2013.15.8.530.
The Joint Commission (TJC). 2018 National patient safety goals.
[Oakbrook Terrace, IL: Author; Retrieved from]
http://www.jointcommission.org/standards_information/npsgs.aspx;
2017.
Touhy TA, Jett KF. Ebersole and Hess' gerontological nursing & healthy
aging. 4th ed. Mosby: St. Louis; 2014.
Webster J, Osborne S, Rickard C, et al. Clinically indicated replacement
versus routine replacement of peripheral venous catheters. Cochrane
Database of Systematic Reviews. 2010;(3);
10.1002/14651858.CD007798.pub2 [CD007798].
Wotton K, Crannitch K, Munt R. Prevalence, risk factors and strategies
to prevent dehydration in older adults. Contemporary Nurse: A Journal
for the Australian Nursing Profession. 2008;31(1):44–56.
Zingg W, Cartier V, Inan C, et al. Hospital-wide multidisciplinary
multimodal intervention programme to reduce central catheterassociated bloodstream infection. PLoS ONE. 2014;9(4):e93898;
10.1371/journal/pone.0093898.
41
Sleep
Canadian content written by, Claudette Taylor PhD, RN, NP adult
Original chapter by, Patricia A. Stockert RN, BSN, MS, PhD
OBJECTIVES
Mastery of content in this chapter will enable you to:
• Define the key terms listed.
• Compare the characteristics of rest and sleep.
• Explain the effect of the 24-hour sleep–wake cycle on biological functions.
• Discuss the mechanisms that regulate sleep.
• Describe the stages of a normal sleep cycle.
• Explain the functions of sleep and rest.
• Compare the sleep requirements of different age groups.
• Identify factors that normally promote sleep and factors that normally disrupt sleep.
• Discuss the characteristics of common sleep disorders.
• Conduct a sleep history for a patient.
• Identify nursing diagnoses appropriate for patients with sleep alterations.
• Identify nursing interventions designed to promote normal sleep cycles for individuals of all
ages.
• Describe ways to evaluate sleep therapies.
KEY TERMS
Biological clocks, p. 1073
Cataplexy, p. 1078
Circadian rhythms, p. 1073
Emotional stress, p. 1081
Excessive daytime sleepiness (EDS), p. 1076
Hypersomnolence, p. 1075
Hypnotics, p. 1092
Insomnia, p. 1076
Narcolepsy, p. 1077
Nocturia, p. 1075
Nonrapid eye movement (NREM) sleep, p. 1074
Parasomnias, p. 1078
Polysomnogram, p. 1076
Rapid eye movement (REM) sleep, p. 1074
Rest, p. 1079
Sedatives, p. 1092
Sleep, p. 1073
Sleep apnea, p. 1076
Sleep architecture, p. 1080
Sleep deprivation, p. 1078
Sleep hygiene, p. 1076
Sleep is essential for good health. Sleep is a basic necessity of life and is as
important as air, food, and water (National Sleep Foundation, 2009). Everyone
requires sleep. For a variety of reasons, individuals are, on average, sleeping
less. Continual sleep loss may have many, yet largely unknown, adverse
outcomes for health and well-being. In the short term, insufficient sleep
alters mood and decreases the ability to concentrate, make decisions, and
participate in daily activities.
To help patients in identifying and treating their sleep pattern
disturbances, nurses need to first understand the nature of sleep, the factors
influencing sleep, and patients' sleep habits. Patients require an
individualized approach that is determined on the basis of their personal
habits and patterns of sleep, to address the particular problem that is
disrupting their sleep. Nursing interventions are often effective in resolving
short- and long-term sleep disturbances.
Sleep provides healing and restoration (Van Cauter, Spiegel, Tasali, et al.,
2008). Achieving the best possible sleep quality contributes to good health
and to recovery from illness. Ill patients often require more sleep and rest
than healthy patients. The nature of illness, however, often prevents some
patients from getting adequate rest and sleep. Sleep can also be made
difficult by the environment of a hospital or extended care facility and the
activities of health care providers. Some patients have pre-existing sleep
disturbances, whereas other patients develop sleep problems as a result of
illness or hospitalization.
Scientific Knowledge Base
Definition of Sleep
Sleep is a universal, dynamic, highly organized, physiological, and
behavioural state required by most living organisms to maintain health and
well-being (Box 41-1) (Carskadon & Dement, 2011; Collop, Salas, Delayo, et
al., 2008).
Box 41-1
Behavioural Characteristics of Sleep
Periodic
Involuntary
Reversibility
Reduced responsiveness to environment
Minimal movement
Closed eyes
Species-specific posture
Carskadon, M. A., & Dement, W. C. (2011). Normal human sleep: An overview. In M. H. Kryger, T.
Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (5th ed., pp. 16–41). Philadelphia,
PA: Elsevier.
Physiology of Sleep
Sleep is a cyclical, physiological, and behavioural process that alternates with
longer periods of wakefulness. Sleep physiology is controlled by three
distinct processes: an ultradian process, a homeostatic process (process S), and
a circadian process (process C). The ultradian process occurs within the sleep
state and is characterized by the alteration of the two sleep stages: nonrapid
eye movement (NREM) sleep and rapid eye movement (REM) sleep. Process
S and process C work together to regulate the timing and organization of
sleep and wakefulness. Process S is dependent on the sleep–wake cycle,
whereas process C functions to maintain a state of wakefulness (Achermann
& Borbely, 2011; Lee-Chiong, 2008).
Circadian Rhythms.
The biological functions of most living organisms are regulated by circadian
rhythms. The term circadian is derived from the Latin words circa, which
means “about,” and dien, which means a day (Smith, Comella, & Hogl, 2008).
People experience cyclical rhythms as part of their everyday life. The sleep–
wake cycle is the most familiar of the 24-hour circadian rhythms. Numerous
biological and behavioural functions are influenced by circadian rhythms.
Changes in body temperature, for example, exhibit circadian rhythmicity.
Normally, a person's body temperature peaks in the afternoon, decreases
gradually, and then drops sharply after a person falls asleep. The initial
period of a person's sleep is characterized by high levels of growth hormones
and increased blood glucose concentrations, blood pressure, and heart rate.
Sensory acuity and mood are also maintained by the 24-hour circadian cycle
(Laposky, Bass, Kohsaka, et al., 2008).
Factors that affect circadian rhythms and daily sleep–wake cycles include
light, temperature, social activities, and work routines. All individuals have
biological clocks that synchronize their sleep–wake cycles, which explains
why some individuals fall asleep at 9 p.m., whereas others go to bed at
midnight. Different individuals also function at their best at different times
of the day.
Hospitals or extended care facilities usually do not adapt care to an
individual's sleep–wake cycle preferences. Typical hospital routines often
interrupt sleep or prevent patients from falling asleep at their usual time. A
person has poor quality of sleep if his or her sleep–wake cycle changes
significantly. A serious illness is often indicated by reversals in the sleep–
wake cycle, such as falling asleep during the day.
When the sleep–wake cycle is disrupted (e.g., by working rotating shifts),
other physiological functions can also change. For example, the person may
experience a decreased appetite and lose weight or may experience other
common symptoms of sleep cycle disturbances, such as anxiety, restlessness,
irritability, and impaired judgement. Failure to maintain the usual sleep–
wake cycle can negatively influence the individual's overall health.
Sleep Regulation.
Sleep involves a sequence of physiological and behavioural states maintained
by highly integrated central nervous system (CNS) activity, which is
associated with changes in the autonomic nervous system and endocrine,
cardiovascular, respiratory, gastrointestinal, renal, and musculoskeletal
systems (Lee-Chiong, 2008). Each sequence of physiological states is
identified by specific physiological responses and patterns of brain activity.
Special instruments provide information about the structural and
physiological aspects of sleep: for example, the electroencephalogram (EEG)
measures electrical activity in the cerebral cortex, the electromyogram (EMG)
measures muscle tone, and the electro-oculogram (EOG) measures eye
movements.
Current theory suggests that sleep is a dynamic multiphase process. The
body's major sleep centre is the hypothalamus. The hypothalamus secretes
hypocretins (orexins) that promote wakefulness. The anterior pituitary gland
also secretes hormones (e.g., growth hormone and prolactin) that promote
sleep (Lee-Chiong, 2008).
Researchers believe the ascending reticular activating system (RAS),
located in the upper brain stem, contains special cells that maintain alertness
and wakefulness. The RAS receives visual, auditory, pain, and tactile sensory
stimuli. Activity from the cerebral cortex (e.g., emotions and thought
processes) also stimulates the RAS. Arousal, wakefulness, and maintenance
of consciousness result from neurons in the RAS that release serotonin and
catecholamines, such as norepinephrine and dopamine (Siegel, 2011).
Whether a person remains awake or falls asleep depends on a balance of
impulses received from higher centres (e.g., thoughts), peripheral sensory
receptors (e.g., sound or light stimuli), and the limbic system (e.g., emotions)
(Figure 41-1). As a person tries to fall asleep, the eyes close and the body
assumes a relaxed position and stimuli to the RAS declines. If the room is
dark and quiet, the RAS further declines. At some point, an area of the brain
called the bulbar synchronizing region (BSR) takes over, causing sleep.
FIGURE 41-1 The reticular activating system and the bulbar synchronizing region
control sensory input by intermittently activating and suppressing the brain's higher
centres to control sleep and wakefulness.
Stages of Sleep.
Changes in brainwave activity, muscle tone, body temperature, and eye
movements are associated with different stages of sleep (Billard, 2008).
Within sleep, two separate phases have been identified: nonrapid eye
movement (NREM) sleep and rapid eye movement (REM) sleep (Box 41-2).
During NREM sleep, a sleeper progresses through three stages (stages 1, 2,
and 3) of increasingly deeper sleep. Stage 1, a light and drowsy sleep, occurs
at the beginning of sleep and is the transitional stage between wakefulness
and sleeping. Stage 2 is a deeper stage of sleep, although a sleeper may be
easily aroused during this stage of sleep. Stage 3 involves even deeper sleep,
and this stage is known as delta sleep or slow-wave sleep (SWS). Delta sleep
or SWS sleep is thought to be the most restorative of all the sleep stages.
REM sleep, also known as paradoxical sleep, follows NREM sleep and is not
divided into stages. REM sleep shares some characteristics of NREM sleep
and of wakefulness. REM sleep is “paradoxical” in the sense that, although a
person is behaviourally asleep, the individual is physiologically active—brain
activity is high, rapid eye movements are occurring, twitching of the
extremities occurs, and males frequently develop erections (Siegel, 2011). The
most characteristic feature of REM sleep is dreaming. REM sleep dreams are
often vivid and emotional (Billard, 2008; Van Cauter et al., 2008). REM sleep is
the phase at the end of each sleep cycle.
Box 41-2
Stages of the Sleep Cycle
Stage 1: Nonrapid Eye Movement
This stage represents the lightest level of sleep.
The person is unresponsive but easily aroused by sensory stimuli, such
as noise.
Physiological activity begins to decrease, accompanied by a gradual fall
in vital signs and metabolism.
Muscle tone is present.
When awakened from this stage, a person feels as though he or she had
been daydreaming.
This stage lasts only a few minutes.
Accounts for about 2% to 5% of total sleep time in adults.
Stage 2: Nonrapid Eye Movement
This stage is a period of sound sleep.
Relaxation progresses.
Body functions continue to slow.
Muscle tone remains present.
Eye movements are absent.
Accounts for the greatest proportion (45% to 55%) of total sleep time in
adults.
Stage 3: Nonrapid Eye Movement
This stage is the deepest period of sleep.
Individuals are difficult to arouse.
Muscles become completely relaxed.
Vital signs are significantly lower than during waking hours, but remain
regular.
Parasomnias sometimes occur during this stage (e.g., sleepwalking,
enuresis [bedwetting])
Accounts for 10% of total sleep time in adults and is more prominent
during the first half of sleep.
If sleep loss has occurred previously, the sleeper will spend a
considerable portion of the sleep period in this stage.
Rapid Eye Movement Sleep
Rapid eye movements are present.
Respirations are irregular and shallow.
Variable heart rate and blood pressure occur.
Vivid and elaborate dreams sometimes occur.
Dreaming occurs more frequently and is more complex than in NREM
sleep.
This stage usually begins about 90 minutes after sleep has begun.
Loss of skeletal muscle tone occurs.
Gastric secretions increase.
The person is difficult to arouse.
The duration of REM sleep increases with each cycle.
Accounts for about 25% of total sleep time in adults.
Billard, M. (2008). Normal sleep. In H. R. Smith, C. L. Comella, & B. Hogl (Eds.), Sleep medicine (pp. 9–
24). New York: Cambridge University Press; and Lee-Chiong, Jr., T. (2008). Sleep medicine: Essentials and
review. New York: Oxford University Press.
Different factors promote or interfere with various stages of the sleep
cycle. It is important to be aware of these factors and know about therapies
that promote sleep and eliminate factors that disrupt it.
Sleep Cycle.
The normal sleep pattern for an adult begins with a pre-sleep period during
which the person is aware of only gradually developing sleepiness. This
period normally lasts 10 to 30 minutes, but if a person has difficulty falling
asleep, it can last an hour or longer. Once asleep, the person usually passes
through four to five complete sleep cycles per night, each consisting of three
stages of NREM sleep and a period of REM sleep (Billard, 2008). Sleep begins
when adults enter stage 1 NREM sleep. This stage usually persists for only a
few minutes, and sleep may be easily interrupted by calling the person's
name or by touching them. Stage 2 NREM sleep follows and continues for
approximately 10 to 25 minutes. In stage 2, a person is not so easily
awakened. Stage 2 NREM sleep then goes to stage 3 NREM, back to stage 2
NREM and then to REM sleep to complete the sleep cycle (Figure 41-2).
NREM sleep and REM sleep continue to alternate throughout a night in this
cyclical pattern (Carskadon & Dement, 2011; Lee-Chiong, 2008). The number
of sleep cycles depends on the total amount of time that a person spends
sleeping.
FIGURE 41-2
The stages of the adult sleep cycle. NREM, Nonrapid eye movement; REM, rapid
eye movement.
The average length of the first cycle is 90 minutes, and subsequent cycles
may last between 100 and 120 minutes. During the night, the NREM/REM
sleep cycle is repeated four to five times, and with each subsequent cycle, less
time is spent in stage 3 NREM sleep while the proportion of time spent in
REM sleep increases. Of the total sleep time, 75% to 85% is spent in NREM
sleep.
Not all people progress consistently through the stages of sleep. For
example, a sleeper may move back and forth for short intervals between the
NREM stages 2 and 3 before entering the REM stage. The amount of time
spent in each stage varies over a person's lifespan. Newborns and children
spend more time in deep sleep or SWS. This stage of sleep is highest in
children, and for this reason it is often very difficult to wake young children
from this particular stage of sleep. As individuals age, less time is spent in
deep sleep (Carskadon & Dement, 2011; Lee-Chiong, 2008).
Functions of Sleep
Although we spend a third of our time sleeping, many of the reasons why we
sleep have yet to be understood. Many theories of why we sleep have been
proposed, and all of these may be partially correct. For instance, it has been
proposed that sleep allows for physiological and psychological restoration
(Van Cauter et al., 2008). During NREM sleep, biological functions slow.
Normally, in daytime hours the heart rate of a healthy adult averages 70 to 80
beats per minute, or less, if the individual is in excellent physical condition.
During sleep, the heart rate slows, beating 10 to 26 fewer times each minute,
or 60 to 120 fewer beats each hour. Clearly, restful sleep is beneficial in
preserving cardiac function. Other biological functions also decrease during
sleep—for example, respirations, blood pressure, muscle tone, urine
production, and hormone secretion (Carskadon & Dement, 2011). The body
needs sleep for physiological restoration such as cell and tissue repair.
Increased cell mitosis and increased protein synthesis have been observed
during periods of NREM sleep (Van Cauter et al., 2008).
REM sleep is necessary for brain tissue restoration and appears to be
important for cognitive restoration (Lee-Chiong, 2008). REM sleep is
associated with changes in cerebral blood flow, increased cortical activity,
increased oxygen consumption, and epinephrine release (Carskadon &
Dement, 2011). During sleep, the brain filters stored information about the
day's activities. The benefits of sleep on behaviour often go unnoticed until a
problem develops as a result of sleep deprivation. A loss of REM sleep leads
to feelings of confusion and suspicion.
Sleep is also believed to be important for immune function, renal function,
regulation of body temperature, metabolism of glucose, and hormone
secretion (Collop et al., 2008; Tibbits, 2008).
In addition to physical functioning, sleep is essential for psychological and
social functioning. Without sleep, individuals are irritable and anxious and
often report high levels of stress.
Dreams.
Dreaming is defined as a mental activity that occurs while individuals are
asleep. Dreams can occur during both NREM and REM sleep. The majority of
dreams take place in the REM sleep stage. REM sleep–related dreams are
often vivid and elaborate, whereas NREM dreams are simpler and more
realistic (Lee-Chiong, 2008; Nielsen, 2011).
Studies of across-the-night changes in the characteristics of dreams
suggest that dreams become more realistic as the night progresses. Dream
content also appears to parallel cognitive and emotional development, as the
recollection of dreams reported by children and adults is quite different
(Stickgold & Wamsley, 2011).
Determinants of dreams, aside from age, include personality, physiological
conditions (e.g., pregnancy), psychological conditions, pharmacological
therapies, and situational factors. Personality also influences the quality of
dreams; for example, a creative person has elaborate and complex dreams,
whereas a depressed person dreams of helplessness (Stickgold & Wamsley,
2011). Most people dream about their immediate concerns, such as an
argument with a spouse or worries over work. Sometimes a person is
unaware of the fears represented in bizarre dreams. Clinical psychologists
can try to analyze the symbolic nature of dreams as part of a patient's
psychotherapy. The ability to describe a dream and interpret its significance
sometimes helps resolve personal concerns or fears.
Numerous theories have been proposed as to why individuals dream. For
centuries, dreams have been seen as messages from the gods, and this belief
is upheld by many cultures today. Sigmund Freud theorized that dreams
were the expression of an individual's unconscious desires and that by
exploring dreams, emotional problems could be cured (Stickgold & Wamsley,
2011).
Physical Illness
Any illness that causes pain, physical discomfort, or mood problems, such as
anxiety or depression, often results in sleep problems. Individuals who are ill
frequently have trouble falling asleep or staying asleep. Illnesses can also
force patients to sleep in unfamiliar positions. For example, when an arm or
leg is in traction, patients have a difficult time finding a comfortable position
for sleep.
Respiratory disease often interferes with sleep. While individuals sleep,
their level of blood oxygen decreases. In healthy individuals, this decrease
can be compensated for easily whereas individuals with respiratory diseases
often require supportive devices, practices, or therapies to assist them while
they are sleeping (Agarwal, Richardson, Krishnan, et al., 2009). Symptoms
associated with respiratory diseases may require individuals to alter their
position to facilitate sleeping. For example, individuals with chronic
obstructive lung disease, such as emphysema, are frequently short of breath
and often require two or three pillows to sleep (Lee-Chiong, 2008).
Cardiovascular disease interferes with sleep. Individuals who are obese are
at greater risk for cardiovascular disease and, thus, for sleep disorders (Box
41-3). Chest pain, shortness of breath, diaphoresis, nausea, and palpitations,
all symptoms associated with cardiovascular disease, frequently occur during
the night and can disrupt sleep. Hypertension often causes early morning
awakening and fatigue (Lee-Chiong, 2008).
Box 41-3
Research Highlight
Sleep Duration and Obesity
Research Focus
Research has shown an association between obesity, sleep time, and the
occurrence of sleep disorders. The prevalence of obesity has increased
considerably over the past 25 years and is considered a global epidemic
(Magee, Iverson, Huang, et al., 2008). Obesity refers to an excess of body fat
and is a disorder that occurs when body fat excess impairs the health of
individuals. Obesity is associated with an increased risk of many chronic
diseases, including heart disease, diabetes, hypertension, and cancer (Anic,
Titus-Ernstoff, Newcomb, et al., 2010). Prior research has shown that obesity
increases morbidity and mortality.
Shorter sleep times have become increasingly more prevalent in Western
countries for many reasons, including lifestyle choices, work or family
requirements, or prevailing physical or psychological problems. Over the
past several years, sleep duration in adults has decreased, on average, by 1.5
to 2 hours per night, and many individuals are reporting sleeping fewer than
6 hours per night. Researchers wanted to determine whether shorter sleep
time increases the risk of obesity.
Research Abstract
Patel, Blackwell, Redline, and colleagues (2008) assessed the sleep pattern of
3 110 older men and 3 219 older women using wrist actigraphy, an objective
method of sleep assessment. Study results demonstrated that a sleep
duration of fewer than 5 hours was associated with an increased body mass
index and truncal (abdominal) fat; the fat was also associated with
cardiovascular disease and diabetes.
Evidence-Informed Practice
• During assessment of a patient's health problems, ask questions related
to sleep quality and sleep patterns.
• If the patient indicates a problem with sleep, conduct a thorough sleep
history.
• Reinforce good sleep hygiene habits.
• Encourage patients to notify their health care provider if they begin to
experience sleep problems.
• Reinforce healthy eating habits.
• Encourage patients to seek the advice of other health care providers (e.g.,
dietitian, nutritionist).
Patel, S. R., Blackwell, T., Redline, S., Ancoli-Israel, S., Cauley, J. A., Hillier, T. A., et al. (2008). The
association between sleep duration and obesity in older persons. International Journal of Obesity, 32(12),
1825–1834.
The sleep of individuals with musculoskeletal disorders such as
osteoarthritis and rheumatoid arthritis may be disrupted by the pain that
often accompanies these conditions (Lavigne, Smith, Denis, et al., 2011).
Nocturia, or urination during the night, disrupts sleep and the sleep cycle.
This condition is most common in older people with reduced bladder tone or
individuals who have cardiac disease, diabetes, or problems with elimination.
After a person awakens repeatedly to urinate, returning to sleep is difficult.
Sleep Disorders
Sleep disorders are conditions that interfere with nighttime sleep. Currently,
more than 80 sleep disorders have been identified in the literature. The
American Academy of Sleep Medicine developed the International
Classification of Sleep Disorders version 2 (ICSD2), which classifies these
disorders into eight major categories (Box 41-4).
Box 41-4
Classification of Sleep Disorders
Insomnias
Acute insomnia (duration of less than one month)
Primary insomnia (unrelated to any other disorder)
Co-morbid insomnia (due to a medical condition)
Nonrestorative sleep
Early morning awakening
Sleep-Related Breathing Disorders
Sleep apnea
Obstructive sleep apnea syndrome
Central sleep apnea syndromes
Primary central sleep apnea
Central sleep apnea due to a drug or substance
Central sleep apnea due to a medical condition
Snoring
Upper airway resistance syndrome
Excessive Sleepiness
Narcolepsy
Narcolepsy secondary to medical disorders
Hypersomnias
Idiopathic hypersomnia (no identifiable cause)
Recurrent hypersomnia (repeated episodes of hypersomnia)
Post-traumatic hypersomnia (associated with head injuries)
Menstrual-related hypersomnia
Behaviourally induced insufficient sleep syndrome
Parasomnias
Disorders of Arousal
Sleepwalking
Sleep terrors
Parasomnias Usually Associated With REM Sleep
Nightmare disorder
REM sleep behaviour disorder
Sleep paralysis
Other Parasomnias
Sleep-related groaning
Sleep-related hallucinations
Sleep-related eating disorder
Sleep-related enuresis (bedwetting)
Due to drug or substance
Due to a medical condition
Circadian Rhythm Sleep Disorders
Primary Circadian Rhythm Sleep Disorders
Delayed sleep phase type
Advanced sleep phase type
Behaviourally Induced Circadian Rhythm Sleep Disorders
Jet lag type
Shift work type
Delayed sleep phase type
Drug or substance use
Sleep-Related Movement Disorders
Restless leg syndrome
Periodic limb movements
Sleep-related leg cramps
Sleep-related bruxism (teeth grinding)
Isolated Symptoms, Apparently Normal Variants, and
Unresolved Issues
Long sleeper
Short sleeper
Snoring
Sleep talking
Benign sleep myoclonus of infancy
Other Sleep Disorders
Physiological (organic) sleep disorders
Environmental sleep disorder
Sleep disorder not due to a substance or physiological condition
Adapted from American Academy of Sleep Medicine: International classes of diseases and international
classification of sleep disorders, as cited in Thorpy, M. (2011). Classification of sleep disorders. In M. H.
Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (5th ed., pp. 680–693).
Philadelphia, PA: Elsevier.
Increasingly, evidence suggests sleep disorders are related to serious
medical conditions. Individuals with sleep disorders are at risk for
developing hypertension, diabetes, and cardiovascular and neurological
diseases. Sleep disorders can affect individuals of all ages, and the prevalence
of these disorders increases with advancing age (Bloom, Ahmed, Alessi, et
al., 2009). Individuals with sleep disorders may complain of difficulty falling
asleep or staying asleep, daytime sleepiness, hypersomnolence, or abruptly
falling asleep during the daytime (Bae & Avidan, 2008).
The insomnias are primary disorders related to difficulty falling asleep.
Individuals with sleep-related breathing disorders have disordered
respirations during sleep. Hypersomnia is a group of disorders that are not
due to sleep related breathing disorders, and are caused by disturbances in
circadian rhythms or in nocturnal sleep. The parasomnias are undesirable
behaviours that usually occur during sleep. Circadian rhythm sleep disorders
are caused by a misalignment between the timing of sleep and the societal
norm or the desires of the individual. In sleep-related movement disorders,
the person experiences movements such as leg cramps or teeth grinding that
disturb sleep. The “other sleep disorders category” contains sleep problems
that do not fit into other categories.
Sleep laboratory studies are often used to diagnose a sleep disorder
(Chervin, 2011). A polysomnogram involves the use of EEG, EMG, and EOG
to monitor stages of sleep and wakefulness during nighttime sleep. The
Multiple Sleep Latency Test (MSLT) provides objective information about
sleepiness and selected aspects of sleep structure by measuring eye
movements, muscle tone changes, and brain electrical activity during at least
four napping opportunities spread throughout the day. The MSLT takes 8 to
10 hours to complete. Patients wear an Actigraph device on the wrist to
measure sleep–wake patterns over an extended period of time. Actigraphy
data provide information such as sleep time, number and duration of
awakenings, and levels of activity and rest (Chervin, 2011).
Insomnia.
Patients experience insomnia when they report problems falling asleep,
staying asleep, or nonrestorative sleep. Insomnia is the second most
commonly expressed complaint reported in clinical practice after pain and
the most common self-reported sleep-related complaint (Wyatt &
Crisostomo, 2008). Insomnia is more common in women, and its incidence
increases with advancing age (Doghramji, 2010). Insomnia may be transient
and may indicate an underlying physical or psychological disorder (Reeve &
Bailes, 2010). People experience transient insomnia as a result of schedule
changes (shift work, travel), situational crises, particular medications, and
excessive intake of alcohol or caffeine. However, transient insomnia may lead
to chronic difficulty if causes are not addressed (Reeve & Bailes, 2010).
Insomnia is often associated with poor sleep hygiene, behaviours that are
problematic for initiating sleep and maintaining sleep. Management of
insomnia depends on whether it is transient or indicative of an underlying
disorder. Treatment may include nonpharmacological therapies such as
relaxation therapy, cognitive-behavioural therapy, or pharmacological agents
(e.g., hypnotics).
Behavioural and cognitive therapies have few adverse effects and show
evidence of sustained improvement in sleep over a 6-month period
(Doghramji, 2010; Snowden, 2008).
Sleep Apnea.
Sleep apnea is a disorder in which people stop breathing for a period of at
least 10 seconds while asleep (Ramar & Guilleminault, 2008). There are two
types of sleep apnea: obstructive sleep apnea (OSA) and central sleep apnea.
Obstructive sleep apnea is the most common form of sleep apnea and results
from an obstruction of the upper airway (Cao, Guilleminault, & Kushida,
2011). Central sleep apnea represents a loss of inspiratory effort due to an
underlying pathological condition (Ramar & Guilleminault, 2008).
Risk factors for developing OSA include age, obesity, gender, ethnicity,
smoking, alcohol, and a positive family history. OSA is more common in
Asians than in Caucasians. OSA may affect middle-aged men more
frequently, particularly when they are obese. OSA is also common in
postmenopausal women and in younger women and children (Ramar &
Guilleminault, 2008).
Excessive daytime sleepiness (EDS) and fatigue are the most common
complaints of individuals who have OSA. Those who have severe OSA often
report taking daytime naps and experience a disruption in their daily
activities because of sleepiness. Feelings of sleepiness are usually most
intense when waking up just after falling asleep and 12 hours after the midsleep period.
In addition to reports of excessive daytime sleepiness, other symptoms of
OSA are fatigue, morning headaches, choking or gasping upon awakening,
irritability, depression, difficulty concentrating, and decreased sex drive (Cao
et al., 2011; Ramar & Guilleminault, 2008). Snoring is a distinguishing
characteristic of OSA, as nearly all patients with this disorder snore (Cao et
al., 2011).
OSA occurs when the muscles or structures of the oral cavity or throat relax
during sleep. The upper airway becomes partially or completely blocked,
thereby diminishing the nasal airflow (hypopnea) or stopping it (apnea) for
as long as 10 to 30 seconds (Cao et al., 2011). The person still attempts to
breathe; chest and abdominal movements continue and often result in loud
snoring and snorting sounds. When breathing is partially or completely
diminished, each successive diaphragmatic movement becomes stronger
until the obstruction is relieved. Apneic episodes are normally terminated by
gasps, snorting, or brief periods of awakening.
Structural abnormalities such as a deviated septum, nasal polyps, certain
jaw configurations, or enlarged tonsils predispose an individual to
obstructive sleep apnea. The effort to breathe during sleep results in arousals
from deep sleep often to the stage 2 cycle. In severe cases, hundreds of
hypopnea or apnea episodes occur every hour, resulting in severe
interference with deep sleep.
OSA causes a serious decline in the saturation level of arterial oxygen.
Individuals with OSA are at risk for cardiac dysrhythmias, heart failure,
pulmonary hypertension, angina, stroke, hypertension, and metabolic
syndrome. Sleep apnea contributes to high blood pressure and increased risk
for heart attack and stroke (National Sleep Foundation, 2009).
Individuals who have OSA rarely achieve deep sleep because sleep is often
fragmented. OSA may exact a heavy emotional toll on the individuals
affected and their families. OSA may affect marital relationships and
interactions within and outside the family, and frequently is an
embarrassment to the patient (National Sleep Foundation, 2009). Treatment
for OSA includes continuous positive airway pressure (CPAP). CPAP consists
of a mask that fits over the nose and mouth through which air is
continuously delivered into the airway to assist in keeping it open during
sleep (Ramar & Guilleminault, 2008). Other treatments include addressing
the underlying cardiac or respiratory complications and emotional problems
that occur as a result of the symptoms of this disorder (Atwood, Strollo, &
Givelber, et al., 2011).
Narcolepsy.
Narcolepsy is a common complex neurological sleep disorder for which there
is no known cure. Narcolepsy is known to affect men and women of any age;
however, it usually appears in adolescence. The clinical manifestations of
narcolepsy are highly variable. Excessive daytime sleepiness is the most
common complaint associated with narcolepsy. During the day, a person who
has narcolepsy may suddenly feel an overwhelming wave of sleepiness and
fall asleep (Ahmed & Thorpy, 2010). Narcolepsy is known to have a
significant impact on REM sleep and is also known to intensify the emotions
associated with this stage of sleep. Many individuals with narcolepsy
experience hallucinations, vivid dreams, night terrors, sleepwalking, sleep
paralysis, and poor memory and concentration, or the feeling of being unable
to move or talk just before waking or falling asleep. Cataplexy, or sudden
bilateral (occasionally unilateral) loss of muscle tone accompanied by an
overpowering urge to sleep, can occur at any time during the day and can last
from a few seconds to as long as 30 minutes. These episodes are sporadic and
can occur occasionally to several times per day. A history of cataplexy may be
obtained by inquiring whether the loss of muscle tone occurs during the
following: upon hearing or telling a joke, while laughing, or when angry.
Other triggers are embarrassment, surprise, stress, or sexual arousal (Ahmed
& Thorpy, 2010; Cook, 2008a, 2008b). Some studies show a genetic link for
narcolepsy (Faraco & Mignot, 2011).
Narcolepsy may also affect energy levels, metabolism, appetite, and
feelings of mental well-being. Individuals with narcolepsy can have intense
cravings for carbohydrates, and greater than one-third of individuals with
narcolepsy suffer from obesity (Smith et al., 2008).
Most people with narcolepsy tend to be diagnosed several years after the
onset of the condition, which means most of the symptoms associated with
this disorder go untreated. Prior to diagnosis, individuals are frequently
regarded as “different,” antisocial, lacking in motivation, and uncooperative
(Jennum, Knudsen, & Kjellberg, 2009).
There is no known cure for narcolepsy; therefore, treatment is targeted at
symptom management. Traditionally, individuals with narcolepsy have been
treated by two groups of drugs: stimulants and antidepressants. Stimulants
promote wakefulness and reduce the frequency of sleeping episodes.
Modafinil is a wakefulness-promoting agent and has been shown to improve
symptoms of fatigue and cognitive function (memory and concentration).
Antidepressants suppress cataplexy and other REM-related symptoms
(Ahmed & Thorpy, 2010; Cook, 2008a, 2008b).
Nonpharmacological management should be initiated in all individuals.
Education is an important component of the treatment plan for individuals
with narcolepsy. Good sleep hygiene should be emphasized. The
fundamental principles of sleep hygiene are listed in Box 41-5. Other
management strategies include regular exercise, strategically timed daytime
naps (if possible), a high-protein diet, deep breathing exercises, and chewing
gum (Cook, 2008b). Patients who have narcolepsy need to avoid factors that
increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, longdistance driving, and extended periods of sitting in hot, stuffy rooms).
Box 41-5
Sleep Hygiene: Fundamental Principles
Avoid late afternoon naps.
Decrease consumption of caffeine, tobacco, and alcohol.
Exercise regularly, but not prior to bedtime.
Eat regular meals, do not go to bed hungry, and decrease consumption
of liquids in the evening.
Maintain a regular sleep–wake schedule, even on weekends.
Maintain the bedroom as an environment solely for sleep.
Ensure a sleeping environment that is comfortable and quiet.
Milner, C. E., & Belicki, K. (2010). Assessment and treatment of insomnia in adults: A guide for
clinicians. Journal of Counseling & Development, 88, 236–244.
Parasomnias.
Parasomnias are undesirable sleep problems that occur while falling asleep,
between sleep phases, or during transitions from sleep to wakefulness. The
word parasomnia is derived from the Greek word para combined with the
Latin word somnus meaning event accompanying sleep (Silvestri & Arico,
2008). The parasomnia may range from abnormal sleep-related movements to
emotions, perceptions, dreaming, or behaviours. Parasomnia may be the
manifestation of an underlying physical or psychological disorder or may be
caused by the ingestion of drugs or other substances (Lee-Chiong, 2008).
Parasomnias are more common in children than in adults (Verrier &
Josephson, 2011).
Parasomnias that occur among older children include somnambulism
(sleepwalking), night terrors, nightmares, nocturnal enuresis (bedwetting),
body rocking, and bruxism (teeth grinding). When adults experience these
symptoms, more serious disorders are often indicated. Specific treatment for
these disorders varies; however, in all cases patients need to be supported
and their safety maintained.
Shift Work.
Shift work sleep disorder (SWSD) is a common sleep disorder experienced by
individuals who work outside the traditional 9-to-5 work day. This disorder
results from imposing a sleep–wake schedule that is contrary to the body's
internal circadian clock. Most commonly associated with nighttime work, the
health and economic consequences of this disorder are profound. Studies
suggest that individuals who engage in shift work have a high risk of
developing cardiovascular disease. The most common problems reported by
shift workers are excessive sleepiness, fatigue, and insomnia. Not all
individuals exposed to shift work develop this disorder (Drake & Wright,
2011).
Sleep Deprivation.
Sleep deprivation refers to insufficient sleep during a specific time period.
The most common causes of sleep deprivation are lifestyle factors or workrelated factors. One approach to understanding the functional significance of
sleep is to consider the behavioural and physiological effects of sleep
deprivation. Numerous studies on animal models subjected to periods of
sleep deprivation demonstrated that sleep deprivation resulted in changes in
metabolism (weight loss despite increased food intake), impaired glucose
metabolism, increased heart rate, skin lesions, decreased body temperature,
and, with prolonged periods, death (Van Cauter et al., 2008).
There are several types of sleep deprivation. Sleep deprivation may be
observed as a reduction in sleep time where sleep time does not meet the
needs of the individual, prolonged wakefulness, and sleep disruption related
to a pathophysiological process (e.g., cancer). The extent to which an
individual experiences the effects of sleep deprivation depends on the
physiological and behavioural requirements of the individual (OrezelGryGlewska, 2009). Moreover, the effects of sleep deprivation are cumulative,
meaning a mild reduction in sleep time over a prolonged period may be
detrimental to the individual (Tibbits, 2008).
Sleep deprivation may be experienced by individuals for a variety of
reasons. Causes include illness (e.g., fever, difficulty breathing, or pain),
emotional stress, certain medications, environmental disturbances (e.g.,
noise, unfamiliar surroundings, frequent nursing care), and variability in the
timing of sleep due to shift work and travel. Factors contributing to sleep
deprivation in hospitalized patients are outlined in Box 41-6. Physicians and
nurses are particularly prone to sleep deprivation because of their long work
schedules and rotating shifts (Elliott, McKinley, & Cistulli, 2011; Lei,
Qiongjing, Qiuli, et al., 2009). Hospitalization, especially in Critical Care
Units (CCUs), makes patients particularly vulnerable to periods of sleep
deprivation. Constant environmental stimuli within the CCU, such as strange
noises from equipment, invasive equipment and procedures, the frequent
monitoring and care given by nurses, and continuous light, lead to an
inability to sleep. Numerous studies have confirmed that CCU patients
frequently experience sleep deprivation (Drouot, Cabello, D'Ortho, et al.,
2008; Elliot, et al., 2011).
Box 41-6
Causes of Sleep Deprivation in Hospitalized
Patients
Environmental Factors
Noise
Uncomfortable bed and pillows
Bright lights
Pathophysiological factors
Pain and discomfort
Use of invasive equipment such as intravenous lines, nasogastric tubes
Emotional Factors
Stress, worry
Lack of control
Lack of privacy
Anxiety about procedures and outcomes of investigations
A person's response to sleep deprivation is highly variable. Patients exhibit
a variety of physiological and psychological symptoms (Box 41-7). The
severity of symptoms is often related to the duration of sleep deprivation.
The most effective treatment for sleep deprivation is the elimination or
correction of factors that disrupt the sleep pattern. Nurses play an important
role in identifying individuals' treatable sleep deprivation problems.
Box 41-7
Sleep Deprivation Symptoms
Physiological Symptoms
Ptosis, visual disturbances such as blurred vision
Clumsiness in fine motor skills
Decreased reflexes
Slowed response time
Decreased reasoning and judgement
Decreased auditory and visual alertness
Cardiac arrhythmias
Increased food intake
Decreasing satiety
Weight loss
Psychological Symptoms
Easily distracted
Confusion and disorientation
Forgetfulness
Increased sensitivity to pain
Irritability, withdrawal, apathy
Excessive sleepiness
Poor concentration
Agitation
Hyperactivity
Decreased motivation
Nursing Knowledge Base
Sleep and Rest
When persons are at rest, they usually feel mentally relaxed, free from
anxiety, and physically calm. Rest does not imply inactivity, although rest is
often thought of as the act of settling down in a comfortable chair or lying in
bed. Usually, when individuals are at rest, they are in a state of mental,
physical, and spiritual activity that leaves them feeling refreshed,
rejuvenated, and ready to resume the activities of the day. Individuals have
their own habits for obtaining rest and can adjust to new environments or
conditions that affect their ability to rest. Rest may be obtained from reading
a book, practising a relaxation exercise, listening to music, taking a long walk,
or sitting quietly.
Illness and unfamiliar health care routines can easily affect the usual rest
and sleep patterns of individuals entering a hospital or other health care
facilities. Nurses may frequently care for patients on bed rest, which confines
patients to bed in order to reduce the physical and psychological demands on
their body. Patients may not necessarily feel rested because they may still
have emotional worries that prevent complete relaxation. For example,
concern over physical limitations or a fear of being unable to return to their
usual lifestyle can cause patients to feel stressed and unable to relax. Nurses
must always be aware of a patient's need for rest. Long periods without rest
can lead to illness or to the worsening of an existing illness.
Normal Sleep Requirements and Patterns
Individual requirements for sleep duration and quality vary among
individuals of all age groups. For example, one person may feel adequately
rested after 6 hours of sleep, whereas another person may require 10 hours of
sleep.
Neonates.
During the first few weeks of life, newborns sleep about 16 hours a day,
sleeping almost constantly during the first week. Sleep occurs equally across
the day and night in newborns and is more strongly influenced by hunger
than by light–dark cues. The sleep cycle of newborns is generally 40 to 50
minutes, with waking occurring after one to two sleep cycles. Sleep is
classified as active sleep (REM sleep equivalent) or quiet sleep (NREM sleep
equivalent). A third stage has also been identified and is known as
indeterminate sleep. This sleep stage cannot be defined as either quiet sleep
or active sleep by polysomnography. Newborn sleep cycles begin with active
sleep; newborns spend the majority of their sleep time in this stage of sleep.
The primary function of active sleep is thought to allow for the continued
development of neural pathways (Crabtree & Williams, 2009; Lee-Chiong,
2008).
Infants.
By age 3 months, the amount of time the newborn spends in active sleep
(REM sleep equivalent) diminishes, the required hours for sleep gradually
decrease, and sleep–wake periods develop into a day/night cycle. By 6 months
of age, infants enter sleep through NREM sleep. The ability to sleep during
the night develops by 6 to 9 months of age. At this point, the infant's
sleeping pattern is characterized by a nocturnal sleep period of 10 to 12
hours' duration, and two to three daytime naps, which collectively amount to
12 to 14 hours of total sleep time. Awakening commonly occurs early in the
morning, although awakening during the night is not unusual (Crabtree &
Williams, 2009; Lee-Chiong, 2008).
Toddlers.
By 2 years of age, most children usually require 12 to 14 hours of sleep each
day, which generally includes a nap in the afternoon and, for some, a
morning nap as well. This amount of sleep is needed to re-energize the
toddler and for continued growth and development. Lack of sleep makes a
toddler feel tired and irritable. Awakening during the night is common for
toddlers. A variety of factors may influence night waking, including dreams
and a fear of being separated from their parents. During this period, the
percentage of REM sleep continues to fall (Crabtree & Williams, 2009;
Hockenberry & Wilson, 2014).
Preschoolers.
A preschooler sleeps about 13 hours a night (about 20% of which is REM
sleep). By 5 years of age, the preschooler rarely takes daytime naps, except in
cultures where siestas are the custom (Hockenberry & Wilson, 2014). The
preschooler usually has difficulty relaxing or quieting down after long, active
days and may experience bedtime fears, waking during the night, or
nightmares. Partial wakening, followed by a normal return to sleep, is
frequent (Hockenberry & Wilson, 2014). In the waking period, the child may
exhibit brief episodes of crying, walking aimlessly, unintelligible speech,
sleepwalking, or bedwetting. Numerous factors may influence the sleep
pattern of preschoolers, including day care and preschool schedules, family
routines, and parental expectations as to the amount of sleep required for
this developmental stage (Crabtree & Williams, 2009).
School-Aged Children.
The amount of sleep needed varies during the school-age years. Both gender
and ethnicity may explain the variability of sleep patterns in school-aged
children. A longer sleep cycle has been observed in school-aged girls
compared with their same-aged male counterparts. Caucasian children have
more NREM stage 1 sleep and less NREM stage 2 sleep than African
American children. Most school-aged children sleep between 9 and 10 hours
each night. Epidemiological studies of school-aged children have shown
shorter sleep times are associated with behavioural problems and symptoms
of depression (Paavonen, Porkka-Heiskanen, & Lahikainen, 2009; Seo, Sung,
Lee, et al., 2010).
Adolescents.
The sleep pattern of adolescents is variable across a 7-day week, with shorter
sleep times occurring during the school week. Consecutive nights of shorter
sleep results in “sleep debt,” with adolescents recovering this sleep on
weekends with longer sleep times. The demands of school (e.g., schedules,
assignments, exams, and extracurricular activities), decreased parental
influence, employment, and social media appear to play a significant role in
the sleep patterns of adolescents (National Sleep Foundation, 2009).
Physiological (circadian and homeostatic) processes that regulate sleep and
wakefulness are also thought to influence the sleep habits of adolescents
(Crabtree & Williams, 2009; Lee-Chiong, 2008). This shortened sleep time
often results in EDS. As a result of EDS, adolescents may experience reduced
performance in school, vulnerability to accidents, behaviour and mood
problems, and increased use of alcohol or other substances (Crabtree &
Williams, 2009; Gradisar, Gardner, & Dohnt, 2011).
Young Adults.
Most young adults average 6 to 8.5 hours of sleep per night. Approximately
20% of sleep time is REM sleep, which remains consistent throughout life.
The stresses of a job, family relationships, and social activities frequently
lead to both insomnia and the use of medications to aid sleep. Daytime
sleepiness contributes to an increased number of accidents, decreased
productivity, and interpersonal problems in this age group. Pregnancy
increases the need for sleep and rest. During the third trimester of
pregnancy, women may experience insomnia, periodic limb movements,
restless leg syndrome, and sleep-disordered breathing (Balserak & Lee, 2011).
Middle-aged Adults.
During middle adulthood, the total time spent sleeping at night begins to
decline. The amount of stage 3 sleep begins to fall and continues to fall with
advancing age. Insomnia is particularly common, probably because of the
changes and stresses experienced in middle age. Anxiety, depression, and
certain physical illnesses cause sleep disturbances. Women who have
menopausal symptoms often experience insomnia (Lee & Moe, 2011).
Older Persons.
Aging results in several physiological and psychological changes, and
alterations in sleep patterns frequently occur because of these changes.
Studies suggest that poor sleep quality is a common complaint of older
persons. Approximately 50% of older persons report difficulty sleeping
(Espiritu, 2008; Neikrug & Ancoli-Israel, 2010; Roepke & Ancoli-Israel, 2010).
Aging is associated with changes in sleep architecture, or sleep pattern.
Greater nighttime disturbances (increased awakenings at night), less slowwave or deep sleep, increased frequency of daytime napping, and decreased
total sleep time are changes in sleep architecture that occur with aging (LeeChiong, 2008).
Older women are at particular risk for sleep problems due to hormonal
changes that accompany menopause. In fact, problems sleeping are reported
by approximately 25% to 50% of menopausal women (Roepke & AncoliIsrael, 2010). Hot flashes (episodes of warmth in the face and chest) occurring
at night can cause problems sleeping and may lead to an increase in the
frequency of nighttime awakenings and, hence, less sleep time.
Numerous other factors are also related to the sleep problems reported by
older men and women. These include the presence of co-morbid
physiological conditions (e.g., heart disease) and psychological conditions
(e.g., depression), primary sleep disorders (e.g., insomnia), chronic pain,
nocturia, use of multiple medications, and alterations in circadian rhythm
expressions (Neikrug & Ancoli-Israel, 2010).
Factors Affecting Sleep
Often, several factors alter the quality and quantity of sleep, such as
physiological, psychological, and environmental influences.
Drugs and Substances.
Many older persons take a variety of medications to control or treat chronic
conditions, and these medications can seriously disrupt sleep. Daytime
sleepiness, insomnia, and fatigue often result as a direct effect of commonly
prescribed medications (Box 41-8). These medications may impair waking
function and alter sleep patterns, which can be problematic for individuals
(Cook, 2008a, 2008b; Smith et al., 2008). Antidepressants, antihistamines, and
pain medications can cause daytime sleepiness or fatigue. Beta blockers have
been associated with nightmares and vivid dreams. Diuretics can cause
nocturia, thereby disrupting sleep. Medications prescribed for sleep can also
be problematic as a result of their sedating effects during daytime hours
(Mendelson, 2011).
Box 41-8
Drugs and Their Effect on Sleep and
Wakefulness
Hypnotics
Decrease NREM stage 3 sleep as well as REM sleep
Increase daytime sleepiness
Lead to poor memory and concentration
Depress respirations
May worsen sleep apnea in older persons
Diuretics
Nighttime awakenings caused by nocturia
Antidepressants
Cognitive impairment
Psychomotor impairment
Increase of NREM stage 1 sleep
Suppression of REM sleep
Decrease in total sleep time
Daytime sleepiness
Stimulants
Caffeine
Prevents the onset of sleep
Interrupts sleep during the night
Decreases the time spent in deep sleep
Interferes with REM sleep
Alcohol
Speeds onset of sleep
Reduces REM sleep
Interrupts sleep during the night and makes returning to sleep difficult
Beta-Adrenergic Blockers
Fatigue
Insomnia
Depression
Psychomotor impairment
Nightmares
Vivid dreams
Benzodiazepines
Alter REM sleep
Increase sleep time
Increase daytime sleepiness
Narcotics
Cause somnolence
Decrease amount of time spent in deep sleep stages
Suppress REM sleep
Depress respirations
Cause cognitive impairment
Cause psychomotor impairment
Anticonvulsants
Decrease REM sleep time
May cause daytime drowsiness
May cause insomnia
Cause impaired cognition
Anti-Parkinsonian Drugs
May cause worsening of cognitive function, especially memory
Cause fatigue
Cause somnolence
Lifestyle.
A person's daily routine influences sleep patterns. An individual working a
rotating shift (e.g., 2 weeks of day shifts followed by a week of night shifts)
often has difficulty adjusting to the altered sleep schedule (National Sleep
Foundation, 2017a). For example, the body's internal clock for bedtime is set
at 11 p.m., but the work schedule instead forces sleep at 9 a.m. The individual
is able to sleep only 3 or 4 hours because the body's clock perceives that the
morning is the time to be awake and active. Difficulties with maintaining
alertness during work time result in decreased and even hazardous
performance. After several weeks of working a night shift, a person's
biological clock usually does adjust. Other alterations in routines that disrupt
sleep patterns are performing unaccustomed heavy work, engaging in latenight social activities, and changing the evening mealtime (Balkin, 2011;
Belenky & Akerstedt, 2011).
Usual Sleep Patterns.
In the past century, the amount of sleep obtained nightly has decreased by
more than 20% (National Sleep Foundation, 2017b), which indicates that
many adults are sleep deprived and experience excessive sleepiness during
the day. Sleepiness becomes pathological when it occurs at times when
individuals need to or want to be awake. Individuals who experience
temporary sleep deprivation as a result of an active social evening or a
lengthened work schedule usually feel sleepy the next day. However, they are
usually able to overcome these feelings despite the difficulty they experience
in performing tasks and remaining attentive. Much more serious than
temporary sleep deprivation is a chronic lack of sleep, which causes serious
alterations in the ability to perform daily functions. Sleepiness tends to be
most difficult to overcome during the performance of sedentary (inactive)
tasks. For example, single-vehicle accidents related to a driver falling asleep
at the wheel occur most often between 2 a.m. and 5 a.m., as a result of the
sleepiness that occurs when individuals are awake during what is their
normal period of sleep (Philip, Sagaspe, & Taillard, 2011).
Emotional Stress.
Sleep is frequently disrupted by worry over personal problems or a personal
situation. Emotional stress causes a person to be tense and often leads to
frustration when sleep does not occur. Stress also causes a person to try too
hard to fall asleep, to awaken frequently during the sleep cycle, or to
oversleep. Continued stress can lead to poor sleep habits.
Older patients frequently experience personal losses, such as retirement,
physical impairment, or the death of a loved one, all of which can lead to
emotional stress. Older persons and other individuals who live with
depressive mood problems may experience delays in falling asleep, the
earlier appearance of REM sleep, frequent awakening, increased total bed
time, feelings of having slept poorly, and early awakening (National Sleep
Foundation, 2017a).
Environment.
The physical environment in which a person sleeps can significantly
influence the ability to fall asleep and remain asleep. Good ventilation is
essential for restful sleep. The size, firmness, and position of the bed also
affect the quality of sleep. If a person usually sleeps with another individual,
sleeping alone often causes wakefulness. On the other hand, sleeping with a
restless or snoring bed partner can disrupt sleep.
In hospitals and other inpatient facilities, noise creates a problem for
patients. Noise in hospitals is usually new or strange and often loud, and
patients wake easily. While in the hospital, the sleep of patients is often
fragmented, with patients experiencing increased total wake times, increased
nocturnal awakenings, and decreased REM sleep and total sleep time.
