SEMI-FINALSPERIOD CHAPTER7 INTERVENTIONSTOPROMOTEOXYGENATION KeyTerms Chest physiotherapy Postural Drainage Nasopharyngeal suctioning Oropharyngeal suctioning Adventitiousbreathsounds Let’ sstart! I. ReviewoftheanatomyandPhysiologyoftheRespiratorySystem Respiration Movement of airintoandout of the lungs(VentilationorBreathing) ExchangeofO2 andCO2 betweenthelungsandtheblood Transport ofthesegases ExchangeofO2 andCO2 betweenthebloodandthetissues FunctionsoftheRespiratorySystem 1. Gasexchange 4. Olfaction 2. Regulationof bloodpH 5. Protection 3. Voiceproduction AnatomyoftheRespiratorySystem UpperRespiratoryTract- Nose,PharynxandLaryn Functions: -transport gases to lower airways -protects lower airways -warning, filtration, and humidification of air LowerRespiratoryTract-Trachea, Bronchi andLung Functions: -clearancemechanism(coughing) -immunologicresponse -exchangeofgases FactorsAffectingOxygenation 1. Physiological factors 7. Lifestylefactors 2. Decreasedoxygen-carryingcapacity 3. Hypovolemia Nutrition Hydration 4. Decreasedinspiredoxygen concentration Exercise Smoking 5. Increasedmetabolicrate 6. Developmental Substanceabuse Stress 8. Environmental AlterationsinRespiratoryFunctioning 1. Hypoventilation Occurswhenalveolarventilationisinadequatetomeet theoxygendemandofthebody eliminatesufficient carbondioxide 2. Hyperventilation or Astateofventilationinwhich thelungsremovecarbondioxidefasterthanit isproducedby cellularmetabolism 3. Hypoxia Inadequatetissueoxygenationat thecellularlevel ASSESSMENTOFCLIENTWITHRESPIRATORYDISORDERS HEALTHHISTORY Identifythechiefreasonforseekinghealth care Nursedetermineswhenthehealth problemsstarted, howlongit lasted, ifit wasrelievedanytime, and howreliefwasobtained. Collectsinformationaboutprecipitatingfactors,duration, severityandassociatedfactorsorsymptoms Assessrisk factorsandgeneticfactorsthatcontributetothecondition Assesstheimpact ofsignandsymptomsonthepatient’ sabilitytoperformactivitiesofdailyliving SIGNSANDSYMPTOMS Dyspnea – difficulty or labored breathing, shortness of breath to any constantly recurring irritan Cough – results from the irritation of mucous membrane anywhere in the respiratory tract. It may arise from infectious process and from airborne irritants such as smoke, dust, and gas SputumProduction– reactionoflungstoanyconstantlyrecurringirritants Chest Pain– sharp, stabbing,andintermittent ormaybedull,aching, andpersistent Wheezing– highpitchedmusical soundheardmainlyonexpiration. (Bronchoconstrictionorairwaynarrowing) ClubbingFingers– foundinclientswithchronichypoxiccondition,chroniclunginfectionandmalignanciesof thelungs. It isdescribedassponginessofthenail bedandlossofnail bedangle Hemoptysis– expectorationofbloodfromrespiratorytract. Asymptomofbothpulmonaryandcardiac disorder Cyanosis– bluishdiscolorationof the skin.Itisa latesignofhypoxia (canleadtoshock ordeath).Cyanosis appearsofthereis5g/dLofunoxygenatedhemoglobin PHYSICALASSESSMENTOFUPPERRESPIRATORYSTUCTURES 1. NoseandSinuses inspect theexternal noseforlesions, asymmetry, orinflammation examinetheinternal structureforswelling, color, exudates, orbleeding inspect forseptumdeviation,perforation, orbleeding palpatethefrontal andmaxillarysinusesfortenderness.Usingthe thumb,thenurseappliesgentle pressureinanupwardfashionatthesupraorbital ridges(frontal sinuses)andinthecheekareaadjacent tothenose(maxillary). Tendernesssuggestsinflammation 2. Pharynx andMouth Instruct theclient toopenmouth andtakedeepbreath Inspectstructuresforcolor,symmetryandevidenceofexudates,ulceration,orenlargement 3. Trachea Placethumbandindexfingerofone handoneithersideofthetracheajust abovethesternal notch. Itis normallyinthemidlineasit entersthethoracicinlet behindthesternum. PHYSICALASSESSMENTOFUPPERRESPIRATORYSTUCTURES 1.CHESTCONFIGURATION– normal ratiooftheantero-posteriordiametertolateral diameteris1:2 Barrel Chest – increaseintheantero-posteriordiameterofthethorax, ribsaremorewidelyspacedand theintercostalsspacetendtobulge Funnel Chest – (pectusexcavatum)depressionof thelowerportionofthesternum PigeonChest – resultsfromdisplacement ofsternum. Thereisanincreaseintheanteriordiameter. Kyphoscoliosis– elevationof thescapula andacorrespondingS shapedspine 2. BREATHING PATTERNS ANDRESPIRATORYRATE Eupnea– normal breathing 12-18bpm, normal depth,andregularrhythm Bradypnea– slowerthannormal <10bpm Tachypnea– rapid,shallow >24bpm Apnea– cessationofbreathing Kussmaul’ s– increasedrateanddepthofbreathing Cheyne-Stokes– regularcyclewheretherateanddepthofbreathingincrease andthendecreaseuntil