Environment-induced noises (e.g., nursing activities) are sources of increased
sound levels. CCUs are sources for high noise levels as the result of staff
consultations, monitor alarms, and equipment sounds (Elliott, et al., 2011).
The environment is unpleasant for sleeping because of the close proximity of
patients, noise from confused and ill patients, the ringing of alarm systems
and telephones, and disturbances caused by emergencies. Noise contributes
to hearing loss, delays healing, impairs the immune function, and increases
blood pressure, heart rate, and stress (Patel, Chipman, Carlin, et al., 2008).
The level of light in a room affects the ability to fall asleep. Some
individuals prefer a dark room for sleep, whereas others, such as children or
older persons, often prefer soft lighting during sleep. Individuals may also
have trouble sleeping because of the temperature of a room. A room that is
too warm or too cold often causes an individual to become restless.
Exercise and Fatigue.
A person who is moderately fatigued usually achieves restful sleep, especially
when the fatigue is the result of enjoyable work or exercise. Exercising that is
completed at least 3 hours prior to bedtime allows the body enough time to
cool down and maintains a state of fatigue that promotes relaxation
(National Sleep Foundation, 2009). However, excess fatigue resulting from
exhausting or stressful work makes falling asleep difficult. Excess fatigue is a
common problem for grade-school children and adolescents.
Food and Caloric Intake.
Following good eating habits is important for proper sleep. Eating a large,
heavy meal or a spicy meal at night often leads to indigestion that interferes
with sleep. Insomnia can result from caffeine, alcohol, or nicotine consumed
in the evening. Coffee, tea, cola, and chocolate contain caffeine and xanthines
that cause sleeplessness. Individuals who have insomnia can improve their
sleep by drastically reducing or completely avoiding these substances (Reeve
& Bailes, 2010). Some food allergies cause insomnia. In infants, a milk allergy
sometimes causes nighttime waking and crying, or colic.
Both weight loss and weight gain influence sleep patterns (Patel, 2009; Van
Cauter et al., 2008). Weight gain contributes to OSA because of the increased
size of the soft tissue structures in the upper airway (Wellman & White,
2011). Weight loss causes insomnia and decreased amounts of sleep (Patel,
2009). Certain sleep disorders are the result of the semi-starvation diets
popular in a weight-conscious society.
Critical Thinking
Successful critical thinking requires a synthesis of knowledge, including
information gathered from individuals, past experience, critical thinking
qualities, and intellectual and professional standards. Clinical judgements
require nurses to anticipate the required information, analyze the data, and
make decisions regarding patient care. Adapting to the changing needs of a
patient, based on sound decision making, constitutes critical thinking.
During assessment (Figure 41-3), nurses need to consider all elements, to
make appropriate nursing diagnoses.
FIGURE 41-3
Critical thinking model for sleep assessment.
In the case of sleep, nurses integrate knowledge from disciplines such as
nursing, pharmacology, and psychology. Nurses' experience with patients
who have sleep problems, together with exploring research related to sleep,
will aid in their understanding of effective forms of sleep therapies. Nurses
need to use critical thinking qualities, such as perseverance, confidence, and
discipline, to complete a comprehensive assessment and to develop a plan of
care that can successfully manage the sleep problem. The framework for
practice developed by the Canadian Nurses Association (2015) and standards
of practice developed by each provincial and territorial nursing organization
identify the nurse's role in patient care. In addition, evidence-informed
geriatric nursing protocols for best practice, such as those in Excessive
Sleepiness (Chasens, Williams, & Umlauf, 2008), provide specific instructions
for assessing and addressing the needs of older patients with sleep disorders.
Nursing Process
Assessment
Patients' sleep patterns are assessed by using the nursing history to gather
information about factors that usually influence sleep. Because sleep is a
subjective experience, only the patient is able to report whether it is
sufficient and restful. If the patient is satisfied with the quantity and quality
of sleep received, the nurse should consider it normal, and the nursing
history is brief. If, however, a patient reports or suspects a sleep problem, the
nurse needs to conduct a detailed history.
Sleep Assessment
Most individuals are able to provide a reasonably accurate estimate of their
sleep patterns, particularly if any changes have occurred. In the nursing
assessment, focus on understanding the characteristics of the patient's sleep
problem and usual sleep habits so that your nursing care strategies to
promote sleep are individualized. For example, if the nursing history reveals
that a patient always reads before falling asleep, then offer reading material
at bedtime.
Sources for Sleep Assessment.
Usually, patients are the best resource for describing their sleep problems
and how these problems differ from their usual sleep and waking patterns.
The patient often knows the cause of sleep problems, such as a noisy
environment or worry over a relationship. In addition, bed partners are able
to provide information on the patient's sleep patterns that assists in
obtaining insight regarding the nature of certain sleep disorders. For
example, partners of patients with sleep apnea often complain that the
patient's snoring disturbs their sleep. Often the partners must sleep in a
different bed or move to another room to obtain adequate sleep. Ask bed
partners whether patients have pauses of breathing during sleep and how
frequently these pauses occur. Some partners mention becoming fearful
when patients stop breathing during sleep.
When caring for children, seek information about sleep patterns from the
parents, who are usually a reliable source of information about their child's
trouble with sleeping.
An infant's difficulty in falling asleep or frequent awakenings during the
night are often the result of hunger, excessive warmth, or separation anxiety.
Parents of infants need to keep a 24-hour diary of their infant's waking and
sleeping behaviour for several days to aid in determining the cause of the
problem. Ask the parents to describe the infant's eating pattern and sleeping
environment, both of which can influence sleeping behaviour. Older children
often are able to verbalize the fears or worries that inhibit their ability to fall
asleep. If children frequently awaken in the middle of bad dreams, parents
may be able to identify the problem, although they may not be able to
understand the meanings of the dreams. Ask parents to describe the typical
behaviour patterns that foster or impair sleep. For example, excessive
stimulation from active play or from visiting friends will predictably impair
sleep. In the case of a child who experiences chronic sleep problems, ask the
parents to describe provoking factors, the duration of the problem, its
progression, and the child's responses.
Tools for Sleep Assessment.
Although subjective reports of sleep are reliable and valid measures of sleep,
some people may be inclined to exaggerate or minimize their sleeping
patterns. One effective, brief method for assessing sleep quality is the use of
a visual analogue scale (Chervin, 2011; Cohen, 2004). Draw a straight
horizontal line 100 mm long. At the opposite ends of the line, print two
opposing statements, such as “best night's sleep” and “worst night's sleep.”
Ask patients to mark a point on the horizontal line that corresponds to their
perception of the previous night's sleep. Measure the distance of the mark
along the line in millimetres; this number is a numerical value for
satisfaction with sleep. Use the scale repeatedly to show change over time.
Such a scale is useful to assess an individual's changes in sleep pattern over
time.
Another brief subjective method to assess sleep is a numeric scale with a 0
to 10 sleep rating (Chervin, 2011; Cohen, 2004). Instruct patients to first rate
their sleep quantity, then their quality of sleep on a scale of 1 to 10, with 0
being the worst sleep and 10 being the best sleep.
Sleep History
When a patient reports having received adequate sleep, a sleep history is
usually brief. The information needed for nurses to plan care conducive to
sleep includes the following: the usual bedtime, bedtime rituals, the
preferred environment for sleeping, and the time the patient usually rises.
When nurses suspect a sleep problem, they should explore the quality and
characteristics of sleep in greater depth by asking patients to describe the
nature of their sleep, including recent changes in their sleep pattern, sleep
symptoms experienced during waking hours, use of sleep medications and
other prescribed or over-the-counter medications, herbal products, diet,
intake of substances such as caffeine or alcohol that influence sleep, and
recent life events that may have affected the patient's mental well-being.
Description of Sleeping Problems.
When a patient reports a sleep problem, the nurse needs to conduct a more
detailed history. A detailed assessment ensures that the appropriate
therapeutic care is provided. Open-ended questions help a patient to
describe the problem more fully. After the patient provides a general
description of the problem, the nurse can ask some focused questions, which
will usually reveal specific characteristics that are useful in planning
therapies. The nurse needs to understand the nature of the sleep problem, its
signs and symptoms, its onset and duration, its severity, any predisposing
factors or causes, and the overall effect on the patient. The nurse should ask
specific questions related to the sleep problem (Box 41-9). Proper questioning
helps to determine the type of sleep disturbance and the nature of the
problem. Box 41-10 gives examples of additional questions for the nurse to
ask the patient when specific sleep disorders are suspected. The questions
assist in selecting specific sleep therapies and the best time for
implementation.
Box 41-9
Nursing Assessment Questions
Nature of the Problem
What type of problem are you having with your sleep?
Why do you think your sleep is inadequate?
Describe for me a recent typical night's sleep. How is this sleep different
from what you are accustomed to?
Signs and Symptoms
Do you have difficulty falling asleep, staying asleep, or waking up?
Have you been told that you snore loudly?
Have you been told you stop breathing or gasp for breath during sleep?
Do you feel drowsy or fall asleep while reading, when watching
television, while driving, or when participating in other daily
activities?
Do you feel excessively sleepy or irritable?
Do you have trouble concentrating during waking hours?
Do you have headaches when awakening?
Does your child awaken from nightmares?
Onset and Duration
When did you notice the problem?
How long has this problem lasted?
Severity
How long does it take you to fall asleep?
How often during the week do you have trouble falling asleep?
How many hours of sleep a night did you get this week?
How does this amount of sleep compare to what is usual for you?
What do you do when you awaken during the night or when you awaken
too early in the morning?
Predisposing Factors
What do you do just before you go to bed?
Have you recently had any changes at work or at home?
Describe your mood. Have you noticed any changes in your mood
recently?
What recreational drugs do you take on a regular basis?
Are you taking any new prescription or over-the-counter medications?
Do you eat food (spicy or greasy foods) or drink substances (alcohol or
caffeinated beverages) that interfere with your sleep?
Do you have a physical illness that interferes with your sleep?
Does anyone in your family have a history of sleep problems?
Effect on the Patient
How has the loss of sleep affected you?
Box 41-10
Questions to Ask to Assess for Specific Sleep
Disorders
Insomnia
Do you have difficulty falling asleep?
After you fall asleep, do you have difficulty staying asleep? How many
times during a night's sleep do you awaken?
When you wake up in the morning, do you feel rested? What time do
you wake up in the morning? What causes you to awaken early?
What do you do to prepare for sleep? What do you do to improve your
sleep?
What do you think about as you try to fall asleep?
When did you notice you had problems sleeping?
How often do you have trouble sleeping?
Do you feel excessively tired or sleepy during the day?
Do you take naps during the daytime?
Do you have any problems with performing tasks (i.e., work-related or
driving) during the daytime?
Sleep Apnea
Do you snore loudly? Does anyone else in your family snore loudly?
Has anyone (e.g., spouse, bed partner, roommate) ever told you that you
stop breathing for short periods during your sleep?
Do you experience headaches after awakening?
Do you have difficulty staying awake during the day?
Narcolepsy
Do you sometimes fall asleep unexpectedly? (Friends or relatives may
report any occurrences.)
Do you feel excessively tired or sleepy during the day?
Do you have trouble concentrating?
Have you ever had an episode of losing muscle control or falling to the
floor after a laughing episode or when angry?
Have you ever had the feeling of being unable to move or talk just
before falling asleep or upon awakening?
Do you have vivid dreams when going to sleep or waking up?
As an adjunct to the sleep history, the patient and the patient's bed partner
can keep a sleep–wake diary for 1 to 4 weeks (Lee-Chiong, 2008). The patient
completes the sleep–wake diary daily to provide information on day-to-day
variations in sleep–wake patterns over extended periods. Entries in the diary
can include 24-hour information about various waking and sleeping health
behaviours, including evening and bedtime routines, the time the patient
goes to bed, the amount of time it took for the patient to fall asleep, the
number of awakenings during the night, total sleep time, sleep quality (did
they feel rested in the morning), the time and length of daytime napping,
mealtimes, type and amount of alcohol and caffeine consumed, current
medications, and daytime activities. A partner helps to record the estimated
times the patient falls asleep or awakens. Although the sleep diary can
provide useful information, the patient needs to be motivated to participate
in recording the entries.
Usual Sleep Pattern.
What constitutes “normal sleep” is difficult to define because individuals
vary in their perception of the adequate quantity and quality of sleep. It is the
responsibility of all health care providers to inquire about sleep quality of all
patients. Patients need to describe their usual sleep pattern to determine the
significance of the changes caused by a sleep disorder. The following
questions can be asked to determine a patient's sleep pattern:
1. What time do you usually go to bed each night?
2. What time do you usually fall asleep? Do you do anything special to
help you fall asleep?
3. How many times do you awaken during the night? Why?
4. What time do you typically wake in the morning?
5. What is the average number of hours you sleep each night?
The patient data are then compared with the predominant sleep pattern
for other patients of the same age. On the basis of this comparison, the nurse
can begin to assess for identifiable patterns, which may indicate a specific
sleep disturbance, such as insomnia.
Patients with sleep problems frequently show patterns that differ
drastically from their usual sleep pattern, or sometimes the change is
relatively minor. Hospitalized patients usually need or want more sleep as a
result of their illness; however, some patients require less sleep because they
are less active. Some patients who are ill think that they need to try to sleep
more than their usual amount of sleep, a perception that eventually makes
sleeping difficult.
Physical and Psychological Illness.
It is important to determine whether the patient has any pre-existing health
problems that interfere with sleep. Poor sleep quality has been associated
with numerous physiological and psychological illnesses. Chronic diseases,
such as chronic obstructive pulmonary disease, and painful disorders, such
as arthritis, interfere with sleep. This may occur because of the conditions
themselves or because of medications taken to treat them. Several symptoms
associated with these conditions, such as shortness of breath, pain, and
nocturia, can potentially disrupt sleep. Psychiatric disorders can also
interfere with sleep. For example, insomnia is common in individuals with
schizophrenia, a chronic psychiatric disorder.
Insomnia is also common among individuals with depression. Anxiety
disorders have also been associated with poor sleep (Ramsawh, Stein, &
Mellman, 2011). Hence, it is very important to assess patients' sleep pattern,
medical and social history (e.g., alcohol, tobacco, and caffeine consumption),
and medication usage, including a description of over-the-counter and
prescribed drugs. The social history can provide useful information, such as a
situational crisis that may be interfering with sleep. If a patient takes
medications to aid sleep, the nurse should gather information about the type
and amount of medication that the patient uses, and assess the effectiveness
of such medications and their effects on daytime function (Lee-Chiong, 2008).
Current Life Events.
During the assessment, the nurse needs to ask whether the patient is
experiencing any changes in lifestyle that could disrupt sleep. A person's
occupation often offers a clue to the nature of the sleep problem (Drake &
Wright, 2011). Changes in job responsibilities, rotating shifts, or long hours
contribute to a sleep disturbance. The nurse can question the patient about
social activities, recent travel, or mealtime schedules to help clarify the sleep
assessment.
Bedtime Routines.
Patients should be asked what they do to prepare for sleep. For example, the
patient may drink a glass of milk, take a sleeping pill, eat a snack, or watch
television. The nurse should note the habits that are beneficial compared
with those that disturb sleep. For example, watching television may promote
sleep for one person, whereas watching TV may stimulate another person to
stay awake. Sometimes pointing out that a particular habit is interfering with
sleep helps patients to find ways to change or eliminate that habit.
Special attention must be paid to a child's bedtime rituals. Parents need to
report whether it is necessary, for example, to read the child a bedtime story,
rock the child to sleep, or engage in quiet play. Some young children need a
special blanket or stuffed animal when going to sleep.
Bedroom Environment.
During the assessment, the nurse should ask the patient to describe his or
her preferred bedroom conditions. These preferences may be the lighting in
the room, music or television in the background, or the need to have the
bedroom door open or closed. Some children require the company of a
parent to fall asleep. In a health care environment, environmental
distractions often interfere with sleep, such as a roommate's television, an
electronic monitor in the hallway, a noisy nurses' station, or another patient
who cries out at night. It is important to identify strategies that the nurse or
the patient can use to reduce the effects of the distractions or to control the
environment (National Sleep Foundation 2009).
Behaviours of Sleep Deprivation.
Some patients are unaware of how their sleep problems affect their
behaviour. The patient should be observed for behaviours such as irritability,
forgetfulness, confusion, lethargy, frequent yawning, and slurred speech. If
sleep deprivation has lasted a long time, psychotic behaviour, such as
delusions and paranoia, sometimes develop. For example, a patient may
report seeing strange objects or colours in the room, or the patient may act
afraid when a nurse enters the room.
Patient Expectations
When a patient experiences a poor night's sleep, a vicious cycle of
anticipatory anxiety may begin. The patient may fear that sleep will again be
disturbed and will try harder and harder to sleep (Morin, 2011). When
assessing a patient's sleep needs, nurses need to use a skilled, individualized,
and caring approach, always asking patients what they expect regarding their
sleep, the interventions they currently use, and the success of these
interventions. Patients should also be asked about what other interventions
they may prefer, and how they could be implemented. It is important to
understand the patients' expectations regarding their sleep pattern. When
patients ask for assistance because of sleep disturbances, they typically
expect a nurse to respond promptly to assist them in improving their
quantity and quality of sleep.
Nursing Diagnosis
Nurses review their assessment to identify clusters of data that characterize a
sleep pattern disturbance. When a sleep pattern disturbance is identified, it
is important to be specific, as numerous factors may be the cause of these
disturbances. By specifying the nature of a sleep disturbance and related
factors, the nurse is able to develop with the patient interventions particular
to the patient's situation. For example, interventions developed for sleep
apnea will differ from those interventions developed to address sleep pattern
disturbances related to psychological distress (e.g., anxiety, stress). Box 41-11
demonstrates how to use nursing assessment activities to identify and cluster
defining characteristics to make an accurate nursing diagnosis related to
sleep pattern disturbances.
Box 41-11
Nursing Diagnostic Process
Insomnia
Assessment Activities
Ask the patient to desc ribe his or her sleep pattern
(past and present), the nature of the sleep problem,
duration, etc .
Related Fac tors
Pathophysiologic al
Treatment
S ituational (personal, lifestyle)
Observe the patient's appearanc e.
Observe the patient's behaviour, and ask the
patient's spouse whether the patient is
experienc ing behavioural c hanges.
Determine whether the patient has experienc ed
rec ent lifestyle c hanges.
Defining Characteristics
The patient reports either a history or no history of sleep problems.
The patient reports diffic ulty in falling asleep, staying asleep, and awakening several
times during the night.
Onc e awakened, the patient reports diffic ulty returning to sleep.
The patient reports the need to nap during the day bec ause of daytime sleepiness.
With the use of a visual analogue sc ale, the patient reports feeling fatigued following
a night's sleep.
The patient reports no regular bedtime routine and frequently remains in bed in the
morning to “c atc h up” on the sleep lost the previous night.
The patient reports frequent awakenings during the night, for example, due to problems
breathing.
The patient reports daytime sleepiness due to medic ation.
The patient reports diffic ulty falling asleep and staying asleep bec ause of a personal
c risis. For example, the loss of a patient's job; the patient reports problems sleeping
related to a rec ent diagnosis of c anc er.
The patient appears pale and has dark c irc les under the eyes.
The patient is irritable and yawns frequently. The patient reports not feeling wellrested and having poor c onc entration.
The spouse desc ribes times when the patient was lethargic and distrac ted.
The patient and the patient's spouse report napping during the day.
The spouse reports that the patient rec ently lost his or her job and is c onc erned
about finding a new position.
The patient reports being under tremendous stress bec ause of a family member's
illness.
Many factors can contribute to disturbed sleep patterns. It is important
that the assessment identifies the probable cause of or factors related to the
sleep disturbance, such as a noisy environment, a situational crisis, or a high
intake of caffeinated beverages in the evening. These causes become the
focus of interventions for minimizing or eliminating the problem. For
example, if a patient is experiencing insomnia as the result of a noisy health
care environment, the nurse can use strategies to promote sleep, such as
controlling the noise of hospital equipment, reducing interruptions, or
keeping doors closed. If the insomnia is related to worry over a threatened
marital separation, the nurse can introduce coping strategies and collaborate
with other health care providers regarding support groups or other services
available to support the patient (Carpenito, 2016; Lei et al., 2009). If the nurse
incorrectly identifies the probable cause or related factors, the patient will
not benefit from the strategies to minimize or eliminate the presumed
sources of disruption.
Sleep problems affect patients in other ways. For example, the nurse may
find that a patient with sleep apnea is in conflict with a spouse who is tired of
and frustrated over the patient's snoring. In addition, the spouse may be
concerned that the patient is breathing improperly and thus is in danger. The
nursing diagnosis of compromised family coping indicates that the nurse needs
to provide support to both the patient and the patient's spouse so that they
both understand sleep apnea and obtain the medical treatment needed. The
following are examples of nursing diagnoses for patients with sleep
problems:
• Anxiety
• Ineffective breathing pattern
• Acute confusion
• Compromised family coping
• Ineffective coping
• Ineffective health maintenance
• Fatigue
• Ineffective protection
• Insomnia
• Disturbed sensory perception
• Sleep deprivation
Planning
Goals and Outcomes.
During the planning of a strategy of care, nurses again synthesize
information from multiple resources to develop an individualized plan of
care (Figure 41-4 and Box 41-12). Nurses must consider standards of nursing
practice and clinical practice guidelines when developing a plan of care.
Clinical practice guidelines are evidence-informed recommendations
developed by expert practitioners and arise from a synthesis of the best
evidence of a particular topic (Morin, 2011).
FIGURE 41-4
Critical thinking model for sleep planning.
Box 41-12
Nursing Care Plan
Disturbed Sleep Pattern
Assessment
Andree Smith is a 36-year-old lawyer who presents to the health care centre
where you are working. Andree, accompanied by her husband, has come to
the clinic because she is having problems sleeping. Andree and her husband
have three children, two in school and one in preschool. As you begin your
assessment, Andree suddenly bursts into tears and tells you her mother has
been recently diagnosed with breast cancer. Andree's assessment includes a
thorough sleep history and a discussion on how this sleep problem is
affecting her life. A physical examination is also conducted.
Assessment
Activities
S leep pattern (present and
past)
Findings and Defining Characteristics*
Andree reports diffic ulty falling asleep at night and awakening several times during the night. Andree states,
“I a m so tired; I ha ve no energy to do a nything. I a m irrita ble a ll of the time a nd I a m ha ving trouble concentra ting
a t work.”
Andree also reports that she has less patienc e with her c hildren.
Relational Fac tors
P athophysiological
Assess whether
Andree reports no personal or family history of sleep problems.
Andree has a history, a
Andree reports she has no history of any medic al or psyc hiatric disorders.
family history, or both
of sleep problems.
Assess whether
Andree has a history
of medic al or
psyc hologic al
disorders.
Treatment
Assess Andree's use of
Andree reports she rec ently started taking melatonin at bedtime to help her sleep. Aside from melatonin,
medic ations (both overAndree is on no other medic ation.
the-c ounter and
presc ription), inc luding
names, dosage, and
frequenc y.
Situational (personal, home, community)
Ask Andree whether she
Andree reports being highly anxious and states, “Everything bothers me.” S he also reports that she has stopped her
has had any rec ent
routine of walking 2–4 km daily bec ause she has no energy.
c hanges in her life.
Situational (personal, lifestyle)
Ask Andree to desc ribe
Andree reports she is going to bed between midnight and 1 a.m., whic h is 2 hours later than her usual bedtime.
her bedtime routine.
It ta kes her a n hour to fa ll a sleep. In the past, she rec eived 7–8 hours of sleep eac h night, but now it is closer to 5–6
hours. S he drinks two to three c ups of c offee after dinner while surfing the Internet for information on her
mother's c ondition. Andree also reports drinking a glass of wine before bedtime to help her relax bec ause she
has been having trouble falling asleep.
Observe Andree's
Andree appears pa le a nd tired . S he has da rk circles under her eyes and is slow to respond to questions asked. S he
appearanc e.
ya wns frequently during the interview and appears restless.
Assess Andree for
signs of sleep
problems.
Observe Andree's
behaviour.
With Andree's permission, Andree's husband reports that she is irrita ble with the c hildren, is forgetful, and c ries easily.
ask her husband whether
Andree has exhibited any
behavioural c hanges.
*
Defining characteristics are in italic type.
Nursing Diagnosis:
Insomnia related to psychological stress from mother's recent cancer
diagnosis.
Planning
Goals (Nursing Outcomes Classification)†
Expected Outcomes
S leep
Andree will ac hieve an improved sense of restorative sleep
within 2 weeks.
Andree will report adherenc e to a regular bedtime routine within
1 week.
Andree will ac hieve a more normal sleep pattern within 2
weeks.
Within 2 weeks, Andree will report sleeping 7 hours nightly.
Andree will report waking less during the night and feeling rested
within 2 weeks.
Within 2 weeks, Andree will fall asleep within 30 minutes of going to
bed.
†
Outcomes from Carpenito L. J. (Ed.). (2016). Nursing diagnosis: Application to clinical practice (15th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Interventions
Interventions (Nursing Interventions
Classification)‡
S leep Enhanc ement
Enc ourage Andree to establish a bedtime routine and a regular
sleep pattern.
Instruc t Andree to limit her c onsumption of c affeine and
alc ohol before bedtime.
Assist Andree in identifying ways to eliminate stressful
c onc erns about work before bedtime (e.g., taking time before
ac tual sleep time to read a light novel).
Adjust the sleep environment: have Andree c ontrol the noise,
temperature, and light in the bedroom.
Exerc ise Promotion
Enc ourage Andree to begin walking routinely during the day,
but not 2 to 3 hours before bedtime.
S imple Relaxation Therapy
Instruc t Andree on how to perform musc le relaxation before
bedtime.
Rationale
Maintaining a c onsistent sc hedule helps induc e sleep (Milner & Belic ki,
2010).
Caffeine is a stimulant that may c ause diffic ulty in falling asleep. Alc ohol has
the effec t of lightening and fragmenting sleep (Milner & Belic ki, 2010).
Exc ess worry and intense ac tivities before bedtime may stimulate the patient
and prevent sleep (National S leep Foundation, 2009).
Develop an environment c onduc ive to sleep (Morin, 2011).
Regular exerc ise inc reases ac tivity levels and improves sleep quality. When
exerc ise oc c urs just before bedtime, it c an ac t as a stimulant that prevents
sleep (National S leep Foundation, 2009).
Relaxation therapy c an help to reduc e anxiety, whic h interferes with sleep
(Lee-Chiong, 2008).
‡
Intervention classification labels from Carpenito, L. J. (Ed.). (2016). Nursing diagnosis: Application to
clinical practice (15th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Evaluation
Nursing Actions
Patient Response and Finding
Ask Andree whether she is
able to fall asleep and stay
asleep.
Ask Andree to desc ribe
her waking behaviours at
work and home during the
day.
Observe Andree's waking
nonverbal expressions and
behaviour.
Andree responds, “It usually takes me 15 to 20 minutes to fall asleep, and I
woke up onc e at night twic e last week.”
Andree responds that she is able to c onc entrate on her work more. S he
reports she is less irritable with her c hildren. S he has restarted her walking
routine.
Achievement of
Outcome
Andree reports she falls asleep
within 30 minutes and wakes up
less frequently during the night.
Andree reports feeling more
rested.
Andree sits in the c hair without shifting position. S he ac tively engages in
Andree says she sleeps for an
c onversation with you. S he does not yawn during the interview. S he is not as average of 7 hours a night.
pale as she was previously and the c irc les under her eyes are almost gone.
As the nurse plans care for the patient with sleep problems, the nurse can
create a concept map to help develop a holistic approach to patient-centred
care (Figure 41-5). The concept map is created after identifying the relevant
nursing diagnoses from the assessment database. In this example, the
nursing diagnoses are linked to the patient's anxiety related to her mother's
recent cancer diagnosis.
FIGURE 41-5
Concept map for a patient who has depression following the news of her mother's
recent cancer diagnosis.
The concept map shows the relationships between the nursing diagnoses
anxiety, disturbed sleep pattern, and impaired social interaction. This approach to
planning care can assist the nurse in recognizing relationships between
planned interventions. For this patient, interventions and successful
outcomes for one nursing diagnosis affect the resolution of another nursing
diagnosis.
When developing goals and outcomes, the nurse and the patient need to
collaborate. As a result, the nurse will be more likely to set realistic goals and
measurable outcomes. An effective plan includes outcomes that focus on the
goal of improving the quantity and quality of sleep in the home over a
realistic period of time. Family members are often very helpful in
contributing to the plan. A sleep promotion plan frequently requires many
weeks to accomplish. The following is an example of a goal with patient
outcomes:
Goal: The patient will control the environmental sources that disrupt
sleep within 1 month.
Outcomes:
• The patient will identify factors in the immediate home
environment that disrupt sleep within 2 weeks.
• The patient will report having a discussion with family
members about environmental barriers to sleep within 2
weeks.
• The patient will report changes made in the bedroom to
promote sleep within 4 weeks.
• The patient will report having fewer than two awakenings per
night within 4 weeks.
Setting Priorities.
The nurse needs to collaborate with the patient to establish the priority
outcomes and interventions. It is important to remember that sleep
problems are frequently the result of other health problems; management of
these problems and their associated symptoms is the nurse's first priority.
Once the symptoms are properly managed, the nurse can then focus on sleep
therapies.
Collaborative Care.
In collaboration with the patient and the patient's significant others, the
nurse should ensure that any planned interventions, such as a change in the
sleep schedule or changes to the bedroom environment, are realistic and
achievable. In a health care setting, the treatments or routines should be
planned so that the patient is able to rest. For example, in the Critical Care
Unit, available electronic monitors can be used to track trends in vital signs
without awakening the patient each hour. Other staff members should be
informed of the plan of care so they can cluster activities at certain times to
reduce the number of awakenings. In an extended care facility, the plan of
care involves better planning of rest periods around the activities of the other
residents. Often, patients' roommates have very different schedules and this
must be considered.
The nature of the sleep disturbance determines whether referrals are
necessary to additional health care providers. For example, if a sleep problem
is related to a situational crisis or an emotional problem, the nurse may refer
the patient to a psychiatric clinical nurse specialist or a clinical psychologist
for counselling. When a patient has chronic insomnia, a referral to a sleep
centre is beneficial. If the patient needs a referral for continued care in the
community, the nurse should offer information about the sleep problem to
the home care nurse. The success of sleep therapy depends on an approach
that fits both the patient's lifestyle and the nature of the sleep disorder.
Implementation
Nursing interventions that are designed to improve the quality of a person's
rest and sleep focus largely on health promotion. Patients need adequate
sleep and rest to maintain active and productive lives. During times of
illness, rest and sleep promotion are important for recovery. Nursing care
provided in acute care, restorative care, or continuing care settings differs
from nursing care in the home setting. The primary differences are in the
environment and the nurse's ability to support normal rest and sleep habits.
The patient's age also influences the types of therapies that are most
effective. Box 41-13 provides principles for promoting sleep in older patients.
Box 41-13
Focus on Older Persons
Promoting Sleep
Sleep–Wake Pattern
• Maintain a regular bedtime and wake-up schedule, even on weekends or
vacations (Lee-Chiong, 2008).
• Eliminate naps unless they are a routine part of the schedule.
• If naps are used, limit them to 20 minutes or less, twice a day, and avoid
napping in the late afternoon or early evening.
• Go to bed when sleepy.
• Use a warm bath and relaxation techniques (reading, music, meditation,
guided visual imagery) to promote sleep (Lee-Chiong, 2008).
• If unable to sleep within 15 to 30 minutes, get out of bed.
• Avoid work-related activities before bedtime (Milner & Belicki, 2010).
Environment
• Sleep where you sleep best.
• Keep noise to a minimum; use soft music to mask noise if necessary.
• Use a night light and keep the path to the bathroom free of obstacles.
• Set the room temperature to your preference; use socks to promote
warmth.
• For “clock watchers” remove the clock from the bedroom
• Listen to relaxing music (Morin, 2011).
Medications
• Use sedatives and hypnotics as a last resort, and then only for the short
term if absolutely necessary (Mendelson, 2011).
• Adjust medications being taken for other conditions, and assess for drug
interactions that may cause insomnia or excessive daytime sleepiness
(EDS).
Diet
• Limit the intake of alcohol, caffeine, and nicotine in the late afternoon
and evening (Lee-Chiong, 2008; Milner & Belicki, 2010).
• Consume carbohydrates or milk as a light snack before bedtime (Milner
& Belicki, 2010).
• Decrease the intake of fluids 2 to 4 hours before sleep.
Physiological and Illness Factors
• Elevate the head of the bed and provide extra pillows as preferred.
• Use analgesics 30 minutes before bed to ease aches and pains.
• Use therapeutics to control symptoms of chronic conditions as
prescribed (Lavigne et al., 2011).
Health Promotion
Nurses can help patients in community health and home settings to develop
behaviours conducive to rest and relaxation. To develop good sleep habits at
home, patients and their bed partners need to learn the techniques that
promote sleep and the conditions that interfere with sleep (Milner & Belicki,
2010) (Box 41-14). Parents should also learn how to promote good sleep habits
for their children. Patients benefit most from instructions that are formed on
the basis of information about their homes and lifestyles, such as the types of
activities that promote sleep for a shift worker or ways to make the home
environment more conducive to sleep. Patients will be more likely to apply
information that is useful and relevant to their needs.
Box 41-14
Sleep Hygiene Habits
Objective
• Patient will follow proper sleep hygiene habits at home.
Teaching Strategies
• Instruct the patient to try to exercise daily, preferably in the morning or
afternoon, and to avoid vigorous exercise within 2 hours of bedtime.
• Caution the patient against sleeping long hours during weekends or
holidays, to prevent disturbance of the normal sleep–wake cycle.
• Explain that the patient should not use the bedroom for intensive
studying, snacking, TV watching, or other nonsleep activity, besides sex.
• Encourage the patient to try to avoid worrisome thinking when going to
bed and to practise relaxation exercises.
• If the patient does not fall asleep within 30 minutes of going to bed,
advise the patient to get out of bed and do some quiet activity until the
patient feels sleepy enough to go back to bed.
• Advise the patient to limit consumption of caffeine and alcohol.
• Ask the patient to examine the sleeping environment. If noise or light is
an issue, suggest the use of earplugs or eyeshades.
• Instruct the patient to avoid eating heavy meals 3 hours before bedtime;
the patient may have a light snack before bedtime.
Evaluation
• Ask the patient to complete a sleep–wake and activity diary for 1 week,
and compare it with the previous week's diary.
• Ask the patient to periodically complete a visual analogue or sleep rating
scale to record perceptions of quality of sleep.
Environmental Controls.
All patients require a sleeping environment with a comfortable room
temperature, proper ventilation, minimal noise, a comfortable bed, and
proper lighting (Morin, 2011; National Sleep Foundation, 2009). Children and
adults vary in their preferences for a comfortable room temperature. Parents
should be instructed to position cribs away from open windows or drafts and
to cover the infant with a light, warm blanket. Older persons often require
extra blankets or covers.
Distracting noise should be eliminated so that the bedroom is as quiet as
possible. In the home, the television, telephone, or the intermittent chiming
of a clock can disrupt a patient's sleep. The family becomes an important part
of the approach to reduce noise in the home, especially if the home is shared
with several family members, all with different bedtime schedules. However,
some patients are accustomed to sleeping with familiar inside noises, such as
the hum of a fan. Commercial products that play soothing sounds, such as
recordings of ocean waves or rainfall, can help to create a soothing
environment for sleep.
The bed and mattress need to provide support and comfortable firmness.
Bed boards can be placed under mattresses to provide additional support.
Sometimes extra pillows can help to position a person comfortably in bed.
For some patients, the position of the bed in the room also makes a
difference.
Patients vary in their preference for the amount of light they can tolerate in
the bedroom. Infants and older persons sleep best in softly lit rooms. Light
should not shine directly on their eyes. Small table lamps can be used to
prevent total darkness. For older persons, proper lighting reduces the chance
of confusion and prevents falls while walking to the bathroom. Heavy shades,
drapes, or slatted blinds are helpful if streetlights shine through windows, or
if patients nap during the day.
Promoting Bedtime Routines.
Bedtime routines help to relax patients in preparation for sleep (Milner &
Belicki, 2010). Individuals should go to bed when they feel fatigued or sleepy.
Going to bed while fully awake and thinking about other things often leads
to insomnia and interferes with the perception of the bed as a stimulus for
sleep. Newborns and infants sleep through so much of the day that a specific
routine is hardly necessary. However, quiet activities, such as holding them
snugly in blankets, singing or talking softly, and gentle rocking, help infants
to fall asleep.
Parents need to reinforce short, predictable routines associated with
preparing for bedtime (Milner & Belicki, 2010). A bedtime routine that is
used consistently (e.g., the same hour for bedtime, eating a snack, or
pursuing a quiet activity) helps young children to avoid delaying sleep.
Bedtime routines can include quiet activities such as reading stories,
colouring, allowing children to sit in a parent's lap while listening to music,
or listening to a prayer.
Adults need to avoid excessive mental stimulation just before bedtime.
Reading a light novel, watching an enjoyable television program, or listening
to music can help a person to relax. Relaxation exercises, such as slow, deep
breathing for 1 or 2 minutes, can help to relieve tension and prepare the body
for rest (see Chapter 36). Guided imagery and praying also promote sleep for
some patients.
At home, patients should be discouraged from trying to finish office work
or to resolve family problems before bedtime. The bedroom is not a place to
work, and patients need to always associate the bedroom with sleep. Working
toward a consistent time for sleeping and wakening helps most patients to
gain a healthy sleep pattern and to strengthen the rhythm of their sleep–
wake cycle.
Promoting Safety.
For any patient prone to confusion or falls, safety is critical. A small night
light can assist the patient in orienting to the room environment before
going to the bathroom. Beds set lower to the floor reduce the chance of a
person falling when first standing. Patients should be instructed to remove
clutter and small rugs from the path used to walk from the bed to the
bathroom. If a patient needs assistance in ambulating from a bed to the
bathroom, a small bell can be placed at the bedside to call family members.
Sleepwalkers are unaware of their surroundings and are slow to react, which
increases their risk of falls. Sleepwalkers should not be startled but instead
gently awakened and led back to bed.
Infants' beds need to be safe. To reduce the chance of suffocation, pillows,
stuffed toys, or the ends of loose blankets should not be placed in cribs.
Loose-fitting plastic mattress covers are dangerous because infants can pull
them over their face and suffocate. Parents should place infants on their back
to prevent sudden infant death syndrome (SIDS) (National Sleep
Foundation, 2009).
Promoting Comfort.
People fall asleep only after feeling comfortable and relaxed (Carpenito,
2016). Minor irritants often keep patients awake. Soft cotton nightclothes
keep infants or small children warm and comfortable. Patients should be
instructed to wear loose-fitting nightwear. An extra blanket is sometimes all
that is necessary to prevent a person from feeling chilled and thus being
unable to fall asleep. Patients need to void before retiring so they are not
kept awake by a full bladder.
Establishing Periods of Rest and Sleep.
Patients living at home should be encouraged to stay physically active during
the day so that they will be more likely to sleep at night. Increasing daytime
activity reduces the likelihood of having problems with falling asleep. In the
home setting, nurses frequently care for patients with chronic debilitating
disease. The nursing care plan includes having patients set aside afternoons
for rest to promote optimal health. To provide uninterrupted rest periods,
nurses should adjust patients' medication schedules, instruct patients to void
before rest periods, and suggest turning off cell phones, electronic tablets,
and other electronic devices.
Stress Reduction.
The inability to sleep because of emotional stress can make a person feel
irritable and tense. When patients feel emotionally upset, they should try not
to force sleep. Otherwise, insomnia can develop, and bedtime is soon
associated with the inability to relax. A patient who has difficulty falling
asleep should be encouraged to get up and pursue a relaxing activity, such as
reading, rather than staying in bed and thinking about sleep.
Preschoolers have bedtime fears (e.g., fear of the dark or fear of strange
noises) and frequently awaken during the night or have nightmares. When a
child experiences a nightmare, the parent should enter the child's room
immediately and talk to the child briefly about fears to provide a coolingdown period. One approach is to comfort children and leave them in their
own beds so that their fears are not used as an excuse to delay bedtime.
Keeping a light turned on in the room will also help some children. Cultural
tradition can cause families to approach sleep practices differently (Box 4115).
Box 41-15
Cultural Aspects of Care
Co-Sleeping
Practices and patterns of sleep and rest vary among cultures. Culture and
biology influence the development of sleep problems in children. Sleep
patterns, bedtime routines, sleep aids, and sleep arrangements are a
component of the cultural practices related to the use of space and the
perception of comfortable distances for interactions with others. Sleep
experts traditionally recommend having infants and children sleep in their
own beds. Co-sleeping (i.e., the practice of infants and children sleeping
with their parents) is a culturally preferred habit and is common in
nonindustrialized countries. Health care providers in Canada frequently
discourage this practice because of safety issues. The Canadian culture
promotes independence in childhood. Because co-sleeping does not promote
this independence, health care workers tend to discourage it. As a nurse, you
need to be culturally sensitive when discussing co-sleeping practices with
parents and developing sleeping plans for children.
Implications for Practice
• Complete a thorough sleep assessment of the child and the family.
• Discuss the risks of the child sleeping with the parents. During the
discussion, remain culturally sensitive to and respectful of the parents'
views.
• Co-sleeping affects the infant's normal sleep pattern by decreasing slowwave sleep and increasing the number of nighttime arousals.
• Co-sleeping has been linked to an increased risk of sudden infant death
syndrome (SIDS) under certain conditions, such as parental smoking
and alcohol or drug use.
• Instruct parents who practise co-sleeping to avoid using alcohol or drugs
that impair arousal. Decreased arousal prevents the parents from
awakening if the child experiences problems.
• Co-sleeping should occur only with parents and not with another adult
or child.
• Encourage the parents who co-sleep to use light sleeping clothes, to keep
the room temperature comfortable, and to not bundle the child tightly
or in too many clothes.
Bedtime Snacks.
Some individuals enjoy bedtime snacks, whereas others cannot sleep after
eating. A dairy product snack, such as warm milk or cocoa, contains Ltryptophan and is often helpful in promoting sleep. A full meal before
bedtime often causes gastrointestinal upset and can interfere with the ability
to fall asleep.
Patients should be encouraged to avoid drinking or ingesting caffeine
before bedtime. Because coffee, tea, cola, and chocolate act as stimulants,
they can cause a person to stay awake or to awaken throughout the night
(National Sleep Foundation, 2009). Infants require special measures to
minimize their nighttime awakenings for feeding. Children commonly need a
middle-of-the-night bottle or to breastfeed at night. Hockenberry and Wilson
(2014) recommend offering the last feeding as late as possible. Parents
should be instructed not to give infants bottles in bed.
Pharmacological Approaches.
Melatonin is a major hormone of the circadian system and plays an
important role in promoting sleep (Buysse, 2011). Melatonin is a popular
nutritional supplement to aid sleep. The recommended dosage is 0.3 to 1 mg
taken 2 hours before bedtime (National Sleep Foundation, 2017a). Older
persons who have decreased levels of melatonin find taking melatonin to be
beneficial as a sleep aid (Lee-Chiong, 2008). Several other herbal products
also assist in promoting sleep. Valerian is effective in addressing mild
insomnia. It effects the release of neurotransmitters and produces a very
mild sedation (Buysse, 2011). Kava helps promote sleep in patients who have
sleep problems related to anxiety but needs to be used cautiously because of
its potential toxic effects on the liver (Morin, 2011). Chamomile, passion
flower, lemon balm, and lavender are other herbal products that have mild
sedative effects. Patients should be cautioned about the dosage and use of
herbal compounds. Because some herbal compounds interact with
prescribed medication, patients should avoid using these treatments
together (Krystal, 2011) (see Chapter 35).
The use of nonprescription sleeping medications is not advisable. Patients
need to learn the risks of such drugs. Although these drugs initially seem to
be effective, over the long term, they can lead to further sleep disruption.
Nurses can help patients to use behavioural and proper sleep hygiene habits
to establish sleep patterns that do not require the use of drugs.
Acute Care
Patients in an acute care setting frequently have their normal rest and sleep
routines disrupted, which makes them more susceptible to periods of sleep
deprivation. Sleep has a restorative function; hence, in this setting, nursing
interventions should focus on controlling factors in the environment that
disrupt sleep, relieving physiological or psychological barriers to sleep, and
providing uninterrupted rest and sleep periods for the patient. The nurse
may accomplish this by organizing procedures to minimize the number of
times the patient's sleep must be disrupted and by avoiding any unnecessary
procedures during rest periods.
Environmental Controls.
In a hospital setting, nurses can promote rest and sleep periods by reducing
or eliminating environmental disturbances. When possible, the doors to
patients' rooms should be closed. In semiprivate rooms, the curtains should
be closed between patients. At night, the lights on a nursing unit should be
dimmed. Noise levels can be reduced by conducting conversations and
reports away from patient rooms and by keeping necessary conversations to a
minimum, especially at night; reducing the volume of alarms, televisions,
and other equipment; turning off bedside oxygen and other equipment not in
use; and, when possible, avoiding noisy procedures till daytime hours
(Carpenito, 2016). Patients' use of cellular telephones and laptop computers
should be discouraged during rest periods, and their minimal use during the
hospitalization period should be encouraged. Moreover, the nurse should
limit visitors during rest periods.
Promoting Comfort.
Compared with beds at home, hospital beds are often harder and of a
different height, length, or width. Keeping beds clean and dry and in a
comfortable position helps patients to relax. Pillows can be used for support
(painful limbs, splinting of surgical incisions). Some patients who have
painful illnesses require special comfort measures, such as the application of
dry or moist heat, use of supportive dressings or splints, or proper
positioning before retiring (Figure 41-6).
FIGURE 41-6
Positioning a patient for sleep.
Establishing Periods of Rest and Sleep.
In a hospital or extended care setting, it is sometimes difficult to provide
patients with the time needed to rest and sleep. However, nurses should plan
their nursing care to avoid awakening patients for nonessential tasks. When
possible, assessments, treatments, procedures, and routines should be
scheduled for times when patients are awake. For example, if a patient's
physical condition has been stable, nurses should avoid awakening the
patient to check vital signs. Allowing patients to determine the timing and
methods of delivery of personal care measures will promote rest. Bed baths
and other routine hygiene measures should not be administered during the
night simply because that timing may be most convenient for the nursing
staff. Blood samples need to be drawn at a time when the patient is awake.
Unless maintaining a drug's therapeutic blood level is essential, medications
can be given during waking hours. Nurses need to work with the radiology
department and other support services to schedule diagnostic studies and
therapies at intervals that allow patients time for rest. Nurses should always
try to provide patients with 2 to 3 hours of uninterrupted sleep during the
night (Cmiel, Karr, & Gasser, 2004). Nurses may accomplish this by
organizing procedures to minimize the number of times a patient's sleep
must be disrupted and by avoiding any unnecessary procedures during rest
periods.
When the patient's condition demands more frequent monitoring,
activities should be scheduled to allow the patient to have extended rest
periods. The nurse should plan activities in such a way both that health care
personnel will avoid returning to the room every few minutes and that the
patient will have up to an hour or more to rest quietly. For example, if a
patient needs frequent dressing changes, is receiving intravenous therapy,
and has drainage tubes from several sites, the nurse should not make a
separate trip into the room to attend to each task. Instead, the nurse can use
a single visit to change the dressing, regulate the intravenous system, and
empty the drainage tubes. Nurses need to become patients' advocates for
promoting optimal sleep, by postponing or rescheduling visits by family,
asking consultants to reschedule visits, and questioning the frequency of
certain procedures.
Promoting Safety.
Patients with OSA are at risk for complications while in the hospital. Surgery
and anaesthesia disrupt patients' normal sleep patterns. Postoperatively,
these patients reach deep levels of REM sleep. This deep sleep causes muscle
relaxation that can lead to OSA (Cao et al., 2011). Patients with OSA who are
given opioid analgesics after surgery have an increased risk of developing
airway obstruction because these medications suppress the normal arousal
mechanisms (Cao et al., 2011). The nurse needs to monitor the patient's
airway, respiratory rate, depth, and breath sounds frequently after surgery.
Nurses can recommend lifestyle changes to patients with OSA, including
sleep hygiene improvements, alcohol moderation, smoking cessation, and a
weight-loss program (Atwood et al., 2011). Such patients should be taught to
prevent sleeping in the supine position by wearing a fanny pack or tight shirt
with a tennis ball on the back, or by elevating the head of the bed 30 to 45
degrees (Atwood et al., 2011). As noted earlier, one of the most effective
therapies is use of a nasal CPAP device at night, which requires a patient to
wear a mask over the nose. The mask delivers room air at a high pressure and
the air pressure prevents airway collapse. The CPAP device is portable and is
effective particularly for OSA (Buchanan & Grunstein, 2011).
Another treatment option is the use of an oral appliance. These appliances
advance the mandible or tongue to relieve pharyngeal obstruction (Cistulli,
Ferguson, & Lowe, 2011). In cases of severe sleep apnea, the tonsils, uvula, or
portions of the soft palate are surgically removed. Success with surgical
procedures is variable.
Stress Reduction.
Patients who are hospitalized for extensive diagnostic testing often have
difficulty resting or sleeping because of uncertainty about their state of
health. Giving patients control over their health care minimizes uncertainty
and anxiety. Providing information about the purpose of procedures and
routines and answering questions will give patients the peace of mind they
need to rest or to fall asleep. During the night shift, nurses can take time to
sit and talk with patients who are unable to sleep and may be able to
determine the factors preventing patients from sleeping. Back rubs help
patients relax more thoroughly. If a sedative is indicated, the nurse should
confer with the physician to ensure the lowest dosage is used initially. A
sedative should be discontinued as soon as possible, to prevent a
dependence that can seriously disrupt the normal sleep cycle. Nurses should
be aware that the metabolism of drugs in older persons is slower, making
them more vulnerable to the adverse effects of sedatives, hypnotics, antianxiety drugs, and analgesics.
Restorative or Continuing Care
Nursing interventions implemented in the acute care setting are also used in
the restorative or continuing care environment. Important considerations
include controlling the environment, especially the noise level; establishing
periods of rest and sleep; and promoting comfort. Nursing interventions
related to the control of barriers to sleep are also implemented in these
settings. Helping a patient achieve restful sleep in this environment
sometimes takes a period of time.
Promoting Comfort.
Comfort measures promote sleep and improve patients' sense of well-being.
Nurses can promote comfort by offering a patient a warm bath or shower
before bedtime. Other personal hygiene measures are mouth care and
toileting (e.g., offering the bedpan or urinal). Back massages, soft music, and
relaxation exercises also promote comfort. Proper positioning of the patient
in bed is also very important. Using pillows to support limbs and other
dependent body parts maintains skin integrity, thereby maintaining comfort
(Milner & Belicki, 2010) (see Chapter 31).
Controlling Physiological Disturbances.
Controlling the symptoms of patients with physical illnesses can promote
sleep. For example, placing patients with respiratory disorders in upright bed
positions and offering additional pillows may assist with their breathing.
Teaching patients with chronic respiratory disorders (e.g., chronic obstructive
pulmonary disease) pursed-lip breathing will decrease their respiratory rate
and also promote comfort and sleep. Humidified air, the use of supplemental
oxygen, if appropriate, and other pharmacological therapies (i.e.,
bronchodilators) are also relevant considerations.
Patients with pain, nausea, and other recurrent symptoms may require
nonpharmacological and pharmacological therapies to promote sleep (Milner
& Belicki, 2010; Morin, 2011). Relaxation measures (e.g., music, guided
imagery) are appropriate diversional therapies. Providing pain relief with
analgesics is also appropriate. To promote patients' comfort and sleep, nurses
need to collaborate with physicians and other health care personnel to
determine the optimal plan for relief of patients' symptoms (Milner & Belicki,
2010).
Pharmacological Approaches.
Numerous pharmacological drugs, both prescription and over-the-counter,
are used to manage insomnia. Conversely, polypharmacy to manage
insomnia is associated with disrupted sleep patterns, including increased
nocturnal awakening and decreased REM sleep and total sleep time.
Therefore, CNS stimulants, such as amphetamines, caffeine, nicotine,
terbutaline, theophylline, and pemoline, need to be used sparingly and only
under medical management (O'Malley, Gleeson, & Weir, 2011). In addition,
withdrawal from CNS depressants, such as alcohol, barbiturates, tricyclic
antidepressants (amitriptyline, imipramine, and doxepin), and triazolam, can
cause insomnia. Nurses need to manage these medications carefully.
Medications that induce sleep are called hypnotics. Sedatives are
medications that produce a calming or soothing effect (Mendelson, 2011).