apnea (usually20seconds)*tachypnea – stop– tachypnea– stop– tachypnea– flat line Biot’ sRespiration– periodof normal breathing(3-4breaths)followedbyvaryingperiodofapnea (usually10secondsto1minute)*shallow– deep– irregular 3. BREATHSOUNDS Crackles– formerlyknownasrales,arediscretenoncontinuoussoundsthat result fromdelayed reopeningofdeflatedairways. Soft high itchedsoundheardduringinspiration CoarseCrackles– discontinuouspoppingsoundheardinearlyinspiration;harshmoist sound originatinginthelargebronchi FineCrackles– discontinuouspoppingsoundheardinlateinspiration;soundlikehairrubbingtogether SonorousWheezes(rhonchi)– deeplow-pitchedrumblingsoundheardprimarilyduringexpiration; causedbyairmovingthroughnarrowedtrachea-bronchialpassages SibilantWheezes– continuous,musical,highpitched, whistlelikesoundshearsduringinspirationand expirationcausedbyairpassingthroughnarrowedorpartiallyobstructedairwaysmayclearwithout coughing. FrictionRubs– harsh cracklingsound, like twopiecesofleatherbeingrubbedtogether.Heardduring inspirationaloneorduringboth inspirationandexpiration DIAGNOSTICPROCEDURES 1. PulmonaryFunctionTests Performedtoassessrespiratoryfunctionandtodeterminetheextentofdysfunction Generallyperformedbyatechnicianusingspirometerthathasavolumecollectingdeviceattachedtoa recorder.It measureslungvolume, ventilatoryfunctionandthemechanicsofbreathing, diffusionand gasexchange.PFTresultsareinterpretedonthebasisof the degreeof deviationfromnormal. 2. Arterial BloodGas ABGlevelsareobtainedthruanarterial punctureat the radial, brachialorfemoralartery. Itmeasuresarterial oxygentension(PaO2)w/cindicatesthedegreeofoxygenationofthebloodand arterialcarbondioxidepressure(PaCO2)indicatesadequacyofalveolarventilation. Italsomeasuresthebody’ sabilitytomaintainnormal pH. NormalValues: pH 7.35– 7.45 HCO3 22– 26mEq/L PaCO2 35– 45mmHg PaO2 80– 100mmHg SaO2 95– 100% 3. 6. indicatesacid-basebalance indicatesmetaboliccomponentofacidbase balance indicatesadequacyofalveolarventilation representsoxygendissolvedinplasma saturationofhemoglobinwith oxygen PulseOximetry Noninvasivemethodofcontinuouslymonitoringtheoxygensaturationof hemoglobin(SaO2) Aprobeorsensorisattachedtothe fingertip,forehead, earlobe, orbridgeofthenose. Thesensordetects changesinoxygensaturationlevelsbymonitoringlightsignalsgeneratedbytheoximeter Normal value: 95– 100% Valueslessthan85%indicatesthat tissuesarenotreceivingenough oxygen Chest X-Ray Normal pulmonarytissuesareradiolucent Mayreveal densitiesindicatingpathologicprocess Takenafterfull inspirationbecausethelungsarebest visualizedwhenaerated 7. PulmonaryAngiography Most commonlyusedtoidentifythromboembolicdiseaseofthelungs Itinvolvesrapidinjectionofa radiopaqueagentintothevascularareofthelungsforradiographicstudy ofthepulmonaryvessels 8. Cultures throat culturesmaybeperformedtoidentifyorganismsresponsibleforpharyngitis 9. SputumStudies Usedtoidentifypathogenicorganismsandtodeterminewhethermalignantcellsarepresent Expectorationistheusual methodforcollectingsputumspecimen Specimenisobtainedearlyinthemorningaftertheyhaveaccumulatedovernight Thepatient isinstructedtoclearthenoseandthroat risethemouth todecreasecontaminationofthe sputum.Aftertakingfewdeepbreaths,thepatient coughsratherthanspits. Thespecimenisdeliveredtothelaboratorywithintwohours. 10. ComputedTomography(CTscan) Animagingmethodinwhich thelungsarescannedinsuccessivelayersbynarrow-beamx-ray Itcandistinguish finetissuedensity Maybeusedtodefinepulmonarynodulesandsmall tumorsadjacent topleural surfacesthat arenot visibletoroutinechest x-ray 11. MagneticResonanceImaging SimilartoCTscanexceptthat magnetic fieldsandradiofrequencysignalsareusedinsteadofnarrow beamx-ray YieldsaremoredetaileddiagnosticimagethanCTscan 12.FluoroscopicStudies Usedtoassistininvasive proceduresuchaschestneedlebiopsyortransbronchialbiopsy MEASURESTOPROMOTEADEQUATERESPIRATORYFUNCTION Manrequires21%ofoxygenfromthe environment. Thehigherthealtitude, the lowerthe oxygen concentration 1. Deepbreathingandcoughingexercises(DBCE)topromotelungexpansionandloosenmucous secretions. PROCEDURE: inhaledeeplythrough the nose, holdbreathforfewsecondsand exhalethroughmouth slowly.Onthethirdbreath,holdbreath andcoughto expectorate secretions 2. Positioning. Semi-Fowler’ sorhigh-fowler’ spositionpromotesmaximumlungexpansion.By gravity, the diaphragmmovesdownandabdominal organsdonot compressthediaphragm. 