Hypnotics and sedatives can be used as sleep medications and will help, if
used correctly. A patient who takes sleep medications needs to understand
their proper use, their risks, and their possible adverse effects. Long-term
use of anti-anxiety, sedative, or hypnotic agents, however, can disrupt sleep
and lead to more serious problems.
One group of drugs considered to be relatively safe is the benzodiazepines.
The benzodiazepines cause relaxation, anti-anxiety, and hypnotic effects by
facilitating the action of neurons in the CNS that suppress responsiveness to
stimulation, thereby decreasing the levels of arousal (Mendelson, 2011).
Unlike sedatives and hypnotics, benzodiazepines do not cause general CNS
depression, and they also have a lower potential for abuse. These drugs are
frequently prescribed because anti-anxiety effects occur at safe, nontoxic
doses. In the older person, short-acting benzodiazepines, such as temazepam
and triazolam, are preferred over long-acting agents (Mendelson, 2011).
Benzodiazepines need to be administered with caution in children younger
than 12 years of age. These medications are contraindicated in infants
younger than 6 months. Pregnant women need to avoid benzodiazepines
because their use is associated with the risk of congenital anomalies. Nursing
mothers do not receive these drugs because they are excreted in breast milk.
Initial doses are small, and increments are added gradually, on the basis of
patient response, for a limited period of time. Patients should be warned not
to take more than the prescribed dose, especially if the medication seems to
become less effective after the initial use. If older patients who were
continent, ambulatory, and alert suddenly become incontinent, confused, or
demonstrate impaired mobility, the use of benzodiazepines needs to be
considered as a possible cause. Regular use of any sleep medication often
leads to drug tolerance. Rebound insomnia is a problem that can be
experienced after stopping the medication (Lee-Chiong, 2008). Immediately
administering a sleeping medication when a hospitalized patient complains
of being unable to sleep will do the patient more harm than good.
Alternative approaches need to be considered for promoting sleep. Routine
monitoring of the patient's response to sleeping medications is also
important.
Evaluation
The patient is an important source of information for evaluating outcomes
related to sleep and rest. Each patient has a unique need for sleep and rest,
and only the patient will know whether sleep problems have improved, and
which interventions or therapies are most successful in promoting sleep
(Figure 41-7). To evaluate the effectiveness of nursing interventions, the nurse
makes comparisons with baseline sleep assessment data.
FIGURE 41-7
Critical thinking model for sleep evaluation.
The nurse needs to determine whether expected outcomes have been met,
using evaluative measures shortly after a therapy has been tried (e.g., by
observing whether a patient falls asleep after noise has been reduced and the
room has been darkened) and after a patient awakens from sleep (e.g., by
asking a patient to describe the number of awakenings during the previous
night). The patient and the patient's bed partner can usually provide accurate
evaluative information. Over longer periods, assessment tools such as the
visual analogue scale or the sleep rating scale can be used to determine
whether sleep has progressively improved.
Nurses also need to evaluate the level of understanding that patients and
their family members have gained after receiving instruction in sleep habits.
Nurses can measure adherence to these practices during a home visit, when
they are able to observe the environment. When expected outcomes are not
met, the nursing measures or expected outcomes need to be revised on the
basis of the patient's needs or preferences. When outcomes are not met, the
nurse can ask questions such as “Do you feel as though you slept better
when you exercised?” or “Do you feel rested when you wake up?”
When nurses successfully develop good relationships with patients and
when they have developed therapeutic plans of care, subtle behaviours often
indicate the patients' levels of satisfaction. The absence of signs of sleep
problems, such as lethargy, frequent yawning, or position changes, may be
noted. The nurse should ask the patient whether his or her sleep needs have
been met, using such questions as “Are you feeling more rested?” or “Can
you tell me if you feel we have done all we can to help improve your sleep?”
If the patient's expectations have not been met, the nurse will need to spend
more time trying to understand the patient's needs and preferences. Working
closely with the patient and the patient's bed partner will enable the nurse to
redefine the expectations that can be realistically met within the limits of the
patient's condition and treatment.
Key Concepts
• Sleep provides physiological and psychological
restoration.
• The 24-hour sleep–wake cycle is a circadian rhythm
that influences physiological function and behaviour.
• The control and regulation of sleep depends on a
balance between regulators within the central nervous
system.
• During a typical night's sleep, a person passes
through four to five complete sleep cycles. Each sleep
cycle contains four nonrapid eye movement (NREM)
stages of sleep and a period of rapid eye movement
(REM) sleep.
• The most common type of sleep disorder is
insomnia.
• The sleep pattern is frequently disrupted by the
hectic pace of a person's lifestyle, emotional and
psychological stress, and alcohol ingestion.
• If a patient's sleep is adequate, the nurse should
assess the patient's usual bedtime, normal bedtime
ritual, preferred environment for sleeping, and usual
rising time.
• When a patient reports a sleep problem, the nurse
needs to conduct a complete sleep history.
Diagnosing sleep problems depends on identifying
the factors that impair sleep.
• When planning interventions to promote sleep, the
nurse needs to consider the characteristics of the
patient's home environment and normal lifestyle.
• A regular bedtime routine of relaxing activities
prepares a person physically and mentally for sleep.
• An environment with a darkened room, reduced
noise, comfortable bed, and good ventilation
promotes sleep.
• Important nursing interventions for promoting
sleep in the hospitalized patient are controlling noise
levels and establishing periods for uninterrupted
sleep and rest.
• Control of pain or other disease symptoms is
essential in promoting the ability to sleep.
• Long-term use of sleeping pills often leads to
difficulty in initiating and maintaining sleep.
Critical Thinking Exercises
1. Andree returns to the health care clinic with her husband, David, for a
follow-up visit. She tells you that since she started her sleep hygiene
plan she feels more rested but is still having some problems sleeping
because of her husband's loud snoring. In addition to Andree's report
of David's snoring, you note that he is overweight. On the basis of
Andree's report of David's snoring, what additional assessment data
should you gather from David?
2. On the basis of David's reported symptoms, what problem do you
suspect he might have?
3. What action would you take at this time?
4. Andree and David also tell you that they are concerned about their 15year-old daughter. Her grades in school are getting worse, and she
says she is always tired. What do you need to know about their
daughter's sleep patterns?
5. What would you recommend to Andree and David about their
daughter?
Review Questions
1. The nurse is gathering a sleep history from a patient who is being
evaluated for obstructive sleep apnea. What symptom is the patient most
likely to report?
1. Headache
2. Early wakening
3. Impaired reasoning
4. Excessive daytime sleepiness
2. When preparing a plan of care to promote sleep for a hospitalized patient,
which of the following priority nursing interventions would the nurse
incorporate?
1. Ensure that the patient follows hospital routines.
2. Avoid awakening the patient for nonessential tasks.
3. Give prescribed sleeping medications at dinner.
4. Turn the TV volume down for late-night programming.
3. Older persons are cautioned about the long-term use of sedatives and
hypnotics because these medications are characterized by which of the
following statements?
1. They cause headaches and nausea.
2. They are expensive and difficult to obtain.
3. They cause severe depression and anxiety.
4. They can lead to sleep disruption.
4. The nurse is providing health teaching for a patient using herbal
compounds, such as valerian, to aid sleep. Key information about the use
of herbal compounds would include the following:
1. It can cause urinary retention.
2. It may cause diarrhea and anxiety.
3. It may interfere with prescribed medications.
4. It can lead to further sleep problems over time.
5. A patient reports having vivid dreams. Through your understanding of the
sleep cycle, you recognize that vivid dreaming occurs during which sleep
phase?
1. REM sleep
2. Stage 1 NREM sleep
3. Stage 4 NREM sleep
4. Transition period from NREM to REM sleep
6. The nurse is providing instruction for a patient who is having dif​ficulty
falling asleep. The nurse identifies the need for further instruction when
the patient says which of the following statements?
1. I should avoid having drinks with caffeine before going to bed.
2. If I can't get to sleep right away, I should get up and read a book.
3. I should have an alcoholic drink before bedtime to help me relax.
4. I should avoid exercising just before going to bed.
7. Which of the following interventions is appropriate to include in a care
plan for improving sleep in the older person?
1. Decrease fluids 2 to 4 hours before sleep.
2. Exercise in the evening to increase fatigue.
3. Allow the patient to sleep as late as possible.
4. Take a nap during the day to make up for lost sleep.
8. Which statement made by a mother being discharged to home with her
newborn infant indicates a need for further teaching?
1. I won't put the baby to bed with a bottle.
2. For the first few weeks, we are putting the cradle in our room.
3. My grandmother told me that babies sleep better on their stomachs.
4. I know I will have to get up during the night to feed the baby when he
wakes up.
9. The nurse is developing a plan of care for a patient experiencing
narcolepsy. Which of the following interventions is appropriate to include
in the plan?
1. Increase the amount of carbohydrates in the diet.
2. Limit fluid intake 2 hours before bedtime.
3. Preserve energy by limiting exercise to morning hours.
4. Take one or two 20-minute naps during the day.
10. Which of the following nursing measures promotes sleep in school-aged
children?
1. Encourage evening exercise.
2. Encourage television viewing.
3. Ensure that the room is dark and quiet.
4. Encourage quiet activities before bedtime.
Answers: 1. 4; 2. 2; 3. 4; 4. 4; 5. 1; 6. 3; 7. 1; 8. 3; 9. 4; 10. 4
Rationales for the Review Questions appear at the end of the book.
Recommended Websites
Canadian Lung Association. https://www.lung.ca.
This website provides information on obstructive sleep apnea (OSA),
including strategies to enhance living with OSA and treatment
modalities, such as continuous positive airway pressure (CPAP)
devices. Sleep apnea in children is also discussed, with exploration of
strategies to reduce the impact of sleep apnea, such as optimal
nutrition and the use of CPAP devices.
Canadian Sleep Society. http://www.css.to.
This website provides a conduit for health care providers and
researchers who are interested in sleep-related disorders, with an
emphasis on sleep research performed in Canada. The site also
provides information for the public on sleep-related topics and links
to other sleep-related organizations, to enhance the understanding of
sleep and its related disorders.
National Sleep Foundation (US). https://www.sleepfoundation.org.
This multilingual website, designed for both health care providers and
the public, provides an exhaustive amount of information on a
plethora of sleep-related topics—for example, restless leg syndrome,
dementia, and menopause. The site provides access to sleep-related
educational material and research reports, such as the 2011 annual
Sleep in America poll that explores the impact of communication
technology on sleep.
Public Health Agency of Canada: Sleep apnea.
https://www.canada.ca/en/public-health/services/chronicdiseases/sleep-apnea.html.
This website includes publications intended for health care providers
and the general public that are related to sleep apnea and other sleep
disorders. It also includes a link to Fast Facts from the 2009 Canadian
Community Health Survey—Sleep Apnea Rapid Response. This survey,
conducted by Statistics Canada, estimated the prevalence of sleep
apnea in the Canadian population.
Veterans Affairs Canada (VAC). http://www.veterans.gc.ca.
This website provides links to services, benefits, publications, and fact
sheets relevant to Canadian veterans. Additionally, the site offers
VAC information on many issues facing Canadian veterans, including
the impact of post-traumatic stress disorder (PTSD) on sleep and
strategies to help get a good night's sleep.
References
Achermann P, Borbely AA. Sleep homeostasis and models of sleep
regulation. Kryger MH, Roth T, Dement WC. Principles and practice of
sleep medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:431–444.
Agarwal S, Richardson B, Krishnan V, et al. Interstitial lung disease and
sleep: What is known? Sleep Medicine. 2009;10(9):947–951;
10.1016/j.sleep.2009.01.004.
Ahmed I, Thorpy M. Clinical features, diagnosis and treatment of
narcolepsy. Clinical Chest Medicine. 2010;31(2):371–381;
10.1016/j.ccm.2010.02.014.
Anic GM, Titus-Ernstoff L, Newcomb PA, et al. Sleep duration and
obesity in a population-based study. Sleep Medicine. 2010;11(5):447–
451; 10.1016/j.sleep.2009.11.013.
Atwood CW Jr, Strollo PJ Jr, Givelber R. Medical therapy for obstructive
sleep apnea. Kryger MH, Roth T, Dement WC. Principles and practice of
sleep medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:1219–1232.
Bae C, Avidan A. Sleep disorders. Smith HR, Comella CL, Hogl B. Sleep
medicine. Cambridge University Press: New York; 2008:9–24.
Balkin TJ. Performance deficits during sleep loss: Effects of time awake,
time of day and time on task. Kryger MH, Roth T, Dement WC.
Principles and practice of sleep medicine. 5th ed. Elsevier: Philadelphia,
PA; 2011:738–744.
Balserak BI, Lee K. Sleep disturbances and sleep-related disorders in
pregnancy. Kryger MH, Roth T, Dement WC. Principles and practice of
sleep medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:1572–1586.
Belenky G, Akerstedt T. Occupational sleep medicine. Kryger MH, Roth
T, Dement WC. Principles and practice of sleep medicine. 5th ed. Elsevier:
Philadelphia, PA; 2011:734–737.
Billard M. Normal sleep. Smith HR, Comella CL, Hogl B. Sleep medicine.
Cambridge University Press: Cambridge, NY; 2008:9–24.
Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based
recommendations for the assessment and management of sleep
disorders in older persons. Journal of American Geriatrics Society.
2009;57(11):761–789; 10.1111/j.1532-5415.2009.02549.x.
Buchanan P, Grunstein R. Positive airway pressure treatment for
obstructive sleep apnea-hypopnea syndrome. Kryger MH, Roth T,
Dement WC. Principles and practice of sleep medicine. 5th ed. Elsevier:
Philadelphia, PA; 2011:1233–1249.
Buysse DJ. Clinical pharmacology of other drugs used as hypnotics.
Kryger MH, Roth T, Dement WC. Principles and practice of sleep
medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:492–502.
Canadian Nurses Association. Framework for the practice of registered
nurses in Canada. Author.: Ottawa; 2015 [Retrieved from]
https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/frameworkfor-the-pracice-of-registered-nurses-in-canada.
Cao MT, Guilleminault C, Kushida CA. Clinical features and evaluation
of obstructive sleep apnea and upper airway resistance syndrome.
Kryger MH, Roth T, Dement WC. Principles and practice of sleep
medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:1206–1218.
Carpenito LJ. Nursing diagnosis: Application to clinical practice. 15th ed.
Lippincott Williams & Wilkins: Philadelphia, PA; 2016.
Carskadon MA, Dement WC. Normal human sleep: An overview.
Kryger MH, Roth T, Dement WC. Principles and practice of sleep
medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:16–41.
Chasens ER, Williams LL, Umlauf MG, et al. Excessive sleepiness.
Capezuti E, Zwicker D, Mezey M. Evidence-based geriatric nursing
protocols for best practice. 3rd ed. Springer: New York; 2008:459–476.
Chervin RD. Use of clinical tools and tests in sleep medicine. Kryger
MH, Roth T, Dement WC. Principles and practice of sleep medicine. 5th
ed. Elsevier: Philadelphia, PA; 2011:666–679.
Cistulli PA, Ferguson KA, Lowe AA. Oral appliances for sleepdisordered breathing. Kryger MH, Roth T, Dement WC. Principles and
practice of sleep medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:1266–
1277.
Cmiel CA, Karr DM, Gasser DM, et al. Noise control: A nursing team's
approach to sleep promotion. American Journal of Nursing.
2004;104(2):40–48.
Cohen FL. Measuring sleep. Frank-Stromborg M, Olsen SJ. Instruments
for clinical-healthcare research. 3rd ed. Jones & Bartlett: Boston, MA;
2004:264–285.
Collop NA, Salas RE, Delayo M, et al. Normal sleep and circadian
processes. Critical Care Clinics. 2008;24(3):449–460;
10.1016/j.ccc.2008.02.002.
Cook NF. Understanding narcolepsy, part 1: Epidemiology and
neurophysiology. British Journal of Neuroscience Nursing. 2008;4(3):108–
114.
Cook NF. Understanding narcolepsy, part 2: Accurate diagnosis and
effective management. British Journal of Neuroscience Nursing.
2008;4(4):170–176.
Crabtree V, Williams NA. Normal sleep in children and adolescents.
Child and Adolescent Psychiatric Clinics of North America.
2009;18(4):799–811; 10.1016/j.chc.2009.04.013.
Doghramji K. The evaluation and management of insomnia. Clinics in
Chest Medicine. 2010;31(2):327–339; 10.1016/j.ccm.2010.03.001.
Drake CL, Wright KP Jr. Shift work, shift work disorder and jet lag.
Kryger MH, Roth T, Dement WC. Principles and practice of sleep
medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:784–798.
Drouot X, Cabello B, D'Ortho MP, et al. Sleep in the intensive care unit.
Sleep Medicine Reviews. 2008;12(5):391–403; 10.1016/j.smr.2007.11.004.
Elliott R, McKinley S, Cistulli P. The quality and duration of sleep in the
intensive care setting: An integrative review. International Journal of
Nursing Studies. 2011;48(3):384–400; 10.1016/j.ijnurstu.2010.11.006.
Espiritu JRD. Aging-related sleep changes. Clinics in Geriatric Medicine.
2008;24(1):1–14; 10.1016/j.cger.2007.08.007.
Faraco J, Mignot E. Genetics of sleep and sleep disorders in humans.
Kryger MH, Roth T, Dement WC. Principles and practice of sleep
medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:184–198.
Gradisar M, Gardner G, Dohnt H. Recent world-wide sleep patterns and
problems during adolescence: A review and meta-analysis of age,
region and sleep. Sleep Medicine. 2011;12(2):110–118;
10.1016/j.sleep.2010.11.008.
Hockenberry MJ, Wilson D. Wong's nursing care of infants and children.
9th ed. Mosby: New York; 2014.
Jennum P, Knudsen S, Kjellberg J. The economic consequences of
narcolepsy. Journal of Clinical Sleep Medicine. 2009;5(3):240–245.
Krystal AD. Pharmacologic treatments: Other medications. Kryger MH,
Roth T, Dement WC. Principles and practice of sleep medicine. 5th ed.
Elsevier: Philadelphia, PA; 2011:916–930.
Laposky AD, Bass J, Kohsaka A, et al. Sleep and circadian rhythms: Key
components in the regulation of energy metabolism. Federation of
European Biochemical Societies. 2008;582(1):142–151;
10.1016/j.febslet.2007.06.079.
Lavigne G, Smith MT, Denis R, et al. Pain and sleep. Kryger MH, Roth T,
Dement WC. Principles and practice of sleep medicine. 5th ed. Elsevier:
Philadelphia, PA; 2011:1442–1451.
Lee KA, Moe KE. Menopause. Kryger MH, Roth T, Dement WC.
Principles and practice of sleep medicine. 5th ed. Elsevier: Philadelphia,
PA; 2011:1592–1601.
Lee-Chiong T Jr. Sleep medicine: Essentials and review. Oxford University
Press: New York; 2008.
Lei Z, Qiongjing Y, Qiuli W, et al. Sleep quality and sleep disturbing
factors of inpatients in a Chinese hospital. Journal of Clinical Nursing.
2009;18(1):2521–2529; 10.1111/j.1365-2702.2009.02846.x.
Magee CA, Iverson DC, Huang XF, et al. A link between chronic sleep
restriction and obesity: Methodological considerations. Public Health.
2008;122(12):1373–1381; 10.1016/j.puhe.2008.05.010.
Mendelson WB. Hypnotic medications: Mechanisms of action and
pharmacologic effects. Kryger MH, Roth T, Dement WC. Principles and
practice of sleep medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:483–
491.
Milner CE, Belicki K. Assessment and treatment of insomnia in adults:
A guide for clinicians. Journal of Counseling & Development.
2010;88(2):236–244; 10.1002.j.1556-6678.2010.tb00015.x/full.
Morin CM. Psychological and behavioral treatments for insomnia I:
Approaches and efficacy. Kryger MH, Roth T, Dement WC. Principles
and practice of sleep medicine. 5th ed. Elsevier: Philadelphia, PA;
2011:866–883.
National Sleep Foundation. Diet, exercise and sleep. Author.: Arlington,
VA; 2009 [Retrieved from] https://sleepfoundation.org/sleeptopics/diet-exercise-and-sleep.
National Sleep Foundation. Melatonin and sleep. Author.: Arlington, VA;
2017 [Retrieved from] https://sleepfoundation.org/sleeptopics/melatonin-and-sleep.
National Sleep Foundation. How much sleep do adults need?. Author.:
Arlington, VA; 2017 [Retrieved from]
http://www.sleepfoundation.org/article/white-papers/how-muchsleep-do-adults-need.
Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult: A minireview. Gerontology. 2010;56(2):181–189; 10.1159/000236900.
Nielsen T. Dream analysis and classification: The reality simulation
perspective. Kryger MH, Roth T, Dement WC. Principles and practice of
sleep medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:76–91.
O'Malley MB, Gleeson SK, Weir ID. Wake-promoting medications:
Efficacy and adverse effects. Kryger MH, Roth T, Dement WC.
Principles and practice of sleep medicine. 5th ed. Elsevier: Philadelphia,
PA; 2011:866–883.
Orezel-GryGlewska J. Consequences of sleep deprivation. International
Journal of Occupational Medicine and Environmental Health.
2009;23(1):95–114.
Paavonen EJ, Porkka-Heiskanen T, Lahikainen AR. Sleep quality,
duration and behavioral symptoms among 5–6-year-old children.
European Child & Adolescent Psychiatry. 2009;18(12):747–754;
10.1007/s00787-009-0033-8.
Patel M, Chipman J, Carlin BW, et al. Sleep in the intensive care unit.
Critical Care Nursing. 2008;31(4):309–318;
10.1097/01.CNQ.0000336817.89300.08.
Patel SR. Reduced sleep as an obesity risk factor. Obesity Reviews.
2009;10(2):61–68; 10.1111/j.1467-789X.2009.00664.x.
Patel SR, Blackwell T, Redline S, et al. The association between sleep
duration and obesity in older adults. International Journal of Obesity.
2008;32(12):1825–1834; 10.1038/ijo.2008.198.
Philip P, Sagaspe P, Taillard J. Drowsy driving. Kryger MH, Roth T,
Dement WC. Principles and practice of sleep medicine. 5th ed. Elsevier:
Philadelphia, PA; 2011:769–774.
Ramar K, Guilleminault C. Sleep apnea (central and obstructive). Smith
HR, Comella CL, Hogl B. Sleep medicine. Cambridge University Press:
New York; 2008:129–156.
Ramsawh H, Stein MB, Mellman TA. Psychiatric disorders. Kryger MH,
Roth T, Dement WC. Principles and practice of sleep medicine. 5th ed.
Elsevier: Philadelphia, PA; 2011:1473–1487.
Reeve K, Bailes B. Insomnia in adults: Etiology and management.
Journal for Nurse Practitioners. 2010;6(1):53–60;
10.1016/j.nurpra.2009.09.013.
Roepke SK, Ancoli-Israel S. Sleep disorders in the elderly. Indian Journal
of Medical Research. 2010;131:302–310.
Seo WS, Sung HM, Lee JH, et al. Sleep patterns and their age-related
changes in elementary school children. Sleep Medicine. 2010;11(6):569–
575; 10.1016/j.sleep.2010.03.011.
Siegel JM. Sleep mechanisms and phylogeny. Kryger MH, Roth T,
Dement WC. Principles and practice of sleep medicine. 5th ed. Elsevier:
Philadelphia, PA; 2011:76–91.
Silvestri R, Arico I. Parasomnias. Smith HR, Comella CL, Hogl B. Sleep
medicine. Cambridge University Press: New York; 2008:47–55.
Smith HR, Comella CL, Hogl B. Sleep medicine. Cambridge University
Press: New York; 2008.
Snowden A. Insomnia: Management and treatments. Nurse Prescribing.
2008;6(9):382–389.
Stickgold R, Wamsley EJ. Why we dream. Kryger MH, Roth T, Dement
WC. Principles and practice of sleep medicine. 5th ed. Elsevier:
Philadelphia, PA; 2011:76–91.
Tibbits GM. Sleep disorders: Causes, effects and solutions. Primary Care
Clinics Office Practice. 2008;35(4):817–837; 10.1016/j.pop.2008.07.006.
Van Cauter E, Spiegel K, Tasali E, et al. Metabolic consequences of sleep
and sleep loss. Sleep Medicine. 2008;9(S1):S23–S28; 10.1016/S13899457(08)70013-3.
Verrier RL, Josephson ME. Cardiac arrhythmogenesis during sleep:
Mechanisms, diagnosis, and therapy. Kryger M, Roth T, Dement WC.
Principles and practice of sleep medicine. 5th ed. Elsevier: Philadelphia,
PA; 2011:1363–1380.
Wellman A, White DP. Central sleep apnea and periodic breathing.
Kryger MH, Roth T, Dement WC. Principles and practice of sleep
medicine. 5th ed. Elsevier: Philadelphia, PA; 2011:1140–1152.
Wyatt JK, Crisostomo MI. Insomnias. Smith HR, Comella CL, Hogl B.
Sleep medicine. Cambridge University Press: New York; 2008:97–112.
42
Nutrition
Canadian content written by, Kathryn Weaver RN, PhD
Original chapter by, Kristine Rose BSN, MSN
OBJECTIVES
Mastery of content in this chapter will enable you to:
• Define the key terms listed.
• Explain the role of each major nutrient in proper nutrition.
• Explain the importance of maintaining a balance between energy intake and expenditure.
• List the end products of carbohydrate, protein, and fat metabolism.
• Explain the significance of saturated, unsaturated, polyunsaturated, and trans fats.
• Be aware of national position statements and recommendations regarding sugar
consumption.
• Describe Eating Well With Canada's Food Guide and its value in planning nutritious meals.
• Specify recommended dietary intake for age and sex groups in Canada to ensure that
patients meet the varied essential vitamins, minerals, and nutritional requirements
throughout their growth and development.
• Understand how to plan sample menus for cardiac diets, renal diets, lactose intolerance,
gluten-free, and diabetes diets.
• Describe how to count calories and substitute items for diabetic patients.
• Identify the role of the dietitian, nutritionist, and speech-language pathologist in promoting
healthy diets and preventing risks such as aspiration.
• Discuss the major methods of nutritional assessment.
• Identify three major nutritional problems, the patients who are at risk, and related nutrition
therapy.
• Formulate a plan of care to help meet the specific nutritional needs of infants, toddlers,
preschoolers, school-aged children, adolescents, adults, and older persons.
• Plan for the daily nutritional intake of pregnant women.
• Identify the potential nutritional deficits associated with vegetarian diets, giving special
consideration to vegan and lacto-ovo diets.
• Identify any risks associated with genetically modified food.
• Explain how to set up a meal tray for the visually impaired patient.
• Discuss diet counselling and patient teaching in relation to patient expectations.
• State the goals of enteral and parenteral nutrition.
• Describe the procedure for initiating and maintaining tube feedings and avoiding related
complications.
KEY TERMS
Amino acids, p. 1099
Anabolism, p. 1102
Anorexia, p. 1125
Anorexia nervosa, p. 1108
Anthropometry, p. 1113
Aquaporins, p. 1100
Aspiration, p. 1102
Basal metabolic rate (BMR), p. 1098
Body mass index (BMI), p. 1113
Bulimia nervosa, p. 1108
Carbohydrates, p. 1099
Catabolism, p. 1102
Cholesterol, p. 1100
Chyme, p. 1102
Complementary proteins, p. 1100
Complex carbohydrates, p. 1099
Dietary reference intakes (DRIs), p. 1103
Dysphagia, p. 1102
Elemental formulas, p. 1141
Enteral nutrition, p. 1135
Enzymes, p. 1102
Essential amino acids, p. 1099
Fat-soluble vitamins, p. 1100
Fatty acids, p. 1100
Food security, p. 1105
Fortified foods, p. 1099
Functional foods, p. 1099
Genetically modified (GM) food, p. 1099
Gluconeogenesis, p. 1103
Glycemic index, p. 1099
Glycogenesis, p. 1103
Glycogenolysis, p. 1103
Hypervitaminosis, p. 1101
Ideal body weight (IBW), p. 1113
Ketones, p. 1103
Lipid emulsions, p. 1156
Lipids, p. 1100
Macrominerals, p. 1101
Metabolism, p. 1102
Minerals, p. 1101
Modular formulas, p. 1141
Monounsaturated fatty acids, p. 1100
Nitrogen balance, p. 1100
Nonessential amino acids, p. 1099
Novel food, p. 1099
Nutrient density, p. 1099
Nutrients, p. 1099
Nutritional assessment, p. 1113
Nutritional screening, p. 1113
Organic food, p. 1099
Parenteral nutrition, p. 1149
Peristalsis, p. 1102
Polymeric formulas, p. 1141
Polyunsaturated fatty acids, p. 1100
Refeeding syndrome, p. 1149
Resting energy expenditure (REE), p. 1098
Saccharides, p. 1099
Saturated (fatty acids), p. 1100
Simple carbohydrates, p. 1099
Specialty formulas, p. 1148
Trace elements, p. 1101
Trans fatty acids, p. 1100
Triglycerides, p. 1100
Unsaturated (fatty acids), p. 1100
Vegetarianism, p. 1111
Vitamins, p. 1100
Waist circumference, p. 1114
Water-soluble vitamins, p. 1101
Proper nutrition and food safety—important to all Canadians—are a shared
responsibility among government, industry, health providers, and
consumers. Food supplies energy for accomplishing everyday activities,
building and repairing tissues, and regulating organs and systems while
helping to prevent the contraction of certain diseases and aid in the recovery
from other diseases. Food also holds symbolic meaning for many cultures
and communities. Since the 1930s, Health Canada has worked collaboratively
with federal partners, provinces, territories, and other stakeholders to
enhance nutritional health and well-being through evidence-informed
nutrition policies and standards. These efforts to advise and inform about
the safety and nutritional value of food have promoted environments that
support Canadians in making healthy food choices (Health Canada, 2015).
As nurses, we must pay as much attention to our patients' diets as to their
illnesses, treatments, and therapies. In fact, in illnesses such as type 1
diabetes mellitus, a common health concern across Western nations, diet can
be a major treatment, and nurses are key professionals responsible for
educating patients and families about food choices and available technology
(e.g., insulin pumps) that influence the course of the disease and assist in
self-management. Along with type 1 diabetes, other conditions, such as type
2 diabetes, hypertension, and inflammatory bowel disease, require highly
specialized nutritional support protocols that include diets low in sugars,
cholesterol, or salt (Leung, Nerenberg, Daskalopoulou, et al., 2016).
In comparison to citizens of other developed countries, the nutritional
health of Canadians is good. This story may be changing, however, as
Canadians face evolving demographic and economic issues that include a
rising poverty rate, a decline in resources available to rural and remote
communities, the aging of the population, and the social isolation or
marginalization of certain groups of citizens. To illustrate, nearly one in six
Canadians was at least 65 years old in 2015 (Statistics Canada, 2015); these
older persons are choosing to stay in their own homes longer, placing them
at risk for poor nutrition associated with mobility impairments and social
isolation. Also, rates of stay-at-home spouses have dropped significantly,
from 1.5 million in 1976 to 500 000 in 2014 (Statistics Canada, 2015), which
leaves the majority of preschool children in day care or school while parents
work. According to the 2015 National Report Card on Child and Family Poverty
in Canada, one in five Canadian children, more than 1.3 million, live below
the poverty line. Poverty rates are even worse among children who are from
Indigenous and racialized communities, in immigrant families, or in families
affected by disability (Lloyd & Bailey, 2015). Indigenous populations
increased by 232 385 people, or 20.1%, between 2006 and 2011, compared with
5.2% for the non-Indigenous population (Statistics Canada, 2016a). This
increase is significant because Indigenous children account for
approximately 7% of all children in Canada (Statistics Canada, 2016a), with
60% of First Nations children on reserves living below the poverty line
(Kirkup, 2016). Alongside the increase in Indigenous population there is an
increase in immigrant population, with nearly 56.9% of the 1 162 900 foreignborn people who immigrated to Canada between 2006 and 2011 coming from
Asia and the Middle East. Together, recent immigrants comprised 17.2% of
the foreign-born population and 3.5% of Canada's total population (Statistics
Canada, 2016b). All these factors, along with the larger international issues
arising from free trade and globalization, influence the nutritional health of
Canadians.
One trend that has taken on alarming proportions is the increase in
overweight and obesity. In 2014, 14 222 521 or approximately 54% of adult
Canadians reported height and weight that classified them as being
overweight or obese (Statistics Canada, 2017). Likewise, the prevalence of
obesity has tripled over the past three decades (Government of Canada,
2016a). Close to one third (31.5%) of 5- to 17-year-olds, an estimated 1.6
million, were classified as overweight (19.8%) or obese (11.7%) in 2009 to 2011
(Roberts, Shields, de Groh, et al., 2015), with the percentage of boys aged 5 to
11 years who were obese (19.5%) being more than three times the percentage
of girls who were obese (6.3%). Type 2 diabetes, an illness largely preventable
through healthy eating and weight management (Canadian Diabetes
Association [CDA], 2016) that in the past occurred mainly in older
individuals, is now being diagnosed in Canadian children (Government of
Canada, 2015). Among Indigenous people, rates of type 2 diabetes are three
to five times higher than those of the general population (Health Canada,
2013a). Factors adversely affecting the nutritional health of today's Canadian
society are serious, and the resultant conditions border on epidemic
proportions. It is critical that nurses acquire nutritional knowledge to apply
to the complexities of diseases, diverse populations, and current
demographics (age, gender, income level, and culture).
Scientific Knowledge Base
Nutrients: the Biochemical Units of Nutrition
The body requires fuel to provide energy for the chemical reactions that
enable cellular growth and repair, organ function, and body movement. The
energy requirement of a person at rest is called the basal metabolic rate
(BMR). This is the energy needed to maintain life-sustaining activities
(breathing, circulation, heart rate, and temperature) for a specific period of
time. The resting energy expenditure (REE) is a measurement that accounts
for BMR plus energy to digest meals and perform mild activity. REE is a
baseline of energy requirement accounting for approximately 60% to 75% of
our daily needs. Factors of age, body mass, gender, fever, environmental
temperature, pregnancy, lactation, starvation, stress, illness, injury, infection,
activity level, thyroid function, or the use of certain drugs may affect energy
requirements or metabolism.
In general, when energy requirements are completely met by kilocalorie
(kcal) intake in food, weight does not change. A kilocalorie (referred to as a
“calorie” by the general public) is the unit of energy required to raise 1
kilogram of water by 1°C. When the kilocalories ingested exceed energy
demands over time, a person gains weight. If the kilocalories ingested fail to
meet energy requirements, a person loses weight.
Nutrients are the elements supplied by food that are necessary for body
processes and function. Energy needs are met from three categories of
nutrients: carbohydrates, proteins, and fats. Other nutrients are water,
vitamins, and minerals, which do not provide energy but contribute to
metabolic processes, including acid–base balance. A nutrient is considered
essential if the body cannot manufacture it in a sufficient quantity to meet
metabolic demands.
Foods are described according to nutrient density, the proportion of
essential nutrients to the number of kilocalories. High nutrient-density
foods, such as fruits and vegetables, provide a large number of nutrients in
relation to kilocalories. Low nutrient-density foods, such as alcohol or refined
sugar, are high in kilocalories but nutrient poor.
Foods may also be described as functional, organic, or novel. Functional
foods (Agriculture and Agri-Food Canada, 2017) have had biologically active
ingredients added that have demonstrated health benefits (e.g., probiotic
yogurt, or pea fibre–fortified breads and pasta). Fortified foods have
additional vitamins and/or minerals to provide added health benefits (e.g.,
fortified soy beverages and fruit juice with calcium), or are enhanced with
bioactive components through plant breeding, genetic modification,
processing, or special livestock feeding techniques (e.g., eggs, milk, and meat
with omega-3). Organic foods are vegetables, fruit, eggs, milk, and meat
produced without synthetic (human-made) pesticides, herbicides, and
fertilizers; genetically modified organisms (GMOs); antibiotics or growth
hormones; or irradiation or ionizing radiation (a way to preserve food with
radiation energy). Organic farmers may use natural pesticides approved for
organic food production (EatRight Ontario, 2017a). Novel or genetically
modified (GM) food has undergone the practice of inserting the genes of one
organism into another organism, often to resist disease and develop desired
characteristics, such as a hardier texture, higher nutritional value, or faster
growth (EatRight Ontario, 2017b). A review of 12 long-term studies (>90 days
and up to 2 years in duration) and 12 multigenerational studies (from two to
five generations) on the effects of diets containing GM corn, potato, soybean,
rice, or triticale (a wheat and rye hybrid) on animal health did not suggest
any health hazards and, for the most part, presented evidence to show GM
plants as being nutritionally equivalent to their non-GM counterparts and as
safe for use in food and feed (Snell, Bernheim, Bergé, et al., 2012).
Nonetheless, Health Canada assesses the safety of all genetically modified
and other novel foods proposed for sale in Canada because novel food
products do not have a history of safe use as a food (Health Canada, 2017a).
There is no mandatory labelling of these foods in Canada, despite intensive
public campaigning and 20 years of polling that has consistently shown over
80% of Canadians want these labels (Canadian Biotechnology Action
Network, 2018). According to Bawa and Anilakumar (2013), the public lacks
trust in institutions and institutional activities regarding GM foods and
perceives that institutions have failed to take account of the public's actual
concerns. On December 13, 2016, the House of Commons Standing
Committee on Agriculture and Agri-Food recommended greater
transparency in the regulation of GM animals and government support for
independent research into the health, environmental, and other effects of
genetic modification technologies (House of Commons, Standing Committee
on Agriculture and Agri-Food, 2016).
Carbohydrates.
Carbohydrates are the recommended main source of energy in the diet. Each
gram of carbohydrate produces 4 kcal and serves as the main source of fuel
(glucose) for the brain, skeletal muscles during exercise, red and white blood
cell production, and cell function of the renal medulla. Carbohydrates are
obtained primarily from plant foods, except for lactose (milk sugar), and are
classified according to their carbohydrate units, or saccharides.
Monosaccharides such as glucose (dextrose) or fructose (fruit sugar) are
the building blocks of all other carbohydrates and cannot be broken down
into a more basic carbohydrate unit. Disaccharides such as sucrose, lactose,
and maltose are composed of two monosaccharides minus one unit of water.
Both monosaccharides and disaccharides are classified as simple
carbohydrates called sugars. Polysaccharides are composed of many
carbohydrate units and are classified as complex carbohydrates. They include
starch (stored form of glucose in plants) and glycogen (stored glucose in
animals and humans). Some polysaccharides cannot be digested because
humans do not have enzymes capable of breaking them down. Insoluble
fibres are not digestible and include cellulose, hemicellulose, and lignin.
Soluble fibres include pectin, guar gum, and mucilage. Dietary fibre is
important to disease prevention, as it decreases low-density lipoprotein
(LDL) cholesterol associated with the development of heart disease
(Wadhera, Steen, Khan, et al., 2016).
Carbohydrate-rich foods are ranked according to their glycemic index, the
effect on blood glucose levels and insulin response (CDA, 2018).
Carbohydrates that release glucose rapidly into the bloodstream (e.g., white
bread, candy) have a high glycemic index. Carbohydrates that produce only
small fluctuations in blood glucose (e.g., barley, lentils) have a low glycemic
index and offer long-term health benefits of sustaining weight loss,
prolonging physical endurance, and reducing risks associated with heart
disease and diabetes.
The Heart and Stroke Foundation of Canada (2017a) recommends
consuming no more than 10% total calories per day from added sugars and
ideally less than 5%; for an average 2 000 calorie-a-day diet, 10% is about 48
grams (or 12 teaspoons) of added sugars. Sugar is found in many foods, both
naturally, such as in vegetables, fruit, and milk, and added. While foods
containing natural sugars are an important part of a healthy diet because
they also contain important nutrients, added sugars provide energy (calories)
but no nutritional value on their own. Sugars are often added to processed
foods to improve their flavour, colour, texture, and shelf life. Added sugar
may be listed as glucose, fructose, dextrose, maltose, or sucrose on the
ingredient listing on food labels. If any of these sugars are listed as the first
or second ingredient on a food label, the food is likely high in sugar. One can
of a soft drink contains approximately 10 teaspoons of daily added sugar.
Other foods often high in added sugar include energy drinks, fruit-flavoured
drinks, sports drinks, hot chocolate, specialty coffees, baked goods, and
desserts. Consuming too much sugar is associated with heart disease, stroke,
obesity, diabetes, high blood cholesterol, cancer, and dental cavities.
Proteins.
Proteins are essential for synthesis (building) of body tissue in growth,
maintenance, and repair. Collagen, hormones, enzymes, immune cells, DNA,
and RNA are all composed of protein. In addition, blood clotting, fluid
regulation, and acid–base balance require proteins. Nutrients and many
pharmacological substances are transported in the blood by proteins.
The simplest form of protein is the amino acid. As with other nutrients,
essential amino acids are those that the body cannot synthesize but must
have provided in the diet. Nonessential amino acids can be synthesized by
the body. Amino acids are linked together by peptide bonds to form larger
protein molecules called polypeptides. Simple proteins such as albumin and
insulin contain only amino acids or their derivatives. The combination of a
simple protein with a nonprotein substance produces a more complex
protein, such as lipoprotein, formed by a combination of a lipid (fat) and a
simple protein.
Protein quality is determined by the balance of essential amino acids.
Incomplete proteins lack a sufficient quantity of one or more essential amino
acids and include cereals, legumes (beans, peas), and vegetables. A complete
protein contains all of the nine essential amino acids in sufficient quantity to
support growth and maintain nitrogen balance. Examples of foods that
contain complete proteins are chicken, soybeans, fish, and cheese. Complete
proteins are referred to as high-quality proteins. Complementary proteins are
pairs of incomplete proteins that, when combined, supply the total amount
of protein provided by complete protein sources.
Protein is the only major nutrient that contains nitrogen (it is 16%
nitrogen) and is the only source of nitrogen for the body. Thus, nitrogen can
be used to determine protein balance in the body. Nitrogen balance is
achieved when the intake and output of nitrogen are equal. When the intake
of nitrogen exceeds the output, the body is in positive nitrogen balance,
which is required for growth, normal pregnancy, maintenance of lean muscle
mass and vital organs, and wound healing. The nitrogen retained by the body
is used for the building, repair, and replacement of body tissues. Negative
nitrogen balance occurs when the body loses more nitrogen than it gains—
for example, with severe infection, burns, fever, starvation, head injury, and
trauma. The increased nitrogen loss is the result of body tissue destruction or
loss of nitrogen-containing body fluids through urine, feces, sweat, and, at
times, bleeding or vomiting. Nutrition during this period must provide
nutrients to put patients into positive balance for healing.
Protein can be used to provide energy (4 kcal/g), but because of protein's
essential role in growth, maintenance, and repair, adequate kilocalories
should be provided in the diet from nonprotein sources. Protein is spared as
an energy source when carbohydrate in the diet is sufficient to meet the
energy needs of the body.
Fats.
Fats (lipids) are the most calorically dense nutrient, providing 9 kcal/g. In
addition to serving as fuel that supplies energy, fat cushions vital organs,
lubricates body tissue, insulates, and protects cell membranes. Fats are
composed of glycerol and fatty acids. Triglycerides circulate in the blood and
are made up of three fatty acids attached to a glycerol. Fatty acids are
composed of chains of carbon and hydrogen atoms with an acid group on
one end of the chain and a methyl group at the other. Fatty acids can be
saturated, in which each carbon in the chain has two attached hydrogen
atoms, or unsaturated, in which an unequal number of hydrogen atoms are
attached and the carbon atoms attach to each other with a double bond.
Monounsaturated fatty acids have one double bond, whereas
polyunsaturated fatty acids have two or more double carbon bonds. Most
animal fats have high proportions of saturated fatty acids, whereas vegetable
fats have higher amounts of monounsaturated and polyunsaturated fatty
acids. The various types of fatty acids have significance for health and the
incidence of disease, including heart disease, stroke, certain cancers, and
diabetes, and are referred to in the dietary guidelines from the Heart and
Stroke Foundation of Canada (2017b), the Canadian Cancer Society (2018),
the Canadian Diabetes Association (2016), and the Canadian Cardiovascular
Society (Anderson, Grégoire, Pearson, et al., 2016).
Trans fatty acids have received attention for their role in the development
of coronary artery disease (Academy of Nutrition and Dietetics, 2014;
Peterson & Zu, 2016). Formed by the partial hydrogenation of vegetable oils
and mostly found in prepared foods, snack foods, and margarines, trans fats
raise blood levels of so-called bad cholesterol (LDL-cholesterol) while
lowering blood levels of so-called good cholesterol (high-density lipoprotein
[HDL]-cholesterol), which protects against heart disease (Government of
Canada, 2016b). Trans fatty acids have also been associated with diabetes (De
Souza, Mente, Maroleanu, et al., 2015; Peterson & Zu, 2016), Alzheimer's
disease and cognitive decline (Barnard, Bunner, & Agarwal, 2014; Morris &
Tangney, 2014), infertility in men and women (Chavarro, Mínguez-Alarcón,
Mendiola, et al., 2014; Sharma, Biedenharn, Fedor, et al., 2013), and prostate
cancer in men (Brasky, Darke, Song, et al., 2013). The evidence, however, is
inconclusive and contradictory.
Increased research and consumer awareness have led to mandatory
nutrition labelling of trans fats in Canada since 2005. The acceptable
macronutrient distribution range (AMDR), the range associated with
reduced risk of chronic illness while providing essential intake of total fat, is
20% to 35% for adults (Academy of Nutrition and Dietetics, 2014). It is
recommended that Canadians decrease their intake of the proportion of
saturated and trans fatty acids. This is best accomplished by using soft
margarines (liquid or tub varieties) over harder, stick forms, looking for “0 g
trans fat” on the nutrition facts label, and choosing whole, natural foods and
foods made with unhydrogenated oil rather than partially hydrogenated or
hydrogenated vegetable oils or saturated fat.
Cholesterol is often discussed in connection with fats, although it is a
sterol, not a triglyceride (Schlenker & Gilbert, 2014). It occurs naturally in
animal foods but is also synthesized by the liver. Cholesterol deposits in
blood vessel walls cause atherosclerosis, which is the underlying cause of
coronary artery disease.
Water.
Water is a critical component of the body because cell function depends on a
fluid environment. Water makes up 60% to 70% of total body weight. The
percentage of total body water is greater for lean people than for obese
people because muscle contains more water than any other tissue except
blood. Infants have the greatest percentage of total body water, and older
people have the least. When deprived of water, a person cannot survive for
more than a few days. Water helps regulate body temperature and acts as a
solvent for nutrients and waste products. Water passes freely through
membranes that separate body fluids inside (intracellular) and outside
(extracellular) cells. Various water-transport proteins called aquaporins
function as water-selective channels in many cells, altering the speed at
which water crosses cell membranes and influencing conditions such as
cataract formation, hypertension, and salivary gland function (Verkman,
Anderson, & Papadopoulos, 2014).
Fluid needs are met by ingesting liquids and solid foods high in water
content, such as fresh fruits and vegetables. Water is also produced during
digestion when food is oxidized. In a healthy individual, fluid intake from all
sources equals fluid output through elimination, respiration, and sweating
(see Chapters 36 and 38). An ill person can have an increased need for fluid
(e.g., with fever or gastrointestinal losses) and also a decreased ability to
excrete fluid (e.g., with cardiopulmonary or renal disease), which may lead to
the need to restrict fluid intake.
Vitamins.
Vitamins are organic substances essential to normal metabolism. The body is
unable to synthesize most vitamins in the required amounts and depends on
dietary intake. The quantity of vitamins in food is affected by food
processing, storage, and preparation. Vitamin content is usually highest in
fresh foods used quickly after minimal exposure to heat, air, or water. Certain
vitamins function as antioxidants that neutralize substances called free
radicals, which are thought to produce oxidative damage to body cells and
tissues and to increase a person's risk for various cancers. Vitamins with
antioxidant properties include water-soluble vitamin C and fat-soluble betacarotene and vitamins A and E (Schlenker & Gilbert, 2014).
Fat-Soluble Vitamins.
The fat-soluble vitamins (A, D, E, and K) can be stored in the body. With the
exception of vitamin D, these vitamins are provided only through dietary
intake. Vitamin D is provided by both dietary intake and synthesis in the
body with exposure to sunlight. Canada's Food Guide recommends that adults
consume 500 mL (2 cups) of milk each day in order to receive adequate
vitamin D. Yet, because vitamin D needs increase after the age of 50 and
obtaining adequate vitamin D from the diet alone is very difficult, Health
Canada (2012) recommends that all adults over the age of 50 take a daily
vitamin D supplement of 10 micrograms (mcg; 400 IU) in addition to
following Canada's Food Guide. The body can store fat-soluble vitamins;
therefore, hypervitaminosis can result from megadoses (intentional or
unintentional) of supplemental vitamins, excessive amounts of vitamins in
fortified food, and excessive fish oils.
Water-Soluble Vitamins.
The water-soluble vitamins are vitamins C and B complex (which consists of
eight vitamins: thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12,
pantothenic acid, and biotin). Another element, choline, is sometimes
classified as a B vitamin. Water-soluble vitamins are easily destroyed by
cooking and must be provided in the daily food intake. Although watersoluble vitamins are not stored in the body, toxicity may still occur with
vitamin megadoses.
Minerals.
Minerals are inorganic elements essential to the body as catalysts in
biochemical reactions. Minerals become part of the structure of the body and
its enzymes. For example, iron becomes attached to protein globin to form
hemoglobin, which enhances oxygen-carrying capacity. Minerals are classified
as macrominerals when the daily requirement is 100 mg or more and as
microminerals or trace elements when less than 100 mg is needed daily. The
macrominerals are calcium, sodium, potassium, phosphorus, magnesium,
sulphur, and chloride. Trace minerals include iron, iodine, fluoride, zinc,
selenium, chromium, copper, manganese, molybdenum, and cobalt. Other
trace minerals such as aluminum, cadmium, arsenic, and boron have
possible but not clearly delineated nutritional functions. Arsenic, aluminum,
and cadmium have toxic effects.
Anatomy and Physiology of the Digestive System
Digestion.
Digestion of food consists of mechanical breakdown that results from
chewing, churning, and mixing with fluid, as well as chemical reactions by
which food is reduced to its simplest form. Each part of the gastrointestinal
system has an important digestive or absorptive function (Figure 42-1).
FIGURE 42-1
Summary of digestive system anatomy and organ function. HCl, Hydrochloric acid.
(From Rolin Graphics.)
Enzymes are an essential component of the chemistry of digestion.
Enzymes are protein-like substances that act as catalysts to speed up
chemical reactions. Most enzymes have one specific function and function
best at a specific pH. The secretions of the gastrointestinal tract have vastly
different pH levels. For example, saliva is relatively neutral, gastric juice is
highly acidic, and the secretions of the small intestine are alkaline.
The mechanical, chemical, and hormonal activities of digestion are
interdependent. Enzyme activity depends on the mechanical breakdown of
food to increase the surface area for chemical action. Hormones regulate the
flow of digestive secretions needed for enzyme supply. The secretion of
digestive juices and the motility of the gastrointestinal tract are also
regulated by physical, chemical, and hormonal factors. Action in the
gastrointestinal tract is increased by nerve stimulation from the
parasympathetic nervous system (e.g., the vagus nerve).
Digestion begins in the mouth, where chewing mechanically breaks down
food. The food is mixed with saliva, which contains ptyalin (salivary amylase),
an enzyme that acts on cooked starch to begin its conversion to maltose. The
longer food is chewed, the more starch digestion occurs in the mouth.
Proteins and fats are broken down physically but remain unchanged
chemically because enzymes in the mouth do not react with these nutrients.
Because simple sugars (monosaccharides) require no digestion, they may be
absorbed from the mouth. Chewing reduces food particles to a size suitable
for swallowing, and saliva provides lubrication to further ease swallowing of
the food. The epiglottis is a flap of skin that closes over the trachea during
swallowing to prevent aspiration. The tongue manoeuvres the mass of
chewed food into the pharynx, which activates the swallowing reflex.
Swallowed food enters the esophagus and is moved along by wavelike
muscular contractions (peristalsis) to the base of the esophagus, above the
cardiac sphincter. Pressure from a bolus of food at the cardiac sphincter
causes it to relax, allowing the food to enter the fundus (uppermost portion)
of the stomach. Difficulty swallowing is referred to as dysphagia.