3. Maintainapatentairwaytopromoteadequategaseousexchange. CausesofAirwayObstruction: -tongue -mucoussecretions -edema oftheairways -spasmofairways -foreignbodies(aspiration) 4. Maintainadequatehydrationtomaintainmoistureofthemucousmembrane.Thisistoliquefyretained secretions.Intakeshouldbeatleast8glassesaday. 1. Avoidenvironmentalpollutantssuchasalcoholandsmoking.Thesefactorsinhibitmucociliaryfunction. 2. PerformChestPhysiotherapy(CPT) Chest physiotherapy(CPT)isa techniqueusedtomobilizeorloosesecretionsinthelungsand respiratorytract. Thisisespeciallyhelpful forpatientswith largeamount ofsecretionsorineffectivecough. Chest physiotherapyconsistsofexternal mechanicalmaneuvers,such aschest percussion, postural drainage,vibration, toaugment mobilizationandclearanceofairwaysecretions, diaphragmaticbreathingwithpursedlips,coughingandcontrolledcoughing. IndicationsofChest Physiotherapy Itisindicatedforpatientsinwhomcoughisinsufficient toclearthick, tenacious, or localizedsecretions.Examplesinclude: Cystic fibros Lungabscess Bronchiectasis Neuromusculardiseases Atelectasis Pneumoniasindependentlungregions ContraindicationsofChest Physiotherapy IncreasedICP Ribfracture Unstableheadorneck injury Fail chest Activehemorrhagewith Uncontrolledhypertension instabilityorhemoptysis Anticoagulation Recent spinal injuryorinjury Riborvertebral fracturesor Empyema osteoporosis Bronchopleural fistula AssessmentforChest Physiotherapy NursingcareandselectionofCPTskillsarebasedonspecificassessmentfindings.The followingaretheassessmentcriteria: 1. Knowthenormalrangeofpatient’ svital signs.ConditionsrequiringCPT,such atelectasis, andpneumonia,affectsvital signs. 2. Knowthepatient’ smedications.Certainmedications, particularlydiuretics antihypertensivecausefluidandhemodynamicchanges.Thesedecrease patient’ stolerancetopositional changesandposturaldrainage. 3. Knowthepatient’ smedical history;certainconditionssuch asincreasedICP, spinal cordinjuriesandabdominalaneurysmresection, contra indicatethe positional changetopostural drainage.Thoracictraumaandchestsurgeriesalso contraindicate percussionandvibration. 4. Knowthepatient’ scognitivelevel offunctioning.Participatingincontrolled coughtechniquesrequiresthe patient tofollowinstructions. 5. Bewareof patient’ sexercisetolerance.CPTmaneuversarefatiguing.Gradual increase inactivityandthrough CPT, patienttolerancetotheprocedureimproves. TechniquesinChest Physiotherapy Anurse orrespiratorytherapistmayadministerCPT, although thetechniquescanoften be taughttofamilymembersofpatients. Themost commonproceduresusedarepostural drainageandchestpercussion, in which the patient isrotatedtofacilitatedrainageofsecretionsfroma specificlobeor segment whilebeingclappedwithcuppedhandstoloosenandmobilizeretained secretionsthat canthenbeexpectoratedordrained. Theprocedureissomewhat uncomfortableandtiringforthepatient. 1.Percussion Chest percussioninvolvesstrikingthechestwall overthearea beingdrained. Percussinglungareasinvolvestheuseofcupped palmtoloosenpulmonarysecretionssothat theycan beexpectoratedwithease. Percussingwith thehandheldinarigid dome-shapedposition,theareaoverthelunglobesto bedrainedinstruck inrhythmicpattern. Usually,thepatient will bepositionedinsupineorprone andshouldnotexperienceany pain. Cuppingisneverdoneonbareskinorperformedoversurgical incisions, belowtheribs,or overthespine orbreastsbecauseofthedangeroftissuedamage. Typically, eachareaispercussedfor30to6osecondsseveral timesaday. Ifthepatienthastenacioussecretions, thearea mustbepercussedfor3-5minutes several timesperday. Patientsmaylearnhowtopercusstheanteriorchest aswell. 2. Vibration Invibration,thenurseusesrhythmic contractionsandrelaxationsisorherarmand shouldermuscleswhileholdingthee patient flatonthepatient’ schestasthepatient exhales. Thepurposeistohelploosenrespiratorysecretionssothat theycanbe expectoratedwith ease.Vibration(ata rateof200perminute)canbedoneforseveral timesa day. Toavoidpatientcausingdiscomfort,vibrationisneverdoneoverthepatient’ sbreasts, spine, sternum,andribcage. Vibrationcanalsobetaughttofamilymembersoraccomplishedwith mechanical device. Procedure:Percussion&Vibration 1. Instruct thepatientusediaphragmaticbreathing 2. Positionthepatient inprescribedpostural drainagepositions.Spineshouldbestraight to promoteribcageexpansion 3. Percussorclapwith cuppedhandsorchest wall for5minutesovereachsegment for5 minutesforcystic fibrosisand1-2minutesforotherconditions 4. Avoidclappingoverspine, liver,spleen,breast, scapula, clavicleorsternum 5. Instruct thepatienttoinhaleslowlyanddeeply.Vibratethechest wallasthepatient exhalesslowlythroughthepursedlips. 6. Placeonehandontopoftheotheraffectedoverareaorplaceonehandplaceoneandon eachsideoftheribcage. 