In the stomach, pepsinogen is secreted by chief cells and then converted
by hydrochloric acid (HCl) to pepsin, a protein-splitting enzyme. Gastric
lipase and amylase are produced to begin fat and starch digestion,
respectively. The stomach's pyloric glands secrete gastrin, a hormone that
triggers parietal cells to secrete intrinsic factor (IF) and HCl. IF is necessary
for absorption of vitamin B12 in the ileum. HCl also destroys bacteria,
increases the absorbability of iron and calcium, and maintains the pH of the
gastric juice. The lining of the stomach is protected from autodigestion by a
thick layer of mucus. Alcohol and aspirin are two substances directly
absorbed through the lining of the stomach. The muscular walls of the
stomach produce a churning action that continues mechanical digestion. The
stomach acts as a reservoir where food remains for approximately 3 hours,
within a range of 1 to 7 hours.
Food leaves the antrum, or distal stomach, via the pyloric sphincter and
enters the duodenum as an acidic, liquefied mass called chyme. Chyme flows
into the duodenum and is quickly mixed with bile, intestinal juices, and
pancreatic secretions. Secretin and cholecystokinin (CCK) are hormones
secreted by the mucosa of the small intestine. Secretin activates release of
bicarbonate from the pancreas, raising the pH of chyme. CCK inhibits
further gastrin secretion and initiates the release of additional digestive
enzymes from the pancreas and gallbladder.
Bile is manufactured in the liver and stored in the gallbladder. Bile acts as a
detergent, as it emulsifies fat to permit enzyme action while suspending fatty
acids in solution. Pancreatic secretions contain six enzymes: amylase to
digest starch; lipase to break down emulsified fats; and trypsin, elastase,
chymotrypsin, and carboxypeptidase to break down proteins.
Peristalsis continues in the small intestine, mixing the secretions with the
chyme. The mixture becomes increasingly alkaline, inhibiting the action of
the gastric enzymes and promoting the action of the duodenal secretions.
Epithelial cells in the inner walls of the small intestine secrete enzymes to
facilitate digestion. These enzymes include sucrase, lactase, maltase, lipase,
and peptidase. The major portion of digestion occurs in the small intestine,
producing glucose, fructose, and galactose from carbohydrates; amino acids
and dipeptides from proteins; and fatty acids, glycerides, and glycerol from
lipids. Approximately 5 hours are required to pass food through the small
intestine via peristalsis.
Absorption.
The small intestine is the primary absorption site for nutrients. Its inner
surface is lined with fingerlike projections called villi, which increase the
surface area available for absorption. Nutrients are absorbed by means of
passive diffusion, osmosis, active transport, and pinocytosis (Box 42-1).
Box 42-1
Mechanisms for Intestinal Absorption of
Nutrients
Mechanism Definition
Active Transport
In this energy-dependent process, particles move from an area of greater
concentration to an area of lesser concentration. A special “carrier ” is
needed to move the particle across the cell membrane.
Passive Diffusion
The force by which particles move outward from an area of greater
concentration to lesser concentration constitutes passive diffusion. The
particles do not need a special “carrier ” to move outward in all directions.
Osmosis
In this process, water moves through a membrane that separates solutions
of different concentrations. Water moves to equalize the concentration
pressures on both sides of the membrane.
Pinocytosis
Large molecules of nutrients are engulfed by the absorbing cell when the
molecule attaches to the absorbing cell membrane.
Data from Nix, S. (2013). Williams' basic nutrition and diet therapy (14th ed.). St. Louis, MO: Mosby; and
Schlenker, E. D., & Gilbert, J. A. (2014). Essentials of nutrition and diet therapy (11th ed.). St. Louis, MO:
Mosby.
The main source of water absorption is via the intestine. Approximately 7 L
of gastrointestinal secretions and 1.2 L of oral intake, totalling 8.2 L of fluid,
must be managed daily within the gastrointestinal tract. The small and large
intestines reabsorb 8.1 L a day. The remaining 0.1 L is eliminated in feces. In
addition to water, electrolytes and minerals are absorbed, and bacteria in the
colon synthesize vitamin K and some B-complex vitamins. Finally, feces are
formed in the colon for elimination.
Metabolism and Storage of Nutrients.
Metabolism refers to all of the biochemical reactions within the cells of the
body. Metabolic processes can be anabolic (building) or catabolic (breaking
down). Anabolism is the production of more complex biochemical
substances by synthesis of nutrients. Anabolism occurs when lean muscle is
added to the body through diet and exercise. Amino acids are anabolized
into tissues, hormones, and enzymes. Catabolism is the breakdown of
biochemical substances into simpler substances. Starvation is an example of
catabolism, when wasting of body tissues occurs. Normal metabolism and
anabolism are physiologically possible when the body is in positive nitrogen
balance, whereas catabolism occurs during physiological states of negative
nitrogen balance.
Nutrients absorbed in the intestines are transported via the circulatory
system to body tissues. Through the chemical changes of metabolism,
nutrients are converted into a number of substances required by the body.
Carbohydrates, protein, and fat undergo metabolism to produce chemical
energy and to maintain a balance between anabolism and catabolism. To
carry out the body's work, the chemical energy produced by metabolism is
converted to other types of energy. For example, muscle contraction involves
mechanical energy, nervous system function involves electrical energy, and
the mechanisms of heat production involve thermal energy. All of these
forms of energy originate in metabolism.
Nutrient metabolism consists of three main processes:
1. Catabolism of glycogen into glucose, carbon dioxide, and water
(glycogenolysis)
2. Anabolism of glucose into glycogen for storage (glycogenesis)
3. Catabolism of amino acids and glycerol into glucose for energy
(gluconeogenesis)
Glycogen, synthesized from glucose and stored in small reserves in liver
and muscle tissue, provides energy during brief periods of fasting and
maintains blood glucose levels as we sleep. Amino acids can be converted to
fat and stored or catabolized into energy via gluconeogenesis. All body cells
except red blood cells and neurons can oxidize fatty acids into ketones for
energy in the absence of dietary carbohydrates (glucose). Some of the
nutrients required by the body are stored in body tissues. The body's major
form of reserve energy is fat, stored as adipose tissue.
Elimination.
Chyme is moved by peristaltic action through the ileocecal valve into the
large intestine, where it becomes feces. As feces move toward the rectum,
water is absorbed into the intestinal mucosa. The longer the material stays in
the large intestine, the more water is absorbed, causing the feces to become
firmer. Exercise and fibre stimulate peristalsis. Feces contain cellulose and
similar indigestible substances, sloughed epithelial cells from the
gastrointestinal tract, digestive secretions, water, and microbes.
Dietary Guidelines
Dietary Reference Intakes.
In 1997, the Food and Nutrition Board of the American National Institute of
Medicine/National Academy of Sciences, in partnership with Health Canada,
developed dietary reference intakes (DRIs) with respect to age, sex,
pregnancy, and lactation (Health Canada, 2013b). The DRIs present
evidenced-informed criteria for an acceptable range of minimum to
maximum amounts of nutrients, vitamins, and minerals needed to avoid
deficiencies or toxicities. The DRIs have four components: (1) the estimated
average requirement (EAR), which is the recommended amount of a nutrient
sufficient to maintain a specific body function for 50% of the population
based on age and gender; (2) the recommended dietary allowance (RDA),
which is the average needs of 98% of the population, not the exact needs of
an individual (Murphy, Guenther, & Kretsch, 2006); (3) the upper intake level
(UL), which is the highest level believed to pose no risk of adverse health
events but is not a recommended level of intake; and (4) the adequate intake
(AI), which is the suggested intake for individuals that is based on observed
or scientifically determined estimates of nutrient intakes and is used when
insufficient evidence exists to set the RDA. Because this evidence is
continually evolving, clinicians should consult current resources, such as
Health Canada web pages and other evidence-informed literature, when
determining a patient's specific nutrition needs or supplementation.
Food Guidelines.
In 1942, Health Canada developed Canada's first food guide, Canada's Official
Food Rules. Since then, the food guide has undergone many changes in name,
appearance, and content. However, its ultimate purpose—to inform daily
food choices and promote optimal nutritional health—has not changed. The
current guide, called Eating Well With Canada's Food Guide, last updated in
2007 (Figure 42-2), is based on a range of evidence resulting from focus
groups, online consultations, regional meetings, and reviews of literature
about the environmental context in which Canadians make food choices.
Although the scientific basis for the 2007 guide is largely consistent with the
latest diet and health evidence, the guide is scheduled to be revised in 2017–
2018. Its review by Health Canada indicated that there are challenges in
understanding and applying certain aspects (e.g., using food guide servings
and healthy meals and snacks recommendations) and that the current format
is not meeting the needs of all audiences (e.g., some want more detail, while
others would prefer less). The revision will strengthen dietary guidance for
replacing saturated fat with unsaturated fat to help decrease the risk of heart
disease and reducing high intakes of sugar-sweetened beverages to help
decrease the risk of obesity. Only high-quality, peer-reviewed systematic
reviews and reports from leading scientific organizations and governmental
agencies will be considered. As with the 2007 revision, input from health
professional groups, industry, and the public will help ensure that the
recommendations are scientifically sound and address those characteristics
of the diet most relevant to the promotion of health and reduction of chronic
disease for Canadian populations. During the revision process, the Food
Guide can continue to be used as a trusted source of information on healthy
eating (Health Canada, 2017a).
FIGURE 42-2
Extract from Eating Well With Canada's Food Guide. (From Health Canada. [2007]. Eating well with
Canada's food guide [Catalogue No. H164-38/1-2007E]. Ottawa: Author. Retrieved from http://www.hc-sc.gc.ca/fn-an/food-guidealiment/index_e.html.
Reproduced with permission of the Minister of Public W orks and Government Services Canada.)
Included in the general guidelines of Eating Well With Canada's Food Guide
are specific suggestions for food choices. Consumers are told to make at least
half their grain selections whole grain; eat at least one dark green and one
orange vegetable per day; and use vegetables and fruits more than juice,
which contains a lower amount of fibre. Lower-fat dairy products, lean meats,
and choices from the lower-fat meat group (e.g., legumes, tofu) are
encouraged. The minimum intake of unsaturated fats is 30 to 45 mL. Two
Food Guide servings of fish each week are suggested on the basis of evidence
relating fish consumption and reduced risk of cardiovascular disease. The
Food Guide lists water as a calorie-free way to quench thirst and recommends
community water supplies be fluoridated to the level of 1 mg/L. No
directional statements are provided to target calorie intakes (Jessri & L'Abbe,
2015).
Recommended intakes and nutritional values according to Canada's Food
Guide are shown in Table 42-1.
TABLE 42-1
Summary of Recommended Intakes and Nutritional Values According to
Eating Well With Canada's Food Guide
VEGETABLES AND
FRUIT
Years of Servings Per
Age
Day
2–3
4–8
9–13
Girls: 14–18
Boys: 14–18
4
5
6
7
8
Women: 19– 7–8
50
Men: 19–50 8–10
Adults: 51+ 7
GRAIN PRODUCTS
Years of
Age
Servings Per
Day
2–3
4–8
9–13
Girls: 14–18
Boys: 14–18
3
4
6
6
7
Women: 19– 6–7
50
Men: 19–50 8
Women: 51+ 6
Men: 51+
7
Some Important Nutrients in the Food Groups
VEGETABLES AND FRUIT
GRAIN P RODUCTS
Carbohydrate
Protein
Fibre
Carbohydrate
Folate
Fibre
Vitamin B6
Thiamin
Riboflavin
Vitamin C
Niac in
Vitamin A
Folate
Magnesium
Iron
Potassium
Zinc
Magnesium
Potassium
MILK AND
ALTERNATIVES
Years of
Servings Per
Age
Day
MEAT AND
ALTERNATIVES
Years of
Servings Per
Age
Day
2–3
4–8
9–13
14–18
Adults: 19–
51
Adults: 51+
2–8
9–13
Girls: 14–18
Boys: 14–18
Women: 19–
50
Men: 19–50
2
2
3–4
3–4
2
3
1
1–2
2
3
2
3
Women: 51+ 2
Men: 51+
3
MILK AND ALTERNATIVES
Protein
Fat
Carbohydrate
Riboflavin
Vitamin B12
Vitamin A
Vitamin D
Calc ium
Zinc
Magnesium
Potassium
MEAT AND ALTERNATIVES
Protein
Fat
Thiamin
Riboflavin
Niac in
Vitamin B6
Vitamin B12
Iron
Zinc
Magnesium
Potassium
Adapted from Health Canada. (2007). Eating well with Canada's food guide. Ottawa, ON: Author. Retrieved
from http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html. Reproduced with permission of the
Minister of Public Works and Government Services Canada.
Canada's Food Guide notes the importance of physical activity in
maintaining energy balance and recommends that adults spend 30 to 60
minutes per day carrying out some physical activity and that children and
youth spend at least 90 minutes per day. The guide provides advice on the
use of vitamin and mineral supplementation when the recommended food
intake pattern does not ensure adequate amounts. Although not specified in
the guide, Canadians are advised to limit salt to “healthy” levels, alcohol to
no more than 5% of total energy, and caffeine to no more than 400 mg for the
general population, no more than 300 mg (or a little over two 8-oz [237 mL]
cups of coffee per day) for women of childbearing age, and no more than 2.5
mg/kg/day for children (Health Canada, 2013c).
Eating Well With Canada's Food Guide has been adapted for First Nations,
Inuit, and Métis populations (Health Canada, 2010). Examples of foods
traditional to Canadian Indigenous populations are wild plants and seaweed
in the fruit and vegetable groups, bannock as a grain product, and wild game
as a meat alternative. Included in the online Food Guide is a link to a
government website for advice on limiting exposure to mercury from eating
locally caught fish. Instructions are also given for including traditional fats in
the diet such as seal and whale oil, ooligan grease, and bacon fat.
In the past, Canada's Indigenous peoples subsisted on foods obtained
from hunting, trapping, fishing, gathering, and agriculture. The resulting
diet, high in animal protein and low in fat and carbohydrates, provided
adequate energy and nutrients. In replacing traditional foods with
contemporary market foods, the current diet became lower in iron, folacin,
calcium, vitamins A and D, fibre, fruit, and vegetables and higher in fat and
sugar intakes. Patterns of food consumption are further influenced by issues
of food security (ability to acquire acceptable foods), preferences in body
size, individual taste preferences, availability of particular species for food,
knowledge of the nutritional deficits of store-bought food, and alteration of
the natural environment. Health problems such as anemia, dental caries,
heart disease, obesity, and diabetes are related to such patterns (National
Collaborating Centre for Aboriginal Health, 2012).
To date, Canada's Food Guide has not been modified to recognize the
nutritional concerns of Chinese Canadians or other immigrant groups,
although it has been translated into 10 languages. In a scoping review to
assess the current literature on issues pertaining to immigrant nutritional
health, Sanou, O'Reilly, Ngnie-Teta, et al. (2014) reported that immigrants
usually have fewer chronic conditions and tend to be healthier than the
Canadian-born population when they first arrive in the country, owing to the
selection effect of immigrants. However, changes due to living environment,
unfamiliarity with grocery stores, availability of foods, and lifestyle factors
such as urbanization and language barriers then impede the immigrants'
efforts to maintain their traditional dietary practices. In attempting to
acquire the ingredients necessary for replicating familiar dishes, immigrants
are limited to highly processed versions that are high in fat and sodium,
therefore increasing their risk for chronic conditions. Long exposure to
Canadian culture is associated with increased prevalence of obesity among
immigrants.
Canada's Food Guide cannot stand alone as a tool to inform certain groups,
including new immigrants and some Indigenous peoples, who ostensibly
face more barriers to food literacy than other groups. Consideration should
be given to support health providers and other stakeholders in making
nutritional information more effective, understandable, and accessible for
household use (Brichta & Howard, 2013). The need for further examples of
culturally appropriate foods and portions will, no doubt, be addressed
through ongoing revisions to the Food Guide.
The Nutrition Label.
Since December 12, 2007, mandatory nutrition labelling of a nutrition facts
table listing energy (calories) and 13 nutrients (fat, saturated fat, trans fat,
cholesterol, sodium, carbohydrate, fibre, sugars, protein, vitamin A, vitamin
C, calcium, and iron) has been required on most prepackaged foods in
Canada. This easy-to-read table, which appears on food labels in a consistent
appearance, provides consumers with information to make informed food
choices and compare products (Figure 42-3). This information includes (a)
the specific amount of the food item that makes up the serving size, an
amount that may differ from the Food Guide serving size, and (b) the percent
daily value (% DV), a general guideline of how the food's nutrient content
contributes to daily diet. It is important to note that the % DV is based on a 2
000-calorie/day adult diet and thus does not address recommended nutrient
intake for those who are pregnant or breastfeeding. The following dietrelated health claims have been established from recognized health and
scientific information:
FIGURE 42-3
Example of food label. (From Health Canada. [2015]. The nutrition facts table. Ottawa: Author. Retrieved from
http://healthycanadians.gc.ca/eating-nutrition/label-etiquetage/understanding-comprendre/nutrition-fact-valeur-nutritive-eng.php. Reproduced
with the permission of the Minister of Public W orks and Government Services Canada.)
• A healthy diet low in sodium and high in potassium
may reduce high blood pressure risk.
• A healthy diet adequate in calcium and vitamin D
may reduce the risk of osteoporosis.
• A healthy diet low in saturated fat and trans fat
may reduce the risk of heart disease.
• A healthy diet rich in vegetables and fruit may
reduce the risk of some types of cancer.
Some other nutrient content claims as regulated by the Canadian
government (Canadian Food Inspection Agency, 2014) are the following:
• Free indicates the number of calories or the amount
of a nutrient is nutritionally insignificant in a
specified amount of food.
• Claims for saturated fatty acids include a restriction
on levels of both saturated and trans fatty acids.
• The claim (naming the percent) fat-free is allowed
only if accompanied by the statement low fat or low in
fat.
• The nutrient content claim light is restricted to
foods that meet the criteria for either reduced in energy
or reduced in fat.
• The only nutrient content claims permitted for
foods for children under 2 years of age are source of
protein, excellent source of protein, more protein, no added
sodium, and no added sugar.
• A claim of reduced in energy or reduced in calories is
allowed if the item has at least 25% fewer calories
than the food to which it is compared.
Health Promotion and Disease Prevention: A Call to Action
from Dietitians.
In 2011, the United Nations recommended monitoring the trends of
noncommunicable diseases, scaling up measures to reduce risk factors
(including unhealthy diet), strengthening health systems and services, and
improving access to health care. In response, Dietitians of Canada (2012)
called for coordinated action to promote healthy eating through the highest
levels of political commitment and cross-sector collaboration to provide (a)
equitable access to adequate, healthy, and safe food, (b) supportive
environments for healthy eating, (c) comprehensive surveillance and
monitoring of food, diet, and health, and (d) access to dietitian services in all
sectors. Dietitians of Canada has a sustained history of advocating for a
continued leadership commitment to nutrition labelling; food fortification;
food policy and regulation, including consistent nutrition information and
standard serving sizes on nutrition labels; the national reduction of salt,
sugar, and trans fat content in packaged and prepared foods; and using the
(National) Nutritious Food Basket Protocol (e.g.,
http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/nutri
in calculating the cost of a healthy diet to reduce poverty-related food
insecurity.
Dietitians and nutritionists are highly prepared to help patients meet their
nutritional needs. A dietitian must successfully complete a 4-year Bachelor of
Science in Nutritional Sciences, a 1-year internship, and a nationwide exam
before being registered with the Commission of Dietetic Registration and
licensed to practise. Registered dietitians work in the hospital, clinic, or
community or in public health, in private practice settings, and in food and
nutrition industries. Their recommendations and treatment plans are
informed by the evidence of scientific studies. In contrast, nutritionists are
unregulated in Canada, have varying degrees of education, and complete a
certificate program. Because nutritionists are not clinically trained to treat
patients with diseases, they often work in private practices and deliver group
nutrition and cooking classes. The term registered nutritionist is regulated in
Alberta, New Brunswick, Nova Scotia, and Quebec and is used there
interchangeably for registered dietitian.
Nursing Knowledge Base
Nutrition During Human Growth and
Development
Infants Through School-Aged Children.
Infancy is marked by rapid growth with high protein, vitamin, mineral, and
energy requirements. The average (50th percentile) birth weight of a fullterm (40-week gestation) Canadian newborn boy is 3 613 g; that for a
Canadian newborn girl, 3 470 g (Kramer, Platt, Wen, et al., 2001). A healthy
birth weight for newborns ranges from 2 500 to 3 999 g (Region of Waterloo
Public Health, 2017). The infant usually doubles birth weight at 4 to 5 months
and triples it at 1 year. An energy intake of approximately 110 kcal/kg/day is
needed in the first 3 months of infancy, 100 kcal/kg/day between 3 and 6
months, 95 kcal/kg/day for 6–9 months, and 100 kcal/kg/day from 9 months to
1 year (Perry et al., 2016). Commercial formulas and human breast milk each
provide approximately 20 kcal/30 mL. A full-term newborn is able to digest
and absorb simple carbohydrates, proteins, and a moderate amount of
emulsified fat. Spitting up is a natural consequence of the baby's anatomy
because the short esophagus and small stomach allow liquid to escape from
the stomach easily (Winter, 2017). Spitting up may occur during the first year
until the gastroesophageal sphincter (which opens to allow food to enter the
stomach and gas to escape after meals) matures and the child learns to sit
independently. The average energy intake in a breastfeeding infant is 500
kcal/day (based on an average milk intake of 0.78 L/day (Perry et al., 2016).
Infants need 100 or more mL/kg per day of fluid because a large portion of
their total body weight is water.
Breastfeeding.
Health Canada, Canadian Paediatric Society, the Dietitians of Canada, and
the Breastfeeding Committee for Canada (Infant Feeding Joint Working
Group, 2015) recommend breastfeeding as the optimal method of infant
feeding and the exclusive use of breast milk for the first 6 months of the
infant's life. Breastfeeding confers immunological and allergy protection to
the infant during the period of breastfeeding, is economical and convenient
(breast milk is always fresh and at the correct temperature), and provides an
excellent opportunity for mother and infant to interact. Breast milk changes
as a baby grows, is easier to digest than formula, helps protect against
sudden infant death syndrome, and may also have a protective effect against
obesity (Gionet, 2015). Breastfed infants need supplemental vitamin D
because breast milk has only 1 to 10 IU/250 mL (Infant Feeding Joint Working
Group, 2015), or 60% of the vitamin D needed by infants under 1 year of age.
Other vitamin or mineral supplementation is not recommended for the first
6 months.
In 2011–2012, 89% of Canadian mothers breastfed their baby, a slight
increase from 85% in 2003 (Gionet, 2015). Breastfeeding rates ranged from
57% in Newfoundland and Labrador to 96% in British Columbia and the
Yukon. Mothers who breastfed exclusively for at least 6 months were
generally older, had postsecondary qualifications, and were more often
married or common-law status (91%), compared with mothers who did not
breastfeed (70%). Among mothers who breastfed for less than 6 months,
about 44% stopped because they perceived having insufficient breast milk,
18% had difficulty with breastfeeding technique, and 9% experienced a
medical condition of the mother or baby. Canadian health practitioners are
encouraged to promote exclusive breastfeeding by creating an appropriate
“baby-friendly” environment of awareness and support to enable women to
breastfeed throughout the continuum of care from hospitals to community
health services (Pound, Unger, & Canadian Paediatric Society, Nutrition and
Gastroenterology Committee, Hospital Paediatrics Section, 2012/2015).
Formula.
Commercially prepared infant formulas, cow's milk–based and iron fortified,
are designed to contain the approximate nutrient composition of human
milk. Protein in the formula is typically supplied as whey, soy, cow's milk
base, casein hydrolysate, or elemental amino acids. The composition,
processing, packaging, and labelling of all infant formulas are regulated
under Canadian food and drug laws. Although it is now also possible to
supplement commercial infant formula with probiotics for the treatment of
infantile colic, evidence is inconclusive and only a few strains have been
tested (Martin, Ling, & Blackburn, 2016). Further investigations are needed to
provide evidence-informed guidelines.
Specialty formulas are indicated for infants with detected or suspected
pathology. Health providers caring for new mothers and their infants can
address mothers' concerns about infant formulas and help them make
informed choices when selecting the best substitute for human milk.
Regular cow's milk should not be used in infant formula before 9 to 12
months of age because it may cause gastrointestinal bleeding, is too
concentrated for the infant's kidneys, increases the risk of milk product
allergies, and is a poor source of iron and vitamins C and E (Martin et al.,
2016). Honey as a potential source of botulism toxin should not be used in
the infant's diet, as the toxin can be fatal in children under 1 year of age
(World Health Organization [WHO], 2017).
Introduction to Solid Food.
Breast milk or formula provides sufficient nutrition for the first 6 months of
the infant's life. After that, iron-rich solids are introduced to meet the infant's
nutrient needs (Infant Feeding Joint Working Group, 2015). Cues indicating
readiness for solid foods are the appearance of fine motor skills of the hand
and fingers, hand-to-mouth movement, interest in adult food and selffeeding, increased milk consumption, ability to move food to the back of the
mouth, and ability to sit alone in a high chair (Infant Toddler Forum, 2014).
Puréed smooth foods are typically the first semi-solid food to be introduced
to an infant. The addition of foods to an infant's diet should be governed by
the infant's nutrient needs and physical readiness to handle different forms
of foods and by the need to detect and control allergic reactions. New foods
should be introduced one at a time, at least 3 to 4 days apart, to help see if
the baby is allergic to any new food. The new food should be one single type
of food, not a mixture of different foods (Newfoundland Labrador Public
Health, 2013). It is best to introduce new foods before milk or other foods to
avoid infant rejection due to satiety (Health Canada, 2014a).
The growth rate slows during toddler years (ages 1 to 3 years). The toddler
needs fewer kilocalories but an increased amount of protein in relation to
body weight; consequently, appetite may decrease at about 18 months of age.
Toddlers exhibit strong food preferences and become picky eaters. Small,
frequent meals consisting of breakfast, lunch, and dinner, with interspersed,
nutrient-dense snacks, may improve nutritional intake (Leung et al., 2012).
Snacks work best mid-way between meals and should not be offered if the
timing or quantity of snacking will interfere with the child's appetite for the
next meal. Calcium and phosphorus are important for healthy bone growth.
Whole milk should be used until the toddler reaches 2 years of age to help
ensure adequate intake of fatty acids for brain and neurological
development. Toddlers and preschoolers need vitamin D supplementation
until their diet includes at least 10 mcg (400 IU) per day of vitamin D from
other dietary sources (i.e., drinking two cups of milk daily and eating one to
two servings of fish weekly). Toddlers who consume more than 720 mL of
milk daily in lieu of other foods may develop milk anemia, as milk is a poor
source of iron.
The oral health of infants and children needs to focus on preventing
cavities. Children who sleep with a bottle are at particular risk of developing
early childhood tooth decay (ECTD), a severe type of tooth decay that can
affect baby teeth, especially the upper front teeth. The sugars from the milk,
juice, and drinks left in the mouth combine with bacteria in plaque to create
an acid that damages the enamel of a tooth. The longer and more often food
is left in the mouth, the greater the chance of developing ECTD (Health
Canada, 2009). Dental visits should begin within 6 months of the eruption of
the first tooth or by 1 year of age at the latest. From the age of 3 years, twiceyearly dental inspections are recommended. Children under 3 years of age
should have their teeth brushed by an adult, and parents need to supervise
children less than 6 years of age during brushing (Canadian Dental
Association, 2018).
Preschoolers' (3 to 5 years old) dietary requirements are similar to those of
toddlers. They consume slightly more than toddlers, and nutrient density is
more important than quantity. Encouragement of healthy eating is an
important goal of parenting, and parents should try to use attractive food
presentations and fun, educational initiatives rather than unhealthy food as a
reward (Leung et al., 2012; Public Health Nutritionists of Saskatchewan,
2015). Because preschoolers have small stomachs, they need to eat small
amounts of food more often throughout the day. One Food Guide serving from
a food group can be divided into smaller amounts and served throughout the
day. For example, half a serving of meat and alternatives may be served at two
different meals, such as one egg at lunch and about 35 g (1 oz) of chicken for
dinner (Health Canada, 2016a).
Safety Alert
Foods such as hot dogs, candy, gum, cough drops, chewable vitamins,
sunflower seeds, fish with bones, peanuts, marshmallows, grapes, raw
vegetables, popcorn, and snacks on toothpicks or skewers have been
implicated in choking deaths of preschoolers and toddlers and should be
avoided or prepared in a safe manner (Cyr & Canadian Paediatric Society,
Injury Prevention Committee, 2016).
School-aged children, 6 to 12 years old, grow at a slower and steadier rate,
with a gradual decline in energy requirements per unit of body weight. The
school-aged child gains 3 to 5 kg in weight and 6 cm in height per year until
puberty. Despite better appetites and more varied food intake, school-aged
children's diets should be carefully assessed for adequate protein and
vitamins A and C. School-aged children frequently fail to eat a proper
breakfast and have an unsupervised food intake at school. High amounts of
fat, sugar, and salt can result from a liberal intake of commercially prepared
snack foods. Recently, only 1 in 10 Canadian youth were found to meet fruit
and vegetable (FV) recommendations (Minaker & Hammond, 2016). FV
consumption is associated with reduced risk for chronic diseases, including
some cancers, cardiovascular disease, obesity, and all-cause mortality (Wang,
Ouyang, Liu, et al., 2014). Youth who meet FV recommendations are more
likely to be younger (Grade 6 compared to Grades 8 to 9) and get good grades
at school (Minaker & Hammond, 2016). Children who increase fruit
consumption have tended to show less body mass index (BMI) gain
compared to those with constantly low or decreasing fruit consumption
(Bayer, Nehring, Bolte, et al., 2014).
According to the WHO cut-offs, an estimated 32.8% of 5- to 11-year-olds in
Canada are overweight or obese (Roberts et al., 2015). Children living in
Newfoundland and Labrador, Northwest Territories, and the Yukon in 2014
were more likely to be overweight than children in British Columbia
(Statistics Canada, 2016c). Health risks associated with being overweight or
obese in childhood include hypertension and high cholesterol, which are risk
factors for cardiovascular disease; impaired glucose tolerance, insulin
resistance, and type 2 diabetes; breathing problems, such as sleep apnea and
asthma; joint problems and musculoskeletal discomfort; fatty liver disease,
gallstones, and gastro-esophageal reflux (i.e., heartburn); and social and
psychological problems, such as discrimination and poor self-esteem, which
can continue into adulthood (Bariatric and Metabolic Institute, 2017). These
diseases and disorders, traditionally limited to adults, are manifesting in
Canadian youth (Public Health Agency of Canada [PHAC], 2012). The
prevention and treatment of obesity in childhood and adolescence is a critical
public health issue and, ultimately, an important determinant of long-term
health. Strategies to reduce childhood overweight and obesity include (a)
making it a collective priority by Ministers of Health to champion and
encourage shared leadership and action from government departments and
other sectors of Canadian society; (b) coordinating policy priorities to
identify and address the risk of overweight and obesity in children early, to
make children's social and physical environments more supportive of
physical activity and healthy eating, and to increase the availability and
accessibility of nutritious foods and decrease the marketing of foods and
beverages high in fat, sugar, and/or sodium to children; and (c) monitoring
progress in reducing childhood overweight and obesity (PHAC, 2012).
Adolescents.
During adolescence, physiological age is a better guide to nutritional needs
than chronological age. Energy needs to increase to meet the greater
metabolic demands of growth. The daily requirement of protein also
increases. Calcium and vitamin D are essential for the rapid bone growth
that occurs during adolescence, and girls need a continuous source of iron to
replace menstrual blood losses. Boys also need adequate iron for muscle
development. In addition to meats and fish, greens, nuts, dried fruits, and
whole grains are iron-rich foods (Marcus, 2013). Iodine supports increased
thyroid activity, so adolescents' use of iodized table salt helps ensure
adequate intake. B-complex vitamins are needed to support heightened
metabolic activity.
The adolescent's diet is influenced by many factors other than nutritional
needs, including concern about body image and appearance, desire for
independence, and fad diets. Nutritional deficiencies may occur in
adolescent girls as a result of dieting (Findlay, S. M., & Canadian Paediatric
Society, Adolescent Health Committee, 2004/2016) and use of oral
contraceptives (Dante, Vaiarelli, & Facchinetti, 2014). Adolescent girls 14 to
18 years old may have inadequate intakes of vitamin B6, vitamin B12, folate,
zinc, iron, magnesium, phosphorus, and vitamin A. Their median calcium,
potassium, and fibre intakes are below the AI level (Health Canada, 2012).
The adolescent boy's diet may be inadequate in vitamin A and magnesium.
Snacks provide approximately 25% of teenagers' total dietary intake. The
consumption of fast foods has been associated with excess weight gain,
which may be related to the higher energy and fat content of most of these
foods. More than 80% of Canadian adolescents report sodium intakes in
excess of the UL—(Health Canada, 2017b). Fast-food restaurants also offer
larger portions of food, and consumers are eating greater amounts (Benton,
2015). To counteract this trend among adolescents, health promotion
initiatives (e.g., reducing the availability of junk foods in school cafeterias
and vending machines) are being implemented in schools to develop
supportive environments for healthier eating.
The onset of eating disorders such as anorexia nervosa or bulimia nervosa
often occurs during early adolescence, when individuals are establishing
independence and autonomy. Dieting and weight control are viewed as a
defence for feelings of inadequacy or ineffectiveness. In later adolescence,
when facing the task of separation–individualization, similar conflicts may
arise (Weaver, 2015). Recognition of eating disorders is essential for early
intervention (Table 42-2).
TABLE 42-2
Potential Assessment for Eating Disorders
Anorexia Nervosa
A. Restric tion of energy intake leading to significa ntly low body weight in the c ontext of age, sex, developmental trajec tory, and physic al
health.
B. Intense fear of gaining weight or bec oming fat, or persistent behaviour that interferes with weight gain, even though at a signific antly low
weight.
C. S elf-evaluation based on body weight or shape; lac king rec ognition of the seriousness of c urrent low body weight.
S pec ify severity:
Mild: BMI >17 kg/m2
Modera te: BMI 16–16.99 kg/m2
Severe: BMI 15–15.99 kg/m2
Extreme: BMI <15 kg/m2
Bulimia Nervosa
A. Rec urrent episodes of binge eating (eating, in a disc rete period of time [e.g., 2 hours], an amount of food larger than usual for most
people) and experienc ing a sense of lac k of c ontrol over eating during an episode.
B. Rec urrent inappropriate c ompensatory behaviours (e.g., self-induc ed vomiting, use of laxatives or diuretic s, stric t dieting or fasting, or
vigorous exerc ise) in order to prevent weight gain.
C. The binge eating and inappropriate c ompensatory behaviours both oc c ur, on average, at least onc e a week for 3 months.
D. S elf-evaluation unduly influenc ed by body weight or shape.
E. Does not oc c ur exc lusively during episodes of anorexia nervosa.
S pec ify severity:
Mild: An average of 1–3 episodes of inappropriate c ompensatory behaviours per week
Modera te: An average of 4–7 episodes of inappropriate c ompensatory behaviours per week
Severe: An average of 8–13 episodes of inappropriate c ompensatory behaviours per week
Extreme: An average of 14 or more episodes of inappropriate c ompensatory behaviours per week
BMI, Body mass index.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Washington, DC: Author. Copyright 2013, American Psychiatric Association. Reprinted with
permission.
Nurses who work with adolescents experiencing eating disorders need to
be aware of the many implications that such a diagnosis can have on an
adolescent. The ever-present threat to physical health must be carefully
monitored. Beyond the illness and treatment, these youth experience difficult
emotions and face issues of identity, low self-esteem, and autonomy. The case
study in Box 42-2 conveys a nurse's experiences caring for an adolescent girl
with an eating disorder.
Box 42-2
Case Study
The Need for Understanding Nutrition in Psychiatric-Mental
Health Nursing*
Sasha, a 14-year-old girl with a diagnosis of anorexia nervosa, was admitted
to the hospital for refeeding and nutritional support. While brushing her
hair and getting ready for the day, she reported slight chest pain and
faintness. As Sasha's nurse, I performed a basic head-to-toe assessment,
including postural vitals (blood pressure, pulse, and symptoms obtained
with the patient in supine and standing or sitting positions). Additionally, I
followed up on Sasha's most recent blood work. Findings from my
assessment included a postural heart rate jump of 60 beats per minute,
slight swelling or edema in her ankles, and a decrease in serum phosphate
levels. These findings were indicative of refeeding syndrome, a serious and
potentially life-threatening condition associated with shifts in fluids and
electrolytes, most commonly seen in malnourished patients who are
experiencing refeeding. I passed along this information to the rest of Sasha's
treatment team so we could prevent serious complications that could
include heart problems, impaired mental status, and seizures.
In making sure to introduce calories in a safe manner, as standard practice
we perform calculations based on the person's age, height, and previous
growth history to achieve a healthy target body weight. This may mean that
if a person diagnosed with an eating disorder cannot finish a meal, we
provide a calorie drink to replace the number of calories not consumed. As
nurses, we may consult with a dietitian or a nutritionist; yet, in order to
sufficiently support patients and families, we need to have a basic
understanding of nutrition. Without application of such knowledge, there
could have been serious implications to Sasha's refeeding and treatment.
Thankfully, because that knowledge guided my assessment and the
treatment team's response, Sasha was able to move past the barrier of
refeeding syndrome, reaching her target weight upon discharge.
After reading the case study, consider the integral role that nutrition plays
in the adolescent girl's growth and development as well as its influence on
the illness and its treatment. What is the impact of maintaining an
unhealthy low weight on the adolescent girl's bone, cardiac, and
reproductive health? Given the pressing need to restore physiological status
through increasing caloric intake and returning to a healthy body weight,
why was the nurse cautious with refeeding and diligent with bedside
assessments? What nutritional support and teaching are required in caring
for adolescents affected by eating disorders and their families?
*
By Sydney Ellis, RN.
Sports and regular exercise necessitate dietary modification to meet the
increased energy needs of adolescents. Carbohydrates, both simple and
complex, are the main source of energy. Protein needs increase to 1.0 to 1.5
g/kg per day; fat needs do not increase. All athletes need to ingest water
before and after exercise to prevent dehydration, especially in hot
environments. It is not necessary to supplement the diet with vitamins and
minerals, but intake of iron-rich foods is required to prevent anemia
(Pasricha, Low, Thompson, et al., 2014) and of calcium with vitamin D to
prevent stress fractures (Sonneville, Gordon, Kocher, et al., 2012).
Parents often have more influence over the adolescent diet than they
believe they have. Effective strategies include limiting the amount of
unhealthy foods kept at home and enhancing the appearance and taste of
healthy foods. Making healthy foods more convenient and available and
working to change social norms that determine what foods are “cool” are
other ways to promote optimal nutritional health among adolescents
(Krølner, Jørgensen, Aarestrup, et al., 2012).
Pregnancy occurring within 4 years of menarche may place the mother and
fetus at risk because of the mother's anatomical and physiological
immaturity. Malnutrition at the time of conception increases risk to the
adolescent and her fetus. Most teenage girls do not want to gain weight, thus
counselling adolescent girls on the nutritional needs associated with
pregnancy may be difficult; suggestions are better tolerated than rigid
directions. The diet of pregnant adolescents is often deficient in calcium,
iron, and vitamins A and C. Prenatal vitamin and mineral supplements are
recommended.
Young and Middle-Aged Adults.
The demands for most nutrients are reduced as the growth period ends.
Adults need nutrients for energy, maintenance, and repair, although their
energy needs usually decline over the years. Obesity may become a problem
as a result of decreased physical exercise, frequent dining out, and the
increased ability to afford more luxury foods. Women who use oral
contraceptives may need extra vitamins. Iron and calcium intake continues to
be important.
Maintaining good oral health is important throughout adulthood. Poor oral
hygiene and periodontal disease are potential risk factors for systemic
diseases such as bacteremia, endocarditis, cardiopulmonary disease, and
diabetes mellitus and for adverse outcomes in pregnancy (Arigbede,
Babatope, & Bamidele, 2012; Parihar, Katoch, Rajguru, et al., 2015).
Pregnancy.
Nutrition during pregnancy influences birth weight and survival chances in
infants. Generally, the fetus's needs are met at the expense of the mother. If
nutrient sources are not available or are unsafe (such as foods affected by the
Listeria bacteria, which can cross through the placenta), both will suffer. Food
poisoning during the first 3 months of pregnancy can cause a miscarriage.
Later in the pregnancy, it can cause the baby to be born prematurely, a
stillbirth, or a baby who is born very ill. Thus, it is paramount that pregnant
women are careful about what they eat and how they store, prepare, and cook
their food. To lower the risk of food poisoning, pregnant women should avoid
eating hot dogs and non-dried deli meats straight from the package without
further heating, dishes containing raw eggs or seafood, unpasteurized dairy
products and fruit juices, raw sprouts, and pâtés and meat spreads that have
to be refrigerated before use (Health Canada, 2016b). The nutritional status
of the mother at the time of conception is important because significant
aspects of fetal growth and development often occur before pregnancy is
suspected.
The energy requirements associated with pregnancy are related to the
mother's body weight and activity levels. Pregnant women need 100 kcal per
day above the usual allowance during the first trimester and approximately
300 extra calories per day in the second and third trimesters. The additional
nutrients should be obtained by including an extra two to three Food Guide
servings from any of the four food groups daily (Health Canada, 2014b).
Including these extra servings, the daily menu for pregnant women consists
of seven to eight servings of vegetables and fruit, six to seven servings of
grain products, two servings of milk and alternatives, and two servings of
meat and alternatives. A sample weekly menu is available at “My Menu
Planner ”: http://www.eatrightontario.ca/en/MenuPlanner.aspx. It is
recommended that pregnant women have at least 150 g of cooked fish each
week to ensure intake of omega-3 fats and other important nutrients and take
a multivitamin containing 0.4 mg of folic acid and 16 to 20 mg of iron every
day (Health Canada, 2014b). Rigid recommendations about weight gain
should be avoided because the quality of nutrition during pregnancy is more
important than weight gain per se or than the number of kilocalories
consumed per day.
Calcium intake is especially critical during the third trimester, when fetal
bones are mineralized. Iron may be supplemented to provide for increased
maternal blood volume, fetal blood storage, and maternal blood loss during
delivery. Iodine needs increase 15 to 17% because of increased activity of the
thyroid gland. Folic acid intake is particularly important for DNA synthesis
and the growth of red blood cells. Inadequate intake may lead to fetal neural
tube defects, anencephaly, or maternal pre-eclampsia (Wen, Guo, Rodger, et
al., 2016). Health care providers, however, should not advise higher doses of
folic acid than prescribed amounts, especially in late pregnancy, because this
may slightly promote the risk of asthma in offspring (Blatter, Han, Y., Forno,
et al., 2013; Brown, Reeves & Bertone-Johnson, 2014). Other supplements may
also have health risks. For example, vitamin A is essential to maternal and
fetal health but is teratogenic (harmful to embryo or fetal growth and
development) when consumed in excess (National Institutes of Health,
2016a).
Pregnant women should drink at least eight glasses of water daily. They
should also avoid artificial sweeteners, alcohol, excessive caffeine, and all
drugs not specifically ordered, as these substances pass through the placenta
and affect the growing baby. Adequate fluid and fibre intake and moderate
exercise help prevent constipation, which is commonly associated with
pregnancy in response to the growing uterus, pregnancy hormones, and iron
supplementation.
Lactation.
Lactating women need 500 kcal per day above the usual allowance because
milk production increases energy requirements. Eating Well With Canada's
Food Guide suggests that lactating women ingest the same nutrient levels as
recommended during pregnancy. The need for calcium remains the same as
during pregnancy, but lactating women require additional vitamins A and C.
Daily intake of water-soluble vitamins (B and C) is needed to ensure
adequate levels in breast milk. Fluid intake should be adequate but need not
be excessive. Caffeine, alcohol, and drugs are excreted in breast milk and
thus should be avoided (Butte & Stuebe, 2016). Alcohol passes freely into
mother's milk and has been found to peak at about 30 to 60 minutes after
consumption, or 60 to 90 minutes when taken with food. It takes a 55-kg
woman about 2 to 3 hours to eliminate from her body the alcohol in one
serving of beer or wine (La Leche League, 2015).
Older Persons.
Adults aged 65 years and older have a decreased need for energy because the
metabolic rate slows with age. However, vitamin and mineral requirements
remain unchanged from middle adulthood.
Many factors influence the nutritional status of older persons (Box 42-3).
Income is significant; for those living on a fixed income, the amount of
money available to buy food may be reduced. A large number of older
patients benefit from home-delivered or congregate meal services. Health
status is another important factor. The older person may be following a
therapeutic diet; have difficulty eating because of physical symptoms, lack of
teeth, or dentures; or be at risk for drug–nutrient interactions. Thirst
sensation may diminish, leading to inadequate fluid intake or dehydration
(see Chapter 40). Meats may be avoided because of the cost or difficulty to
chew them. Cheese, eggs, and peanut butter are useful high-protein
alternatives. Cream soups and meat-based vegetable soups are nutrientdense sources of protein; yet, commercial soups and packaged meats contain
a high salt content. Milk continues to be an important food for older persons
to protect against osteoporosis (a decrease of bone-mass density). Although
research has shown that older men lag behind women by approximately a
decade in developing osteoporosis, screening and treatment are necessary for
both older men and women (National Osteoporosis Foundation, 2014). The
diets of older persons should contain choices from all food groups and may
require a vitamin and mineral supplement.
Box 42-3
Focus on Older Persons
Factors Affecting Nutritional Status
• Age-related gastrointestinal changes that affect digestion of food and
maintenance of nutrition include changes in the teeth and gums,
decreased bite force, reduced saliva production, atrophy of oral mucosal
epithelial cells, increased taste threshold, decreased thirst sensation,
reduced gag reflex, and decreased esophageal and colonic peristalsis
(Rémond, Shahar, Gille, et al., 2015).
• Presence of other diseases, such as diabetes and cognitive impairments
related to delirium, dementia, and depression, increase risk of poor
nutrition (Leslie & Hankey, 2015).
• Malnutrition in older persons has multiple causes, such as low income,
low educational level, lack of physical functional level to meet activities
of daily living, loss, dependency, loneliness, and lack of transportation
(Ramage-Morin & Garriguet, 2015).
• Medications may have adverse effects, such as causing anorexia (loss of
appetite), xerostomia (severe dryness of the mouth), early satiety, and
impaired smell and taste perception. Older persons are more likely to be
prescribed medications than younger individuals (Pilgrim, Robinson,
Sayer, et al., 2015).
• Intake of calcium, vitamin D, and phosphorus may be deficient,
increasing the risk for osteoporosis. Vitamin B12 may be deficient among
older persons because of the high prevalence of gastrointestinal
pathology and use of medications that alter vitamin B12
pharmacokinetics (Lachner, Steinle, & Regenold, 2012).
• Many nutrients interact with medications, and nurses should consult a
drug handbook for information about specific interactions.
Alternative Food Patterns
Many people follow special patterns of food intake that are based on religion
(Table 42-3), cultural background (Box 42-4) ethics, health beliefs, personal
preference, or concern for the efficient use of land to produce food. Such
special diets are not necessarily more or less nutritious than diets based on
Eating Well With Canada's Food Guide or other nutritional guidelines because
good nutrition depends on a balanced intake of all required nutrients.
TABLE 42-3
Religion-Based Dietary Restrictions and Guidelines
Islam
Pork
Alc ohol
Caffeine
Emulsifiers made from
animal fats, espec ially
margarines
Ramadan fasting sunrise to
sunset for 1 month
Ritualized methods of
animal slaughter required
for meat ingestion
Christianity
Minimal or no
alc ohol
Holy-day
observanc es
may restric t
meat
Hinduism Judaism
All meats
Alc ohol
Onions
Garlic
Pork
Predatory fowl
S hellfish (eat only
fish with sc ales)
Rare meats
Blood (blood
sausage, etc .)
Do not mix milk or
dairy produc ts with
meat dishes
Must adhere to
kosher food
preparation
methods
24 hours of fasting
on Yom Kippur, a
day of atonement
No leavened bread
eaten during
Passover (8 days)
No c ooking on the
S abbath (S aturday)
Church of Jesus
Christ of Latter-Day
Saints (Mormons)
Alc ohol
Tobac c o
Caffeine
Limit meat
SeventhDay
Adventists
Pork
S hellfish
Alc ohol
Vegetarian
diet
enc ouraged
Box 42-4
Cultural Aspects of Care
Nutrition
Food patterns developed as a child, through habits and culture, interact to
influence food intake. Culture also influences the meaning of food not
related to nutrition. Eating is associated with sentiments and feelings such
as “good” and “bad.” For example, children are often rewarded for “being
good” with a treat such as candy. They then associate candy with “being
good.” Food is also the first thing parents give to their children, usually in
the moments after birth, and it is measurable. While love and advice are
offered, a tall glass of milk or a second helping of homemade casserole can
be immediately seen and can make parents feel they have done something
positive for their child.
The incidence of lactose intolerance around the world occurs in the
following ethnic or racial groups: Asian-Pacific, African and African
American, Native American, Mexican American, Middle Eastern, and
Whites. This condition affects nutrient absorption, and calcium deficiency
results. See Table 42-7 for food lists appropriate to lactose intolerance diets.
The theory of “hot” and “cold” foods predominates in many cultures. The
foundation of the theory is that to keep harmony with nature, one must
balance “cold,” “hot,” “wet,” and “dry.” Some cultures believe hot
characterizes warmth, strength, and reassurance, whereas cold represents
menace and weakness. Classification of a food has nothing to do with
spiciness but is a symbolic representation of temperature.
Implications for Practice
• Identify the meaning that certain types of food have for each patient.
• Lactose and other food intolerances unique to specific cultures require
diet adaptation to meet nutrient, mineral, and vitamin daily-intake
requirements.
• In some cultures, specific conditions require hot foods. Menstruation,
cancer, pneumonia, earache, colds, paralysis, headache, and rheumatism
are “cold” illnesses requiring hot foods (e.g., rice, grain cereals, alcohol,
beef, lamb, chili peppers, chocolate, cheese, temperate-zone fruits, eggs,
peas, goat's milk, corn husks, oils, peanuts, onions, pork, radishes,
tamales).
• Other conditions, such as pregnancy, fever, infections, diarrhea, rashes,
ulcers, liver problems, constipation, kidney problems, and sore throats,
are “hot” conditions requiring cold foods (e.g., beans, citrus fruits,
tropical fruits, dairy products, most fresh vegetables, honey, raisins,
chicken, fish, and goat meat).
Adapted from Giger, J. N. (2016). Transcultural nursing: Assessment and intervention (7th ed.). St. Louis,
MO: Elsevier Health Sciences.
Vegetarian Diet.
Vegetarianism is the consumption of a diet predominantly of plant foods.
Vegetarian diets, in general, are low in saturated fat and cholesterol and high
in fibre, folate, antioxidants such as vitamin C and E, potassium, and
magnesium. Because of this, vegetarian diets may lead to lower blood
pressure, improved cholesterol levels, healthier weight, and less incidence of
type 2 diabetes (Heart and Stroke Foundation, 2017b; Trapp & Levin, 2012).
Vegetarian diets may include the following:
1. Semi or partial-vegetarian: May eat some milk products, eggs, poultry,
and fish while primarily consuming plant-based foods
2. Pesco-vegetarian: May eat fish, eggs, dairy products, grains,
vegetables, fruits, legumes, seeds, and nuts while avoiding meat and
poultry
3. Lacto-ovo-vegetarian: Eating eggs, dairy products, grains, vegetables,
fruits, legumes, seeds, and nuts while avoiding meat, poultry, and fish
4. Lacto-vegetarian: Eating dairy products, grains, vegetables, fruits,
legumes, seeds, and nuts while avoiding meat, fish, poultry, and eggs
5. Vegan: Eating grains, vegetables, fruits, legumes, seeds, and nuts
while avoiding meat, fish, poultry, eggs, dairy, and honey
Appropriately planned vegetarian diets can help prevent colon cancer
(Orlich, Singh, Sabate, et al., 2015). Specifically, vegan diets seem to confer
lower risk for overall and for female-specific cancer, compared to other
dietary patterns; lacto-ovo-vegetarian diets seem to confer protection from
cancers of the gastrointestinal tract (Tantamango-Bartley, Jaceldo-Siegl, Fan,
et al., 2013).