7. Tensethemusclesofthehandsandhandswhileapplyingmoderatepressuredownward andvibratearmsandhands 8. Relievepressureonthethoraxasthepatientinhales. 9. Encouragethepatient cough,usingabdominal muscles,afterthreeorfourvibrations. 10. Allowthepatientrest several times 11. Listenwith stethoscopeforchangesinbreath sounds 12. Repeat thepercussionandvibrationcycle accordingtothepatient’ stoleranceand clinical response: usually15-30minutes. 3. PosturalDrainage Postural drainageisthepositioningtechniquesthat drainsecretionsfromspecific segmentsofthelugsandbronchi intothetrachea. Becausesomepatientsdonotrequirepostural drainageforall lungsegments, the proceduremust bebasedontheclinical findings. Inpostural drainage,thepersonistiltedorproppedat anangletohelpdrainsecretions fromthelungs. Also,thechest orback maybeclappedwith acuppedhandtohelploosensecretions— thetechniquecalledchest percussion. Postural drainagecannotbeusedforpeoplewhoare: unabletotoleratethepositionrequired, aretakinganticoagulationdrugs, haverecentlyvomitedupblood, havehadarecentriborvertebral fracture, or havesevereosteoporosis. Posturaldrainagealsocannotbeusedforpeoplewhoareunabletoproduceanysecretions (becausewhenthishappens, furtherattemptsat postural drainagemaylowerthelevel of oxygenintheblood). 1. 2. 3. 4. Procedure Thepatient'sbodyispositionedsothat thetracheaisinclineddownwardandbelowtheaffected chest area. Postural drainageisessential intreatingbronchiectasisandpatientsmustreceivephysiotherapy tolearntotipthemselvesintoa positioninwhichthelobetobedrainedisuppermostat least three timesdailyfor10-20minutes. Thetreatmentisoftenusedinconjunctionwiththetechniqueforlooseningsecretionsinthe chest cavitycalledchestpercussion. Articlesrequired Pillows Sputumcup Tilt table Papertissues Steps 1. Use specific positions so the force of gravity can assist in the removal of bronchial secretions from affectedlungsegmentstocentral airwaysbymeansofcoughingandsuctioning. 2. The patient is positioned so that the diseased area is in a near vertical position, and gravity is used to assist thedrainageofspecificsegment. 3. Thepositionsassumedaredeterminedbythelocation, severity,anddurationofmucousobstruction. 4. Theexercisesare performed two tothree times a day, before meals andbedtime. Each positionisdone for3-15minutes. 5. The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs. These symptomsmayindicatehypoxemia.Discontinueif hemoptysisoccurs. 6. Bronchodilators, mucolytics agents, water, or saline may be nebulized and inhaled before postural drainage and chest percussion to reduce bronchospasm, decrease thickness of mucus and sputum, andcombatedema ofthebronchial walls, therebyenhancingsecretionremoval. 7. Performsecretionremoval proceduresbeforeeating. 8. Make sure patient iscomfortable before the procedure starts and ascomfortable aspossible, he or she assumeseach position. 9. Auscultate the chest todeterminetheareasofneededdrainage. 10. Encouragethepatient todeepbreath andcoughafterspendingtheallottedtimeineachposition. 11. Encourage diaphragmatic breathing throughout postural drainage: this helps widen airways so secretionscanbedrained. Positions ADULT Lungsegment Positionrecommended Bilateral HighFowler’ s Apical-rightupper lobe-anteriorsegment Sittingonsideofthebed Supinewithheadelevated Left upperlobe-anterior Supinewithheadelevated Rightupperlobe-posterior Side-lyingwith right sideofthechest elevatedonpillows Left upperlobe-posterior Side-lyingwith left sideofthechestelevatedonpillows RightMiddlelobe-anterior segment Three-fourthsupinepositionwith dependent lungin Trendelenburg’ sposition RightMiddlelobe-posterior segment Pronewith thoraxandabdomenelevated Both lowerlobes-anterior segments SupineinTrendelenburg’ sposition Left lowerlobelateral position Right side-lyinginTrendelenburg’ sposition Rightlowerlobe-lateral segment Left side-lyinginTrendelenburg’ sposition Rightlowerlobe-posterior segment Pronewith right sideofchest elevatedinTrendelenburg’ s position Both lowerlobes-posterior segment ProneinTrendelenburg’ sposition CHILD Bilateral-Apical segments Sittingonnurse’ slap, leaningslightlyforwardflexedoverpillow. Bilateral-middleanterior segments Sittingonnurse’ slap, leaningagainstnurse Bilateral-anteriorsegments Lyingsupineonnurse’ slap, back supportedwithpillow. 4. Coughing Coughinggentlyormakingshort gruntingnoiseswiththemouth slightlyopenwill helploosenthemucus. Dothisperiodicallythroughout thedrainageprocedure. 