It may take planning across the lifespan to get enough protein, iron, zinc,
calcium, vitamins D and B12, and omega-3 fats from foods or supplements
(Dietitians of Canada, 2014). As a general rule, our bodies need
approximately 0.8 grams of protein for every kilogram of body weight. This
means that a person weighing 60 kg requires approximately (60 kg × 0.8) 48
grams of protein daily. Children who follow a vegetarian diet are at risk for
protein, iron, and vitamin deficiencies such as vitamin B12 (Amit & Canadian
Paediatric Society, 2010/2016). Based on the lower digestibility of plant
proteins, it is suggested that protein intake may need to be increased by 30 to
35% for infants up to 2 years of age, 20 to 30% for 2- to 6-year-olds, and 15% to
20% for those older than 6 years of age. A range of plant protein products are
needed because particular amino acids that are abundant in some foods may
be limited in other foods and vice versa. By consuming a wide variety of
foods, the amino acids “complement” each other to provide the essential
amino acids in proper balance. Sources of protein include soy and soy
products; meat alternatives (e.g., textured vegetable protein and veggie
burgers); dried beans (e.g., kidney, black, and white beans), peas (e.g.,
chickpeas and black-eyed peas), and lentils (e.g., red, brown, and green
lentils); and grains, nuts, and seeds (Dietitians of Canada, 2014). For children
under the age of 4, certain high-protein foods such as whole nuts or seeds are
to be avoided, as they represent a choking risk (Cyr & Canadian Paediatric
Society, Injury Prevention Committee, 2016).
Recognizing that iron deficiency is the most common nutritional deficiency
in children, it is essential that food sources rich in iron are included for this
population. Canadian adolescent girls and women of reproductive age who
are vegetarian are at greater risk for low iron stores because diets high in
plant foods contain dietary iron inhibitors (National Institutes of Health,
2016b). Vegetarian athletes need almost twice the iron of non-vegetarians and
should have their iron checked periodically by their primary care provider to
determine if a supplement is needed (Dietitians of Canada, 2013a). Vegan
iron sources include the above protein sources, specifically firm or extra firm
tofu, pinto and adzuki beans, almonds, and sesame seeds (Dietitians of
Canada, 2014). Iron is additionally found in fruits such as prunes, raisins, and
apricots; dark green vegetables such as collards, okra, and bok choy; and
blackstrap molasses (Dietitians of Canada, 2014). The form of iron present in
foods of plant origin is not well absorbed by the body; its rate of absorption
can be increased by incorporating foods high in vitamin C (e.g., oranges and
grapefruit and their juices, lemons, limes, kiwis, mangos, cantaloupe,
potatoes, sweet peppers, broccoli, snow peas, and some green leafy
vegetables).
Calcium deserves special attention in vegetarian food guidelines. A major
criticism of using Canada's Food Guide for vegetarian diet planning is that soy
milk is the only vegan milk alternative mentioned. In addition to fortified soy
drinks and products (e.g., soy yogurts, tofu), good vegan sources of calcium
include navy beans and white beans; nuts and nut products such as almonds
and almond butter; seeds such as sesame seeds and their butter (tahini);
blackstrap molasses; vegetables such as bok choy, okra, collard greens, and
turnip greens; and fruits such as figs and fortified orange juice (Dietitians of
Canada, 2014).
Zinc is found in soy products; dried beans, peas, and lentils; nuts such as
peanuts, pecans, and cashews; seeds such as pumpkin and flax; and whole
grains and fortified cereals.
Unsupplemented vegan diets do not provide vitamin B12. It is
recommended by Dietitians of Canada (2013b) that all people over the age of
50, regardless of type of diet, take at least 2.4 mcg of vitamin B12 in
supplements and fortified foods (e.g., fortified nondairy milks, fortified meat
alternatives, and breakfast cereals). Vitamin B12 is also contained in Red Star
nutritional yeast, the only brand of nutritional yeast in Canada fortified with
vitamin B12. It has a similar flavour to cheese and can be sprinkled on top of
casseroles and in soups. Vegan diets require a source of vitamin D when sun
exposure is insufficient. Good sources of vitamin D include fortified soy and
other fortified non-dairy drinks and soft margarines (Dietitians of Canada,
2014). It is recommended that people over the age of 50 take 400 IU of
vitamin D each day from a supplement (Dietitians of Canada, 2014). There is
no mention of vegetarian sources of omega-3 in Canada's Food Guide. Omega3 fats are found in oils (canola, flax seed, walnut, and soybean); ground flax
seed; and soybeans, tofu, and walnuts.
Critical Thinking
Critical thinking requires the gathering and synthesizing of knowledge,
experience, and information from patients that is gained through intellectual
and professional standards. Clinical judgements involve the anticipation of
required information, analysis of the data, and openness to new ideas and
multiple perspectives when making decisions regarding patient care. Critical
thinking is thus a dynamic process. During assessment (Figure 42-4), all
elements that contribute to the rendering of appropriate nursing diagnoses
are considered.
FIGURE 42-4
Critical thinking model for nutrition assessment. REE, Resting energy expenditure.
When assessing nutrition, the nurse must integrate knowledge from
nursing and other disciplines, previous experiences, information gathered
from patients and families about food preferences, clinical observations, and
dietary history. Professional standards, such as the DRIs and Eating Well With
Canada's Food Guide (Health Canada, 2016c), provide guidelines for assessing
and maintaining patient nutritional status. Other professional standards
from the Heart and Stroke Foundation of Canada, the Canadian Cancer
Society, Canadian Society for Clinical Nutrition, and Diabetes Canada are
available. These standards are research based and regularly updated for
optimal care.
Nursing Process and Nutrition
Nurses are in an excellent position to recognize signs of poor nutrition and
take steps to initiate change. Close contact with patients and their families
enables nurses to make observations about physical status, food intake,
weight changes, and responses to therapy.
Assessment
Early recognition of malnourished or at-risk patients has a strong, positive
influence on both short- and long-term health outcomes. A recent study
identified that 45% of adult patients who were hospitalized for more than 2
days were nutritionally at risk upon hospital admission and that such
malnutrition increases hospital stays by approximately 3 days longer than
nourished patients, costing the health care system $1 500 to $2 000 per
malnourished patient in 2012 dollars (Canadian Malnutrition Task Force,
2016). Other studies have found poorer quality of life, poorer physical
functioning, and higher care complexity in malnourished cardiac patients
(Pathirana, Lokunarangoda, Ranathunga, et al., 2014) and delayed wound
healing in malnourished surgical patients (Mahakalkar, Modi, Yeola, et al.,
2014). Baxter, Al-Madhaki, and Zlotkin (2014) reported the overall prevalence
of malnutrition using body mass index (BMI) for age in Canadian pediatric
patients as being 39.6% to 46%, of which 8.8% and 30.8% of admitted patients
were under- and over-nourished, respectively. Furthermore, 6.9% to 13% were
determined to be acutely malnourished and 13.4% chronically malnourished.
The high prevalence of overall malnutrition suggests that initial screening
using simple anthropometric measures should be conducted on hospital
admission so that patients can receive appropriate nutrition-specific care.
Nutritional screening is a process of identifying characteristics known to
be associated with nutrition problems to identify those who have a nutrition
diagnosis and would benefit from further assessment and treatment by a
dietitian (Canadian Malnutrition Task Force, 2016). The Canadian Nutrition
Screening Tool (CNST) (Table 42-4) is a nutrition-risk screening tool that
consists of two questions about weight loss and fluid intake. Two “YES”
answers indicate increased nutritional risk (Laporte, Keller, Payette, et al.,
2015).
TABLE 42-4
Canadian Nutrition Screening Tool (CNST), 2014
Ask the patient the following questions
Yes No
1. Have you lost weight in the past 6 months without trying to lose this weight?
• If the pa tient reports a weight loss but ga ined it ba ck, consider it a s a NO weight loss.
2. Have you been eating less than usual for more than a week?
• Two “YES” a nswers indica te nutrition risk.
• If the patient is unc ertain regarding weight loss, ask if c lothing is now fitting more loosely.
• If the patient is unable to answer the questions, a knowledgeable informant c an be asked to provide the information.
From Laporte, M. (June 2013). Part of a presentation given at the Canadian Nutrition Society Conference.
Retrieved from http://nutritioncareincanada.ca/sites/default/uploads/files/Comparison-of-nutrition-screeningtools-for-hospital-use.pdf.
If the patient was not at risk upon admission, the person should be
rescreened 1 week later. As well, inadequate food intake (<50% of meals
provided) should be identified and patients weighed weekly (Davidson,
2014).
Nutritional assessment goes beyond nutritional screening and involves
five major areas: anthropometry, laboratory tests, dietary and health history,
clinical observation and physical examination, and patient expectations. It is
important to assess nutritional status when a condition exists that interferes
with the patient's ability to ingest, digest, or absorb adequate nutrition. No
single area or measurement accurately determines nutritional status, and a
patient's personal and social health context needs to be considered.
Anthropometry.
Anthropometry is a measurement system of the size and makeup of the
body. Height and weight are obtained for each patient admission to any
health care setting. If height cannot be measured with the patient standing,
the patient should be positioned lying flat in bed as straight as possible with
arms folded on the chest and measured lengthwise. If possible, the patient
should be weighed at the same time each day, on the same scale, and with the
same apparel. Serial measures over time provide more useful information
than one-time measurement. An ideal body weight (IBW) provides an
estimate of what a person should weigh. Rapid weight gain usually reflects
fluid shifts. Five hundred mL of fluid equals 0.45 kg. For example, for a
patient with renal failure or heart failure, a weight increase of 0.9 kg is
significant, as it may indicate that the patient has retained a litre of fluid.
Recent weight changes should be documented.
Body mass index (BMI) measures weight corrected for height and serves
as an alternative to traditional height–weight relationships.
Calculation of BMI is achieved by dividing the patient's weight in
kilograms by height in metres squared: Weight (kg)/Height2 (m2). The BMI
nomogram is available on Health Canada's website, at http://www.hcsc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/bmi_chart_javagraph_imc_java-eng.php. A BMI measuring between 25 and 30 indicates
overweight, and greater than 30 defines obesity (Health Canada, 2016d). The
BMI is a valid measurement of weight in relation to health; however, it is not
recommended for use as the sole measurement of body composition or level
of fitness because it does not differentiate between excess fat and muscle or
bone and does not consider age, gender, or ethnicity (Al Dokhi & Shahid
Habib, 2013; Gutterman, 2014). Care must be taken when interpreting
overweight and obesity results for Canadian child obesity, as cutoff points
different from adult cutoffs have been used. In 2015, the Canadian Task Force
on Preventive Care recommended the use of the 2014 WHO growth charts;
this recommendation was also endorsed by the College of Family Physicians
of Canada (Canadian Task Force on Preventive Care, 2015).
Heart and Stroke Foundation research indicates that for most people, the
waist circumference (WC) measurement may be used to determine health
risk. Overweight people who carry excess pounds around the waist are at
greater risk of heart disease and stroke than those who carry it on their hips,
thighs, and buttocks. The WC is measured at the part of the trunk located
midway between the lower costal margin (bottom of lower rib) and the iliac
crest (top of pelvic bone) while the person is standing, with feet somewhat
apart. The person doing the measuring should stand beside the individual
and fit the tape snugly, without compressing any underlying soft tissues. The
circumference should be measured to the nearest 0.5 cm, at the end of a
normal expiration. In men, a WC of 102 cm (40 inches) or greater places them
at significant increased risk for heart disease and stroke. In women, this
measurement is 88 cm (35 inches) or more (Health Canada, 2016d; Heart and
Stroke Foundation, 2017c).
Laboratory and Biochemical Tests.
No single laboratory or biochemical test can be used to diagnose
malnutrition. Factors that may alter test results include fluid balance, liver
function, kidney function, and the presence of disease. Common laboratory
tests used to study nutritional status include measures of plasma proteins
such as albumin, transferrin, prealbumin, retinol-binding protein, total iron-
binding capacity, and hemoglobin. After feeding, the response time for
changes in these proteins ranges from hours to weeks. The metabolic half-life
of albumin is 21 days; transferrin, 7 days; prealbumin, 2 days; and retinolbinding protein, 12 hours. A meta-analysis of 63 studies, which included 2
125 patients, investigated the effects of starvation on serum albumin levels in
otherwise healthy individuals and reported that the levels remained normal
until the patients reached extreme states of starvation (BMI <12 or greater
than 6 weeks of starvation) when the malnutrition was already physically
evident (Lee, Oh, Lee, et al., 2015). From this finding, it is evident that
albumin cannot be reliably used as a marker for diagnosing protein-calorie
malnutrition. Serum albumin levels are affected by hydration; hemorrhage;
renal or hepatic disease; AIDS; high-output drainage of wounds, drains,
burns, or the gut; steroid administration; albumin infusions; age; pregnancy;
and trauma, burns, stress, or surgery. Albumin level is a better indicator of
chronic illnesses, whereas prealbumin level is a preferred indicator of acute
conditions.
Nitrogen balance is important to establish serum protein status (see
“Proteins” section). Nitrogen balance is calculated as nitrogen intake minus
nitrogen loss from the body and is useful for evaluating protein metabolism
because nitrogen is an essential part of protein building blocks—amino
acids. Nitrogen output can be measured through laboratory analysis of a 24hour urinary urea nitrogen level (Bharadwaj, Ginoya, Tandon, et al., 2016). For
patients with diarrhea or fistula drainage, a further addition of 2 to 4 g of
nitrogen output is estimated. A positive (more nitrogen taken in than put
out) 2- to 3-g nitrogen balance is ideal for anabolism. In contrast, negative
(more nitrogen put out than taken in) nitrogen balance is present in catabolic
states, such as starvation or physiological stress.
Dietary History and Health History.
The nurse needs to gather information about the patient's illness or activity
level to determine energy needs and compare that information with food
intake. Nursing assessment of nutrition also includes health status; age;
cultural background (see Box 42-4); religious food patterns (see Table 42-3);
socio​economic status; personal food preferences; psychological factors; use
of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements
and prescription or over-the-counter drugs; and the patient's general
nutrition knowledge. Polypharmacy, or multiple concurrent medication use,
is a significant predictor of nutritional status in older persons and requires
careful assessment (Illario, Maione, Rusciano, et al., 2016; Silveira, Dalastra,
& Pagotto, 2014).
In addition to the general nursing health history, a diet history is needed to
assess the patient's needs (Table 42-5). The dietary history focuses on the
patient's habitual intake of foods and liquids, as well as information about
preferences, ability to obtain food, and allergies. Eliciting the diet and health
history requires careful and respectful exploration of the patient's perceived
health status to identify any hidden areas of concern, such as high use of
alcoholic beverages, which Quintero-Platt, González-Reimers, MartínGonzález, et al. (2015) found to be associated with vitamin D deficiency, low
lean mass, liver dysfunction, and greater long-term mortality.
TABLE 42-5
Obtaining a Dietary History (Acronym: FASTCHECK)
Components of a
Dietary History
Food P ractices
Number, type, and
loc ation of meals eaten
per day
Food preferenc es
Food-preparation
prac tic es
Food-purc hasing
prac tic es
Allergies
Areas to Assess and Questions to Ask
How many meals do you eat? At what times do you usually eat? Are these sc heduled meals or snac ks? Where do
you usually eat meals and snac ks? With whom?
What types of food do you like?
Who prepares the food?
Who purc hases the food?
Are you allergic to any foods? S pec ify these foods. What happens when you eat these foods? S pec ify the type of
allergic response (e.g., hives, itc hing, anaphylaxis). What is done to treat allergies (e.g., EpiPen, oral
antihistamines)?
Symptoms
Indigestion, heartburn, What foods c ause indigestion, gas, or heartburn? Does this oc c ur eac h time you eat the food? Have you notic ed
gas, alterations in taste any c hanges in taste? Did these c hanges oc c ur with medic ations or following an illness?
Relief prac tic es
What relieves the symptoms?
Twenty-Four Hour Recall
To c onduc t the 24-hour diet rec all (National Canc er Institute, 2017), ask the patient to desc ribe every item of food and drink ingested in a
24-hour period. The easiest time period to rec all is from the time one awakens to the time one goes to bed again.
a. Using open-ended questions and systematic repetition, ask, “When you first woke up yesterday, what was the first thing you put in your
mouth?” “How muc h of it did you have?” “What time was that?” “What did you eat or drink next?” Do not ask about spec ific meals. Do ask
for foods and drinks between any meals and at bedtime.
b. Ask for spec ific types of foods and drinks: for example, “What kind of milk—whole, fat-free?” What kind of ric e—brown, white?”
c . Rec ord time and amounts of all food eaten.
d. Find out about methods of preparation (e.g., salt, fat) and ingredients in mixed dishes.
e. Rec ord intake of drinks to assess the adequac y of fluid intake.
f. Determine if this intake is typic al of most days.
g. Rec ord type and amount of alc oholic beverages and nonfood items c onsumed. Doc ument servings c onsumed under “Other foods and
beverages.”
After all the information for the diet history is c ollec ted, evaluate the 24-hour rec all by
a. Counting and rec ording the number of servings eaten for eac h food group
b. Comparing servings eaten to rec ommended daily servings appropriate for the age and sex of the patient
Be aware that an individual may have diffic ulty estimating portion sizes and remembering everything, that 24 hours may not be
representative of diet, and that the individual may feel pressure to say what is perc eived as desired.
Do you wear dentures? Full or partial? Orthodontic devic es? Are the dentures or devic es c omfortable? Assess
Chewing and
the c ondition of the patient's teeth.
Swallowing
Do you experienc e mouth pain or sores (e.g., c old sores, c anker sores)?
Do you have diffic ulty swallowing?
Do you c ough or gag when you swallow?
Hunger
Appetite
S atiety
Have you had a c hange in appetite?
Have you notic ed a c hange in weight?
Was this c hange an antic ipated c hange (e.g., were you following a weight-reduc tion diet)?
Do you stop eating when feeling full?
Do you pic k at food between meals or eat substantially before bedtime?
Elimination P atterns
How often do you have bowel movements?
Do you experienc e diarrhea with meals or spec ific foods? If yes, how do you manage the diarrhea?
Do you experienc e c onstipation? If yes, how do you manage it?
Chemical Substances
Medic ation use
Over-the-c ounter
substanc es
Alc ohol
S upplements
Knowledge
What medic ations do you take?
Do you take any over-the-c ounter medic ations that your doc tor does not presc ribe? If yes, spec ify them.
How many servings of alc oholic beverages do you drink eac h day—one, two, three, five, ten, or more?
Desc ribe any nutritional or herbal supplements you use.
Do you believe your c urrent diet is adequate for meeting your energy needs? If not, what would you like to
c hange?
Outpatients may keep a food diary spanning several days, which will
enable more accurate calculation of nutritional intake and comparison to
Eating Well With Canada's Food Guide and DRIs to see if dietary habits are
adequate. Culturally sensitive food-frequency questionnaires may also be
used to establish patterns over time.
Clinical Observation and Physical Examination.
Clinical observation is key to nutritional assessment. Because improper
nutrition affects all body systems, the patient should be observed for signs of
nutritional alterations during physical assessment (see Chapter 32). When
the general physical assessment of the body systems is complete, pertinent
areas can be rechecked to evaluate the patient's nutritional status. The
clinical signs of nutritional status (Table 42-6) provide guidelines for
observation during physical assessment.
TABLE 42-6
Clinical Signs of Nutritional Status
Body Area Signs of Good Nutrition
Signs of Poor Nutrition
General
appearanc e
Weight
Listless, apathetic , c ac hec tic appearanc e
Alert; responsive
Weight appropriate for height, age, body
build
Posture
Erec t posture; straight arms and legs
Musc les
Well-developed, firm musc les; good tone;
some fat under skin
Nervous
Good attention span; lac k of irritability or
system c ontrol restlessness; normal reflexes; psyc hologic al
stability
Obese or underweight appearanc e (spec ial c onc ern for underweight)
S agging shoulders; sunken c hest; humped bac k
Flac c id appearanc e, poor tone, underdeveloped tone; tenderness; edema;
wasted appearanc e; inability to walk properly
Inattention; irritability; c onfusion; burning and tingling of hands and feet
(paresthesia); loss of position and vibratory sense; weakness and tenderness
of musc les (may result in inability to walk); dec rease or loss of ankle and
knee reflexes
Gastrointestinal Good appetite and digestion; normal regular Anorexia; indigestion; c onstipation or diarrhea; liver or spleen enlargement
func tion
elimination; no palpable organs or masses
Cardiovasc ular Normal heart rate and rhythm; lac k of
func tion
murmurs; normal blood pressure for age
General vitality Enduranc e; energy; good sleep habits;
vigorous appearanc e
Hair
S hiny, lustrous appearanc e; firmness; strands
not easily pluc ked; healthy sc alp
S kin (general) S mooth and slightly moist skin with good
c olour
Fac e and nec k Uniform c olour; smooth, pink, healthy
appearanc e; lac k of swelling
Lips
S moothness; good c olour; moist (not
c happed or swollen) appearanc e
Mouth, oral
Reddish pink, intac t muc ous membranes in
membranes
oral c avity
Gums
Pink; healthy appearanc e; lac k of swelling
or bleeding
Tongue
Pink or deep reddish c olour; lac k of
swelling; smoothness, presenc e of surfac e
papillae; lac k of lesions
Teeth
Lac k of c avities and pain; bright, straight
appearanc e; lac k of c rowding; well-shaped
jaw; c lean appearanc e with no disc oloration
Eyes
Bright, c lear, shiny appearanc e; lac k of sores
at c orner of membranes; eyelids moist and
healthy pink c olour; prominent blood
vessels or lac k of mound of tissue or sc lera;
lac k of fatigue c irc les beneath eyes
Nec k (glands) Lac k of enlargement
Nails
Firm, pink appearanc e
Legs, feet
Lac k of tenderness, weakness, or swelling;
good c olour
S keleton
Lac k of malformation
Rapid heart rate (above 100 beats/minute), enlarged heart; abnormal rhythm;
elevated blood pressure
Easily fatigued; lac k of energy; falling asleep easily; tired and apathetic
appearanc e
S tringy, dull, brittle, dry, thin, and sparse, depigmented appearanc e; strands
that c an be easily pluc ked
Rough, dry, sc aly, pale, pigmented, irritated appearanc e; bruises; petec hiae;
subc utaneous fat loss
Greasy, disc oloured, sc aly, swollen appearanc e; dark skin over c heeks and
under eyes; lumpiness or flakiness of skin around nose and mouth
Dry, sc aly, swollen appearanc e; redness and swelling (c heilosis); angular
lesions at c orners of mouth; fissures or sc ars (stomatitis)
S wollen, boggy oral muc ous membranes
S pongy gums that bleed easily; marginal redness, inflammation; rec eding
gums
S welling, sc arlet, and raw appearanc e; magenta c olour, beefiness (glossitis);
hyperemic and hypertrophic papillae; atrophic papillae
Unfilled c aries; absent teeth; worn surfac es; mottling (fluorosis);
malpositioned appearanc e
Pale eye membranes (pale c onjunc tivae); redness of membrane (c onjunc tival
infec tion); dryness; signs of infec tion; buildup of keratin debris in the
c onjunc tiva (Bitot's spots), redness and fissuring of eyelid c orners (angular
palpebritis); dryness of eye membrane (c onjunc tival xerosis); dull appearanc e
of c ornea (c orneal xerosis); soft c ornea (keratomalac ia)
Thyroid enlargement
S poon shape (koilonyc hia); brittleness; ridges
Edema; tender c alves; tingling; weakness
Bowlegs; knoc k knees; c hest deformity at diaphragm; prominent sc apulae and
ribs
From Hood, W. A. (2015). Nutritional status assessment in adults technique. Medscape. Retrieved from
http://emedicine.medscape.com/article/2141861-technique; Kirkpatrick, K. (2014, February 18). 9 ways your
body is trying to tell you that your diet stinks. Huffington Post. Retrieved from
http://www.huffingtonpost.com/kristin-kirkpatrick-ms-rd-ld/diet-problems_b_4456679.html.
The patient should also be assessed for aspiration (choking) risk and
dysphagia (difficulty when swallowing). Those at risk of aspiration may have
decreased levels of alertness, decreased gag or cough reflexes, difficulty
managing saliva, or a wet, gurgling voice. The warning signs of dysphagia
include coughing during eating; change in voice tone or quality after
swallowing; abnormal movements of the mouth, tongue, or lips; slow, weak,
imprecise, inconsistent, or uncoordinated speech; abnormal gag reflex;
delayed swallowing; incomplete oral clearance or pocketing of food or
medications; and regurgitation. In Canada, approximately half of all new
stroke patients older than 65 years of age live with dysphagia for months
after the stroke. Patients with dysphagia often do not show overt signs such
as coughing when food enters the airway. Aspiration may be silent; this
absence of any outward sign or distress is known as “silent aspiration,”
reported as occurring in over 40% of patients (Cohen, Roffe, Beavan, et al.,
2016) but unsuspected as the cause of death by clinicians in one third of
these patients (Hu, Yi, & Ryu, 2014). Early detection of dysphagia improves
outcomes such as malnutrition, dehydration, pulmonary compromise,
mortality, length of hospital stay, and overall health care expenditures
(Hebert, Lindsay, McIntyre, et al., 2016; Wirth, Dziewas, Beck, et al., 2016).
The 2015 Canadian Stroke Rehabilitation Best Practice Guidelines (Hebert
et al., 2016) recommend early assessment of all stroke patients by
rehabilitation professionals with specialized training in stroke care and
recovery. Along with nurses, the core rehabilitation interprofessional team
includes physiatrists, other physicians with expertise in stroke rehabilitation,
occupational therapists, physiotherapists, speech-language pathologists,
social workers, and dietitians. Nurses should implement aspiration
precautions (Skill 42-1) and refer patients at risk of malnutrition, including
those with dysphagia, to a dietitian for nutrition assessment and ongoing
management.
SKILL 42-1
ASPIRATION PRECAUTIONS
Delegation Considerations
The assessment of aspiration risk and
determination of positioning c annot be
delegated to unregulated c are providers
(UCPs). However, UCPs may feed patients after
rec eiving instruc tions about aspiration
prec autions. It is important to instruc t UCPs
about the following:
• Appropriate patient positioning to dec rease
aspiration risk
• Reporting of any onset of c oughing, gagging, or
poc keting of food
P ROCEDURE
STEP S
1. Give patients who are not alert within the first 24
hours post-stroke nothing by mouth (NPO) and
Equipment
• Chair or elec tric bed (to allow patient to sit upright)
• Thic kening agents as needed (c ommerc ial prethic kened produc ts or c ommerc ial
thic kening agent)
• Tongue blade
• Penlight
RATIONALE
• Risk of aspiration is high (Hebert et al., 2016).
monitor c losely.
2. Patients should be sc reened for swallowing
defic its as soon as they are alert and ready for
trialling oral intake using a valid sc reening tool by
an expert in dysphagia.
3. Assess patients for signs and symptoms of
dysphagia (e.g., c ough, c hange in voic e after
swallowing). Video fluorosc opic swallow study
or fibre-optic endosc opic examination of
swallowing should be performed on all patients
c onsidered at risk for pharyngeal dysphagia or
poor airway protec tion, based on results from the
bedside swallowing assessment (Hebert et al.,
2016).
4. Ask patient about any diffic ulties with c hewing or
swallowing foods with different textures.
5. Ensure that the c linic al bedside sc reening trial is
c onduc ted by a speec h language pathologist
(S LP) or appropriately trained spec ialist.
6. Elevate head of patient's bed so that hips are
flexed at a 90-degree angle and head is flexed
slightly forward, or help patient to the same
position in a c hair.
7. The c linic al bedside sc reening trial involves
giving 3 to 10 mL of water, and if that is well
tolerated, it is followed by a small c up (50–90 mL)
of water.
8. For a patient who may feed self, explain that you
are initially observing while the patient eats:
A. Observe patient c onsume various
c onsistenc ies of food and liquids, watc hing for
signs of dysphagia.
B. Note at the end of the meal if patient bec omes
tired.
C. Report signs and symptoms of dysphagia.
• An individualized management plan should be developed to address dysphagia,
dietary needs, and spec ialized nutrition plans (Hebert et al., 2016).
• Patients at risk inc lude those who have c hronic obstruc tive pulmonary disease or
neurologic al or neuromusc ular diseases and those who have had trauma to or
surgic al proc edures of the oral c avity or throat.
• Certain types of food are more easily aspirated.
• The S LP is qualified to assess and to advise on the safety of the patient's swallowing
ability and the c onsistenc y of diet and fluids.
• Reduc es risk of aspiration (Metheny, 2016).
• The Water S wallow Test is a useful bedside sc reening tool for aspiration in stroke
patients, espec ially for its c onvenienc e and c ost-effec tiveness in c linic al prac tic e.
The test ac c urac y is related to the water volume; water volumes of 3 mL (Hayashi,
Yahiro, S akuragi, et al., 2016), 50 mL (Martino, Maki, & Diamant, 2014), and 90 mL
(Chen, Chuang, Leong, et al., 2016) have been tested and rec ommended for
sc reening aspiration in stroke patients. There is no c onsensus among studies of the
method of sc reening for dysphagia in the adult stroke population (Almeida, Cola,
Pernambuc o, et al., 2015; Hayashi et al., 2016).
• S elf-feeding may reduc e the risk of pneumonia (Hebert et al., 2016) and inc reases
patient c ooperation.
• Referral to a dietitian and S LP is appropriate if patient has diffic ulty with a partic ular
c onsistenc y.
• Fatigue inc reases risk of aspiration.
• S igns or symptoms indic ate the need for further evaluation of swallowing by an S LP
in c ollaboration with the radiology department, suc h as a fluorosc opic swallow
study (Hebert et al., 2016; Koidou, Kollias, S dravou, et al., 2013). A signific ant
number of individuals who aspirate do not exhibit signs and symptoms of dysphagia
(Teasell, Foley, Martino, et al., 2016).
• Alerts the health c are team to the problem and helps the team to develop and
implement an individualized plan of c are.
• Inc reases patient c omfort.
D. Plac e identific ation on patient's rec ord
indic ating that dysphagia is present.
9. For patients who require supervision or
assistanc e with eating bec ause dysphagia and risk
of aspiration have been identified, explain that you
will assist them with their meal:
A. Perform hand hygiene.
• Reduc es transmission of mic roorganisms.
B. As ordered or rec ommended by the
• Thin liquids suc h as water and fruit juic e are diffic ult to c ontrol in the mouth and are
feeding/swallowing team, add thic kener to thin
more easily aspirated (Leder, Judson, S liwinski, et al., 2013). It is essential to follow
liquids to c reate the c onsistenc y of nec tar,
the team's determination for c onsistenc y bec ause best prac tic es have not yet been
honey, or pudding.
established (S teele, Alsanei, Ayanikalath, et al., 2015). It was shown that in a spec ific
subset of individuals who swallowed puree c onsistenc y without aspiration but
exhibited pharyngeal dysphagia and aspiration with thin liquid c onsistenc y, both
nec tar-like and honey-like thic kened liquids were swallowed without aspiration, with
100% suc c ess (Leder et al., 2013).
C. Plac e 1/2 (2.5 g) to 1 teaspoon (5 g) of food on • Provides patient with tac tile c ues to begin eating.
unaffec ted side of the mouth, allowing utensil to
touc h the mouth or tongue.
D. Plac e hand on throat to gently palpate
• Helps evaluate swallowing effort.
swallowing event as it oc c urs. S wallowing
twic e is often nec essary to c lear the pharynx.
E. Provide verbal c oac hing and positive
• Verbal c ueing keeps patient foc used on swallowing. Positive reinforc ement
reinforc ement while feeding patient.
enhanc es patient's c onfidenc e in ability to swallow.
• Feel the food in your mouth.
• Chew and taste the food.
• Raise your tongue to the roof of your
mouth.
• Think about swallowing.
• Close your mouth and swallow.
• S wallow again.
• Cough to c lear the airway.
F. Observe for c oughing, c hoking, gagging, and
drooling of food; suc tion airway as nec essary.
G. Provide rest periods as nec essary during meal
to avoid rushed or forc ed feeding.
H. Using a penlight and tongue blade, gently
inspec t patient's oral c avity during and after the
meal to detec t poc kets of food.
I. Ask patient to remain sitting upright for at least
30 minutes after the meal.
J. Help patient to perform hand hygiene and mouth
c are. Provide educ ation and support to enable
patient to meet his or her oral hygiene needs, be
able to selec t and use appropriate oral hygiene
equipment, and rec ognize and manage diffic ulty
of swallowing.
K. Rec ord intake and report any observations
indic ative of feeding and swallowing diffic ulties.
L. Ensure return of patient's tray to appropriate
plac e, and perform hand hygiene.
10. Weigh patient weekly at the same time on the
same sc ale.
UNEXP ECTED OUTCOMES
Coughs, ga gs, food “stuck in throa t,” or left in mouth
Avoida nce of certa in textures of food
Weight loss
• These are indic ations that suggest dysphagia and risk for aspiration.
• Avoiding fatigue dec reases the risk of aspiration.
• Poc kets of food in the mouth often indic ate diffic ulty swallowing.
• Reduc es the risk of gastroesophageal reflux, whic h c auses aspiration (Teasell et al.,
2016).
• Mouth c are after meals helps c ontrol dental plaque and maintain patient's oral
hygiene (Teasell et al., 2016).
• Reduc es spread of mic roorganisms.
• Determines if weight is stable and reflec ts adequate c aloric level.
RELATED INTERVENTIONS
• Patient may require a swallowing evaluation.
• Initiate c onsultation with an S LP for swallowing exerc ises and tec hniques to
improve swallowing and reduc e risk of aspiration.
• Notify the nurse in c harge, health c are provider, and S LP of any symptoms that
oc c urred during meal and whic h foods c aused the symptoms.
• Change c onsistenc y and texture of food.
• Disc uss findings with the nurse in c harge, health c are provider, S LP, or registered
dietitian.
RECORDING AND REP ORTING
• Doc ument the following in the patient's c hart: patient's toleranc e of various food textures, amount of assistanc e required, position during
meal, absenc e or presenc e of any symptoms of dysphagia, and amount eaten.
• Report any c oughing, gagging, c hoking, or swallowing diffic ulties to the nurse in c harge or the health c are provider.
Safety Alert
The importance of safety considerations (i.e., checking consistency of fluid,
correct drinking utensil and volume of fluid, 90-degree head-of-bed
elevation, supervision) for patients with impaired swallowing cannot be
overstressed. Healthy people can tolerate the dynamic and often fast flow of
liquids during swallowing to cleanly direct liquids past the airway and into
the esophagus. However, individuals with dysphagia find the flow of liquids
difficult to control during passage through the pharynx. This can result in
impaired airway protection. One method of managing this challenge is to
thicken liquids so that they flow more slowly, thus allowing the individual
time to coordinate safe swallowing. Liquids are thickened to various levels of
viscosity with a range of starches and gums, including commercially
prepared products, and typically range from the least viscous liquid (akin to
the thickness of nectar) for mild dysphagia to increasingly thicker liquids
(honey-like and spoon-thick or pudding consistency) for more severe
dysphagia (Cichero, 2013). Prescription of fluid thickness is patient specific.
Patients who have dysphagia are not to drink with a straw unless
specifically advised by their therapist. When deemed safe to use, drinking
straws reduce the volumes of discrete sips. Narrower straw diameters are
associated with smaller bolus volumes (Clark, Anderson, & Hietpas, 2014). A
straw may make it easier to get the liquid into the mouth and to take
sequential sips without liquid spilling out of the mouth; however, healthy
adult participants who drank from a cup ingested significantly more than
those who used a straw (Veiga, Fonseca, & Bianchini, 2014). Additional study
is needed to determine whether individuals with dysphagia demonstrate
similar patterns of bolus size associated with straws (Cichero, 2013; Clark et
al., 2014; Clark & Shelton, 2014).
Patient Expectations.
Because patients rely on nurses and other health care providers to identify
problems, nurses must be knowledgeable about nutrition, nutritional
screening, assessment, and referral to meet patient expectations and needs.
Nursing Diagnosis
Assessment enables determination of any actual or potential nutrition
problems. Assessment data are clustered together to inform a clinical
judgement about individual, family, or community responses to problems
and life processes. A problem may occur when overall intake is significantly
decreased or increased, or when one or more nutrients are not ingested or
absorbed. For example, a man is seen at the community health clinic with a
diagnosis of dysthymia (a chronic form of depression that is milder in
severity than major depression) and with the profile shown in Box 42-5.
Specific diagnoses are related to the actual nutritional problem (e.g.,
excessive intake) but may also involve problems that place the patient at risk
for nutritional or health difficulties, such as physical inactivity.
Box 42-5
Nursing Diagnostic Process
Imbalanced Nutrition: More Than Body Requirements
Assessment
Data and Defining Characteristics
Activities
Obtain height
and weight
Obtain 24-hour
food history
Fluid
Physic al
assessment
Laboratory
values
Medic ation
S oc ial
52-year-old man
Height: 180 c m
Weight: 122 kg
Body mass index (BMI) = 37.7
Lac k of satiety
High fat and c arbohydrate intake, three meals plus a large evening snac k/day, three to four beers per day
Fluid intake is c ola, beer, and juic e, all high c aloric and lac king nutrient density
S hort of breath on walking
Large abdomen
Blood pressure: 158/88 mm Hg
Pulse: 102 beats/minute
Respirations: 32 breaths/minute
Reports low energy, fatigue, and intermittent feelings of hopelessness sinc e his partner left him last year
Cholesterol and triglyc erides elevated. All others within normal limits
None
Eats out with his 12- and 14-year-old sons two times a week. S ays, “My sons are the only thing I have to look forward to.
Without them, I would just be sitting behind my desk at work all day or else laid bac k in front of the TV at night.”
The nursing diagnostic statement is based on defining characteristics
present in the assessment database. The suspected health problem related to
the nursing diagnosis is stated. The following are examples of nursing
diagnoses relevant to nutritional problems that may pertain to the 52-yearold man with dysthymia being seen at the community health clinic (see Box
42-5):
• Excess fluid volume
• Health maintenance, ineffective
• Imbalanced nutrition: more than body requirements
• Fatigue
• Hopelessness
• Activity intolerance
• Risk for impaired cardiovascular function
• Social isolation
Planning
The planning for enhanced, optimal nutritional status requires a higher level
of care than simply correcting problems. Information from multiple sources
must be synthesized to devise an individualized approach to care that is
responsive to the patient's needs (Figure 42-5). All data sources need to be
considered when developing a nursing care plan (Box 42-6). It is crucial to
refer to published standards that are based on scientific findings.
FIGURE 42-5
Critical thinking model for nutrition planning.
Box 42-6
Nursing Care Plan
Imbalanced Nutrition: Less Than Body Requirements
Assessment
Belinda Wong, a nurse practitioner in a community health centre, is seeing
68-year-old Mrs. Cooper, who has a history of heart failure. Recently, Mrs.
Cooper noticed a weight loss (15%). She has been taking an antidepressant
(sertraline) for 3 months for an initial episode of depression related to the
loss of her husband 6 months ago. Mrs. Cooper was referred for counselling
3 months ago to help with grief and depression. When Belinda inquired
about Mrs. Cooper's financial situation, Mrs. Cooper responded that it was
difficult living on an income from the Canada Pension Plan, but she was able
to manage.
Assessment Activities
Data and Defining Characteristics
Ask Mrs. Cooper about her food intake during the
last 2 days.
S he says she drinks one glass of juic e in the morning and two or three c ups of c offee.
S he may eat a sandwic h in the late afternoon. “I'm just not interested in food. It has no
taste.”
S he says she does not need to worry about being overweight and believes her diet is
adequate for her needs, as she does not feel hungry. S he says she thinks she should be
eating more vegetables and drinking more milk. Her meal preparation is “quic k and
easy,” whic h pleases her. S he says she is “too tired to fuss over food.”
S he takes the following presc ribed medic ations as instruc ted on a daily basis: sertraline,
digoxin (c ardiac glyc oside), c hlorothiazide (diuretic ), and c aptopril (antihypertensive).
Mrs. Cooper says she is lonely and does not get out muc h, although her psyc hologist
rec ommended more soc ializing. Her friends at c hurc h c all to ask her to c ome to
meetings, but she is not ready. S he says she tires easily.
This weight loss oc c urred over 6 months, down 11 kg. S he has stooped posture. S he
has a low body mass index (BMI) of 17.
Dull, thinning hair
Dry, sc aling skin
Pale c onjunc tivae and muc ous membranes
2+ bilateral pitting ankle edema
Generalized poor musc le tone
Assess Mrs. Cooper's knowledge base by asking
her what she sees as strengths of her diet, about
areas in whic h her diet is ineffec tive, and what
resourc es she uses in guiding her meal planning.
Assess her use of medic ation.
Ask Mrs. Cooper about soc ial interac tion.
Weigh Mrs. Cooper and assess her posture.
Observe Mrs. Cooper for signs of poor nutrition.
Palpate her musc les and extremities.
Nursing Diagnosis:
Imbalanced nutrition: less than body requirements related to a decreased
ability to ingest food as a result of depression and loss of appetite associated
with antidepressant use.
Planning
Goals (Nursing Outcomes Classification)*
Expected Outcomes
Mrs. Cooper will progressively gain weight.
Weight Control
Patient will gain 0.5 to 1 kg/month until goal of 59 kg is reac hed.
Nutritional Status: Nutrient Intake
Patient will ingest 1 900 kc al/day, inc luding 50 g of protein per day.
Physic al assessment and laboratory values will be within normal limits.
Mrs. Cooper will c onsume adequate nourishment eac h day.
Mrs. Cooper will exhibit no signs of malnutrition.
*
Outcome classification labels are adapted from Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E.
(2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis: Elsevier.
Interventions
Interventions (Nursing
Interventions Classification)†
Nutritional Counselling
Coordinate a plan of c are with Mrs. Cooper, her
family doc tor, therapist, and dietitian.
Individualize menu plans.
Teac h Mrs. Cooper about the value assoc iated
with c onsulting Ea ting Well With Ca na da 's Food
Guide.
Nutritional Monitoring
Monitor Mrs. Cooper monthly for weight gain,
anemia, serum albumin level, and total
lymphoc yte c ount (TLC).
Perform physic al assessment of hair, eyes, mouth,
skin, and musc le tone.
Nutritional Management
Enc ourage Mrs. Cooper to eat small meals and
inc rease dietary intake to help offset anorexia
sec ondary to use of sertraline.
Enc ourage fluid intake early in the day.
Rationale
S uc c essful nutrition c are planning involves an interdisc iplinary approac h (Tappenden
Quatrara, Parkhurst, et al., 2013).
Enc ourages intake by inc orporating food preferenc es (Weaver, Dwyer, Fulgoni, et al.,
2014).
Health Canada (2016c ) rec ommendations for food selec tions provide optimal nutrition.
Weight gain should be slow and progressive. S erum albumin of 40 g/L and TLC of 1
500/mm3 are within normal limits ( Robinson, 2015 ).
To monitor for improved nutritional status.
S ertraline is a selec tive serotonin reuptake inhibitor (S S RI) medic ation; diminished taste
and anorexia are c ommon effec ts of S S RIs. Frequent small meals help to reduc e anorexiaassoc iated weight loss.
Older persons need eight 250-mL glasses per day of fluid from beverage and food
sourc es. Conc entrating intake in the morning and early afternoon prevents noc turia.
Enc ourage fibre intake.
Fibre helps prevent c onstipation.
Enc ourage Mrs. Cooper to have c ongregate
Eating with others enc ourages good nutrition and promotes soc ialization with peers.
meals (lunc h at senior c entre) five times per week. Overc oming soc ial isolation is helpful for older persons who do not exerc ise and eat
nutritiously (Government of Canada, 2014).
†
Intervention classification labels adapted from Bulechek, G. M., Butcher, H. K., Dochterman, J. M., &
Wagner, C. (Eds.). (2012). Nursing interventions classification (NIC) (6th ed.). St. Louis: Elsevier.
Evaluation
Nursing
Actions
Ask Mrs. Cooper
to keep a food
diary for 3 days.
Observe Mrs.
Cooper's
appearanc e.
Weigh Mrs.
Cooper.
Ask Mrs. Cooper
about appetite and
energy level.
Patient Response and Finding
Achievement of Outcome
Her diary reflec ts that she ate her main meal at the senior c entre at Mrs. Cooper is selec ting more nutritionally ric h
noon, had fruit and grain produc ts for breakfast, and had a
foods, c onsistent with c urrent guidelines.
sandwic h with fruit and milk in the evening.
Her skin is less pale, hair appears to be in better c ondition and
Mrs. Cooper has improved physic al parameters of
styled. Ankle edema is present, but less than 1+.
nutrition; still needs follow-up.
Weight gain of 2 kg in 4 weeks.
Mrs. Cooper responds that on days when she eats at the senior
c entre, her appetite seems better and she “wants to do more
things.” S he notes that weekends are very lonely.
Weight gain is steady; she is still below ideal body
weight.
Weekday support for nutritional status appears
effec tive. Mrs. Cooper needs to inc rease ac tivity
status and nutritional intake during weekends.
In clinical situations, patients have multiple related problems. The concept
map in Figure 42-6 shows the relationship of nursing diagnoses for a patient
with diabetes.
FIGURE 42-6
Concept map for patient with diabetes. BMI, Body mass index.
Goals and Outcomes.
Goals and outcomes and priorities of care reflect the patient's physiological,
therapeutic, and individualized needs. Mutually planned goals negotiated
between the patient, nurse, and dietitian help ensure success. An overall goal
for an obese patient might be “to achieve appropriate BMI height–weight
range or be within 10% of ideal body weight.” To accomplish this, it is
important to establish regular, attainable goals, such as moderate weight
loss, rather than one large, overwhelming goal (Weinberg, 2013). These
smaller goals or outcomes can help the patient achieve the goal:
• Daily nutritional intake meets the minimal DRIs.
• Daily nutritional fat intake is less than 30%.
• Sugared beverages are removed from diet.
• Patient refrains from eating between meals and
after dinner.
• Patient loses 0.5 to 1 kg per week.
The setting of goals and outcomes requires interdisciplinary input. A
satisfactory care plan requires accurate exchange of information between
disciplines.
Setting Priorities.
By identifying patients at risk for nutritional problems, health providers can
help prevent or minimize these problems through timely interventions.
Although changes in the patient's weight are often gradual, improving
nutritional intake is a priority. With acute illness or surgery, food intake is
often altered. The priority of care may be to provide optimal preoperative
nutrition support for patients with malnutrition. Resumption of food intake
postoperatively depends on the return of bowel function, the extent of the
surgical procedure, and presence of complications (see Chapter 48).
Sometimes other priorities take precedence. For example, patients who
have had throat surgery must be out of pain and comfortable before
nutritional priorities can be addressed. It is also important to collaborate
with the patient and family when setting care priorities so that all persons
involved in the patient's care understand and support these priorities. Food
purchase and preparation may involve the family, and the care plan may not
succeed without their commitment, involvement, and understanding.
Continuity of Care.
In any health care setting, continuity of care is essential, including continuity
of nutritional interventions. Hospital discharge planning should extend
nutritional interventions to the home or long-term care facility. In extended
settings, the dietitian monitors the patient's nutritional status and intake and
makes recommendations for changes.
When patients require long-term care or care at home, occupational
therapists can help them to choose assistive devices, such as large-handled
utensils and cups with a space for the nose. Food preparation areas can be
rearranged to maximize the patient's function. Speech language pathologists
(SLPs) recommend appropriate dietary textures and feeding strategies and
assist patients with swallowing exercises and techniques to reduce aspiration
risk.
Diet Planning.
Diet planning to manage specific illnesses such as diabetes, cardiac or renal
disease, and conditions of lactose and gluten intolerance usually requires the
patient to consult with a dietitian, nurse, and other interdisciplinary team
members to develop relevant knowledge and skills (Table 42-7).
TABLE 42-7
Sample Menu Planning for Cardiac and Renal Diets and for LactoseIntolerant and Gluten-Free Diets
Health Concern
Menu Planning With Daily Servings and Examples
Cardiac
The DASH diet, similar to Ca na da 's Food Guide, rec ommends a higher level of vegetable and fruit intake.
Goal is to reduc e
DAS H food groups: vegetables; fruit; grains (mainly whole grains); low-fat or no-fat dairy foods; lean
hypertension and
meats, poultry and fish; nuts, seeds and dry beans; and fats and oils. DAS H daily servings and examples:
overweight to prevent risk • Vegetables: 4–5 servings
of stroke and heart attac k
250 mL (1 c up) raw leafy vegetables
125 mL (
c up) c ooked vegetables
170 mL (6 oz) juic e
• Fruit: 4–5 servings
1 medium piec e of fruit
63 mL (
c up) dried fruit
125 mL (
c up) fresh, frozen, or c anned fruit
• Grains (mainly whole grains): 7–8 servings
1 slic e bread
250 mL (1 c up) ready-to-eat c ereal
125 mL (
c up) c ooked ric e, pasta, or c ereal
• Low-fat or no-fat dairy foods: 2–3 servings
250 mL (1 c up) milk
250 mL (1 c up) yogurt
50 g (
oz) c heese
• Lean meats, poultry and fish: 2 servings or less
85 g (3 oz) c ooked lean meats, skinless poultry, or fish
• Nuts, seeds, and dry beans: 4–5 servings per week
1/3 c up (1.5 oz) nuts
30 mL (2 tbsp) peanut butter
2 tbsp (
oz) seeds
1/2 c up c ooked dry beans or peas
• Fats and oils: 2–3 servings
5 mL (1 tsp) soft margarine
15 mL (1 tbsp) low-fat mayonnaise
30 mL (2 tbsp) light salad dressing
5 mL (1 tsp) vegetable oil
Renal
There is no “spec ial kidney diet” for everyone. Eac h person has individual nutritional needs depending on
his or her age, medic al history, amount of kidney func tion, ac tivity level, and other fac tors.
Goal is to meet nutritional
needs, reduc e workload on • Fats—Use monounsaturated and polyunsaturated fats suc h as olive oil, c anola oil, and safflower oil.
the kidneys, preserve
• P rotein—Prior to starting dialysis, a low-protein diet (2 servings of 75–90 g protein foods per day) may be
kidney func tion that is left
helpful. Onc e dialysis starts, the person needs to eat more protein (about 3 servings of 75–90 g protein foods
(before starting dialysis),
per day) to replac e musc le and tissue loss. Egg whites, egg white powder, or protein powder are good
and c ontrol buildup of food protein sourc es.
wastes like urea
• Calcium and phosphorus—Limit foods that c ontain large amounts of phosphorus, whic h c an c ause itc hy skin
or painful joints and loss of c alc ium from bones. High- and moderate-phosphorus foods inc lude milk, c heese,
and other milk produc ts, and protein foods suc h as seeds, nuts, dried peas, beans, and bran c ereals. Colas and
soft drinks also c ontain phosphorus. When dairy produc ts c annot be inc orporated in the daily diet, c alc ium
supplements help prevent bone problems and vitamin D c ontrols the balanc e of c alc ium and phosphorous.
The provider or dietitian c an disc uss how best to get these nutrients.
• Sodium—Do not add salt to food. Reduc ing sodium helps c ontrol high blood pressure and prevents fluid
retention. Read food labels to find hidden salt and avoid foods that c ontain a lot of salt, sodium, or MS G.
Avoid salt substitutes, as they are high in potassium.
• P otassium—Cardiac arrhythmias may result from a buildup of potassium. It is best to c hoose low-potassium
fruits suc h as apples, pears, plums, and blueberries. Vegetables suc h as bean sprouts, c abbage, green beans,
and lettuc e are also low in potassium.
• Fluids—As kidney disease gets worse, fluid intake may need to be limited as too muc h fluid will lead to
shortness of breath, an emergenc y that needs immediate medic al attention. S oups, gelatin desserts, and ic e
c ream are c onsidered fluids. The provider and dialysis nurse will let the patient know how muc h to drink
every day. Tips to keep from bec oming thirsty inc lude avoiding salty foods, freezing juic e in an ic e c ube
tray and eating it like a popsic le (these ic e c ubes are c ounted in the daily amount of fluids), and staying c ool
on hot days.
• Carbohydrates—As a good sourc e of energy, c alories from c arbohydrates may replac e the c alories from
protein if a low-protein diet is rec ommended. Most fruits, breads, grains, and vegetables provide energy, as
well as fibre, minerals, and vitamins. Fruits and vegetables that c ontain large amounts of potassium may be
limited. High-potassium oranges and orange juic e, nec tarines, kiwis, raisins or other dried fruit, bananas,
c antaloupe, honeydew melon, prunes, and nec tarines should be limited. Also limit or avoid asparagus,
avoc ado, potatoes, tomatoes or tomato sauc e, winter squash, pumpkin, avoc ado, and c ooked spinac h.
• Fats –Monounsaturated and polyunsaturated fats (olive oil, c anola oil, safflower oil) c an be a good sourc e of
c alories that help protec t heart health.
• Iron –People with advanc ed kidney failure also have anemia and usually need extra iron. Foods that c ontain
extra iron are liver, beef, pork, c hic ken, lima and kidney beans, and iron-fortified c ereals. The provider or
dietitian will determine whic h foods with iron c an be eaten bec ause of the kidney disease.
Lactose Intolerance
Lac tose is a sugar found in milk and milk produc ts. Lac tose intoleranc e happens when the body does not
have enough lac tase (enzyme needed to digest lac tose). Without lac tase, undigested lac tose passes into
the large intestine where it is fermented by bac teria, c ausing bloating, gas, c ramping, nausea, diarrhea, and
weight loss (in c hildren).
Most people with lac tose intoleranc e c an tolerate some lac tose in their diet. They are enc ouraged to eat
small amounts of foods or beverages that have lac tose with their meals. Lower lac tose-c ontaining foods
eaten in small amounts (60–125 mL) c an inc lude c ottage c heese, hard, aged c heese (c heddar, S wiss,
Parmesan), yogurt, c hoc olate milk, and sour c ream.
If these amounts c ause disc omfort, persons c an try eating less or using lac tose-free produc ts or foods low
in lac tose, preferably fortified with c alc ium, suc h as lac tose-hydrolyzed milk (e.g., Lac taid, Lac teeze) and
soy and ric e beverages. Lac tase enzyme drops or tablets reduc e the lac tose in milk or dairy produc ts.
Many foods that c ontain lac tose are also important sourc es of c alc ium and vitamin D. Other sourc es of
these nutrients are needed if lac tose-c ontaining foods are avoided. Examples of alternate sourc es of
c alc ium are c anned salmon (with the bones) and sardines, fortified soy and ric e beverages, and c alc iumfortified fruit juic es. Lac tose-free sourc es of vitamin D inc lude fish, liver, and egg yolks. Lac tose-free soy
and ric e beverages and non-hydrogenated margarine have been fortified with vitamin D. Persons are
advised to talk to a registered dietitian if c onc erned they are not getting enough c alc ium from food and if
they should take a c alc ium supplement.
Gluten-Free
Gluten is a protein found in grains suc h as wheat, barley, rye, and tritic ale. Gluten c auses inflammation in
the small intestines of people with c eliac disease.
Goal is to treat c eliac
Foods that are naturally gluten-free inc lude beans, seeds, and nuts in their natural, unproc essed form; fresh
disease by avoiding foods
eggs; fresh meats, fish, and poultry (not breaded, batter-c oated or marinated); fruits and vegetables; and
that c ontain gluten
most dairy produc ts. Various gluten-free produc ts, suc h as bread and pasta, are available in groc ery stores.
Grains and starc hes that are gluten-free inc lude arrowroot, buc kwheat, c orn and c ornmeal, flax, quinoa,
ric e, and gluten-free flours (ric e, soy, c orn, potato, and bean).
It is c ritic al to avoid wheat and other produc ts unless labelled “gluten-free.” Health Canada's regulatory
requirement for “gluten-free” foods does not refer to any spec ific threshold for gluten in produc ts
represented as “gluten-free”; however, Health Canada c onsiders levels of gluten protein below 20 parts
per million generally not representing health risks to c onsumers with c eliac disease. The Canadian Food
Inspec tion Agenc y (2016) published a position on the Complianc e and Enforc ement of Gluten-Free Claims
that reflec ts the Health Canada position.
Persons living with c eliac disease must be alert to hidden sourc es of gluten. The list of ingredients on all
labels must be read every time.
Cardiac diet: Heart and Stroke Foundation of Canada. (2016). The DASH diet to lower high blood pressure.
Retrieved from http://www.heartandstroke.ca/get-healthy/healthy-eating/dash-diet.
Renal diet: U.S. National Library of Medicine. (2015). Diet—chronic kidney disease. Retrieved from
https://medlineplus.gov/ency/article/002442.htm.
Lactose diet: Dietitians of Canada. (2013). Healthy eating guidelines for managing lactose intolerance.
Retrieved from http://www.dietitians.ca/Your-Health/Nutrition-A-Z/Lactose/Managing-LactoseIntolerance.aspx.
Gluten-free diet: Canadian Celiac Association. (2016). About celiac disease. Retrieved from
http://www.celiac.ca/?page_id=882; Canadian Food Inspection Agency. (2012). Compliance and
Enforcement of Gluten-Free Claims. Retrieved from http://www.inspection.gc.ca/food/labelling/foodlabelling-for-industry/allergens-and-gluten/gluten-free-claims/eng/1340194596012/1340194681961;
Canadian Food Inspection Agency. (2016). Gluten-free claims. Retrieved from
http://www.inspection.gc.ca/food/labelling/food-labelling-for-industry/allergens-andgluten/eng/1388152325341/1388152326591?chap=2.
Example of Diabetic Meal Planning.
Patients who are diagnosed with diabetes cannot properly use and store
glucose for energy. Glucose comes from foods such as fruit, milk, some
vegetables, starchy foods, and sugar. To control blood glucose, patients need
to eat a diet of healthy foods with a controlled amount of glucose, be active,
and may need to take insulin or oral antihyperglycemic agents.
Meal planning to control blood glucose levels is structured around eating
three meals per day at regular times and spacing meals no more than 6 hours
apart. Healthy snacks may be needed. Sugars and sweets such as sugar,
regular soft drinks, desserts, candies, jam, and honey are limited. High-fat
food such as fried foods, chips, and pastries are limited because they may
cause weight gain, which lessens blood glucose control and decreases heart
health (Diabetes Canada, 2018). Eating more high-fibre foods is
recommended for satiety and to lower blood glucose and cholesterol levels.
Persons living with diabetes are instructed to drink water rather than regular
soft drinks and fruit juice, which raise blood glucose. Regular physical
activity improves blood glucose control.
Diabetes Canada recommends the plate method (Figure 42-7) to control
portion sizes.
FIGURE 42-7
Plate method for meal planning. (Based on Diabetes Canada. [2017]. Basic meal planning. Retrieved from
https://www.diabetes.ca/diabetes-and-you/healthy-living-resources/diet-nutrition/basic-meal-planning.)
Persons living with diabetes should have at each meal at least three out of
the four key food groups from Eating Well with Canada's Food Guide:
vegetables and fruit, grain products, milk and alternatives, and meat and
alternatives (Diabetes Canada, 2018). Fats are added in small amounts to
help control weight and blood cholesterol. Carbohydrate counting, which
focuses on foods that contain carbohydrate, as these raise blood glucose the
most, is used to plan meals. The goal for grams of carbohydrate at each meal
and snack is chosen in consultation with the registered dietitian and diabetic
nurse educator to help reach or maintain a healthy weight. For accuracy in
determining the carbohydrate content of food portions, patients are taught to
use measuring cups and food scales and to check the nutrition label on food
packages, food composition books, restaurant fact sheets, and pertinent
websites. They are to write down what they eat and drink throughout the day
(Diabetes Canada, 2018).
Implementation
Chronic Disease, Nutrition, and Prevention.
Chronic diseases are long term and not contagious. They include diseases
such as obesity, diabetes, cardiovascular diseases, cancers, chronic respiratory
diseases, osteoporosis, mental illnesses, and dental diseases. Half of
Canadians (52%) over the age of 20 live with a chronic disease. This includes
the 62% of adults and 32% of children and youth who have excess weight or
obesity; the more than one in four who live with diabetes (which is expected
to rise to one in three by 2020); the 1.3 million people who live with heart
disease, the leading cause of death and hospitalizations in Canada; and the
two in five Canadians with high blood pressure or considered
prehypertensive (Dietitians of Canada, 2015).
The main focus of the WHO's 2013–2020 Global Action Plan is on the
prevention and control of four types of chronic diseases—cardiovascular
diseases, cancer, chronic respiratory diseases, and diabetes—which make the
largest contribution to morbidity and mortality and which share behavioural
risk factors of tobacco use, unhealthy diet, physical inactivity, and harmful
use of alcohol. WHO (2013) recommends (a) provision of sufficient, safe, and
varied food supplies to prevent malnutrition and reduce the risk of chronic
diseases and (b) tackling root causes of malnutrition (i.e., genetic factors,
poverty, and inequity) via political and social action, of which nutritional
programs can be one aspect.
Health Promotion/Illness Prevention.
Nurses are in a key position to educate patients about proper nutritional
habits that may promote health and prevent the development of many
diseases. Early identification of potential or actual problems is the best way
to avoid more serious problems. Outpatient and community-based settings
are key locations for nursing assessment of nutritional practices and status.
Frequently, nurses are in a position to educate families about nutrition,
inform them of community resources, and provide contact information so
that families can direct questions to a dietitian or other professional nurse.
Insufficient income is the most significant barrier to healthy eating (Track,
2015). Food selection and quantity are positively associated with income.
Across Canada, approximately 8.3% of households experience food
insecurity; however, in Nunavut, nearly half (48.7%) of families with children
lack access to basic food because of their low income (Mehler Paperny, 2015).
Elsewhere in the world, low-income preschoolers and toddlers had the lowest
mean intake of fruits and milk and dairy products compared to middle- and
high-income groups (Mohd Shariff, Lin, Sariman, et al., 2015). Higher fruit
and vegetable intake among children has been associated with better
education of mothers (Van Ansem, Schrijvers, Rodenburg, et al., 2014) and
food availability at home (Lehto, Ray, Te Velde, et al., 2014), both of which
relate to income status. At the same time, lower socioeconomic status and
issues of cost, accessibility, and parental time commitment are associated
with physical inactivity in Canadian children (Lipnowski & Canadian
Paediatric Society, Healthy Active Living and Sports Medicine Committee,
2012).
In March 2016, 863 492 people received food from a food bank in Canada,
an increase of 1.3% from the same time the previous year, and of 28% from
March 2008; food banks assisted 2.4% of the Canadian population, with 35.6%
of those helped under the age of 18 years (Food Banks Canada, 2016). The
problem is worsened when children cannot access nutritional programs at
schools: Canada is the only G8 country without a national school-based
feeding program (Howard & Edge, 2013). Besides children, members of atrisk population groups for food insecurity also include Indigenous peoples,
lone-parent families, women, immigrants, and older persons.
Although mandatory fortification of staple foods with micronutrients has
helped to reduce income-related disparities (Dwyer, Wiemer, Dary, et al.,
2015), other interventions are also needed to counter the threat to good
nutrition and health from lack of purchasing power at individual and
collective levels. For those on limited budgets, food preparation can be
modified for substances that need to be used sparingly; for example, bean or
cheese dishes can often replace meat. Menu planning a week in advance
helps patients adhere to a specific diet, eat nutritiously, and stay within their
budget. A nurse or dietitian may check menus for content. Often, simple tips
can help, such as baking rather than frying to reduce fat intake, using lemon
juice or spices to add flavour to low-sodium diets, and avoiding grocery
shopping when hungry because it can lead to spontaneous purchases of
foods not included in meal plans. Strategies to help financially disadvantaged
groups improve their nutrition include collective kitchens and gardens
(Loopstra & Tarasuk, 2013), coalitions with community-based organizations,
antipoverty advocacy, and political commitment to policies of full
employment (Wells, 2016). Also important are public-awareness forums
(Food Secure Canada, 2015) and a rights-based approach to food security at
federal and provincial levels (Blay-Palmer, 2016) with support to families that
have inadequate resources to meet their daily nutritional needs (Food Banks
Canada, 2016). See Box 42-7 for an example of an innovative program that
aims to increase food security for individuals, families, and communities.
Box 42-7
Focus on Food Security
Nutrition North Canada (NNC) is a federal government subsidy program
launched on April 1, 2011 to provide northerners in 103 isolated
communities in Saskatchewan, Manitoba, Ontario, Quebec, Labrador, Yukon,
the Northwest Territories, and Nunavut with improved access to perishable
nutritious food. The program is designed to reduce the high cost to
consumers of food in the north where grocery costs are driven by
transportation, the cost of maintaining stores, staff costs, spoilage and theft,
high inventory costs, and retailer profit margins.
NNC works with stores across the north and food suppliers in southern
Canada. NNC subsidizes (a) various perishable and nutritious food items
(e.g., fruit, vegetables, milk, eggs, meat, and cheese) shipped by air to an
eligible community and (b) traditional food commercially processed in the
North (e.g., Arctic char, musk-ox, and caribou) shipped by air to an eligible
community. Retail subsidies are applied against the total cost of an eligible
product (including product purchasing cost, transportation, insurance, and
overhead) shipped by air to an eligible community. Customers in eligible
communities can purchase subsidized food from registered northern
retailers or directly from registered southern suppliers. To be eligible for
NNC, a community must lack year-round road, rail, or marine access. In
addition, the community must meet the territorial or provincial definition of
a northern community, have a year-round population according to the
national census, and have an airport, post office, or grocery store.
Based on a market-driven model, the subsidy is provided to retailers and
suppliers who apply and are selected to register with the program. In turn,
these businesses are responsible for passing on the full subsidy to
consumers. Currently, 84 communities receive a “full subsidy” of between
$1.20 and $16 per kilogram of eligible food shipped; retailers in the
remaining 19 communities receive a “partial subsidy” of $0.05 per kilogram
of eligible food shipped. According to a federal government statement in
early 2015, “the results are clear—Nutrition North Canada has succeeded in
reducing prices of eligible food in isolated northern communities, and in
increasing the amount of perishable nutritious food available.” Between
April 2011 and March 2015, the cost of a food basket for a family of four
dropped approximately 5%, or $94 per month.
There are several criticisms of NNC. Despite its reported success, the cost
of food in northern communities is still extremely high. In communities that
receive the full NNC subsidy, the annual cost of the Revised Northern Food
Basket for a family of four in March 2013 was $21 372, or $411 per week—
more than double the cost of a roughly equivalent basket of food purchased
in Toronto. Also, because the federal government does not currently have
access to information on retailer profit margins, it cannot be verified that the
NNC subsidy is being fully passed on to consumers. In sum, NNC is an
innovative attempt to reduce food insecurity to remote regions of Canada's
north; however, further review is needed to gauge its effectiveness.
From Pegg, S. (2016). Food Banks Canada: Is Nutrition North Canada on shifting ground? Retrieved from
https://www.foodbankscanada.ca/getmedia/b9aa8a8f-b66b-4efc-b7d6-03f54dc77427/Is-Nutrition-NorthCanada-on-Shifting-Ground.pdf.aspx
Safety Alert
Food safety is also an important public health issue. Food-borne illnesses
can occur from poor hygiene practices and improper food storage or
preparation. Nurses should educate patients about reducing the risks of
food-borne illnesses (Table 42-8 and Box 42-8).
TABLE 42-8
Food Safety
Food-Borne
Organism
Disease
Botulism
Clostridium
botulinum
Esc heric hia c oli Escherichia coli
0157:H7
Listeriosis
Perfringens
enteritis
S almonellosis
S higellosis
S taphyloc oc c us
Listeria
spec ies
L.
monocytogenes
Clostridium
spec ies
C. perfringens
Sa lmonella
spec ies
S. typhi
S. pa ra typhi
Shigella
spec ies
S. dysenteria e
Sta phylococcus
spec ies
S. a ureus
Food Source
Symptoms*
Improperly home-c anned foods, smoked S ymptoms vary from mild disc omfort to death in 24 hours,
and salted fish, ham, sausage, shellfish
initial nausea and dizziness progressing to motor
(respiratory) paralysis
Underc ooked meat (ground beef)
S evere c ramps, nausea, vomiting, diarrhea (may be
bloody), renal failure. Appears 1–8 days after eating, lasts 1–
7 days
S oft c heese, meat (hot dogs, pâté, lunc h S evere diarrhea, fever, headac he, pneumonia, meningitis,
meats), unpasteurized milk, poultry,
endoc arditis, appears 3–21 days after infec tion
seafood
Cooked meats, meat dishes held at room Mild diarrhea, vomiting. Appears 8–24 hours after eating,
or warm temperature
lasts 1–2 days
Milk, c ustards, egg dishes, salad
dressing, sandwic h fillings, polluted
shellfish
Mild to severe diarrhea, c ramps, vomiting. Appears 12–24
hours after ingestion, lasts 1–7 days
Milk, milk produc ts, seafood, salads
Mild diarrhea to fatal dysentery. Appears 7–36 hours after
ingestion, lasts 3–14 days
Custards, c ream fillings, proc essed
meats, ham, c heese, ic e c ream, potato
salad, sauc es, c asseroles
S evere abdominal c ramps, pain, vomiting, diarrhea,
perspiration, headac he, fever, prostration. Appears 1–6
hours after ingestion, lasts 1–2 days
*
Symptoms are generally more severe for youngest and oldest age groups.
From Nix, S. (2013). Williams' basic nutrition and diet therapy (14th ed.). St. Louis, MO: Mosby.
Box 42-8
Patient Teaching
Food Safety
Objectives
• Patient will verbalize measures to prevent food-borne illness.
• Patient will understand the primary types of illness and how they are
transmitted.
• Patient will not experience food-borne illness.
Teaching Strategies
Populations particularly at risk are older and younger people and
immunosuppressed individuals. Instruct patients on the following:
• Wash hands with warm, soapy water for at least 20 seconds before
touching or eating food.
• Separate cutting boards. Use one board for produce and another for raw
meat, poultry, fish, and seafood.
• Wash fresh fruits and vegetables thoroughly.
• Do not eat raw meats or drink unpasteurized milk.
• Do not buy or consume food that has passed the expiration date.
• Keep foods properly refrigerated at 4°C and frozen at −18°C.
• Wash dishes and cutting boards with hot, soapy water or use a bleach
sanitizer of 5 mL bleach in 750 mL water.
• Thaw food, especially raw meat, poultry, fish, or seafood, in the
refrigerator.
• Cook food completely, using a clean thermometer to measure the
temperature of meat, poultry, and fish. Keep a temperature chart that
gives the safe cooking temperatures of foods handy to always know at
what temperature each food is fully cooked. Insert the thermometer
probe into the thickest part of the food to ensure accuracy.
• Refrigerate leftovers within 2 hours. Do not save for more than 4 days in
the refrigerator.
• Wash dishcloths and towels regularly, or use paper towels.
• Clean the inside of the refrigerator and microwave regularly to prevent
microbial growth.
• Wash reusable grocery bags frequently.
Evaluation
• Ask patient to describe measures to prevent food-borne illnesses.
• Observe the patient at home for safe practices, if making a home visit.
From EatRight Ontario. (2016). Test the temperature—Use a thermometer for food safety. Retrieved from
https://www.eatrightontario.ca/en/Articles/Food-safety/Test-the-temperature-%E2%80%93-Use-athermometer-for-food.aspx; Government of Canada. (2014). Food safety and you. Retrieved from
https://www.canada.ca/en/health-canada/services/general-food-safety-tips/food-safety-you.html
Acute Care.
Many factors influence nutritional intake in acute care settings. Ill or
debilitated patients often have loss of appetite (anorexia). The ketosis that
accompanies starvation can further suppress appetite, as can the pain that
results from surgical procedures and trauma. During hospitalizations,
mealtimes are often interrupted or the patient is too fatigued or
uncomfortable to eat. Worry about families, finances, employment, or illness
often interferes with getting an adequate diet. Medications may impair taste,
cause nausea, interfere with absorption, or affect metabolism. Diagnostic
testing may disrupt mealtimes or require a nothing by mouth (NPO) status.
Patients who are NPO and receive only standard intravenous (IV) fluids for
more than 7 days are at nutritional risk.
Nurses must continuously assess patient nutritional status and plan
interventions that promote normal dietary intake, digestion, and metabolism
of nutrients. Patients may have a gradual progression of dietary intake or
need therapeutic diets to manage their illnesses (Box 42-9).
Box 42-9
Diet Progression and Therapeutic Diets
Clear Liquid
This diet is limited to broth, bouillon, coffee, tea, carbonated beverages,
clear fruit juices, gelatin, or Popsicles.
Thickened Liquid
All liquids (e.g., juice, tea, coffee, water, etc.) must be thickened to the
appropriate consistency (nectar, honey, or pudding) as recommended by the
speech language pathologist/feeding team when thin fluids cannot be safely
swallowed and may be aspirated.
Full Liquid
To a clear- or thickened-liquid diet can be added smooth-textured dairy
products, custards, refined cooked cereals, vegetable juice, puréed
vegetables, or any fruit juices.
Puréed
This diet includes all of the above with the addition of scrambled eggs,
puréed meats, vegetables, fruits, or mashed potatoes and gravy.
Mechanical Soft
This diet includes all of the above with the addition of ground or finely diced
meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light
breads, cooked vegetables, cooked or canned fruits, bananas, soups, or
peanut butter.
Soft or Low Residue
Low-fibre, easily digested foods, such as pastas, casseroles, moist tender
meats, canned cooked fruits and vegetables, desserts, cakes, and cookies
without nuts or coconut, can be added.
High Fibre
This diet includes fresh uncooked fruits, steamed vegetables, bran, oatmeal,
and dried fruits.
Low Sodium
A low-sodium diet is limited to 4 g (no added salt), 2 g, 1 g, or 500 mg
sodium (severe sodium restriction), requiring selective food purchases.
Low Cholesterol
This diet is restricted to <200 mg/day cholesterol, in keeping with the
National Cholesterol Education Program (NCEP) recommendations
(Heimburger, 2016) and the Heart and Stroke Foundation of Canada (2017c).
Diabetic
In general, people with diabetes should follow a healthy diet recommended
for the general population in Eating Well With Canada's Food Guide (Diabetes
Canada, 2018; Dietitians of Canada, 2017). This includes consuming a variety
of foods from the four food groups (grain products, vegetables and fruits,
milk products, meat and alternatives), attaining and maintaining a healthy
body weight, decreasing total fat intake to <30% of calories, and ensuring an
adequate intake of carbohydrate, protein, essential fatty acids, vitamins, and
minerals.
Regular
Dietary restrictions are not necessary unless specified.
Promoting Appetite.
In providing an environment that promotes a patient's appetite, it is
important to eliminate unpleasant odours, provide oral hygiene as needed to
remove disagreeable tastes, and maintain patient comfort. Certain
medications can affect dietary and nutrient intake; for example, insulin,
glucocorticoids, and thyroid hormones affect metabolism. Other
medications, such as antifungal agents, can affect taste. Some psychotropic
medications affect appetite, cause nausea, and alter taste. At times the nurse
and dietitian can help the patient select foods to reduce the altered taste
sensations or nausea. In other situations, medication may need to be
changed. Physicians may order pharmacological agents to stimulate appetite
(e.g., cyproheptadine [Periactin], megestrol [Megace]) or to manage
symptoms that interfere with nutrition.
Assisting Patients With Feeding
Many conditions, including cancer, stroke, and neuromuscular disorders, can
cause feeding difficulties. The task of feeding requires nursing knowledge
and skilled intervention to protect patient safety, independence, and dignity.
Before Feeding.
The nurse should assess the patient's risk of aspiration (see “Assessment” in
this chapter and Skill 42-1). The patient should sit as upright as possible with
head tilted slightly forward and may be supported by pillows, foam wedges,
or rolled towels. A patient who is lying back or has the neck arched or
hyperextended should not be fed because these positions create an open
airway susceptible to aspiration. Glasses, hearing aids, and dentures should
be functioning and in place. Clothing and bedding should be protected with
napkins, towels, or aprons, and these items should not be called “bibs.” The
nurse needs to ensure that the suction apparatus at the bedside has been
checked.
During Feeding.
The patient should be kept upright. To feed the patient the nurse uses a
rocking motion of the utensil on the patient's tongue. When the patient has
hemiplegia (one-sided weakness), the head should be tilted slightly toward
the stronger side to avoid pouching (Lampert, 2015) and small bites of food
placed on the stronger side of the patient's mouth. If indicated by the
feeding/swallowing team, the patient can take a drink between each
mouthful of food to ease the process of eating. The patient should be
observed for pouching of food. A metal teaspoon is usually the best utensil to
use for feeding patients with bite reflexes.
The nurse needs to assess swallowing during feeding and give patients
with dysphagia enough time to chew, allowing at least 5 to 10 seconds or
longer for each bite or sip. Two completed swallows should be observed
between mouthfuls. The patient's Adam's apple should move up and down.
If the food is still present, the nurse can offer an empty spoonful to stimulate
swallowing.
The nurse who is helping the patient to eat should sit in the patient's line
of vision and provide prompting, encouragement, and direction, both
verbally and nonverbally, when appropriate. The nurse avoids hovering with
the next spoonful of food as this may cause a patient to hurry and worsen any
swallowing difficulties. Patience, attention, and time are essential. When
possible, the nurse should try to heed special requests, such as for the food
to be warmed up. Nurses can promote comfort and a sense of independence
by providing opportunities for patients to direct the order and speed at
which they want to eat. The nurse should give the patient as much choice as
possible, for instance, by asking if the patient wants peas and potatoes
together or separate on the spoon. The family can be asked about the
patient's favourite foods. Because mealtime is usually a social activity, it is
important that nurses and other health providers talk to patients during
meals. Nurses can use this opportunity to educate patients about therapeutic
diets, medications, or adaptive devices.
Patients with visual deficits also need special assistance. If possible, the
nurse should read aloud menu items and let the patient choose the meal. The
patient should be told when the meal has arrived and where the tray is
placed. Food needs to be positioned within the patient's visual field. If the
patient wears glasses or contact lenses, they should be clean and in place. A
dark tray or cloth can be placed under a light plate to define the plate edges,
making it easier to locate the food. Patients with poor vision or blindness
may be able to feed themselves if adequate care and information is given.
The nurse can describe where certain foods are located on a plate (Figure 428) using either the clock-face method (e.g. “The meat is at 6 o'clock, mashed
potatoes are at 9 o'clock, and the peas at 12 o'clock”) or by saying items are at
the top, bottom, or right or left side of the plate (Vision Australia, 2012). Meat
should be placed at 6 o'clock, or at the bottom of the plate, as this is easiest
for cutting. The patient should be told where the beverage is located in
relation to the plate (e.g., “The glass of water is to the right or above 2
o'clock”). The nurse should ask the patient if he or she would like assistance
with removing packaging from items. Hot drinks should be in non-spill
containers; the nurse needs to tell the patient where they are placed.
FIGURE 42-8
Using the clock-face method to identify contents and location of food on a plate.
When food intake is less than usual because of illness or fatigue, nutrientdense items should be provided first. Small frequent meals, five to six per
day, may be required. Patients with decreased motor skills may retain more
independence by using large-handled adaptive utensils, which are easier to
grip and manipulate.
After Feeding.
The patient should remain upright for 30 minutes after eating. The nurse
should check again for pocketing of food. If the patient needs to lie down
because of fatigue, the head of the bed can be raised to sitting-up level.
Intake should be noted and documented. The nurse needs to identify if any
particular food was eaten faster (e.g., a preference) or with difficulty (e.g., soft
meat may need to be replaced with ground), and report and document any
instances of choking and fatigue. After each meal, the patient should
perform oral hygiene.
Restorative and Continuing Care
Patients discharged from a hospital with dietary prescriptions often need
dietary education to plan meals that meet specific therapeutic requirements.
Restorative care includes immediate postsurgical care and routine medical
care pertinent to hospitalized and home care patients. The case study in Box
42-10 illustrates the need for nurses to educate visitors about a patient's
nutritional status in order to avoid complications and enhance the patient's
recovery following abdominal surgery.
Box 42-10
Case Study
Not a Textbook Recovery*
My 46-year-old patient had come back to the floor after undergoing a total
bowel resection. The protocol that we follow for reintroducing oral fluids,
food, and medications is very strict because of the large surgical interruption
in the body's natural state. The patient was NPO and on intravenous (IV)
fluids until he produced flatus and bowel sounds in all four quadrants.
During my initial postoperative assessment of this patient, he had no
bowel sounds in any quadrant. I explained to him the protocol for
nutritional supplementation following surgery. For 24 to 48 hours, he would
be placed on a clear fluid diet that would be advanced as he progressed
through his recovery. My patient, unfortunately, told his family that he was
starving. Because they were not fully aware of the protocol, they gave him
something to eat. His body was not ready to handle food, and he became
nauseated and vomited the food he had eaten, as well as coffee ground
emesis. The coffee ground emesis indicated that he required abdominal
decompression. I placed a nasogastric (NG) tube, which for several days was
connected to low intermittent suction to alleviate his abdominal distension.
I replaced NG tube losses 1 : 1 with an additional IV solution to maintain
electrolyte balance. Blood work was done at least once a day to monitor
electrolyte levels, hemoglobin, and any dehydration. When it was apparent
that his recovery was taking longer than planned, we closely monitored his
lab results for any signs of decreased nutritional status. We also began the
process of determining whether total parental nutrition (TPN) would be
appropriate. However, before needing to progress to TPN, we began to see
improved laboratory results and were able to stop and remove the NG tube
and suction, as he had regained faint bowel sounds in all four quadrants. We
started him on a clear fluid diet, which he tolerated well, so we advanced
him to a full fluid diet, which he also tolerated well. He regained full bowel
sounds and had flatus the following day. We were able to advance him all the
way to a regular diet. His lab work showed no nutritional deficits, and he
continued on to make a full recovery.
What I hope undergraduate nurses will take away from this case is that
meeting nutritional needs in patients following surgery is always different—
rarely does a patient follow a “textbook” recovery. Decisions must be based
on not only the nurse's past experiences and expertise but also on the unique
combination of the patient's past medical history, symptoms, and family
support. Nurses need to follow their patients in providing appropriate
person-led interventions that promote the best outcomes for a particular
care situation.
In this case study, how and why did the nurse evaluate her patient's bowel
motility? What nutritional teaching is required for patients who have
undergone bowel resection surgery and their families?
*
By Ashley Kay, RN, BN; MN student.
After surgical intervention, particularly bowel resections and colon
surgery, coordinated bowel motility temporarily ceases. This lack of
coordinated propulsive action prevents effective transit of intestinal contents
or tolerance of oral intake and leads to the accumulation of gas and fluids
within the bowel. Motility typically returns within 1–3 days (Cagir, 2017).
Evaluation
Care plans should reflect achievable goals and outcomes. Nurses need to
evaluate outcomes of nursing actions and be alert for signs that goals are
being met. They also need to allow adequate time for testing each nursing
approach to a problem.
Patient Care.
The effectiveness of nutritional interventions is best measured by meeting
the expected patient outcomes and goals of care (Figure 42-9). Nutrition
therapy does not always produce rapid results. Ongoing comparisons may be
made with baseline measures of weight, serum albumin or prealbumin, and
protein and kilocalorie intake. Medications may produce unwanted adverse
effects. If gradual weight gain is not observed, or if weight loss continues, the
prescription may need to be adjusted. Changes in health condition may
indicate a need to change the nutritional care plan. Interdisciplinary team
members should be consulted, and the patient should be an active
participant whenever possible. The patient's ability to incorporate dietary
lifestyle changes with the least amount of stress or disruption will ensure
success. When expected outcomes are not met, the interventions or outcomes
need to be revised on the basis of the patients' needs and preferences.
FIGURE 42-9
Critical thinking model for nutritional evaluation.
Patient Expectations.
Patients expect competent and accurate care. They expect nurses to alter the
care plan if outcomes of nutritional therapies are unsuccessful. Nurses'
expectations and health values may differ from those held by patients. By
working closely with patients, nurses can understand their expectations and
try to meet them within the limits of their conditions and treatments.
Self-Monitoring of Blood Glucose
Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes
management. By providing a real-time blood glucose reading, SMBG enables
the patient to make decisions regarding diet, exercise, and medication
management.
Portable blood glucose meters are used at the hospital bedside and by
patients who perform SMBG independently (Figure 42-10). In Canada, the
only continuous glucose monitoring system (CGMS) available is the
Medtronic MiniMed Paradigm REAL-Time System. A sensor is inserted
under the skin, and data are sent from the sensor to a transmitter, which
displays the glucose value on an insulin pump continuously; values are
updated every 5 minutes (Figure 42-11). This system assists the patient and
health care provider to identify trends and track patterns. Thus, it is
particularly useful for managing insulin therapy, alerting the patient during
episodes of hypoglycemia and hyperglycemia, and allowing prompt,
immediate, and corrective action.
FIGURE 42-10
Blood glucose monitor. (Courtesy LifeScan, Inc., Milpitas, CA.)
FIGURE 42-11 A tiny sensor (A) implanted under skin transmits continuous
reading to receiver (B), to alert wearer of any deviation from desired glucose target
range. Readings are displayed and stored on the monitor (C). (Courtesy DexCom, Inc.)
The blood glucose level reported by a laboratory is sometimes higher than
the measurement by the patient's home glucose monitor or the hospital's
portable meter. This is because some meters measure capillary blood glucose
from whole blood (via finger stick), whereas laboratory venous samples yield
plasma readings. Plasma samples, or venous samples, are 15–20% higher
because plasma has a higher water content than that of whole blood, so there
is more dissolved glucose in plasma than in whole blood (Austin, 2013). Most
blood glucose meters (BGMs) for home use now report blood glucose only in
terms of plasma glucose to be more readily compared with laboratory values.
Instructions for using a BGM accompany each product. Because errors in
monitoring technique can cause errors in management strategies, thorough
patient education is crucial. Once initial education has occurred, follow-up
educational sessions should take place at each subsequent patient contact
and also be timed to coincide with regular appointments for reassessment. In
addition, patients must be taught to calibrate their BGM and use control
solutions. In Canada, the control solutions are not included in the BGM kits
and are not stocked by most pharmacies. A person with diabetes must call
the company to ask for the control solution, and it will be sent to them at no
charge. The control solution has a very narrow expiry date and once opened
lasts only 3 months. The person must run the control test every week.
The chief advantage of SMBG is that it supplies immediate information
about blood glucose levels that can be used to make adjustments in food
intake, activity patterns, and medication dosages. It also produces accurate
records of daily glucose fluctuations and trends, as well as alerting the
patient to acute episodes of hyperglycemia and hypoglycemia. SMBG is
recommended as an essential part of daily diabetes management for all
people using insulin or oral hypoglycemic agents (OHAs). The frequency of
monitoring depends on several factors, including the patient's glycemic
goals, type of diabetes, ability and willingness to perform the test
independently, and treatment regimen. It is recommended that patients with
type 1 diabetes test their blood glucose at least three times per day and
include both preprandial and postprandial testing. Those using an insulin
pump may test more frequently. People with type 2 diabetes treated with
OHAs or through lifestyle changes alone have more variable and
individualized testing regimens. For patients with type 2 diabetes treated
with once-daily insulin and OHAs, monitoring at least once daily is
recommended (CDA, 2013).
Blood glucose testing should also be performed whenever hypoglycemia is
suspected so that immediate action can be taken if necessary. When the
person with diabetes is ill, the blood glucose should be tested every 2 to 4
hours to determine the effects of this stressor on blood glucose level (CDA,
2013). If a patient is visually or cognitively impaired or has limited manual
dexterity, the degree to which SMBG can be performed independently must
be evaluated carefully. (See Skill 42-2 for a description of how to monitor
blood glucose.)
SKILL 42-2
BLOOD GLUCOSE MONITORING
When venipunc ture c annot be performed to obtain c apillary
blood, skin punc ture is an alternative method to reduc e the
frequenc y of needle stic ks and for self-management of diabetes
mellitus. The proc edure is less painful than venipunc ture, and
patients c an perform this proc edure.
There are two methods for self-testing of blood gluc ose level.
Both methods require obtaining a large drop of blood by skin
punc ture. A hand-held single-use lanc et or an automatic lanc etholder devic e c an be used. The drop of blood is then applied
on the spec ially prepared testing strip.
The first self-testing method involves visually reading the
reagent strip by c omparing it with the c olour c hart on the
c ontainer. Examples of suc h strips are Chemstrip bG, Gluc ostix,
and TrendS trips. If the c olour on the strip appears between two
referenc e bloc ks on the c hart, the user may need to estimate
the results. Consequently, results of blood gluc ose
measurement using this method may not always be ac c urate.
The sec ond type of blood gluc ose monitoring entails the use
of reflec tanc e meters (see Figure 42-10). A variety of meters
are on the market, suc h as the Gluc ometer II (Ames), Ac c uChek III (Boehringer Mannheim), Gluc osc an 3000 (LifeS c an),
and OneTouc h (LifeS c an). After a drop of blood from the skin
punc ture is plac ed on the testing strip, the meter provides an
ac c urate measurement of blood gluc ose level in less than 60
sec onds.
For these meters, a wet-wash or dry-wipe method of testing is
used. To perform a wet wash, the user flushes the blood-c oated
testing strip with water before
inserting the strip into the gluc ose meter. The dry-wipe method
requires the user to wipe off the blood-c oated testing strip with a
dry c otton ball before making a reading. S ome produc ts do not
require blood to be flushed or wiped before a reading. The various
methods enable measurement of blood gluc ose between 1.1 and
44.4 mmol/L, whic h is a sensitive measurement of blood gluc ose
level.
These meters differ in the amount of blood needed for eac h test,
testing speed, overall size, ability to store test results in memory,
c ost of the meter, and c ost of test strips (Tsai, 2015). S ome larger
meters are voic e ac tivated, whic h is helpful for older persons with
visual impairments. The amount of time to c omplete the gluc ose
testing with the c urrent gluc ose meters varies from 5 sec onds to 50
sec onds. S ome meters c an be programmed to monitor gluc ose
levels for a c ontinuous 72 hours.
Most meters allow for alternative sites, suc h as the forearm, palm,
and thigh. Two new methods of obtaining gluc ose measurement are
available on the market. Minimally invasive gluc ose meters have a
very small, fine plastic sensor inserted through the abdomen, and
they provide c ontinuous readings of blood gluc ose levels. A
biosensor is taped on the external abdomen (Figure 42-11). Using a
hand-held wireless meter, the patient ac tivates the biosensor to
transmit the blood gluc ose level at any time without punc turing the
skin. Another model, the noninvasive gluc ose meter, punc tures the
skin not with a needle but with laser tec hnology.
Delegation Considerations
The task of measuring blood gluc ose level after skin punc ture
(c apillary punc ture) c an be delegated to an unregulated c are
provider (UCP) who is spec ific ally instruc ted in performing
the skill. The nurse must first assess the patient to determine
that it is appropriate to delegate blood gluc ose monitoring. If
the patient's c ondition c hanges frequently, this task should not
be delegated. The nurse direc ts the UCP by
• Explaining appropriate sites to use for punc ture and when to
obtain gluc ose levels
• Reviewing expec ted levels and when to report to the nurse
unexpec ted gluc ose levels
P ROCEDURE
STEP S
1. Assess understanding of proc edure and purpose. Determine
whether patient with diabetes mellitus understands how to
perform test and realizes importanc e of gluc ose monitoring.
2. Determine whether spec ific c onditions need to be met before or
after sample c ollec tion (e.g., with fasting, after meals, after
c ertain medic ations, before insulin doses).
3. Determine whether risks exist for performing skin punc ture
(e.g., low platelet c ount, antic oagulant therapy, bleeding
disorders).
4. Assess area of skin to use as punc ture site. Inspec t the patient's
fingers, toes, and heel. Alternative sites are the palm, arm, and
thigh. Avoid areas that have bruises and open lesions.
Equipment
• Antiseptic swab
• Cotton ball or tissue
• S terile lanc et or blood-letting devic e
• Heel-warming devic e (optiona l)
• Paper towel
• Blood gluc ose meter (e.g., OneTouc h)
• Blood gluc ose test strips (brand determined by meter used)
• Disposable gloves
RATIONALE
• Data set guidelines for nurse to develop teac hing plan.
• Dietary intake of c arbohydrates and ingestion of c onc entrated
gluc ose preparations alter blood gluc ose levels.
• Abnormal c lotting mec hanisms inc rease risk for loc al ec c hymosis
and bleeding.
• S ides of fingers, toes, and heels are c ommonly selec ted bec ause they
have fewer nerve endings. Measurements at alternative sites are
meter spec ific and may be different from measurements at traditional
sites (Mc Culloc h, 2017). As an alternative to the traditional fingertip
site, periungual punc ture sites are assoc iated with less pain, good
reproduc ibility, and no signific ant differenc e in the values of blood
gluc ose obtained (Cristiano, Catanuso, Di Gregorio, et al., 2015).
• The punc ture site should not be edematous, inflamed, or rec ently
punc tured bec ause these fac tors c ause inc reased interstitial fluid and
blood to mix and also inc rease the risk for infec tion.
5. Review health c are provider's order for times and frequenc y of • Health c are provider determines test sc hedule on the basis of patient's
measurement.
physiologic al status and risk for gluc ose imbalanc e.
6. If diabetic patient performs test at home, assess patient's ability to • Patient's physic al health may c hange (e.g., vision disturbanc e, fatigue,
handle skin-punc turing devic e. The patient may c hoose to
pain, disease proc ess), preventing patient from performing test.
c ontinue self-testing while in hospital.
7. Expec ted outc omes after c ompletion of proc edure:
• Punc ture site shows no evidenc e of bleeding or tissue damage. • Hemostasis ac hieved. Lanc et or needle did not punc ture skin too
• Blood gluc ose level is normal.
deeply.
• Patient demonstrates proc edure.
• Normal fasting gluc ose level is 4 to 6 mmol/L, indic ating good
• Patient explains test results.
metabolic c ontrol.
• Patient demonstrates psyc homotor learning.
• Patient validates knowledge.
8. Explain proc edure and purpose to patient or family, or both. Offer • S uc h explanations promote understanding and c ooperation.
patient and family opportunity to prac tise testing proc edures.
Provide resourc es and teac hing aids for patient.
9. Perform hand hygiene before proc edures.
• Hand hygiene reduc es transfer of mic roorganisms.
10. Instruc t patient to perform hand hygiene with soap and warm
• Handwashing promotes skin c leaning and vasodilation at selec ted
water, if patient is able.
punc ture site. It establishes prac tic e for patient when test is performed
at home. Bec ause of its ability to remove food residue from the hands
and fingers, handwashing is superior to using alc ohol pads to c leane
the test site.
11. Position patient c omfortably in c hair or in semi-Fowler's
• This position ensures easy ac c essibility to punc ture site. Patient will
position in bed.
assume position when self-testing.
12. Remove test strip from c ontainer, then tightly seal c ap. Chec k
• S ealing c ap protec ts unused strips from ac c idental disc oloration
c ode on the test strip vial.
c aused by exposure to air or light. Code on test strip vial must matc h
c ode entered into the gluc ose meter.
13. Turn on gluc ose meter, if nec essary.
• Turning on ac tivates meter.
Critical Decision P oint: Some monitors a re a ctiva ted when the test strip is inserted a nd therefore do not ha ve a specific on-off switch.
14. Insert strip into gluc ose meter (refer to manufac turer's
• S ome mac hines must be c alibrated; others require zeroing of timer.
direc tions), and make nec essary adjustments (see S tep 14
Eac h meter is adjusted differently.
illustration).
STEP 14
Load test strip into meter. (Courtesy Accu-Chek
Glucometer.)
15. Remove unused gluc ose test strip from meter and plac e on
paper towel or c lean, dry surfac e with test pad fac ing up (see
manufac turer's direc tions).
16. Apply disposable gloves.
17. Choose punc ture site. Punc ture site should be vasc ular. In
adults, selec t lateral side of finger; be sure to avoid c entral tip of
finger, whic h has more dense nerve supply.
18. Hold the finger that you will punc ture in dependent position
while gently massaging finger toward punc ture site.
19. Clean site with antiseptic swab, and allow it to dry c ompletely.
• Moisture on strip c an alter ac c urac y of final test results.
• Wearing gloves reduc es risk for c ontamination by blood.
• Vasc ularity ensures free flow of blood after punc ture.
• Massage inc reases blood flow to area before punc ture.
• The site must be allowed to dry bec ause alc ohol c an c ause blood to
hemolyze.
• Cover keeps tip of lanc et or needle sterile.
20. Remove c over of lanc et or blood-letting devic e. Hold lanc et
perpendic ular to punc ture site, and pierc e finger or heel quic kly
in one c ontinuous motion (do not forc e lanc et).
21. S ome employers use lanc et devic es with an automatic blade
• Blood-letting devic es are designed to pierc e skin to a spec ific depth,
retrac tion system. This reduc es the possibility of self-stic ks,
ensuring adequate blood flow. Perpendic ular position ensures proper
preventing exposure to blood-borne pathogens. Plac e bloodskin penetration.
letting devic e firmly against side of finger and push release
button, c ausing needle to pierc e skin (see S tep 21 illustration).
STEP 21 Prick side of patient's finger with lancet.
(Courtesy Accu-Chek Glucometer.)
22. Wipe away first droplet of blood with c otton ball. (S ee
manufac turer's direc tions for meter used.)
• First drop of blood may c ontain more serous fluid than blood c ells.
23. Lightly squeeze punc ture site (without touc hing) until a sec ond • Adequate-sized droplet is needed to ac tivate monitor and obtain
large droplet of blood has formed (see S tep 23 illustration).
ac c urate results. Exc essive squeezing of tissues during blood sample
Repunc turing is nec essary if a large enough drop does not form c ollec tion may c ontribute to pain, bruising, sc arring, hemolysis, and
to ensure ac c urate test results. (S ee manufac turer's direc tion
c ontamination of the blood with interstitial and intrac ellular fluid,
regarding how blood is applied.)
leading to inac c urate results (Krleza, Dorotic , Grzunov, et al., 2015).
STEP 23
Squeeze puncture site until a large droplet of
blood is expressed.
Critical Decision P oint: Dia betic pa tients frequently ha ve periphera l va scula r disea se. This ma kes it difficult to produce a la rge drop of blood a fter a
fingerstick. To improve blood flow, be sure to hold pa tient's finger in dependent position before puncturing.
24. Obtain test results.
• Exposure of blood to test strip for presc ribed time ensures proper
results.
Critical Decision P oint: Some meters (such a s OneTouch [LifeSca n]) require blood sa mple to be a pplied to test strip a lrea dy in the meter. Once the drop
of blood is a pplied, the meter a utoma tica lly ca lcula tes the rea ding.
A. Be sure meter is still on. Bring test strip in the meter (in this
• Blood is absorbed into strip, and gluc ose devic e will show message
example, an Ac c u-Chec k) to the drop of blood (see S tep 24A
on sc reen to signal that enough blood is obtained.
illustration). The blood will be absorbed into the test strip (see
manufac turer's instruc tions).
STEP 24A Touch the test strip to the blood drop. Blood is
absorbed into the test strip. (Courtesy Accu-Chek
Glucometer.)
Critical Decision P oint: Do not scra pe blood onto the test strips or a pply blood to wrong side of test strip. This prevents a ccura te glucose mea surement.
Ensure enough blood is a pplied to completely fill the test window. Otherwise a fa lse rea ding or error messa ge will be displa yed.
B. The blood gluc ose test result will appear on the sc reen (see
S tep 24B illustration). S ome devic es beep when measurement
is c ompleted.
STEP 24B
Results appear on meter screen. (Courtesy
Accu-Chek Glucometer.)
25. Turn meter off. Dispose of test strip, lanc et, and gloves in proper • Meter is battery powered. Proper disposal reduc es risk for
rec eptac le.
needlestic k injury and spread of infec tion.
26. Disc uss test results with patient.
• Disc ussion promotes partic ipation and provides a perfec t teac hing
opportunity for c ontinued self-monitoring of blood gluc ose testing.
27. Reinspec t punc ture site for bleeding or tissue injury.
• S ite is possibly a sourc e of disc omfort and infec tion.
28. Compare gluc ose meter reading with normal blood gluc ose
• Comparison helps determine whether gluc ose level is normal.
levels and previous test results.
29. Ask patient to disc uss proc edure.
• Disc ussion validates patient's level of learning.
30. Ask patient to explain test and results.
• Results of test may c ause anxiety. Patient may misunderstand spec ific
step of proc edure.
UNEXP ECTED OUTCOMES
RELATED INTERVENTIONS
• Apply pressure.
Puncture site bruised a nd continues to bleed
• Elevate hand above level of heart
• Notify health c are provider.
• Continue to monitor patient.
Blood glucose level a bove or below ta rget ra nge
• Chec k for medic ation orders regarding deviations in gluc ose level.
• Administer insulin or c arbohydrate sourc e as ordered, depending on
gluc ose level.
• Notify health c are provider.
Glucose meter ma lfunction
Pa tient misundersta nding of procedure a nd results
• Review instruc tions for troubleshooting gluc ose meter.
• Repeat test.
• Call the 1-800 c ompany phone number found at the bac k of every
blood gluc ose testing meter.
• Repeat instruc tions to patient.
• Have patient demonstrate proc edure.
RECORDING AND REP ORTING
• In nurses' notes or spec ial flow sheet, rec ord proc edure, gluc ose level, and ac tion taken for abnormal range.
• Desc ribe response, inc luding appearanc e of punc ture site, in nurses' notes.
• Rec ord and report abnormal blood gluc ose levels.
• S tress importanc e of timing the testing of blood gluc ose levels, partic ularly in patients with diabetes mellitus.
TEACHING CONSIDERATIONS
• Provide information on where a patient with diabetes mellitus c an obtain testing samples, if applic able. When possible, teac h with the same
meter that the patient will use at home.
• Provide patient with information on where to obtain assistanc e if gluc ose meter has malfunc tioned.
• Instruc t patient in what to do and whom to c ontac t if gluc ose meter malfunc tions.
P EDIATRIC CONSIDERATIONS
• Young c hildren should be allowed to c hoose punc ture site.
• Heel and great toe are c ommon punc ture sites in infants.
• It is nec essary to assess for loc alized c omplic ations in heels of premature infants who must have blood drawn repeatedly.
• Heel warming fac ilitates obtaining a spec imen from a neonate.
• Infec tion or absc ess of the heel and nec rotizing osteoc hondritis are the most serious c omplic ations of heelstic k punc ture in infants.
• To avoid osteoc hondritis, the punc ture should not be deeper than 0.85 mm for premature neonates up to 3 kg, or 2.0 mm for infants under
6 months of age, and is made at the outer aspec t of the heel (Krleza et al., 2015).
• The earlobe has been used to obtain blood and to estimate arterial blood gas c ontent, based on the hypothesis that blood from dilated
c apillaries of the earlobe c ontains a higher proportion of arterial than venous blood. However, studies have shown c ontradic tory results
on the ac c urac y of this tec hnique for blood gas measurement (Vaquer, Masip, Gili, et al., 2014).
• Young c hildren should be allowed with parent to demonstrate tec hnique; tec hnique c an be inc orporated in play ac tivity for further
understanding.
AGE-RELATED CONSIDERATIONS
• Warming fingertips may fac ilitate obtaining spec imen.
• S ome older persons have vision or dexterity problems that interfere with performing self-fingerstic ks.
HOME CARE CONSIDERATIONS
• Patients c an use gluc ose meters routinely in their homes.
• Patients should be enc ouraged to attend a diabetic support group if it is needed.
• As visual ac uity may affec t a patient's ability to perform self-testing at home, there are new blood gluc ose testing meters that have talking
ability (Tsai, 2015).
Reproduced from Perry, A. G., & Potter, P. A. (2010). Clinical nursing skills and techniques (7th ed., pp.
1153–1158). St. Louis, MO: Elsevier/Mosby.
Enteral Tube Feeding
Enteral nutrition refers to nutrients given via the gastrointestinal tract. When
the patient cannot ingest food but is still able to digest and absorb nutrients,
enteral tube feeding is indicated. Feeding tubes can be inserted through the
nose (or orally if necessary) into the stomach or intestines (nasogastricorogastric or nasointestinal-orointestinal tubes), surgically through a stoma
(a surgically created opening) into the stomach or jejunum (gastrostomy or
jejunostomy tubes), or endoscopically (percutaneous endoscopic
gastrostomy [PEG] or jejunostomy [PEJ] tubes).
A registered nurse may insert nasogastric or orogastric tubes for
abdominal decompression and for enteral feedings with an order from a
physician (Saskatoon Health Region, 2017). Large-diameter (large-bore) sump
tubing nasogastric tubes are most often used for both decompression and
short-term enteral feeding, whereas small-bore, silastic tubing with insertion
stylet is used for longer-term feeding needs. The small-bore nasogastric or
nasojejunal tube is preferred over large-bore tubes as they reduce patient
discomfort and gastric erosion (Holmes, 2012) and can be used for longer
periods (Silk & Quinn, 2015). All other tubes must be inserted by a physician.
In some settings (e.g., the Critical Care Unit), a large tube is used to start the
tube feed and if the patient tolerates it for the first 24 to 48 hours, a smallbore tube is then inserted. As well, if the patient has a small-bore tube
placed in the duodenum, the physician may elect to leave the sump tube in
the stomach for gastric decompression and prevent vomiting or aspiration. If
enteral nutrition therapy is to be administered for less than 4 weeks,
nasoenteral tubes may be used. Surgical or endoscopically placed tubes are
preferred for long-term feeding (>4 weeks) to reduce the discomfort of a
nasal tube and to provide a more secure, reliable access (Villela, Sakai,
Almeida, et al, 2014). Box 42-11 conveys the everyday experiences of a child
and his family with long-term tube feeding. Patients with gastroparesis
(decreased or absent innervation to the stomach causing delayed gastric
emptying) or esophageal reflux, those at risk for aspiration, and those with a
history of aspiration pneumonia require placement of tubes beyond the
stomach into the intestine (Blumenstein, Shastri, & Stein, 2014).