5. ControlledCoughingTechnique Controlledcoughingisoneoftheessential techniquesingoodrespiratorycare. Patient performthismaneuveraftereachdrainagepositionandoftenthroughout theday. Theabdominal musclesareverypowerfulmusclesusedincoughingandexhaling. Inhaledeeplythroughthenose. Pause. Cough2to3sharpstaccatocough with properhand/armplacement. Breatheineasilythroughthenose. 7.SteamInhalation Inhalingthewarmvaporsofboilingwaterhasanumberoftherapeuticeffects. Steammayreduceviral loadandpreventtheseverityoftheinfection. Breathingwarmandmoist airproducedbya vaporizeriscalledsteam/moistinhalation.Thevalueof steaminhalationlieschieflyinthemoistureandheat,althoughthemedicinesusedarealsohelpful as theyareactingasrespiratoryantiseptics. Itistheprocessinwhich waterisboiledtosteamwhich isinhaledthroughnoseandmouth for therapeuticpurpose. PURPOSES 1. Torelievetheinflammationand congestionofthemucous membraneoftherespiratorytract membranesoflungsandupper respiratorypassages. 5. Toaidintheabsorptionofoxygen. andparanasal sinuses. 2. Tosoftenthick tenaciousmucous. 6. Torelievespasticconditionofthe larynx andbronchi. 3. Tohelpinexpectoration. 4. Toprovide heatandmoistureandto 7. Todecrease the edemaof the respiratorytract. preventthedrynessofmucous Methodsforgivingsteaminhalation: 1. Byjugmethod 2. Bysteamtent 3. Byelectricsteaminhaler OpenJugMethod Openjugmethodfortheinhalationisusedfortheinfantsandtoddlerswhocannotinhalethroughthe inhaler. Intheopenjugmethod, boilingwaterismixedwith thetapwaterinproportionoffivepartsof boiling watertoone partoftapwater. Thejugshouldbehalffilled. Atowel orathickpaperordiscardedx-rayfilmcanbe foldedaroundthejugtoforma funnel. SteamTent Whena high concentration of steam isrequired, a steam tent may be used. There are different ways of makingatent. Aquick andeasymethod isto place a screenon eithersides on the patient’ s bed and stretch blankets orsheetsacrossthemthusformingacanopy. Thesteamcanthenbedirectedintothetent fromthespoutofthekettle Neverpoint thespout towardtheface ofthepatient.Thesteammaybegivenfor20-30minata timeand it mayberepeatedevery4hrs.continuousobservationisrequiredtoavoidscaldingofthepatient. Electricsteaminhaler Small electricvaporizerscanbeusedtogive steaminhalation. Itconsistsofa small jar witha heatingelement extendingintothejar. Thejarisfilledwith water. Onthetopofthejarisa removableperforated cuptowhich isattacheda small metal spout. Asthewaterboils, themedicatedsteamis directedthrough thespout whichisinhaledby thepatient. GENERALINSTRUCTIONS 1. Thespout oftheinhalermust beplacedinsucha waythat cannot touch it orput hisfacetoonear. the patient 2. Havethewaterinthejugmethodat amoderate temperature.Thetemperatureismaintainedbetween120 to160F [54.4to76.7C].ifthewateriscold, it will not generatesteam. Ifthewater istoohot, it maycausescaldingofthepatient. 3. Keepthepatient warmandprevent draught before, duringand aftertheinhalation.Duringthetreatment,thebloodvessel is easily chilledwhenexposedtodraught.Thispredisposeshimtoa moresevereandprolongedattackof inflammationandcongestion.Therefore, thepatient shouldnotgointoacoldatmosphereforseveral hrs. afterthetreatment.Thewindowsanddoorsareclosed, andthefanisputoffduringthe treatment to prevent draught. Askthepatient toemptythebladdertoensurethatthepatient will remainonthe bed forseveral hoursafterinhalation. 4. Placea sputumcupinthe reach ofthepatient tospit thesputumthatiscoughedupduringtheinhalation. 5. Explaintheproceduretothepatientorparentsbeforethepreparationoftheinhalation,sothat notimeis lost tostarttheinhalationoncetheinhalerwith boilingwateristakentothebedside. If thetimeislost for explanationsthetemperatureofthewaterwill bereduced 8.Suctioning Oropharyngeal, tracheal,andendotracheal suctionaremethodsofclearingsecretionsbythe applicationofnegativepressurevia eithera yankAuersucker(oropharyngeal)oranappropriatelysized trachealsuctioncatheter(tracheal/endotracheal) PURPOSE: 1.Thepurposeofperformingoral suctionistomaintainoral hygieneandcomfort forthe patient orto removebloodandvomit inanemergencysituation. 2. Thepurposeoftracheal/endotracheal suctionistoremovepulmonarysecretionsinpatientswhoare unabletocough andcleartheirownsecretionseffectively.Thepatient maybefullyconsciousorhavean impairedconsciouslevel. 3. Secretionsareclearedfromthesepatients’ airwaysinordertomaintainairwaypatency, toprevent atelectasissecondarytoblockageofsmallerairwaysandtoensurethat adequategasexchange(particularly oxygenation)occurs. INDICATIONS: 1. Visiblepresenceof secretionsintubeorifice 2. Coarsetubularbreathsoundsonauscultationinpatient unabletocough orwithout artificial airwayin place. 