Box 42-11
Case Study
Working With Riley and His Family*
I had the opportunity to look after Riley, an active 3-year-old who loved being
read to and playing with super-hero action figures. Riley was meeting all of
his developmental milestones except one: He had never learned to eat
enough to sustain himself and appropriately gain weight. Although Riley ate
a small amount of food (potato chips and hot dogs), no physical,
psychosocial, or emotional cause for his reluctance to eat was found.
Eventually it was decided to put in a G-tube, which Riley simply called a
“button” after hearing nurses use this term. Riley often played with the Gtube and occasionally pulled it out. He seemed to think the G-tube was an
extension of his body and was surprised to find out that not everyone had a
G-tube.
I became involved in Riley's care once he was discharged home. As a
community care nurse, my primary roles were to provide emotional support
to Riley's parents while providing age-appropriate care for Riley. My familycentred approach included recognizing the parents as the decision makers in
their child's life and focusing on the family's abilities and challenges. I
reinforced the teaching that had occurred within the hospital related to
Riley's G-tube and nutritional needs. In addition, I helped Riley's family
navigate various health and social systems to ensure that adequate supports
were in place.
Despite numerous attempts to decrease the nighttime feedings, Riley was
not able to maintain sufficient intake for the G-tube to be removed or for the
feedings to be completely discontinued. From my perspective, most health
care providers were completely supportive; however, a few contravened
family-oriented care by negatively judging Riley's family and suggesting that
his parents were somehow responsible for Riley's nutritional challenges. For
example, one health care provider suggested that Riley's parents preferred
the G-tube as it took less time than convincing Riley to try to eat enough
nutritious food to maintain his weight.
Riley is now 12 years old and still has a G-tube in place; he receives a tube
feeding every second night. He does well in school and actively participates
in sports, although he is sometimes self-conscious about his “button.”
Riley's mother continues to worry that he will dislodge the G-tube while
playing sports. From this situation of caring for Riley and his parents over
time, I have learned that children are incredibly resilient, even when faced
with a significant health challenge, and that both children and their families
thrive when family-centered care is provided.
In reading the case study of the young boy living with a G-tube, what are
the advantages of the family-centred approach to care that the community
nurse used to help meet the child's nutritional needs? What teachings about
the G-tube and children's nutrition are critical? How might you engage Riley
in discussing the meaning that G-tube feeding holds for him?
*
By Donna Bulman, RN, PhD, University of New Brunswick.
Box 42-12 lists indications for enteral nutrition. The nurse inserts the
nasoenteral tube (Skill 42-3), and the nurse or others, including family in the
home setting, can administer enteral tube feedings. It is highly
recommended that tube placement be verified by X-ray examination before
the patient receives the first enteral feeding.
Box 42-12
Indications for Enteral Nutrition
Cancer
• Head and neck
• Upper gastrointestinal tract
Critical Illness or Trauma
• Respiratory failure with prolonged intubation/inadequate oral intake
• Patients in critical care with suspected/evidence of catabolism
• Trauma patients, especially those in a hypermetabolic state (e.g., burns)
Neurological and Muscular Disorders
• Brain neoplasm
• Stroke
• Cerebrovascular accident
• Neuromuscular disorders (e.g., amyotrophic lateral sclerosis, multiple
sclerosis, Parkinson's disease)
• Dementia:
Patients with advanced dementia are offered quality-of-life diets; they risk
injury with multiple insertions related to self-extubation of feeding tubes.
Enteral feeding for end-stage dementia is controversial. Common reasons to
initiate enteral feedings in these patients include prolonging survival,
improving quality of life, preventing pressure injuries, and palliative care.
However, the evidence to support artificial nutrition in people with advanced
dementia is limited. Expert consensus is that artificial hydration and
nutrition in people with advanced dementia are not appropriate when
swallowing problems or disinclination to eat is a result of advancing disease,
and that they should not be used solely to prolong life (Parker & Power,
2013). Decisions about artificial nutrition in people with dementia should be
made on an individual basis after conducting a comprehensive,
multidisciplinary assessment that includes confirmation of advanced
dementia and the absence of an acute, potentially reversible cause of the
swallowing difficulty. It is paramount to involve the person's family or
caregivers to manage their expectations and to ensure that the wishes of the
person with dementia are taken into account.
• Myopathy
• Parkinson's disease
Gastrointestinal Disorders
• Enterocutaneous fistula
• Inflammatory bowel disease
• Mild pancreatitis
Other Situations
• Respiratory failure with prolonged intubation
• Inadequate oral intake
• Continuous feedings
• Supine positioning:
A 45-degree elevation is recommended when possible for supine
patients to reduce their risk of aspiration and, if intubated, prevent
ventilator-associated pneumonia (Dhaliwal, Cahill, Lemieux, et al., 2014).
Supine position is an indication for enteral feeding. Enteral feedings may
be provided at the same rate as in the prone position, since they are likely to
have the same residual in either position (Saez de la Fuente, Saez de la
Fuente, Estelles, et al., 2014).
• Cerebral vascular accident
• Local trauma
• Anorexia nervosa
• Difficulty chewing and swallowing
• Severe depression
SKILL 42-3
INSERTING A SMALL-BORE NASOENTERIC OR ORAL TUBE FOR
ENTERAL FEEDING
Delegation Considerations
At most Canadian institutions, the insertion of a sump naso/orogastric tube
without stylet is an advanc ed nursing c ompetenc y, requiring one-time
c ertific ation. The insertion of a silastic feeding tube with stylet is c onsidered a
delegated medic al func tion requiring yearly rec ertific ation. For this reason, this
skill should not be delegated to unregulated c are providers or those without a
c ertified c ompetenc y.
Equipment
• Nasogastric or nasointestinal (orogastric or
orointestinal) tube (8 to 12 Fr) with guide wire or stylet
• S tethosc ope
• 60-mL or larger Luer-Lok or c atheter-tip syringe
• Entriflex nasogastric feeding tubes with safe enteral
c onnec tions. (This weighted polyurethane feeding tube
is designed for nasogastric and nasoduodenal feeding
with a slimmer, lighter weighted tip for easier insertion.
The feeding port is inc ompatible with Luer-Lok or
intravenous [IV] c onnec tions, reduc ing the risk of
ac c idental c onnec tion or inadvertent administration of IVintended medic ations through the feeding tube, a prac tic e
started in Great Britain and the United S tates to address
the JCAHO [2014] Tubing Misc onnec tions S entinel
Alert.)
• Hypoallergenic tape and tinc ture of benzoin or tube
fixation devic e
• S c issors
• pH indic ator strip (sc ale 0.0 to 11.0)
• Medic ation c up or c ontainer for aspirated fluid
• Glass of water and straw (not required for intubated
patients)
• Water-soluble lubric ant
• Emesis basin
• Absorbent pad
• Fac ial tissues
• Disposable gloves (multiple pairs needed)
• S uc tion equipment in c ase of aspiration
• Penlight to c hec k plac ement of nasopharynx
• Tongue blade
• Disposable tape measure
• Felt-tip marker
P ROCEDURE
STEP S
1. Assess patient's need for enteral tube feeding: NPO (nothing by mouth)
status, func tional gastrointestinal trac t, inability to ingest suffic ient nutrients.
RATIONALE
• Identifying patients who need tube feedings before they
bec ome nutritionally depleted may help to prevent
c omplic ations related to malnutrition.
A. Review physic ian's order for insertion of tube and enteral feeding
• Proc edures and tube feedings require a physic ian's
sc hedule.
order.
2. Explain proc edure to patient.
• Patient c an c ooperate with the proc ess.
3. Assess patenc y of nares. Have patient c lose eac h nostril alternately and
• Nares may be obstruc ted or irritated, or a septal defec t
breathe. Examine eac h naris for patenc y and skin breakdown.
may be present.
4. Assess the gag reflex by plac ing a tongue blade in patient's mouth, touc hing • This ac tivity assesses ability to swallow and determines
uvula to induc e a gag response.
whether the patient is at risk for aspiration.
Critical Decision P oint: Pa tients with impa ired level of consciousness, or who a re intuba ted a nd seda ted, ma y a lso ha ve impa ired ga g reflex, a nd their
risk of a spira tion is increa sed during this type of procedure a nd subsequent tube feedings. For pa tients who a re intuba ted, seda ted, or too ill to pa rticipa te in
the procedure, ensure tha t the pa tient's hea d is tilted towa rd the chest for entera l feeding tube insertion.
5. Review patient's medic al history for nasal problems (e.g., nosebleeds, oral or • Nasoenteral tubes are c ontraindic ated in patients with
fac ial surgery, antic oagulation therapy, history of aspiration).
rec ent nasal surgery, fac ial traumas, nosebleeds, or
surgic al proc edures requiring a transsphenoid approac h
(e.g., to remove pituitary tumours) or who are rec eiving
antic oagulation therapy (Metheny, 2016).
6. Perform hand hygiene.
• Hand hygiene reduc es transfer of mic roorganisms.
7. Ausc ultate abdomen for bowel sounds.
• Absenc e of bowel sounds may indic ate dec reased or
absent peristalsis and inc reased risk for aspiration or
abdominal distension.
8. Explain proc edure to patient and how to c ommunic ate during insertion by
• Explanations reduc e anxiety and help patient assist in
raising index finger to indic ate gagging or disc omfort.
insertion.
9. S tand on same side of bed as naris for insertion, and assist patient to high
• These ac tions fac ilitate manipulation of tube. Fowler's
Fowler's position unless c ontraindic ated. Plac e pillow behind patient's head
position reduc es risk of aspiration and promotes
and shoulders.
effec tive swallowing.
10. Plac e absorbent pad over patient's c hest. Keep fac ial tissues within reac h.
• Pad prevents soiling of gown. Insertion of tube may
c ause patient's eyes to tear.
11. Determine length of tube to be inserted and mark with tape:
• Length approximates distanc e from nose to stomac h for
Traditional method for plac ing the tube to the stomac h: Measure distanc e
98% of patients. For duodenal or jejunal plac ement, an
from tip of nose to earlobe and then to xiphoid proc ess of sternum (see S tep
additional 20 to 30 c m is required.
11 illustration).
STEP 11
Length of tube to be inserted is equal to distance from tip of nose to
earlobe to xiphoid process.
If plac ing the tube to small bowel (duodenum), follow agenc y-spec ific
protoc ol; for example, the administration of 10 mg metoc lopramide as a
bowel motility agent, turning patient on right side, and injec ting 200 c c of
air to inflate the stomac h.
12. Prepare nasogastric or nasointestinal tube for insertion ac c ording to
manufac turer rec ommendation:
A. Plastic tubes should not be ic ed.
13. Perform hand hygiene and put on gloves.
A. If long-term tube, injec t 10 mL of water from 30 mL or larger c atheter-tip
syringe into the tube and insert stylet/guide wire.
B. Make c ertain that guide wire is sec urely positioned against weighted tip
and that c onnec tions are snugly fitted together.
• Tubes that are ic ed bec ome stiff and inflexible, c ausing
trauma to muc ous membranes.
• Hygiene and gloves reduc e transmission of
mic roorganisms.
• Water releases a mec hanism in the tip of the tube holding
the guide wire in plac e to enable the guide wire to be
removed following tube insertion.
• S ec ure positioning and snug-fitting c onnec tions
promote smooth passage of tube into gastrointestinal
trac t. Improperly positioned stylet c an induc e serious
trauma (i.e., trac heal perforation, pneumothorax).
• Tape is used to anc hor tubing after insertion.
14. Cut tape 10 c m long or prepare tube fixation devic e. S plit one end of tape
lengthwise 5 c m.
15. Dip tube with surfac e lubric ant into glass of water. If tube is not prelubric ated, • Ac tivates lubric ant to fac ilitate passage of tube into naris
use water-soluble lubric ant.
to gastrointestinal trac t.
16. Insert tube through nostril to bac k of throat (posterior nasopharynx). Aim
• Natural c ontour fac ilitates passage of tube into
bac k and down toward ear.
gastrointestinal trac t and reduc es gagging by patient.
17. Have patient tilt head toward c hest after tube has passed through
• Tilting head forward c loses off glottis and reduc es risk of
nasopharynx.
tube entering trac hea. This tec hnique is also used in
patients who are intubated and sedated.
Critical Decision P oint: Encoura ge a pa tient who is a lert a nd communica ting to swa llow by giving sma ll sips of wa ter or ice chips when possible. For
pa tients who a re intuba ted a nd seda ted, or a re not a ble to pa rticipa te in the procedure, tilt pa tient's hea d towa rd the chest. Adva nce tube a s pa tient
swa llows or a s pa tient's hea d is tilted towa rd chest. Rota te tube 180 degrees while inserting.
18. Emphasize the need to mouth-breathe and swallow during the proc edure
• Mouth-breathing and swallowing fac ilitate passage of
(when possible).
tube and alleviate patient's fear during the proc edure.
19. When tip of tube reac hes the c arina (about 25 c m in an adult), stop insertion, • If air is heard, the tube could be in the respiratory tract;
hold end of tube near your ear, and listen for air exc hange from the distal
remove tube and start over. This listening step should
portion of the tube.
never be used to verify tube placement (Metheny, 2016).
20. Advanc e tube eac h time patient swallows until desired length has been
• Advanc ing tube while patient swallows reduc es
passed.
disc omfort and trauma to patient.
Critical Decision P oint: Do not force tube insertion. If resista nce is met or pa tient sta rts to cough, choke, or become cya notic, stop a dva ncing the tube
a nd pull tube ba ck. It is importa nt to note tha t hea vily seda ted, coma tose, or pa ra lyzed pa tients ma y not exhibit a cough or ga g reflex during insertion
a nd so this should not be used a s the sole method of determining improper tube pla cement. It is a lso possible to slip a sma ll-bore feeding tube into the
tra chea down pa st a n endotra chea l tube without loss of oxygena tion; therefore, X-ra y exa mina tion is the definitive step in determining tube pla cement.
21. Chec k for position of tube in bac k of patient's throat with penlight and tongue • Tube may be c oiled, kinked, or entering trac hea.
blade.
(Withdraw tube immediately if tube is c oiled, respiratory
status of patient c hanges, or patient begins to c ough and
skin c olour c hanges. If distress is not present, withdraw
tube fully and retry. Note whether tube was kinked; if so,
it is likely to kink again in the same plac e.)
22. Perform measures to verify plac ement of tube, onc e desired length has been • Tube plac ement must be verified by X-ray examination
passed. S ec ure tube before X-ray examination, bec ause it may bec ome
before enteral feedings are initiated. Other tests that c an
dislodged during proc edure.
be done at the bedside to ensure ongoing plac ement are
as follows:
• Observe for a c hange in length of the external portion
of the feeding tube, as indic ated by movement of the
marked portion of the tube.
• Review routine c hest and abdominal radiography
reports to look for notations about tube loc ation.
• Observe c hanges in volume of aspirate from the
feeding tube—a large inc rease in volume may signal
the upward disloc ation of a small-bowel feeding tube in
the stomac h; persistent inability to withdraw fluid (or
only a few drops of fluid) from the tube may signal
upward displac ement of a gastric tube into the
esophagus.
• Measure the pH of feeding tube aspirates.
• Enc ourage obtaining of a radiograph to c onfirm tube
position if the tube's position is in doubt (Metheny,
2016).
Critical Decision P oint: Ausculta tion is not a relia ble method for verifica tion of tube pla cement beca use a tube ina dvertently pla ced in the lungs,
pha rynx, or esopha gus ca n tra nsmit a sound simila r to tha t of a ir entering the stoma ch (Boeykens et a l., 2014; Na tiona l Associa tion of Children's
Hospita ls, 2012).
23. After gastric aspirates are obtained (see Box 42-16), anc hor tube to patient's
• A properly sec ured tube allows the patient more
nose and avoid pressure on nares. Mark exit site with indelible ink. S elec t
mobility and prevents trauma to nasal muc osa. Mark tube
one of the following options:
at tip of naris; measure from line to end of tube; tape and
sec ure to maintain position.
A. Apply tape.
(1) Apply tinc ture of benzoin or other skin adhesive on tip of patient's nose • S kin adhesive helps tape adhere better and protec ts
and tube and allow it to bec ome “tac ky.”
patient's skin.
(2) Plac e the intac t end of tape over bridge of patient's nose. Wrap eac h of • S ec uring tape to nares prevents tissue nec rosis.
the 5-c m strips around tube as it exits nose. Change position of tube at
Changing tube position avoids erosion of naris.
naris every 8 hours (q8h) (see S tep 23A(2) illustration).
STEP 23A(2)
Wrapping tape to anchor nasoenteral tube.
B. Apply tube fixation devic e, using shaped adhesive patc h.
(1) Apply wide end of patc h to bridge of nose.
(2) S lip c onnec tor around tube as it exits nose (see S tep 23B(2)
illustration).
STEP 23B(2)
• Fixation devic e sec ures tube and reduc es fric tion on
nares (Ambutas, S taffileno, & Fogg, 2014).
Slipping connector around feeding tube.
24. A sec ond anc horing of tube against c heek with gauze and transparent
dressing may be advised, so that tube does not rest over bony points.
• Fastening the tube this way may help prevent the tube
from being pulled by c onfused patients and avoids
pressure points. However, the available evidenc e on
interventions to reduc e nasogastric tube dislodgement
and adverse events is of limited quantity and validity
(Brugnolli, Ambrosi, Canzan, et al., 2014).
25. For intestinal plac ement, position patient on right side, when possible, until
• Positioning patient on right side promotes passage of the
c orrec t plac ement has been verified radiologic ally. Remove gloves. Perform tube into the small intestine (duodenum or jejunum).
hand hygiene, and assist patient to a c omfortable position.
Critical Decision P oint: Lea ve stylet/guide wire in pla ce until correct position is ensured by X-ra y film or check a gency policy tha t sta tes how long
you ca n lea ve the wire or stylet in pla ce if the X-ra y or interpreta tion is dela yed. Never a ttempt to reinsert pa rtia lly or fully remove stylet/guide wire
while feeding tube is in pla ce.
Clinica lly sound judgement is a lwa ys required for na soga stric insertion a nd pla cement verifica tion. Cortra k is a device used to pla ce sma ll-bore
tubes, in a n effort to improve efficiency a nd reduce pa tient discomfort by checking pla cement a s the tube is inserted a t bedside. This reduces the need to
verify pla cement. Cortra k involves computer technology to guide clinicia ns in the pla cement of na soenteric feeding tubes. The device a ids feeding tube
pla cement by showing the rela tive loca tion of the feeding tube tip a s it descends into the tra ct. The tip of the feeding tube stylet ha s a n electroma gnetic
tra nsmitter. A receiver unit is pla ced on the pa tient's xiphoid during the procedure, to a cquire the signa l (Smitha rd, Ba rrett, Ha rgroves, et a l., 2015).
26. Obtain X-ray film of abdomen.
• Plac ement of tube is verified by X-ray examination
(Dhaliwal et al., 2014; Metheny, 2016).
27. Perform hand hygiene, apply c lean gloves, and administer oral hygiene (see
Chapter 38). Clean tubing at nostril.
28. Remove gloves, dispose of equipment, and perform hand hygiene.
29. Inspec t patient's naris and oropharynx for any irritation after insertion.
• Oral hygiene promotes patient c omfort and integrity of
oral muc ous membranes.
• These ac tions reduc e transmission of mic roorganisms.
• If tube insertion was diffic ult, irritation of naris or
oropharynx may have oc c urred.
30. Ask patient whether he or she feels c omfortable.
• Patient's level of c omfort is evaluated. (This may be a
c hallenge if a language barrier exists or if the patient has
dementia or is c onfused.)
31. Observe patient for any diffic ulty breathing or for c oughing or gagging.
• Improper position of the tube may c ause these
symptoms or inc rease symptoms in patients who have
heart failure, pneumonia, asthma, and other c ardiac or
respiratory c onditions.
32. Ausc ultate lung sounds.
• Abnormal lung sounds c an be an early sign of aspiration.
33. Assess for feeding tube plac ement at 4-hour intervals to ensure that the tube
To repeat from S tep 22:
has remained in the desired loc ation.
• Observe for a c hange in length of the external portion of
the feeding tube.
• Observe c hanges in volume of aspirate from the feeding
tube.
• Measure the pH of feeding tube aspirates.
• Enc ourage obtaining of a radiograph to c onfirm tube
position if the tube's position is in doubt.
34. Assess for intoleranc e to feedings every 4 hours.
• Monitor gastric residual volumes, abdominal disc omfort,
nausea/vomiting, and abdominal girth/distension
(Dhaliwal et al., 2014).
UNEXP ECTED OUTCOMES
RELATED INTERVENTIONS
• Position patient on side.
Aspira tion of stoma ch contents into the respira tory tra ct (immedia te response),
• S uc tion nasotrac heally and orotrac heally.
evidenced by coughing, dyspnea , cya nosis, a usculta tion of cra ckles or wheezes
• Consult physic ian immediately to order c hest X-ray
examination.
• Consult physic ian to obtain order for c hest X-ray film.
Aspira tion of stoma ch contents into respira tory tra ct (dela yed response), evidenced by
• Prepare for possible initiation of antibiotic s.
dyspnea , fever, a usculta tion of cra ckles or wheezes
Development of ba cteria l a spira tion pneumonia from conta mina ted sa liva for pa tients • Limited oral hydration leads to dry mouth and inc reased
c onc entration of oral bac teria. It is imperative that
NPO or being fed entera lly.
sc rupulous oral hygiene be maintained for these
individuals, whic h inc ludes using a soft toothbrush to
c lean teeth, gums, roof of mouth, and c heeks. Patients
and their families must be c ounselled regarding this risk
for those who are disc harged home or maintain self-c are
(Casaubon, S uddes, Ac ute S troke Best Prac tic es
Working Group, 2013; Maeda & Akagi, 2014).
• Confirm that mark on tube (made at initial insertion) is at
Displa cement of feeding tube to a nother site (e.g., from duodenum to stoma ch, which
exit site (if tube is moved, mark at new exit site).
ma y occur when pa tient coughs or vomits)
• Remeasure distanc e from naris to tip of xyphoid proc ess,
and c ompare with baseline measurement from insertion.
• Aspirate gastrointestinal c ontents and measure pH
(Boeykens et al., 2014).
• Disc uss findings with physic ian.
• Rec onfirm plac ement by X-ray film (optional).
• If tube is displac ed, prepare to remove displac ed tube,
and insert and verify plac ement of new tube.
• If there is a question of aspiration, obtain c hest X-ray film.
Critical Decision P oint: To prevent clogging of feeding tube in rela tion to feedings, flush feeding tube with ta p wa ter (Fisher & Bla lock, 2014) a fter
checking residua l volume, a fter intermittent feeding, every 4 hours during continuous feedings, a nd before a nd a fter a dministra tion of medica tions. On
a vera ge, use 15 to 30 mL or more of wa ter for flushing. The a mount of wa ter required va ries with the individua l length of tube. Try to find a n a lterna tive
route for medica tion a dministra tion when sma ll-bore tubes (especia lly the tempora ry na soga stric sila stic tubes) a re used beca use they frequently clog.
• To prevent feeding-tube c logging that results from
Clogging of feeding tube
medic ation, use liquid forms of medic ation whenever
possible. When the solid form of dosage is used, make
sure tablets c an be c rushed and that there is no
c ontraindic ation to c rushing them (i.e., sustained-release
c ardiac medic ations should not be c rushed as they will
adversely affec t the patient's hemodynamic status [heart
rate and blood pressure]) and that c apsules c an be
opened; dissolve tablets or c apsules well, and administer
eac h medic ation separately (Lohmann, Gartner, Kurze, et
al., 2015).
• Aspirate gastric c ontents with 60-mL syringe to assess
patenc y of tube.
• Irrigate tube with water. Researc h c learly supports water
as the best c hoic e for initial dec logging efforts (Fisher &
Irrita tion of na ris a nd na sa l mucosa
Blaloc k, 2014).
• Notify physic ian and prepare to administer panc relipase
or other enzymatic dec logging agent upon physic ian
order or standing protoc ol. Panc relipase dissolves
foodstuff but is ineffec tive in dissolving pill partic les.
• Attempt to c lear tube with panc relipase using a 50- to 60mL syringe. Do not use a small-barrel syringe (i.e., 20 c m
or less) bec ause smaller syringes have greater psi
(pounds per square inc h) and injec tion of air or liquid
under high pressure (above 40 psi) may c ause tube
rupture (Fisher & Blaloc k, 2014).
• Provide hygiene, and remove and replac e tube. (Note:
This ac tion requires a physic ian's order.)
• Consider removing tube and inserting it into the other
naris (physic ian order required).
RECORDING AND REP ORTING
• Rec ord and report type and size of tube plac ed, loc ation of distal tip of tube (mark and measure), patient's toleranc e of proc edure, pH
value, and c onfirmation of tube position by X-ray examination.
Enteral nutrition has been used successfully after surgery or trauma to
provide fluids, electrolytes, and nutritional support. Gastric ileus may
prevent nasogastric feedings, while nasointestinal or jejunostomy tubes
allow successful postpyloric feeding of formula directly into the small
intestine or jejunum or beyond the pyloric sphincter of the stomach
(Blumenstein et al., 2014). Enteral feedings can be administered through a
nasoenteric tube (Skill 42-4) or via a gastrostomy or jejunostomy tube (Skill
42-5).
SKILL 42-4
ADMINISTERING ENTERAL FEEDINGS VIA NASOENTERIC TUBE
Delegation Considerations
Administration of enteral tube feeding via nasoenteric tube is
an institution-spec ific proc edure that may or may not be
delegated to unregulated c are providers (UCPs) after the
nurse verifies tube plac ement. The nurse is responsible for
patient assessment. Depending on the institution's protoc ol,
the nurse direc ts the UCPs to
• Ensure that the patient is sitting upright in a c hair or in bed
• Infuse the feeding slowly
• Report any diffic ulty infusing the feeding or any disc omfort
voic ed by the patient
P ROCEDURE
STEP S
1. Assess patient's need for enteral tube feedings: impaired
swallowing, trac heostomy, dec reased level of c onsc iousness,
head or nec k surgery, fac ial trauma, surgic al proc edures
involving upper alimentary c anal.
2. Evaluate patient's nutritional status (see Table 42-4). Obtain
baseline weight and laboratory values (e.g., albumin,
transferrin, prealbumin). Assess patient for fluid volume exc ess
or defic it, elec trolyte abnormalities, and metabolic
abnormalities, suc h as hyperglyc emia.
3. Verify physic ian's order for formula, rate, route, and
frequenc y and for laboratory data and bedside assessments,
suc h as fingerstic k blood gluc ose measurement.
4. Explain proc edure to patient.
5. Perform hand hygiene.
6. Ausc ultate for bowel sounds before feeding.
Equipment
• Disposable feeding bag and tubing or ready-to-hang system
• 30-mL or larger Luer-Lok or c atheter-tip syringe
• S tethosc ope
• pH indic ator strip (sc ale 0 to 14)
• Infusion pump (required for intestinal feedings): use pump designed for
tube feedings
• Presc ribed enteral feedings
• Disposable gloves
• Equipment to obtain blood gluc ose by fingerstic k
RATIONALE
• Identify patients who need tube feedings before they bec ome
nutritionally depleted.
• Enteral feedings are intended to restore or maintain a patient's nutritional
status. Fluid volume assessment provides objec tive data to measure
effec tiveness of feedings.
• Tube feedings, laboratory tests, and bedside tests must be ordered by
the physic ian.
• Well-informed patients tend to be c ooperative and c omfortable.
• Hand hygiene reduc es transmission of mic roorganisms.
• Absenc e of bowel sounds may indic ate dec reased ability of
gastrointestinal trac t to digest or absorb nutrients.
7. Prepare feeding c ontainer to administer formula:
A. Chec k expiration date on formula and integrity of c ontainer. • Tube feedings administered within the designated shelf life from a
c ontainer without c rac ks or breaks reduc es the patient's risk of ac quiring
tube feeding–borne gastrointestinal infec tions.
B. Have tube feeding formula at room temperature.
• Cold formula may c ause gastric c ramping and disc omfort bec ause the
liquid is not warmed by the mouth and esophagus.
C. Perform hand hygiene and apply gloves.
D. S hake formula c ontainer well, and fill feeding c ontainer
• Filling the tubing with formula prevents exc ess air from entering.
with formula (see S tep 7D illustration). Open stopc oc k on
• Tubing must be free of c ontamination, to prevent bac terial growth.
tubing and fill with formula to remove air.
STEP 7D
Pouring formula into feeding container.
E. Connec t tubing to c ontainer as needed, or prepare ready-tohang c ontainer.
Critical Decision P oint: Tube feedings a re infused by feeding pumps a nd the tubes do not fit intra venous (IV) pump.
8. For intermittent feeding, have syringe ready, and ensure
• Cold formula may c ause gastric c ramping.
formula is at room temperature.
9. Plac e patient in high Fowler's position, or elevate head of bed • Elevating the patient's head helps prevent aspiration.
to at least 45 degrees.
10. Verify tube plac ement (see Box 42-15). Consider the results
• On oc c asion, c olour alone may differentiate gastric from intestinal
from pH testing together with the aspirate's appearanc e.
plac ement. Bec ause most intestinal aspirates are stained by bile to a
distinc t yellow c olour and most gastric aspirates are not so stained, the
differenc e may be distinguished. However, c olour differenc es among
the stomac h and intestine are often diffic ult to disc ern, and the aspirate's
c olour must be c onsidered in c ombination with other assessment data
(Ellett et al., 2014).
11. Chec k pH of aspirate; c onfirm measurement of length of tube • Aspirates from initially plac ed nasogastric tubes with a pH of ≤5.5 are
from naris to tip of c onnec tion port; ensure original mark is in reliable to differentiate if the tube is in or outside the stomac h, but this
the same position.
does not c ompletely rule out esophageal plac ement (Boeykins et al.,
2014; Meert, Caverly, Kelm, et al., 2015).
12. When available, c hec k CO2 at the distal end of naso- or
• The detec tion of CO 2 at the distal end of NG/OG tubes (c apnography)
orogastric (NG/OG) tubes.
to asc ertain unsuspec ted respiratory plac ement was 100% ac c urate in 10
c ritic ally ill adults (Ellett et al., 2014). Based on available researc h, more
than one method of monitoring the plac ement of NG/OG tubes at the
bedside should be used; an abdominal radiograph should be obtained if
there is any doubt that the tube ends in the stomac h.
Critical Decision P oint: Ausculta tion is not considered a relia ble method for verifica tion of pla cement of tube beca use a tube ina dvertently pla ced in
lungs, pha rynx, or esopha gus ca n tra nsmit sound simila r to tha t of a ir entering stoma ch (Ellett et a l., 2014; Metheny, 2016).
13. Chec k for gastric residual.
• Residual volume indic ates whether gastric emptying is delayed. The
A. Draw 30 mL of air with syringe. Connec t to end of
Canadian Critic al Care Nutrition guideline rec ommends a range of 250 to
feeding tube. Flush tube with air.
500 mL (Dhaliwal et al., 2014). For pediatric patients, the amount of
B. Pull bac k evenly to aspirate gastric c ontents (see S tep
13B illustration).
STEP 13B
residual volume will be less. What c onstitutes a high gastric residual
volume is debated. Volumes greater than 200 are c onsidered high in
c ritic ally ill patients who have airways in plac e. Depending on agenc y
polic y and physic ian or dietitian dec ision, if residual volume exc eeds
500 mL, feedings may be withheld. However, bec ause sec retion of
saliva and gastric fluids alone may total 188 mL/hour, a gastric residual
volume of 200 may be too low a c riterion for stopping the feeding
(Flynn Makic , Rauen, & VonRueden, 2013). Further researc h is needed
to rec ommend the frequenc y of the need to monitor gastric residual
volumes. One event of elevated residual volume should not prompt
c essation of enteral tube feeding but instead should prompt the nurse to
monitor for signs and symptoms of intoleranc e (Flynn Makic et al.,
2013).
Check for gastric residual (small-bore
tube).
Please note that if c hec king for gastric residual when a smallbore tube is in plac e, c onsult agenc y polic y. S oft, small-bore
tubes may c ollapse when GRV is c hec ked, making
assessment of residuals falsely low (Rollins & Boggs, 2013).
Remember that tube loc ation is important. A tube in the small
bowel would have ongoing sec retions and muc h more
residual and, therefore, c hec king residuals would not be
nec essary.
C. Return aspirated c ontents to stomac h if spec ified by agenc y
polic y.
14. Flush tubing with 30 to 50 mL of tap water at room
temperature (Ric e, 2016).
15. Label feeding tube bag. Complete and post nutrition label on
bag to indic ate type of formula, rate, time, and date.
16. Initiate feeding:
A. S yringe or intermittent feeding:
(1) Pinc h proximal end of the feeding tube.
(2) Remove plunger from syringe and attac h barrel of
syringe to end of tube.
(3) Fill syringe with measured amount of formula (see S tep
16A[3] illustration). Release tube and hold syringe high
enough to allow it to empty gradually by gravity, and
refill; repeat until presc ribed amount has been delivered to
the patient.
STEP 16A(3)
• Return of aspirate is also a c ontroversial topic that requires further
researc h (Parker, Torrazza, Li, et al., 2015).
• Ensure tube is c lear and patent.
• Pinc hing prevents air from entering patient's stomac h.
• Gradual emptying of tube feeding by gravity from syringe or feeding
bag reduc es risk of abdominal disc omfort, vomiting, or diarrhea induc ed
by bolus or too-rapid infusion of tube feedings.
Fill syringe with formula.
(4) If feeding bag is used, hang feeding bag on an IV pole
(see S tep 16A[4] illustration). Fill bag with presc ribed
• A feeding pump is used to infuse the formula. An IV pump must not be
used for enteral feedings.
amount of formula, and allow bag to empty gradually over
at least 30 minutes, depending on the amount of feeding.
STEP 16A(4)
Administration via feeding bag.
(5) Doc ument tube assessment for plac ement, formula
infusing, and infusion rate; elevate head of bed to at least
45 degrees.
B. Continuous-drip method (see S tep 16B illustration):
(1) Prime and hang feeding bag and tubing.
(2) Connec t distal end of tubing to the proximal end of the
feeding tube.
(3) Connec t tubing through infusion pump and set rate (see
illustration).
(4) Do not hang any longer than a 4-hour supply, to
dec rease risk of food spoilage potentially resulting in
gastrointestinal irritation or infec tion.
STEP 16B
• Continuous feeding method is designed to deliver a presc ribed hourly
rate of feeding. This method reduc es risk of abdominal disc omfort.
P atients who receive continuous-drip feedings should have residuals
checked as per agency policy. Frequenc y of c hec king gastric residuals
varies, and researc h has not c learly determined the need. A protoc ol of
enteral nutrition management without residual gastric volume
monitoring was found not inferior to a similar protoc ol that inc luded
residual gastric volume monitoring as protec tion against ventilatorassisted pneumonia (Reignier, Merc ier, Le Gouge, et al., 2013). Residual
gastric volume monitoring leads to unnec essary interruptions of enteral
nutrition delivery with subsequent inadequate feeding and, arguably,
should be removed from the standard c are of c ritic ally ill patients
rec eiving invasive mec hanic al ventilation and early enteral nutrition
(Reignier et al., 2013). In nursing prac tic e, however, gastric residual
volumes are usually c hec ked every 4 hours × 48 hours post-initiation of
new c ontinuous feed. For established gastric feeds (greater than 48
hours), residuals are c hec ked when patients exhibit signs of gastric
intoleranc e (abdominal distension, nausea, and vomiting). Measurement
of gastric residuals every 4 hours is prudent in c ritic ally ill patients
(S askatoon Health Region, 2017).
• Tube plac ement verific ation is diffic ult with c ontinuous feeding bec ause
pH of formula affec ts the stomac h pH.
Prime and connect tubing through infusion
pump.
17. Advanc e the rate of tube feeding gradually (see Box 42-13).
• Tube feedings should be advanc ed gradually to prevent diarrhea and
gastric intoleranc e to formula.
• Flushing maintains patenc y of feeding tube and provides patient with a
sourc e of water to help maintain fluid and elec trolyte balanc e.
18. After intermittent infusion or at end of c ontinuous infusion,
flush nasoenteral tubing with water. On average, 30 mL of
water is used, but the amount c an vary from 10 mL to over 30
mL. Repeat every 4 to 6 hours. Remove gloves and perform
hand hygiene.
Critical Decision P oint: It ma y be necessa ry to consult with a dietitia n to recommend a tota l free wa ter requirement per da y. This a voids the potentia l of
fluid overloa d.
19. When tube feedings are not being administered (e.g., they
may be held prior to tests or proc edures suc h as extubation),
c ap or c lamp the proximal end of the feeding tube.
20. Rinse bag and tubing with water whenever feedings are
interrupted or every 8 hours.
21. Change bag and tubing every 24 hours.
• Closing the end of the tube prevents air from entering stomac h between
feedings and prevents c ontamination.
• Rinsing bag and tubing c lears old tube formula and reduc es bac terial
growth.
• Changing bag and tubing reduc es patient's exposure to bac terial growth
oc c urring in those items.
22. Measure amount of aspirate (residual) every 8 to 12 hours.
• These measurements help evaluate toleranc e of tube feeding.
23. Monitor fingerstick blood glucose level every 6 hours until
• These levels alert the nurse to patient's toleranc e of gluc ose. Remember
maximum administration rate is reached and maintained for
that if feedings are stopped, monitor for any drop in gluc ose level—
24 hours.
espec ially if patient is on insulin therapy.
24. Monitor intake and output every 8 hours and c ompute 24• Intake and output are indic ations of fluid balanc e or fluid volume exc ess
hour totals.
or defic it.
25. Weigh patient daily until maximum administration rate is
• Weight gain is an indic ator of improved nutritional status; however,
reac hed and maintained for 24 hours; then weigh patient three
sudden gain of more than 1 kg in 24 hours usually indic ates fluid
times per week.
retention.
26. Observe patient's respiratory status.
• Inc reased respiratory rate may indic ate aspiration of tube feeding.
27. Observe return of normal laboratory values.
• Improving laboratory values (e.g., albumin, transferrin, and prealbumin)
indic ate an improved nutritional status.
UNEXP ECTED OUTCOMES (in addition to those identified in RELATED INTERVENTIONS
Skill 42-1)
Ga stric residua l exceeding 200 to 500 mL (see agenc y polic y) • S ee S tep 13 for further information about residual volumes. If established
by agenc y polic y, withhold feeding and notify physic ian.
For example, ac c ording to S askatoon Health Region (2017):
• Maintain patient in semi-Fowler's position, or have head of bed elevated
• If the residual is less than or equal to 350 mL, refeed the
at least 30 to 45 degrees.
aspirated volume and c ontinue feeding as before.
• Perform physic al assessment.
• If the residual is greater than or equal to 350 mL, refeed 350
• Assess glyc emic c ontrol.
mL, disc ard remaining aspirated volume, and hold feed × 4
hours. Restart the feed at 10 mL/hr and inc rease by 10 mL/hr
every 1 hour bac k to the previous tolerated rate.
• If the residual is greater than or equal to 350 mL a sec ond time,
refeed 350 mL, disc ard remaining aspirated volume, and hold
feed × 6 hours.
• Notify physic ian.
Dia rrhea three times or more in 24 hours
• Confer with dietitian.
• Institute skin-c are measures.
• Diarrhea c ould indic ate formula is being administered too rapidly
(S askatoon Health Region, 2017).
• Look for other c auses of the diarrhea (e.g., antibiotic s; c onsider c hange
in antibiotic s only for patients rec eiving antibiotic s).
• Notify physic ian.
Na usea a nd vomiting
• Chec k patenc y of tube.
• Aspirate for residual.
• Ausc ultate for bowel sounds.
RECORDING AND REP ORTING
• Rec ord amount and type of feeding and patient's response to tube feeding, patenc y of tube, and any side effec ts.
• Report patient's toleranc e and adverse effec ts.
HOME CARE CONSIDERATIONS
• Teac h patient or primary c aregiver how to determine c orrec t plac ement of feeding tube using pH strips.
• Inform patient or primary c aregiver of signs assoc iated with pulmonary aspiration and delayed gastric emptying.
• Desc ribe signs and symptoms assoc iated with feeding tube c omplic ations, and advise when to c all physic ian.
SKILL 42-5
ADMINISTERING ENTERAL FEEDINGS VIA GASTROSTOMY OR
JEJUNOSTOMY TUBE
Delegation Considerations
Administration of enteral tube feeding via a gastrostomy or jejunostomy tube is a
proc edure that—depending on agenc y polic y—c an be delegated to an unregulated
c are provider (UCP) after the nurse verifies tube plac ement. UCPs should never test
the position of the tube or give the first dose of a tube feeding.
• Ensure that the patient is sitting upright in a c hair or in bed, and instruc t the UCP to
infuse the feeding slowly.
• Instruc t the UCP to report any diffic ulty infusing the feeding or any disc omfort voic ed
Equipment
• Disposable feeding c ontainer or ready-to-hang
bag.
• 30-mL or larger Luer-Lok or c atheter-tip
syringe
• Formula
• Infusion pump: Use pump designed for tube
feedings
by the patient.
P ROCEDURE
STEP S
1. Assess patient's need for enteral tube feedings (see S kill 42-3 and S kill 42-4): impaired
swallowing, dec reased level of c onsc iousness, surgic al proc edures involving upper
alimentary trac t, need for long-term enteral nutrition.
2. Obtain baseline weight and laboratory values (blood gluc ose, albumin, transferrin,
prealbumin).
3. Verify physic ian's order for formula, rate, route, and frequenc y.
4. Perform hand hygiene.
5. Explain proc edure to patient.
6. Auscultate for bowel sounds before feeding. Consult physician if bowel sounds are
absent.
7. Assess gastrostomy or jejunostomy site for breakdown, irritation, or drainage.
8. Perform hand hygiene and apply gloves.
9. Prepare feeding c ontainer to administer formula:
A. Have tube feeding formula at room temperature.
B. Connec t tubing to c ontainer as needed, or prepare ready-to-hang bag.
C. S hake formula well. Fill c ontainer and tubing with formula.
10. For intermittent feeding, have syringe ready and ensure formula is at room
temperature.
11. Elevate head of bed to 45 degrees.
12. Apply gloves and verify tube plac ement.
A. Gastrostomy tube: Attac h syringe and aspirate gastric sec retions; observe their
appearanc e and c hec k pH. Return aspirated c ontents to stomac h unless the volume
exc eeds 100 mL or spec ified amount based on patient's age. If the volume is greater
than 100 mL or the spec ified amount on several c onsec utive oc c asions, c hec k
agenc y polic y regarding stopping the feeding and notifying the physic ian.
B. Jejunostomy tube: Aspirate intestinal sec retions, observe their appearanc e, and
c hec k pH.
13. Flush with 30 mL of room temperature tap water.
14. Initiate feedings:
• pH indic ator strips (sc ale 0 to 14)
• Medic ation c up or c ontainer for aspirated fluid
• S tethosc ope
• Disposable gloves
• Equipment to obtain blood gluc ose by
fingerstic k
RATIONALE
• This assessment identifies patients who need
tube feedings before they bec ome nutritionally
depleted. Enteral feeding preserves the func tion
and mass of the gut, promotes wound healing,
diminishes hypermetabolism in burn injuries,
and may dec rease infec tion in c ritic ally ill
patients (Blumenstein et al., 2014; RahnemaiAzar, Rahnemaiazar, Naghshizadian, et al.,
2014).
• Enteral feedings are intended to restore or
maintain nutritional status. Baseline weight and
laboratory values provide objec tive data to
measure effec tiveness of feedings.
• Tube feedings must be ordered by a physic ian.
• Hygiene reduc es transmission of
mic roorganisms.
• Well-informed patients are more c ooperative
and more at ease than patients who are illinformed.
• Absenc e of bowel sounds may indic ate
dec rease in or absenc e of peristalsis and
inc reased risk of aspiration or abdominal
distension.
• Infec tion, pressure from tube, or drainage of
gastric sec retions c an c ause skin breakdown.
• Cold formula may c ause gastric c ramping and
disc omfort bec ause the liquid is not warmed by
mouth and esophagus.
• Tubing must be free of c ontamination, to
prevent bac terial growth.
• Plac ement of formula through tubing prevents
exc ess air from entering gastrointestinal trac t.
• Cold formula may c ause gastric c ramping.
• Elevating patient's head helps prevent c hanc e
of aspiration.
• Fluid from gastric tube of patient who has fasted
for at least 4 hours usually has a pH of 1 to 4,
espec ially when patient is not rec eiving a
gastric -ac id inhibitor. Continuous administration
of tube feedings may elevate pH (Temblett &
George, 2013). Gastric residual may indic ate
whether gastric emptying is delayed.
• Presenc e of intestinal fluid indic ates that end of
the tube is in the small intestine (i.e., the
duodenum or jejunum). In general, the intestinal
residual is very small (10 mL or less). If fluid
appears ac idic on pH test, if fluid looks like
gastric fluid, or if the residual volume is large
(more than 10 mL), displac ement of the tube
into the stomac h may have oc c urred.
• Gastrostomy and jejunostomy feedings are
usually given c ontinuously to ensure proper
absorption. However, initial feedings may be
given by bolus to assess patient's toleranc e to
formula. S ee Box 42-13 for guidelines to
advanc e enteral feedings.
A. S yringe feedings:
(1) Pinc h proximal end of gastrostomy or jejunostomy tube.
• Pinc hing prevents exc ess air from entering the
patient's stomac h and prevents the leaking of
gastric c ontents.
(2) Remove plunger and attac h barrel of syringe to end of tube; then fill syringe with
formula.
(3) Release tube and elevate syringe. Allow syringe to empty gradually by gravity. • Gradual administration of tube feedings by
Refill until presc ribed amount has been delivered to patient.
gravity reduc es the risk of diarrhea induc ed by
bolus tube feedings.
B. Continuous drip method:
• Continuous-feeding method is designed to
deliver a presc ribed hourly rate of feeding. This
method reduc es the risk of diarrhea and risk of
abdominal disc omfort. Patients who rec eive
c ontinuous-drip feedings should have residuals
c hec ked as per agenc y polic y and tube
plac ement verified every 4 hours. It is usual to
measure gastric residuals every 4 hours in
c ritic ally ill patients (S askatoon Health Region,
2017).
• Gastric residual volumes c an be reduc ed in
nonc ritic ally ill patients after the first 48 hours
of being fed.
(1) Verify that volume in c ontainer is suffic ient for length of feeding (4 to 8 hours,
c hec k manufac turer's rec ommendations).
(2) Hang c ontainer on IV pole, and c lear tubing of air.
• Hanging the c ontainer allows for gravity-based
flow of formula, whic h prevents ac c umulation
of air in the patient's stomac h.
(3) Thread tubing into pump ac c ording to manufac turer's direc tions.
(4) Connec t tubing to end of gastrostomy or jejunostomy tube.
(5) Begin infusion at presc ribed rate.
15. Administer water via feeding tube as ordered with or between feedings.
• Water helps patients maintain fluid and
elec trolyte balanc e.
16. Flush tube with 30 mL of water every 4 to 6 hours and before and after administering
• Flushing maintains patenc y of tube and
medic ations via feeding tube.
provides patient with some free water. S mall
jejunal tubes are prone to c logging and are
diffic ult to replac e (Fisher & Blaloc k, 2014).
17. When tube feedings are not being administered, c ap or c lamp the proximal end of the
• Closing the end of the tube prevents exc ess air
gastrostomy or jejunostomy tube.
from entering the gastrointestinal trac t between
feedings and prevents leakage of gastric
c ontents.
18. Rinse c ontainer and tubing with water after all intermittent feedings.
• Rinsing c lears formula from tubing and reduc es
bac terial growth in c ontainer and tubing. The
c ontainer and tubing should be c hanged every
24 hours.
19. Assess skin around tube exit site. Before site has healed, c lean with normal saline. A
• Report any drainage, redness, swelling, or
small prec ut gauze dressing may be applied to exit site and sec ured with tape. The
displac ement of the tube to the physic ian.
dressing is assessed for drainage and c hanged daily and as needed. Onc e site has
Leakage of gastric drainage may c ause skin
healed, c lean the skin around the tube daily with warm water and mild soap. A fully
irritation.
healed tubing exit site is left open to air. If patient rec eived nasogastric feedings before • Postproc edure monitoring is performed to
tube insertion and then undergoes a proc edure, tube is not used for first 4 to 6 hours
c hec k for bleeding.
after proc edure. (Patient will be NPO status the night before the proc edure.
Postproc edure doc umentation—as per agenc y polic y—will indic ate when to use tube.)
Feeding will resume at previous nasogastric rates onc e it is safe to begin feeding.
20. Dispose of supplies, and perform hand hygiene.
• Hygiene helps prevent transmission of
mic roorganisms.
21. Evaluate patient's toleranc e to tube feeding. Measure the amount of aspirate every 8 to • Measurements help in evaluation of toleranc e
12 hours.
of tube feeding.
22. Monitor fingerstic k blood gluc ose level every 6 hours until maximum administration
rate is reac hed and maintained for 24 hours.
23. Monitor intake and output every 24 hours.
24. Weigh patient daily until maximum administration rate is reac hed and maintained for 24
hours; then weigh patient three times per week.
25. Observe return of normal laboratory values.
• Alerts nurse to patient's toleranc e of gluc ose.
• Intake and output are indic ations of fluid balanc e
or fluid volume exc ess.
• Weight gain indic ates improved nutritional
status; however, a sudden gain of more than 1
kg in 24 hours usually indic ates fluid retention.
• Improved laboratory values (albumin,
transferrin, prealbumin) indic ate improving
26. Inspec t stoma site for impaired skin integrity.
UNEXP ECTED OUTCOMES
Aspira tion of formula when ga stric emptying is dela yed or formula is a dministered too ra pidly
a nd produces vomiting
Skin brea kdown a round ga strostomy or jejunostomy site
nutritional status.
• Enteral tubes c an c ause pressure and
exc oriation at the stoma site. In addition, gastric
sec retions irritate patient's skin.
RELATED INTERVENTIONS
• Position patient in side-lying position.
• S uc tion airway.
• Notify physic ian.
• Obtain c hest X-ray film.
• Institute skin c are prac tic es.
• Use pressure relief measures around tube.
• Provide appropriate wound c are (see Chapter
46).
RECORDING AND REP ORTING
• Rec ord amount and type of feeding and patient's response to tube feeding, patenc y of tube, stoma site, and skin integrity, and doc ument
any side effec ts.
• Report to inc oming nursing staff type of feeding, status of feeding tube, patient's toleranc e, and adverse effec ts.
HOME CARE CONSIDERATIONS
Teaching patient or primary caregiver how to determine correct placement of feeding tube
• Aspirate and c hec k pH.
• Measure tube length.
Signs associated with pulmonary aspiration and delayed gastric emptying
• Advise patient or primary c aregiver to be alert for inc reased or laboured breathing.
• Instruc t patient or c aregiver to report shortness of breath.
• Instruc t patient or c aregiver to report enlarged or tender abdomen.
• Instruc t patient or c aregiver to be alert for residuals exc eeding 200 mL (inc reased residuals may be related to aspiration) (Metheny, 2016).
Reinforcing signs and symptoms associated with feeding tube complications and when to call physician
• S hortness of breath
• Laboured breathing
• Cramping, vomiting
• Diarrhea two to three times per day
• Constipation
• Tube oc c lusion
• Tube length inc rease of 3 to 5 c m or dislodgement
Initiating Enteral Tube Feedings
Enteral formulas are usually one of four types. Polymeric formulas (1.0 to 2.0
kcal/mL) include milk-based blenderized foods prepared by hospital dietary
staff or in the patient's home. The polymeric classification also includes
commercially prepared whole-nutrient formulas. For this type of formula to
be effective, the patient's gastrointestinal tract must be able to absorb whole
nutrients. Modular formulas (3.8 to 4.0 kcal/mL) are single-macronutrient
(e.g., protein, glucose, polymers, or lipids) preparations and are not
nutritionally complete. This type of formula is added to other foods for
meeting the patient's individual nutritional needs. Elemental formulas (1.0 to
3.0 kcal/mL) contain predigested nutrients that are easier for a partially
dysfunctional gastrointestinal tract to absorb. Finally, specialty formulas (1.0
to 2.0 kcal/mL) are designed to meet specific nutritional needs in certain
illnesses (e.g., liver failure, pulmonary disease, or human immunodeficiency
virus [HIV] infection).
Tube feedings are typically started at full strength at slow rates (Box 42-13).
The hourly rate is increased every 12 to 24 hours if no signs of intolerance
(nausea, cramping, vomiting, diarrhea) appear.
Box 42-13
Advancing the Rate of Tube Feeding
Intermittent
1. Start formula at ordered concentration.
2. If based on physician order and agency policy, infuse bolus of formula
over at least 20 to 30 minutes via syringe or feeding container.
3. Begin feedings with no more than 150 to 250 mL at one time. Increase
incrementally by 50 mL per feeding per day for adults to achieve
needed volume and calories in six to eight feedings. Rates for pediatric
patients may be increased by 5 to 10 mL per 8 to 24 hours. (Note:
Concentrated formulas at full strength may be infused at slower rates
until tolerance is achieved.)
Continuous
1. Start formula at ordered concentration full strength for isotonic
formulas (concentration of all nutrients in the formula is the same as
the concentration of plasma—the fluid component of blood—at
approximately 300 mOsm/kg water) or at ordered concentration.
Usually hypertonic formulas are also started at full strength but at a
slower rate because hypertonic formulas create a pressure gradient
that draws water into the intestine and may cause diarrhea and
cramping.
2. Begin infusion rate at designated rate.
3. Advance rate slowly (e.g., 10 to 20 mL/hour per day, depending on
patient's age) to target rate if tolerated (tolerance indicated by absence
of nausea and diarrhea and by low gastric residuals).
Studies have demonstrated a beneficial effect of enteral feedings in
comparison with parenteral (intravenously administered) nutrition. Feeding
by the enteral route may reduce sepsis, blunt the hypermetabolic response to
trauma, and maintain intestinal structure and function (Silk & Quinn, 2015).
To remove the tube, the procedure outlined in Box 42-14 is used.
Box 42-14
Procedural Guideline
Discontinuing Enteral Feedings via Nasogastric Tube
Equipment:
• Clean gloves, facial tissues, towel or absorbent pad, disposable bag
Procedure:
1. Check the physician's order to discontinue nasogastric tube.
2. Educate patient about what to expect during procedure:
A. Patient may experience irritation of nose and throat, as well as
watering of the eyes.
B. Encourage patient to breathe out as the tube is being removed,
to promote comfort and ease of removal.
3. Perform hand hygiene and apply gloves.
4. Assist patient to sit up in high Fowler's position, if possible (to protect
patient from drainage). Encourage patient participation.
A. Place towel over patient's chest.
B. Provide tissues to patient.
5. Disconnect tube from pump and from patient's gown.
6. Ask patient to take a deep breath and exhale slowly; pinch tube and
withdraw it slowly.
7. Provide oral care to patient; provide skin care around patient's nares.
8. Document procedure and total fluid balances.
Preventing Complications
A serious complication associated with enteral feeding is aspiration of
enteral formula into the tracheobronchial tree. Aspiration of enteral formula
into the lungs irritates the bronchial mucosa, resulting in decreased blood
supply to affected pulmonary tissue (Blumenstein et al., 2014). This leads to
necrotizing infection, pneumonia, and potential abscess formation. The high
glucose content serves as a bacterial growth medium, thereby promoting
infection. Adult respiratory distress syndrome is also frequently associated
with pulmonary aspiration. Common conditions that increase the risk of
aspiration include coughing, nasotracheal suctioning, an artificial airway,
decreased level of consciousness, and lying flat during and after feeding.
Researchers have investigated the problems associated with nasoenteral
tube placement, type of feeding instilled, rate of feeding, and complications
associated with tube feeding. Small-bore feeding tubes create less discomfort
for patients and are currently most often used (Figure 42-12). For adults,
most of these tubes are 8 to 12 Fr and 91 to 109 cm long. A stylet is often used
during insertion of a small-bore tube to stiffen it. The stylet is removed when
the correct position of the feeding tube is confirmed.
FIGURE 42-12
Enteral tubes, small bore.
At present, the most reliable method for verification of placement of smallbore feeding tubes is X-ray examination (Box 42-15). Measuring the pH of
secretions withdrawn from the feeding tube may also help differentiate the
location of the tube (Box 42-16). Patients who take acid inhibitor medications
usually have an acidic pH value ranging from 4.0 (after 4 hours of fasting) to
6.0 (with continuous enteral nutrition infusion). In contrast, intestinal
aspirate has a pH of 7.8 to 8.0. More precise indicators are needed to help
differentiate the source of tube feeding aspirate (Boeykens, Steeman, &
Duysburgh, 2014; Ellett, Cohen, Croffie, et al., 2014).
Box 42-15
Research Highlight
Accuracy in Determining Placement of Feeding Tubes
Research Focus
Two possible adverse outcomes of enteral nutrition are (1) accidental
placement of a nasoenteral feeding tube into the lung and (2) pulmonary
aspiration of gastric contents.
Research Abstract
The precise incidence of accidental tube misplacements into the lung is
unknown, but estimates of close to 5% have been cited. Patients at highest
risk are those with a decreased level of consciousness; those who are
confused, uncooperative, or agitated; those who have an endotracheal tube;
those who have undergone recent extubation; and those with poor gag reflex.
A feeding tube accidentally inserted into the lung may end in the
tracheobronchial tree or may perforate into the pleural space. In either
event, efforts are made to detect the misplacement before the introduction
of tube feedings because inadvertent infusion of formula into the lung
promotes tissue consolidation, pneumonia, and respiratory failure. The most
accurate method for checking feeding tube placement is X-ray examination;
the most effective nonradiological method is aspirating fluid from the
feeding tube, measuring its pH, and describing its appearance. Although
observing for respiratory distress is helpful in alert patients (especially when
firm large-diameter tubes are used), it is of little benefit in those who have a
decreased level of consciousness and when small-bore tubes are used. Risk
factors for pulmonary aspiration in tube-fed patients include feeding into
the stomach in the presence of gastric atony (which results in high gastric
residual volumes), poor gag reflexes, mechanical ventilation, and flat
positioning in bed. Bedside methods used to detect pulmonary aspiration
are not well defined.
Evidence-Informed Practice
• Radiography is the most reliable method available to confirm correct
feeding tube location, and radiographic verification is required in most
acute care facilities when small-bore tubes are initially inserted.
• When the radiographic method is not feasible, measurement of CO2
levels at the distal end of the tube have been found to be accurate in
critically ill adults (Ellett et al., 2014).
• A less reliable method involves testing the feeding tube aspirate's pH
and observing its appearance. A properly obtained pH of 0 to 5.5 is a
good indication of gastric placement; a pH of 6 or higher could indicate
placement in the lung, intestine, or stomach, in which gastric pH is
usually high. Intestinal fluid is usually bile-stained (dark golden yellow);
in contrast, gastric fluid is usually grassy green, off-white to tan, or clear
and colourless.
• A supplementary method to confirm placement consists of marking the
feeding tube with indelible ink at the exit site from the naris or lip at the
time of radiography. The nurse must confirm this mark before feeding or
administering medication through the tube. The measurement from
naris to tip of tube must also be recorded. The exit-point mark is not a
foolproof indication of correct tube placement, inasmuch as the tube's
distal tip can move from its original position while the external portion
remains intact.
• The auscultatory method should not be used to determine tube location.
• The dye method (adding Blue No. 1 food colouring to enteral formula to
assist with the detection of formula aspirated into the lung) is no longer
used because of its association with patient deaths.
Blumenstein, I., Shastri, Y. M., & Stein, J. (2014). Gastroenteric tube feeding: Techniques, problems and
solutions. World Journal of Gastroenterology, 20(26), 8505–8524. doi:10.3748/wjg.v20.i26.8505; Boeykens,
K., Steeman, E., & Duysburgh, I. (2014). Reliability of pH measurement and the auscultatory method to
confirm the position of a nasogastric tube. International Journal of Nursing Studies, 51(11), 1427–1433.
doi:10.1016/j.ijnurstu.2014.03.004; Dhaliwal, R., Cahill, N., Lemieux, M., & Heyland, D. K. (2014). The
Canadian critical care nutrition guidelines in 2013: An update on current recommendations and
implementation strategies. Nutrition in Clinical Practice, 29(1), 29-43; Ellett, M. L. C., Cohen, M. D.,
Croffie, J. M. B., Lane, K. A., Austin, J. K., & Perkins, S. M. (2014). Comparing bedside methods of
determining placement of gastric tubes in children. Journal for Specialists in Pediatric Nursing , 19(1), 68–
79. doi:10.1111/jspn.12054; Food and Drug Administration. (2003; updated 2015). FDA public health
advisory: Subject: Reports of blue discoloration and death in patients receiving enteral feedings tinted
with the dye FD&C Blue No. 1. Retrieved from
http://www.fda.gov/ForIndustry/ColorAdditives/ColorAdditivesinSpecificProducts/InMedicalDevices/ucm142395.
Metheny, N. A. (2016). Prevention of aspiration in adults. Critical Care Nurse, 36(1), e20–e24.
doi:10.4037/ccn2016831; Saskatoon Health Region. (2013). Nasogastric/orogastric tube: Insertion, care of,
and removal. Retrieved from https://www.saskatoonhealthregion.ca/about/NursingManual/1040.pdf.
Box 42-16
Procedural Guideline
Obtaining Gastrointestinal Aspirate for pH Measurement, Largeand Small-Bore Feeding Tubes: Intermittent and Continuous
Feeding
Critical Decision Point: Obtaining gastrointestinal aspirate for pH
measurement to verify placement is crucial, whether a large- or small-bore
tube is used and whether the tube will be used for decompression or
feeding. Note: An X-ray examination to verify tube placement must be
completed before enteral feedings are initiated.
Delegation Considerations:
The skill of measuring pH in gastrointestinal aspirate should not be
delegated to unregulated care providers.
Equipment:
• 60 mL syringe
• pH test paper (scale of 0 to 11)
• Absorbent pad
• Small medication cup
• Disposable gloves
Procedure:
1. Perform hand hygiene. Perform measures to verify placement of tube:
A. For intermittently fed patients, test placement immediately
before feeding (usually a period of at least 4 hours will have
elapsed since previous feeding). More frequent checking has
been associated with increased clogging of small-bore tubes. To
avoid clogging, flush tube with 30 mL of water after aspirating
for the residual volume (Fisher & Blalock, 2014).
B. For continuously tube-fed patients, check agency policy. If the
patient is tolerating the feedings without incident and other
indicators of correct location are present (the mark on the tube at
the exit site has remained in its original position, and the most
recent X-ray films confirm correct position of tube), it is
reasonable to continue feedings. If risk of tube displacement is
high and the tube has moved, consider the need for an X-ray
film to verify placement (Ellett et al., 2014; Metheny, 2016). Plan
to test pH at times when feeding may be withheld (e.g., during
diagnostic testing, during chest physiotherapy, or to avoid
medication interaction).
C. Wait at least 1 hour after medication administration by tube or
mouth.
2. Apply disposable gloves.
3. Draw 30 mL of air, or an equivalent amount for infants and children,
into syringe, then attach syringe to end of feeding tube. Flush tube
with the 30 mL of air to clear out formula or medications before
attempting to aspirate fluid. It will probably be more difficult to
aspirate fluid from the small intestine than from the stomach.
Repositioning the patient from side to side may be helpful. More than
one bolus of air through the tube may be needed.
4. Draw back on syringe and obtain 5 to 10 mL of gastric aspirate. Observe
appearance of aspirate (see illustration Step 4A). Gently mix aspirate
in syringe. Then expel a few drops into a clean medicine cup. Dip the
pH strip into the fluid or apply a few drops of the fluid to the strip (see
illustration Step 4B). Compare the colour of the strip with the colour
on the chart provided by the manufacturer.
A. The pH of gastric fluid usually ranges from 1–2 up to 4–5
(Helmenstine, 2017).
B. The pH of intestinal fluid is usually higher than 6.
C. Patients with continuous tube feeding may have a pH of 5 or
higher.
D. The pH of pleural fluid from the tracheobronchial tree is
generally higher than 6.
STEP 4A Gastrointestinal contents. A, Stomach. B, Stomach. C, Intestinal.
(Courtesy Dr. Norma A. Metheny, Professor, St. Louis University School of Nursing.)
STEP 4B Comparing pH strip with colour chart.
5. Remove gloves and discard supplies. Perform hand hygiene.
Critical Decision Point: If after repeated attempts it is not possible to
aspirate fluid from a tube that was originally confirmed by X-ray
examination to be in the desired position, the tube is considered correctly
placed if (1) no risk factors for tube dislocation exist, (2) the tube has
remained in the original taped position and the tube's measurement
remains constant, and (3) the patient is not experiencing difficulty (Irving,
Lyman, Northington, et al., 2014). If in doubt, repeat radiographic
examination of patient to confirm placement.
Major complications of enteral nutrition are outlined in Table 42-9. Of
special note, severely malnourished patients are at risk for electrolyte
disturbances from refeeding syndrome (metabolic disturbances that occur as
a result of reinstituting nutrition) because cations such as potassium,
magnesium, and phosphate move intracellularly during enteral nutrition or
parenteral nutrition therapy. Recall also the appearance of refeeding
syndrome in the case study of the adolescent living with anorexia nervosa
(see Box 42-2). There can be situations where enteral nutrition is not effective
in nourishing the body and your role as a nurse is to support a patient in a
different way. Box 42-17 tells the story of a nurse who learned the importance
of nourishing a person's soul.
TABLE 42-9
Complications of Enteral Tube Feeding
Problem
Possible Cause
Pulmonary aspiration Regurgitation of formula
Feeding tube displac ed
Patient in supine position
Defic ient gag reflex
Diarrhea
Gastroesophageal reflux
disease
Delayed gastric emptying
Hyperosmolar formula or
medic ations
Allergy to elixir ingredients
(sorbitol)
Antibiotic therapy
Bac terial c ontamination
Malabsorption
Constipation
Lac k of fibre
Lac k of free water
Medic ations
Inac tivity
Tube oc c lusion
Pulverized medic ations
given per tube
Insuffic ient tube irrigation
S edimentation of formula
Reac tion of inc ompatible
medic ations or formula
Tube displac ement
Coughing, vomiting
Tube not taped
sec urely
Abdominal c ramping, High osmolality of formula
nausea, or vomiting
Delayed gastric
emptying
Intervention
Verify tube plac ement
Reposition tube and verify tube plac ement
Elevate head of bed 45 degrees during feedings and for 2 hours afterward
Reassess for return of normal gag reflex; until then, plac e patient on aspiration
prec autions and plac e patient in supine position
Verify tube plac ement
Lower rate of delivery to inc rease toleranc e
Deliver formula c ontinuously, deliver at lower rate, dilute formula, or c hange to
isotonic enteral nutrition (physic ian order required and may c onsult with dietitian)
Liquid medic ations are often sweetened with sorbitol; c onsider this as possible c ause of
diarrhea
Antibiotic s may destroy normal intestinal flora; physic ian may c hange medic ation; treat
symptoms with antidiarrheal agents
Do not hang formula longer than 4–8 hours in bag; wash bag out well when
refilling; c hange tube feeding bags every 24 hours; use aseptic prac tic es
Chec k expiration dates
Chec k for panc reatic insuffic ienc y; use low-fat, lac tose-free formula and c ontinuous
feedings
S elec t a formula c ontaining fibre
Add water as needed as flushes*
Evaluate adverse effec ts; suggest stool softener or bulk-forming laxative
Monitor patient's ability to ambulate; c ollaborate with physic ian for ac tivity order or
physiotherapy
Irrigate with 30 mL water before and after eac h medic ation per tube*
Ideally, eac h medic ation should be given separately
Dilute c rushed medic ations if not liquid
S hake c ans well before administering (read label)
Read pharmac ologic al information on c ompatibility of drugs and formula
Replac e tube and c onfirm plac ement before restarting tube feeding
With plac ement verific ation, c hec k that tape is sec ure (nasoenteral)
S uggest an isotonic formula, or dilute c urrent formula
S uggest use of lac tose-free formula
S top feeding if there is a risk of gastrointestinal trac t obstruc tion
Use greater proportion of c arbohydrate
Warm formula to room temperature
Rapid inc rease in rate or
volume
Delayed gastric emptying
Lower rate of delivery to inc rease toleranc e
Lac tose intoleranc e
Intestinal obstruc tion
High-fat formula used
Cold formula used
Diabetic gastroparesis
Prematurity
Inac tivity
S uggest use of lac tose-free formula
S top feeding if there is a risk of gastrointestinal trac t obstruc tion
Use greater proportion of c arbohydrate
Warm formula to room temperature
Consult with physic ian regarding medic ation for inc reasing gastric motility
Chec k for residual (see agenc y polic y)
Consult physic ian regarding advanc ing tube to intestinal plac ement
If the gastric residual is >250 mL after a sec ond gastric residual c hec k, a promotility
agent should be c onsidered
A full assessment should be c onduc ted to find out reason for high level
S erum elec trolyte
imbalanc e
Inc reased respiratory
quotient
Fluid overload
Hyperosmolar
dehydration
Exc ess gastrointestinal
losses
Dehydration
Cirrhosis
Heart failure, edema
Diabetes mellitus
Overfeeding of
c arbohydrates
Refeeding syndrome in
malnutrition
Exc ess free water or
diluted (hypotonic )
formula
Hypertonic formula with
insuffic ient free water
Monitor medic ations and pathologic al c onditions that may affec t gastrointestinal
motility
Monitor serum elec trolyte levels daily
Provide free water as per dietitian's rec ommendation
Know of links with spec ific pathologic al c ondition
Monitor patient's weight
Monitor gluc ose toleranc e and type of feedings
Balanc e kiloc alorie needs provided from fat, protein, and c arbohydrate with greater
proportion of fat in formula (to dec rease CO 2 produc tion)
Restric t fluids if nec essary, and use either a spec ialized formula or a diluted enteral
formula at first
Monitor levels of serum proteins and elec trolytes
Use a more c onc entrated formula with fluid volume exc ess that does not c arry a
risk of refeeding syndrome
S low rate of delivery, dilute, or c hange to isotonic formula
*
Check first for fluid restrictions that would affect volume of water given. A physician's order is required to
add free H2O; this will be patient-specific.
Box 42-17
Case Study
Nourishing the Mind and Soul*
Phoebe, a 62-year-old woman with end-stage cancer, was admitted to
palliative care for management of symptoms including anxiety, pain, and
anorexia. Daily nursing interventions involved assessing and maintaining
Phoebe's overall comfort in mind, body, and soul. Although Phoebe was
experiencing less pain and anxiety, she continued to have little interest in
food or eating. As a nursing instructor, I guided a student nurse to explore
Phoebe's loss of appetite. Phoebe expectedly denied any interest in eating,
stating, “I'm just not hungry.” A loss of appetite is not unusual at the end of
life. As one's body begins to “turn off,” energy from food is no longer
required; and yet, when the student nurse asked Phoebe if there was
anything she was craving, Phoebe responded, surprisingly, “a roast chicken
dinner with all the fixings!” Although Phoebe was not hungry in the
traditional sense, she was hungry for a roast chicken dinner experience.
Excited about helping Phoebe, the student nurse connected with Phoebe's
daughter to grant Phoebe's wish to have a chicken dinner with her closest
family members. Thankfully, the palliative care unit had a full kitchen for
patients and their families. When the day arrived, Phoebe's family set to
work in the kitchen. Soon the unit was filled with the nostalgic smell of a
roasting chicken. Phoebe was delighted! This was the first meal she had
looked forward to in quite some time. When dinnertime arrived, Phoebe, in
her finest clothes, was wheeled to the family kitchen. She moved her fork
through her plate of dinner, but did not eat any of it. Still, she laughed and
told stories with her loved ones. When their meal was finished, although
exhausted, Phoebe was glowing! Although her physical body no longer
required food for energy, the experience of a sentimental meal and close
family members to share it with was required to nourish Phoebe's mind and
soul.
Exploring Phoebe's loss of appetite was based on principles of dignity,
hope, comfort, and quality of life for people facing the end of life. We
focused on Phoebe's needs and health care wishes in order to reinforce her
personal autonomy, right to be actively involved in her own care, and greater
sense of control. The student and I played a key role in the palliative
approach to care by initiating communication that honoured Phoebe's values
and preferences and supported her family. Critically reflecting on the need
for compassionate and holistic family-oriented care helped us provide a
therapeutic presence and maximize quality of life (and death) to Phoebe and
her family.
In the situation of caring for Phoebe, the instructor and student strove to
satisfy the craving of the palliative care patient through a chicken dinner
experience. Knowing that food holds symbolic meaning for people, how
might this same goal be accomplished if the physical setting did not have a
full kitchen? In what other ways might nurses nurture their patients' soul at
the end of life?
*
By Amy Carrier Fanjoy, BN, RN; MN student, University of New Brunswick.
Large-Bore Tube and Nasogastric or
Orogastric Suctioning
Gastric decompression is the use of suction to drain the stomach to relieve
blockage of the intestinal tract, to wash out stomach contents when a person
has taken poisonous material or after surgery (Gastric suction, 2017).
After surgery, the objectives for drainage are as follows:
• Reduce abdominal distension
• Speed the return of bowel function
• Reduce the chance of wound dehiscence and hernia
The two types of tubes most commonly used for gastric decompression are
the Levine and Salem sump tube. The tubes are large: 16 to 18 Fr may be
inserted through nares or orally (Silk & Quinn, 2015). (See Skill 42-6 and Box
42-18.)
SKILL 42-6
INSERTING A LARGE-BORE NASOENTERIC OR OROGASTRIC TUBE FOR
GASTRIC SUCTIONING
Delegation Considerations
This skill requires problem-solving and knowledge applic ation
unique to a professional nurse. For this reason, this skill should
not be delegated to unregulated c are providers.
P ROCEDURE
STEP S
1. Assess the need for large-bore tube (i.e., for gastric
suc tioning or lavage).
A. Review physic ian's order for type of tube and enteral
feeding sc hedule.
Equipment
• Nasogastric or nasointestinal (orogastric or orointestinal) tube (12 to 18
Fr)
• S tethosc ope
• 60-mL or larger Luer-Lok or c atheter-tip syringe
• Hypoallergenic tape and tinc ture of benzoin or tube fixation devic e
• S c issors
• pH indic ator strip (sc ale of 0 to 14)
• Glass of water and straw (not required for intubated patients)
• Water-soluble lubric ant
• Emesis basin
• Absorbent pad
• Fac ial tissues
• Disposable gloves (multiple pairs needed)
• S uc tion equipment in c ase of aspiration
• Penlight to c hec k plac ement in nasopharynx
• Tongue blade
• Disposable tape measure
• Felt-tip marker
• S uc tion devic e for c ontinuous or intermittent suc tioning
RATIONALE
• Identify patients who require gastric drainage or flushing.
• P rocedure and tube feedings require a physician's order.
2. Perform hand hygiene. Assess patenc y of nares. Have patient • Nares may be obstruc ted or irritated, or septal defec t may be present.
c lose eac h nostril alternately and breathe. Examine eac h naris
for patenc y and skin breakdown.
3. Assess the gag reflex. Plac e tongue blade in patient's mouth, • Assessing gag reflex identifies patient's ability to swallow and
touc hing uvula to induc e a gag response.
determines risk for aspiration.
Critical Decision P oint: Pa tients with impa ired level of consciousness or who a re intuba ted a nd seda ted ma y a lso ha ve impa ired ga g reflex, a nd their
risk of a spira tion is increa sed during this type of procedure a nd subsequent tube feedings. For a pa tient who is intuba ted, seda ted, or too ill to pa rticipa te,
ensure tha t the pa tient's hea d is tilted towa rd the chest for entera l feeding tube insertion.
4. Review patient's medic al history for nasal problems (e.g.,
• Nasoenteral tubes are c ontraindic ated in patients who have undergone
nosebleeds, oral or fac ial surgery, antic oagulation therapy,
rec ent nasal surgery, have sustained fac ial traumas, have nosebleeds, or
history of aspiration).
are rec eiving antic oagulation therapy. Rec ently, a Foley c atheter plac ed
emergently in the left naris of an injured c yc list for nasopharyngeal
hemorrhage was shown on follow-up imaging to be positioned in the
frontal lobe (Veeravagu, Joseph, Jiang, et al., 2013). Bec ause of suc h risk
for improper tube plac ement, c aution must be exerc ised while
performing any endonasal proc edure in the settings of trauma where
disruption of the anterior c ranial base is possible.
5. Perform hand hygiene (before ausc ultating abdomen).
• Hygiene reduc es transfer of mic roorganisms.
6. Ausc ultate patient's abdomen for bowel sounds.
• Absenc e of bowel sounds may indic ate dec rease in or absenc e of
peristalsis and inc reased risk for aspiration or abdominal distension.
7. Explain proc edure to patient and how to c ommunic ate during • Information reduc es anxiety and helps patient assist in insertion. Patients
intubation, by raising index finger to indic ate gagging or
who are alert and c ommunic ating tolerate the proc edure better than
disc omfort.
other patients.
8. S tand on same side of bed as naris for insertion, and assist
• Fowler's position allows easier manipulation of tube, reduc es risk of
patient to high Fowler's position unless that position is
aspiration, and promotes effec tive swallowing.
c ontraindic ated. Plac e pillow behind patient's head and
shoulders.
9. Plac e absorbent pad over patient's c hest. Keep fac ial tissues
• Pad prevents soiling of gown. Insertion of tube may c ause patient's eyes
within reac h.
to tear.
10. Determine length of tube to be inserted, and mark with tape.
• Length approximates distanc e from nose to stomac h in 98% of patients.
Traditional method: Measure distanc e from tip of nose to
For duodenal or jejunal plac ement, an additional 20 to 30 c m is required.
earlobe to xiphoid proc ess of sternum (see S tep 10
illustration).
STEP 10 Length of tube to be inserted is equal to
distance from tip of nose to earlobe to xiphoid process.
11. Prepare nasogastric or nasointestinal tube for intubation.
12. Perform hand hygiene, and put on gloves.
13. Cut tape 10 c m long or prepare tube fixation devic e. S plit one
end of tape lengthwise 5 c m.
14. Dip tube with surfac e lubric ant into glass of water. If tube is
not self-lubric ating, then water-soluble lubric ant should be
used.
15. Insert tube through nostril to bac k of throat (posterior
nasopharynx). Aim bac k and down toward ear.
16. Have patient tilt head toward c hest after tube has passed
through nasopharynx.
• Hygiene and gloves reduc e transmission of mic roorganisms.
• To be used to anc hor tubing after insertion.
• Ac tivates lubric ant to fac ilitate passage of tube into naris to
gastrointestinal trac t. Do not use petroleum-based produc ts bec ause of
the risk of aspiration into the lung and resultant c hemic al pneumonitis.
• Natural c ontour fac ilitates passage of tube into gastrointestinal trac t and
reduc es gagging by patient.
• Tilting head forward c loses off glottis and reduc es risk of tube's entering
trac hea. This tec hnique is also used in patients who are intubated and
sedated.
Critical Decision P oint: Encoura ge pa tients who a re a lert a nd communica ting to swa llow by giving sma ll sips of wa ter or ice chips when possible. For
pa tients who a re intuba ted a nd seda ted or not a ble to pa rticipa te, tilt hea d towa rd chest. Adva nce the tube a s pa tient swa llows or a s hea d is tilted towa rd
chest. Rota te tube 180 degrees while inserting.
17. Emphasize the need to mouth-breathe and swallow during the • Mouth-breathing and swallowing fac ilitate passage of tube and alleviate
proc edure (when possible).
patient's fears during the proc edure.
18. When tip of tube reac hes the c arina (about 25 c m in an adult), • If air is heard, the tube could be in the respiratory tract; remove tube
stop insertion, hold end of tube near your ear, and listen for air and start over. This listening step should never be used to verify tube
exc hange from the distal portion of the tube.
placement (Metheny, 2016).
Critical Decision P oint: Do not force tube insertion. If resista nce is met or pa tient sta rts to cough, choke, or become cya notic, stop a dva ncing the tube
a nd pull tube ba ck.
19. Chec k for position of tube in bac k of throat with penlight and
tongue blade.
• Tube may be c oiled, kinked, or entering trac hea. (Withdraw tube
immediately if tube is c oiled, if respiratory status of patient c hanges, or if
patient begins to c ough and skin c olour c hanges; if distress is not
present, withdraw tube fully and retry. Note whether tube was kinked; if
so, it is likely to kink again in the same plac e.)
20. Perform measures to verify plac ement of tube, by measuring • Note: Tube plac ement must be verified by X-ray examination before
pH.
enteral feeds are initiated. Another test that c an be done at the bedside to
ensure ongoing plac ement is to measure pH of aspirated gastric fluids.
A. Examine gastric c ontents and yield.
• Respiratory and gastric c ontents may look similar, but aspirating gastric
c ontents yields a greater amount, whereas aspirating respiratory
c ontents may yield only a few millilitres.
Critical Decision P oint: Ausculta tion is no longer considered a relia ble method for verifica tion of tube pla cement beca use a tube ina dvertently pla ced in
the lungs, pha rynx, or esopha gus ca n tra nsmit a sound simila r to tha t of a ir entering the stoma ch (Boeykens et a l. , 2014; Na tiona l Associa tion of
Children's Hospita ls, 2012).
21. After gastric aspirates are obtained, anc hor tube to patient's
• A properly sec ured tube allows the patient more mobility and prevents
nose and avoid pressure on nares. Mark exit site on tube with
trauma to nasal muc osa. Mark tube at tip of naris; measure from line to
indelible ink. S elec t one of the following options to sec ure
end of tube; tape and sec ure to maintain position.
tube:
A. Apply tape
(1) Apply tinc ture of benzoin or other skin adhesive on tip • S kin adhesive helps tape adhere better and protec ts skin.
of patient's nose and tube and allow it to bec ome “tac ky.”
(2) Plac e intac t end of tape over bridge of patient's nose.
• S ec uring tape to nares prevents tissue nec rosis.
Wrap eac h of the 5-c m strips around tube as it exits nose.
B. Apply tube fixation devic e, using shaped adhesive patc h.
• Devic e sec ures tube and reduc es fric tion on nares.
(1) Apply wide end of patc h to bridge of patient's nose.
22. Fasten end of nasogastric tube to patient's gown with a piec e • Fastening tape to gown reduc es trac tion on the naris if tube moves. Tape
of tape (not safety pin).
is rec ommended bec ause safety pins may bec ome unfastened and
possibly c ause injury to the patient.
23. Remove gloves. Perform hand hygiene and apply c lean
• Oral hygiene promotes patient c omfort and integrity of oral muc ous
gloves, and administer oral hygiene (see Chapter 38). Clean
membranes.
tubing at nostril.
24. Remove gloves, dispose of equipment, and perform hand
• Hygiene reduc es transmission of mic roorganisms.
hygiene.
25. Inspec t naris and oropharynx for any irritation after insertion. • If tube insertion was diffic ult, irritation of naris or oropharynx may have
oc c urred.
26. Ask patient whether he or she feels c omfortable.
• Patients' level of c omfort is evaluated. (This may be a c hallenge if a
language barrier exists or if the patient has dementia or is c onfused.)
27. Observe patient for any diffic ulty breathing, for c oughing, or • Improper position of the tube may c ause these symptoms or inc rease
for gagging.
symptoms in patients who have heart failure, pneumonia, asthma, and
other c ardiac or respiratory c onditions.
28. Ausc ultate lung sounds.
• Abnormal lung sounds c an be an early sign of aspiration.
29. Connec t tube to suc tion devic e as ordered.
Box 42-18
Procedural Guideline
Providing Suction
Equipment:
• May be ordered as a c ontinuous or intermittent suc tion and at various
pressures (e.g., 80 mm Hg). In some c irc umstanc es, tubes are plac ed by
surgeon but c ontraindic ated or stric t protoc ols for flush or suc tion (i.e.,
post-esophagec tomy).
• Suction device, connecting tubing (connector as required)
Procedure:
1. Check the physician's order for type and amount of suction. Suctioning
may be ordered as continuous or intermittent. The amount must be
ordered by the physician.
2. To reduce the patient's anxiety, educate the patient about the
procedure.
3. Wash hands thoroughly to limit spread of microorganisms.
4. Set up suction device as per institution or agency policy.
5. Set type and amount of suction as ordered.
6. Monitor patient and suction system regularly. Provide data for overall
care. Monitor for bleeding or blockage:
Patient: Note abdominal distension, nausea, feeling of
discomfort, bowel sounds, electrolyte levels.
Device: Note kinks, blockages, flow, and settings.
Drainage: Note amount, colour, and consistency.
7. Secure tubing as described in Skill Box 42-3, Step 23A(2). Keep tubing
higher than stomach to facilitate drainage. Secure tubing to prevent
inadvertent pulling or removal.
8. Measure output at least every 8 hours or as per institutional or agency
policy.
9. Document as per institution or agency protocol.
Medication
It is recommended that medications not be administered via large-bore tube
while suctioning is required. If a large-bore tube must be used, then
suctioning should be withheld for at least 30 minutes after medication is
administered. Nurses need to consult with the pharmacist and refer to
institutional or agency policy.
Parenteral Nutrition
Parenteral nutrition is a form of specialized nutrition support in which
nutrients are provided intravenously. Safe administration of this form of
nutrition depends on appropriate assessment of nutrition needs, meticulous
management of the central venous catheter (CVC) or central venous access
device (CVAD), and careful monitoring to prevent or treat metabolic
complications. Parenteral nutrition is administered in a variety of settings,
including the patient's home. Regardless of the setting, the nurse adheres to
the same principles of asepsis and infusion management to ensure safe
nutrition support.
Patients who are unable to digest or absorb enteral nutrition benefit from
parenteral nutrition. Patients in highly stressed physiological states, such as
sepsis, head injury, or burns, are also candidates for parenteral nutrition
therapy. Box 42-19 lists other indications for parenteral nutrition. Clinical and
laboratory monitoring by a multidisciplinary team is required throughout
parenteral nutrition therapy. The need for continued parenteral nutrition is
re-evaluated regularly, with the goal of eventually using the gastrointestinal
tract. Disuse of the gastrointestinal tract has been associated with villus
atrophy and generalized cell shrinkage. Translocation of bacteria from the
local gut to systemic regions has been noted in relation to gastrointestinal
cell shrinkage; such translocation can result in gram-negative septicemia.
Box 42-19
Indications for Parenteral Nutrition
Nonfunctional Gastrointestinal Tract
Massive small bowel resection or gastrointestinal surgery
Paralytic ileus
Intestinal obstruction
Trauma to abdomen, head, or neck
Severe malabsorption
Intolerance of enteral feeding (established by trial)
Chemotherapy, radiation therapy, bone marrow transplantation
Extended Bowel Rest
Enterocutaneous fistula
Inflammatory bowel disease exacerbation
Severe diarrhea
Moderate to severe pancreatitis
Preoperative Total Parenteral Nutrition
Preoperative bowel rest
Treatment for comorbid severe malnutrition in patients with
nonfunctional gastrointestinal tracts
Severely catabolic patients when gastrointestinal tract is nonusable for
more than 4 to 7 days
Lipid emulsions provide supplemental kilocalories and prevent
deficiencies of essential fatty acids. These emulsions can be administered
through a separate peripheral catheter, through the CVC by Y-connector
tubing (see Chapter 40), or as an admixture to the parenteral nutrition
solution. The addition of lipid emulsion to the parenteral nutrition solution
is called a 3-in-1 admixture and is administered over a 24-hour period. The
admixture should not be used if oil droplets are observed or if an oil or
creamy layer is observed on the surface of the admixture. This observation
indicates that the emulsion has broken into large lipid droplets that can
cause fat emboli if administered. Lipid emulsions are white and opaque;
thus, care should be taken to avoid confusing enteral formula with parenteral
lipids.
Contraindications to giving lipids are hyperlipidemia, lipid nephrosis,
severe liver failure, and egg allergy.
Initiating Parenteral Nutrition
Patients with short-term nutritional needs often receive intravenous
solutions of less than 10% dextrose in a peripheral vein in combination with
amino acids and lipids. Peripheral solutions are not as calorically dense and
therefore are less irritating to the peripheral veins, and their use is usually
temporary. Administering parenteral nutrition with greater than 10%
dextrose requires a CVC (Figure 42-13) that is placed into a high-flow central
vein (such as the superior vena cava) by a physician using sterile technique
(see Chapter 40).
FIGURE 42-13 Parenteral nutrition via central venous catheter (CVC). TPN, Total parenteral
nutrition. (From Mosby's dictionary of medicine, nursing, and health professionals [10th ed.], 2017. St. Louis, MO: Mosby.)
Nurses who have special training insert peripherally inserted central
catheters (PICCs) that are started in a vein of the forearm or upper arm and
threaded into the subclavian vein or the superior vena cava (Figure 42-14).
FIGURE 42-14
Peripherally inserted central catheter (PICC) line insertion.
After central catheter or PICC placement is verified by chest X-ray
examination or radiographically confirmed and documented, the catheter is
flushed with saline or heparin. The physician may suture the CVC in place. A
PICC is usually stabilized with sterile strips of tape and a sterile dressing.
The types of dressings to be applied vary between institutions and a variety
of policies and protocols are adhered to. The nurse who is new to the nursing
unit can check the appropriate dressing protocol and policy before
proceeding. Wing-to-tip of the PICC should be measured and documented
daily. With a tube suspected of migrating 2 cm or more, all fluids should be
stopped and radiography should be repeated for placement verification. Also
to verify placement, the PICC line may be flushed by specially trained nurses
and, if noted to be occluded, special procedures (e.g., alteplase) are carried
out to ensure line patency.
Before beginning any parenteral infusion, the nurse verifies the physician's
order and inspects the solution for particulate matter or a break in the lipid
emulsion. An infusion pump is always used. An initial rate of 40 to 60
mL/hour may be recommended. In some institutions, the solutions are
infused separately at a specified rate until the therapy is no longer required.
In this instance, each solution would have a separate infusion pump.
Parenteral nutrition in the hospital is infused 24 hours a day. The parenteral
infusion is refrigerated until needed, whereas the lipids are stored at room
temperature.
The rate is gradually increased until the patient's complete nutritional
needs are supplied. Patients who receive parenteral nutrition at home
frequently administer the entire daily solution over 12 hours at night. This
allows the patient to disconnect from the infusion each morning, flush the
central catheter, and have independent mobility during the day.
Preventing Complications
Complications of parenteral nutrition include mechanical complications
from insertion of the CVC, infection, and metabolic alterations (Table 42-10).
Pneumothorax occurs when a puncture in the pulmonary system results in
accumulation of air in the pleural cavity and subsequent impairment in
breathing. Pneumothorax is usually accompanied by symptoms of sudden
sharp chest pain, dyspnea, and coughing. In relation to parenteral nutrition,
pneumothorax most often occurs during CVC placement.
TABLE 42-10
Complications of Parenteral Nutrition (PN)
Problem
Signs and
Symptoms
Intervention
Air embolism
Tac hypnea, apnea,
Turn patient to left lateral dec ubitus position, instruc t
wheezing,
patient to perform Valsalva manoeuvre (holding
hypotension, c yanosis one's breath and “bearing down”), and lower head of
bed. Cap the open end of c atheter or tape perforation
in c atheter wall. Administer oxygen; notify physic ian.
Catheter
oc c lusion
No flow or sluggish
flow through the
c atheter
Temporarily stop infusion and flush with saline or
heparin. If effort to flush is unsuc c essful, attempt to
aspirate c lot; if still unsuc c essful, follow protoc ol for
use of thrombolytic agent (e.g., alteplase).
Catheter sepsis Fever, c hills, gluc ose Change c atheter site dressing if it bec omes wet or
intoleranc e, positive
c ontaminated, use sterile mask and gloves when
blood c ulture
c hanging dressing or tubing, c atheter c aps, or
parenteral nutrition c ontainers. Change infusion
tubing regularly (usually every 24 hours). Assess
insertion sites for signs and symptoms of infec tion
(see Chapter 33). Do not hang a single c ontainer of
parenteral nutrition for more than 24 hours or a
c ontainer of lipids more than 12 hours; use an inline
0.22 mc g filter when possible.
Elec trolyte
Monitor Na, Ca, K, Cl,
S ee Chapter 40 for signs of defic ienc y or
imbalanc e
PO 4, Mg, and CO 2
toxic ity.
Monitor intake, output, and elec trolytes,
levels
espec ially potassium, magnesium, and
phosphorous levels during the first week of
parenteral therapy. Chec k total parenteral nutrition
(TPN) for supplemental elec trolyte levels at
regular intervals—often weekly. Notify physic ian
of imbalanc es. S upplemental vitamin K must be
given as ordered throughout therapy.
Hyperc apnia
Inc reased O 2
Ventilator-dependent patients are at risk; to prevent,
monitor parameters, provide 30% —60% of energy
c onsumption,
requirements as fat per physic ian's order.
inc reased CO 2,
respiratory quotient
>1.0, minute
ventilation
Hypoglyc emia Diaphoresis,
To prevent, do not disc ontinue PN abruptly but taper
shakiness, c onfusion, rate down to within 10% of infusion rate 1 to 2 hours
loss of c onsc iousness before stopping. If hypoglyc emia is suspec ted, test
blood gluc ose level, and administer IV bolus of 10%
dextrose per physic ian order if nec essary.
Hyperglyc emia Thirst, headac he,
Monitor blood gluc ose level daily until it is stable
lethargy, inc reased
and then as ordered or as needed. PN is initiated
urination
slowly and tapered up to maximal infusion rate.
Additional insulin may be required during therapy if
problem persists (or if patient has diabetes mellitus).
Hyperglyc emic Hyperglyc emia (>500 To prevent, monitor blood gluc ose, blood urea
hyperosmolar mg/dL), glyc osuria,
nitrogen, serum osmolarity, gluc ose in urine, and
nonketonic
serum osmolarity >350 fluid losses; administer insulin as ordered; replac e
dehydration or mOsm/L, c onfusion,
fluids as needed; maintain c onsistent infusion rate; and
c oma
azotemia, headac he,
provide 30% of daily energy needs as fat. Patients at
severe signs of
risk are those who are hypermetabolic , those
dehydration (see
rec eiving steroids, older persons, diabetic patients,
those who have impaired renal or panc reatic
Chapter 40),
func tion, and those who are septic .
hypernatremia,
metabolic ac idosis,
c onvulsions, c oma
Refeeding
syndrome
Cardiac dysrhythmias, Watc h malnourished or c ac hec tic patients for low
heart failure,
serum (extrac ellular) levels of elec trolytes and
respiratory distress,
edema.
Rationale
The Valsalva manoeuvre inc reases venous
pressure to prevent air from entering the
bloodstream during c atheter insertion and
when c atheter is disc onnec ted or c ap is
c hanged. Maintaining integrity of c losed
system prevents air emboli.
Alteplase has been shown to be effec tive in
restoring c atheter patenc y.
Filtered tubing is required to remove
bac teria. With 3-in-1-admixture TPN,
filtration is not possible bec ause of large
lipid molec ules.
Adequate hydration and balanc e of
elec trolytes is essential for normal func tion
of c ells and organs. Vitamin K c an be
synthesized by mic roflora found in the
jejunum and ileum with normal use of the
gastrointestinal trac t; however, bec ause
parenteral nutrition c irc umvents
gastrointestinal use, exogenous vitamin K
must be administered.
Bec ause the c ombustion of fat yields less
c arbon dioxide than either c arbohydrate or
protein c ombustion, a higher fat diet may be
preferable for reduc ing hyperc apnia.
S udden disc ontinuation of the solution c an
c ause hypoglyc emia. Patients with diabetes
are espec ially at risk.
Prevent and c orrec t hyperglyc emia
bec ause its development during PN has
been independently assoc iated with higher
rates of mortality and hospital c omplic ations
(Gosmanov & Umpierrez, 2013).
Too-rapid administration of hypertonic
dextrose c an result in an osmotic diuresis
and dehydration (see Chapter 40). Thus, if
an infusion falls behind sc hedule, the nurse
should not inc rease the rate in an attempt to
c atc h up.
Ingestion of c onc entrated gluc ose
inc reases the basal metabolic rate and is
ac c ompanied by inc reases in endogenous
c onvulsions, c oma, or
death
Pneumothorax
Thrombosis of
c entral vein
insulin produc tion, whic h c auses c ations
(potassium, magnesium, and phosphorus) to
move intrac ellularly. The shifting of
elec trolytes and fluid balanc e inc reases
c ardiac workload and heart rate as well as
inc reased oxygen c onsumption, whic h
strains the respiratory system.
S evere dyspnea,
Complic ation that oc c urs upon c atheter insertion may Enables pneumothorax to be detec ted early
c yanosis, radiographic evolve slowly afterward. Monitor patient for first 24 and monitors for enlargement.
c onfirmation
hours for pulmonary distress.
Unilateral edema of
Notify physic ian.
Thromboprophylaxis is not rec ommended,
nec k, shoulder, and
Prevention of c atheter-related thromboses
based on the results of randomized
arm; pain
inc ludes proper positioning of the c atheter and
c ontrolled trials, in whic h there was no
prevention of infec tions. Thromboprophylaxis
statistic ally signific ant differenc e (Roila,
for patients with a c entral venous c atheter is not
2012). Confirmatory researc h and c ostrec ommended.
effec tiveness analysis of this approac h are
needed before it is rec ommended.
Electrolyte abnormalities should be corrected before starting parenteral
nutrition. Calorie goals should be reached gradually. It is very important to
base the caloric and protein needs on the patient's current weight to avoid
overfeeding.
The goal is for patients to switch from parenteral nutrition to enteral
nutrition and/or oral feeding. Specified weights and intakes are recorded.
Once patients are meeting one-third to one-half of their kilocalorie needs per
day, parenteral nutrition is usually decreased to half the original volume.
Enteral nutrition feedings should then be increased to meet needs. When
75% of daily energy needs are consistently met with tube feeding, parenteral
nutrition may be discontinued. Patients who make the transition from
parenteral nutrition to oral feedings typically have early satiety and
decreased appetite. Calorie and protein counts are recommended when
patients begin taking soft foods. Parenteral nutrition should be gradually
decreased in response to increased oral intake. If oral intake is inadequate,
small, frequent meals may prove helpful. Some institutions will discontinue
lipid emulsion first, then parenteral infusion is continued until requirements
are met.
Key Concepts
• Nurses must have current, culturally sensitive
nutritional knowledge to apply to the complexities of
health care and illness and to the changing needs of
diverse populations and demographics.
• A balanced diet featuring carbohydrates, fats,
proteins, vitamins, and minerals provides the
essential nutrients to carry out the body's normal
physiological functioning throughout the lifespan.
• Through digestion, food is broken down into its
simplest form for absorption. Digestion and
absorption occur mainly in the small intestine.
• Dietary reference intakes (DRIs) provide a range of
values that address the needs of groups (estimated
average requirement) and individuals (adequate
intakes, recommended dietary allowances, and
tolerable upper intake level).
• Guidelines for dietary change advocate reduced
saturated and trans fats, reduced sodium, and
reduced refined sugars, as well as an increased intake
of complex carbohydrates and fibre.
• Nutritional screening helps in identifying patients
at risk of malnourishment. Because improper
nutrition can affect all body systems, nutritional
assessment includes total physical assessment.
• Interdisciplinary collaboration is essential to
helping a patient achieve optimal nutrition.
• Special diets alter the composition, texture,
digestibility, and residue of foods to suit the patient's
particular needs.
Critical Thinking Exercises
1. Charlene MacDonald, a 63-year-old accountant, is overweight with a
sedentary lifestyle, uses alcohol infrequently, consumes restaurant
food for most meals, and takes 400 IU of vitamin D daily. She wants to
undergo cataract surgery to improve her vision; however, the surgeon
has advised her to take off at least 10 kg of weight before the
operation. Ms. MacDonald weighs 90 kg and has a height of 156 cm.
Her waist circumference is 100 cm. What indications would lead you
to believe Ms. MacDonald is adequately caring for her health? What
additional laboratory tests and dietary and health history information
are needed to perform a comprehensive nutritional assessment?
What conclusions can you draw from the information available about
Ms. MacDonald's weight status? Using Eating Well With Canada's Food
Guide, what suggestions would you make to Ms. MacDonald to help
her achieve weight loss?
2. Corey Green, a 32-year-old mother, is considering switching her entire
family to a vegan diet because she believes it will make her 3-year-old
twin daughters healthier. What nutritional concerns should you watch
for? How would you assess the family's nutritional needs and monitor
for such concerns? What advice would you offer to Corey to enhance
her family's health while following a vegan diet? Plan one day of
meals for this family, indicating food servings for the twins that would
meet their protein needs and respect the vegan food diet.
3. Daniele, a middle-school student, is unhappy with her shape and
weight. Using an Internet site, she calculated her BMI as 29 one
month ago. “I am the smallest person in my family, but I am too fat!”
she thought. During the past 4 months, she has skipped breakfast
and lunch and exercised for 2 hours a day to “tone up.” Her skin, lips,
and hair are becoming dry. Daniele denies having lost weight even
though her clothes look loose and baggy. Her friends told the
homeroom teacher that Daniele goes to the bathroom immediately
after eating any food. The teacher requests that you plan a session
with Daniele to increase her understanding of her daily nutritional
requirements and of healthy eating patterns. What will you discuss
with Daniele?
Review Questions
1. A function of carbohydrates in the diet is to:
1. Enable chemical reactions
2. Promote growth and repair of tissues
3. Supply energy
4. Maintain water balance
2. A patient asks if he should take vitamin pills to get the nutrients his body
needs. You tell him that essential nutrients:
1. Are made by the body
2. Generally must be supplied by food
3. Include herbal teas and alcohol
4. Are best obtained through taking vitamin pills
3. Which patient would usually exhibit positive nitrogen balance?
1. Patient with HIV/AIDS infection
2. Patient admitted with anorexia nervosa
3. Patient with 30% burn injury
4. Patient in third trimester of pregnancy
4. What are the determinants of healthy eating? (Select all that apply.)
1. Educational level
2. Income
3. Food preferences
4. Vitamin supplementation
5. Availability and accessibility of fresh produce
6. Policies that increase taxation of high-energy, low-nutrient dense foods
5. When a patient is unable to take fluid or food by eating normally over an
extended period of time, what is the best alternative?
1. Liquid nutrients through a tube leading from the mouth or nose to the
stomach or intestine
2. Giving solutions through a tubing in a peripheral vein
3. Giving continuous tube feedings regulated via an electric feeding pump
4. Giving feedings through a tube inserted through the skin and tissue of
the abdomen
6. A nutrient content claim of light means:
1. The food may be light in colour
2. The food has no added sugar or salt
3. The food is reduced in calories or fat by 10%
4. The levels of saturated and trans fatty acids are restricted
7. When a mother tells you that she would like to switch her 15-month-old
toddler from whole to skim milk so the child will not get “too fat,” you
encourage her to continue with the whole milk because:
1. Whole milk has more calcium than skim
2. Whole milk has a longer refrigerated storage life
3. Whole milk costs the same as skim milk
4. Whole milk contains fatty acids needed for the toddler's brain
development
8. Which intervention is appropriate for the patient experiencing dysphagia?
1. Encourage the patient to rest lying down for at least 30 minutes after a
meal.
2. Offer thin liquids to make swallowing easier.
3. Place the food on the strong side of the patient's mouth.
4. Leave the patient with all food items within easy reach and tell the
patient when you will come back to take away the tray.
9. The nurse cares for a patient with dysphagia. Which action(s) by the nurse
reflect appropriate care for the patient?
1. The nurse assesses the client's ability to swallow.
2. The nurse positions the client at a 45-degree angle.
3. The nurse offers the client clear fluids.
4. The nurse instructs the client to place food on the left side of the mouth.
5. The nurse consults with the physical therapist for feeding positioning.
10. Older persons at risk for malnutrition:
1. Have the security of living on a fixed income
2. Know about the amounts of fat, sodium, and cholesterol in the foods
they eat
3. Experience age-related gastrointestinal changes such as reduced saliva
production, increased taste threshold, and decreased peristalsis
4. Have diseases such as diabetes and depression well controlled
11. The nursing activity most likely to prevent the clogging of a nasogastric
feeding tube is:
1. Attaching the tubing to suction after each feeding
2. Filling the tube with water and clamping it after each feeding
3. Clamping the tube before all of the nourishment has drained
4. Giving the patient ice chips to suck after each feeding
Answers: 1. 3; 2. 2; 3. 4; 4. 1, 2, 3, 5, 6; 5. 1; 6. 4; 7. 4; 8. 3; 9. 1; 10. 3; 11. 2
Rationales for the Review Questions appear at the end of the book.