3. Patientwith anartificialairway. NURSINGCONSIDERATIONS: 1. Reviewthepatient'schartforphysicianorder,andnoteanyindications,contraindications, orpotential sideeffectsoftherapyordered. Reviewthepatient'shistory, physical diagnosis, progressnotes, CXR,labreports (includingPFT'sandABG'S)andmedicationsbeforeperformingtheprocedure. 2.Identifypatient bycomparinghospitalandbillingnumbersonthearmbandtothoseonthe physicians’ ordersfortherapy. 3. Examine andauscultatepatient. 4. AssembleEquipment: Attach connectivetubingtosuctionregulator/equipmentandinlet ofsuctioncontainer. Connect suctionmachinetovacuumwall outlet. Turnvacuumonandoccludetip connectivetubing.Ifnosuctionis demonstratedongauge,tightenall connections.If stillnosuctionoccursincrease vacuum.Ifstill suction occurs, labelmachine"defective" obtainanothersuctionmachine,reassemble, andretest. 5. Identifypatient byverificationofnameonarmbandandbyverbal questioning. 6. Identifyyourselfandyourdepartment. 7. Informthepatient/familyoftheprocedureanditspurpose. Bepreparedtoansweranyquestions about theprocedurethatthepatient mayhave. 8. Position: Forconsciouspts: SFUnconsciouspts: GROUP PORTABLE WALL SIZE(Fr) ADULT 10-15mmHg 100-120 12-18 CHILD 5-10mmHg 95-110 8-10 INFANT 2-5mmHg 50-95 5-8 9.Identifyproperpressureonthesuction machine/identifyappropriatecathetersize 10.Donsterileglovestoprevent introductionofmicroorganisms. 11.Lubricatecatheterusinga water-solublelubricant/ sterilewater. 12.Applysuctionduringwithdrawal ofthesuctioncathetertopreventtrauma tothemucous membranes. 13.Applysuctionfor5-10seconds, with20-30secondinterval inbetweensuctions. 14.Hyperoxygenate pt beforeandaftersuctioningtoprevent hypoxia. 15.Provideoral andnasal hygiene. 16.Assesseffectivenessofsuctioning. 9. Incentivespirometry Incentivespirometry,alsoknownas SustainedMaximal Inspiration(SMI), isatechniqueusedtoencouragea patienttotakea maximal inspiration usingadevice tomeasureflowor volume. Amaximal inspirationsustainedover threesecondsmayincreasethetranspulmonarypressurethereby improvinginspiratoryvolumesand inspiratorymuscleperformance.With repetition, andaspart ofanoverall bronchial hygieneprogram,SMImaneuversmayreverselungatelectasisandrestoreandmaintain airwaypatency. ThedeviceusedtofacilitateSMI, theincentivespirometer, incorporatesvisual indicatorsof performanceinordertoaidthetherapist incoachingthepatienttooptimal performance. Likewise, patientsmayusethisvisual feedbacktomonitortheirownefforts. 10. OxygenTherapy Oxygentherapyistheadministrationofoxygenasa therapeuticmodality.It isprescribedbythe physician, whospecifiestheconcentration, methodof delivery, andliterflowperminute. BenefitsofOxygenTherapy: • Increasedclarity • Relievesnausea • Canpreventheartfailureinpeoplewith severelungdisease • Allowsthebodiesorganstocarryout normal functions Long-TermBenefitsofOxygenTherapy: • Prolongslifebyreducingheart strain • Decreasesshortnessofbreath • Makesexercisemoretolerable • Resultsinfewerdaysof hospitalization OxygenDeliverySystems 1.NasalCannula • Alsocallednasal prongs. • Isthemost commoninexpensivedeviceusedtoadministeroxygen. • It iseasytoapplyanddoesnot interfere with theclient’ sabilitytoeat ortalk. • It deliversarelativelylowconcentrationofoxygenwhich is24%to45%atflowratesof2to6 litersperminute. 2.FaceMask • It coverstheclient’ snoseandmouthmaybeusedforoxygeninhalation. • Exhalationportsonthesidesofthemaskallowexhaledcarbondioxidetoescape. TypesofFaceMasks: 1. SimpleFace Mask -Deliversoxygenconcentrationsfrom40%to60%at literflowsof5to8litersper minute, respectively. 2. Partial RebreatherMask – Deliversoxygenconcentrationof60%to90% literflowsof6to10litersperminute, respectively. 3. Non-RebreatherMask – Deliversthehighest oxygenconcentration 95%to100%– bymeansotherthanintubationormechanical flowsof10to15litersperminute. at possible ventilation,at liter 4. VenturiMask – Deliversoxygenconcentrationsvaryingfrom24%to40%or50%at literflowsof4to 10litersperminute 3.FaceTent • It canreplaceoxygenmaskswhenmasksare poorlytoleratedbyclients. • It providesvaryingconcentrationsof oxygensuch as30%to50%concentrationofoxygenat4to8 litersperminute 4.TranstrachealOxygenDelivery • It maybeusedforoxygen-dependent clients. • Theclientrequireslessoxygen(0.5to2litersperminute)becauseall thelowdeliveredentersthe lungs. OxygenTherapySafetyPrecautions: 1. Forhomeoxygenuseorwhenthefacilitypermitssmoking,teach familymembersandroommatesto smokeonlyoutsideorinprovidedsmokingrooms away fromtheclient. 2. Placecautionarysignsreading“ NoSmoking: Oxygeninuse” onthe client’ sdoor,at thefootor headof the bed,andontheoxygenequipment. 3. Instructtheclientandvisitorsaboutthehazardofsmokingwithoxygenuse. 4. Makesurethat electricdevices(suchasrazors,hearingaids, radios,televisions,andhearingpads)are ingoodworkingordertoprevent the occurrence ofshort-circuit sparks. 5. Avoidsmaterialsthat generatestaticelectricity, suchaswoolenblanketsandsyntheticfabrics. Cottonblanketsshouldbeused, andclientandcaregiversshouldbe advisedtowearcottonfabrics. 6. Avoidtheuseofvolatile, flammablematerialssuchasoils,greases, alcohol, ether,andacetone(e.g., nail polish remover),nearclientsreceivingoxygen. 7. Groundelectricmonitoringequipment, suctionmachines, andportable diagnosticmachines. 8. Makeknownthelocationofthefireextinguishers,andmakesurepersonnel aretrainedintheiruse. CHAPTER8 INTERVENTIONSTOPROMOTENUTRITION KeyTerms Nutrition Digestion Metabolism Absorption Special Diets NasogastricTubeFeeding Parenteral Feeding Let’ sstart! Overviewof the AnatomyandPhysiologyof the Digestive System TheGITiscomposedof2general parts: MainGIT: Mouth – Esophagus– Stomach– Small intestines– LargeIntestines– Rectum AccessoryGlands: Salivarygland,Liver, Gallbladder, Pancreas FoodandFluidRegulatoryCenter: HYPOTHALAMUS DIGESTION -processbywhichfoodisbrokendownforthebodyto useingrowth,development, healingandpreventionof diseases ABSORPTION -processbywhichdigestedCHO, CHON,fats,minerals andvitaminsareactivelyandpassivelytransportedintoorgansandtissues METABOLISM -processbywhichnutrientsareconvertedtoenergytosupport cellulargrowthandrepair NUTRITION -studyofnutrientsandthe processesbywhich theyareusedbythebody MACRONUTRIENTS 1. Carbohydrates 2. Protein- MICRONUTRIENTS 1. Vitamins 2. Minerals CALORIE(KILOCALORIE) -1g(CHO) -4CAL -1G (CHON)- 4CAL VariableaffectingCaloricNeeds 1. Ageandgrowth 2. Gender(higherBMRin males) 3. Climate(cold=higherBMR) ReviewofVitamins 3. Fats -1G (FAT)-9CAL 4.Sleep(lowerBMR) 5.Activity 6.Fever 7.Illness Fat-solubleVitamins: Thesevitaminsare unaffectedbynormal temperatureandmethodsoffoodpreparation. Arefoundinthefatsandoilsoffoods. Arestoredintheliverandinthefattytissuesofthebodyforlongperiods. Water-solubleVitamins: Thesevitaminsare easilyaffectedbycookingprocessandexposuretoair. Thebodycannotstoretheminlargeamountsasthekidneysfilterout anyextracomingfromthediet. Taxonomy MedicalName Sources Deficiency A Retinol (animal) All yelloworange fruitsand vegetables Xerophthalmia-Night blindness Rice, chicken, fish, nuts Wernicke’ sencephalopathy Carotene(Plants) B1 Thiamine Decreasedlevelofconsciousnessduetoincreased intracranial pressure SevereBodyfatigue B2 B3 Riboflavin Eggs,eggplant, coconut Ariboflavinosis Cheilosis— Crackingat thesideofthelips Niacin/ Nicotinic Legumes, root crops,Pellagra Acid/ Nicotinamide cassava,avocado 3signsofpellagra 1. Dementia 2. Dermatitis 3. Diarrhea B5 Pantothenic Malunggay, all meat Poormental performance Stantedgrowth Noenergyorbodymalaise Liverfailure(ifsevere) B6 Pyridoxine SameasB2 Microcyticanemia-thepresenceofsmall, often hypochromic, redbloodcells Peripheral neuritis- conditions that result when nerves that carrymessagesto and fromthebrainandspinal cord from andtotherest ofthebodyaredamagedordiseased Paresthesia Paralysis B7 Biotin Corn, aubergine, pork Burningfeetsyndrome-alsoknownasGrierson-Gopalan syndrome, isasetofsymptomsinwhichthefeetoften becomeuncomfortablyhot andpainful. B9 Folicacid/Folate Milk Neural tubedefect- are birth defectsofthebrain, spine,or spinal cord. B12 Cyanocobalamin (Onlyabsorbedin theintestines) All vegetable,all meat PerniciousAnemia-conditioninwhich thebodycan't make enoughhealthyredbloodcellsbecauseitdoesn't have enoughvitaminB12. C Ascorbic Citrus Weakimmunesystem Scurvy, poorwoundhealing D Calciferol DriedFish, Milk, Osteomalacia, rickets Anchovies, sardines E Tocopherol Vegetableoil, nuts, Dryskin, comedones(skin-colored, small bumps(papules) atis frequentlyfoundontheforeheadandchinofthosewith acne), saggedskin K Phytomenadione/ Liver, passionfruit Bleeding Aquamenadione H InactivatedBiotin Sameasb7 ReviewofMinerals ASSESSMENTOFNUTRITIONALSTATUS 1. ANTHROPOMETRICMEASUREMENTS height weight (best indicatorofnutritional status) Skinfolds(Fatfolds) ArmMusclecircumference BodyMassIndex=wtinkg/ (ht inmeter)2 BMI result: 20-25%-----Normal 27.5-30%--- MildObesity Burningfeet syndrome 30-40%-----ModerateObesity Above40%-SevereObesity 2. Biochemicaldata HgbandHct indices -SerumAlbumin -NitrogenBalance -Creatinine Excretion 3. Clinicalsigns -hair, skin, tongue,mucousmembrane, abdominalgirth 4. DietaryHistory -24hr. diet recall;72hr. dietrecall MEASURESTOSTIMULATEAPPETITE 1. Servefoodinpleasantandattractivemanner 2. Place patient inacomfortable position(SF/HFtoprevent aspiration) 3. Providegoodoral hygiene measures 4. Promotecomfort 5. Rememberthat coloraffectscolor 6. Engageinpleasantconversation 7. Assistweak patient infeeding NURSINGINTERVENTIONSFORNAUSEAANDVOMITING 1. PositionconsciousclientsinSForHFposition;unconsciouspatientsinlateral positiontoprevent aspiration 2. Providegoodoral hygiene measures 3. Suctionthemouthasneededif the client isunabletoexpelvomitus 4. Relieve nauseabyofferingtheclient: -icechips -hot teawithlemon/ lime -hot gingerale -drytoastorcrackers -coldcola beverage 5. ReplacelossfluidbyhydrationandIVtherapy 6. Observeforpotential complications: a. DEHYDRATION -Thirst (first sign) - oliguria -drymouthandmucousmembrane - dark,concentratedurine -warm, flushed, dryskin - high urineSG -fever, tachycardia, lowbp - poorskinturgor -weight loss - alteredLOC -sunkeneyeballs - elevatedBUN,Crea -elevatedHct b. Acid-basebalance MetabolicAlkalosis: excessivevomiting MetabolicAcidosis: excessivediarrhea 7. Administerantiemeticasorderedbythephysicianforvomiting Metoclopramide (Plasil) Trimethobenzamide(Tigan) Promethazine(Phenergan) Prochlorperazinemaleate(Compazine) TherapeuticDiet Normal diet that ismodifiedtotreat orcurediseases; Therapeutic=treat orcure Diet-foodorbeveragesingestedfora special reason Dietitian specialist indietetics performstherapeuticandpreventiveroles workswithboth ill andhealthypeople Nutritionist aspecialist inthestudyofnutritionconcernedwith the studyofnutrients, hownutrientsareusedin thebodyandrelationshipbetweendiet, health, anddisease. TYPESOFBASICANDTHERAPEUTICDIETS 1. Regular/Standard/HouseDiet forpatientswhodoesnot havespecial needsordietarymodification Omitted: foodsthatproduceflatus(cabbage),highlyseasoned,andfriedfoods 2. DietasTolerated(DAT) whenpatient’ sappetite, abilitytoeat, andtoleranceforfoodmaychange ex.1stpost opdaypatientmaybegivenclearliquid.Ifnonauseaoccurs, normal intestinalmotility returned(activebowel sounds, passesgas, andfeelslikeeating)diet maybeadvancedtofull liquid orregulardiet 3. ColdLiquidDiet Purposes:BloodClotting o Posttonsillectomy o Postthyroidectomy ColdFoodsallowed o Plainicecream(vanilla) o Sherbet o Post adenoidectomy o Post dental extraction o Coldmilk o ColdTraditional IcedTea 4. LiquidDiet CLEARLIQUID Purpose Initial diet aftercompletebowel rest to: o preventandcorrectdehydration o relievethirst FULLLIQUID Intermediatediet betweenclearliquid& softdiet Foodsthat meltorliquefyatbodytemp o minimizegastricstimulation Providesfluidandcarbohydrates (sugar) Short – termdiet for24– 36hrs Indications: o post-surgery o acuteinflammatoryofGIT(diarrhea, gastroenteritis, pancreatitis) Toprovide toclients whoareunabletotolerate solidfoods. Indications o unabletotoleratesolidorsemi-solid foods o GITdisturbances o burnsandillness o burnsandillness Foods allowed water,coffee (decaf/regular),tea all inclearliquiddiet carbonateddrinks milk andmilk drinks fat freestrainedbouillonorbroth(soup stock) eggs(inpuddingandcustards) clearordilutedfruitjuices(apple,grape, cranberry) plainicecream,sherbet yogurt orange juice popsicles vegetablejuices gelatin cream,butter, margarine, smoothpeanut butter hardcandy strainedcreamsoups Foodsnot allowed Dairyproductsandmilk Fruit juiceswithpulp 5. ModifiedConsistencyDiets SOFTDIET Purpose PUREEDDIET diet afterfull liquid Modificationof soft diet easilychewedanddigested Anyfoodthatisaddedwithwaterand blendedtoproducea semi-solid consistency low– residueorlowfiberdiet Indications o chewingandswallowingdifficulties o strokepatient Tosupplynutritiontoclientswith NGTor gastrostomytubes(osterizedfeeding– foodisplacedintoa sterilebottleand discardedafter24hrs) o mandibularfractures,brokenjaw Indications o mobilityorrefusedfoodasobstructionof esophagus o Anorexianervosa o Severeburns o Comatose Foods allowed all foodsinliquiddiet pureedandblendedfoods lean, tender, cooked,mincedground meat, poultry,andfish(chopped/ shredded) scrambledegg, omelet, poachedeggs, cottagecheese,andmildcheeses lowfiberfruitswithoutskinandseeds (banana, mango, sectionedorange, papaya) lowfibercookedchoppedvegetables (mashedpotato, carrots,chayote, squash) Rice, Pasta, softbread, soft cake, bread pudding Foodsnot longfibers, hardfriedfoods, highly allowed seasoned, foodswithskin/nuts/seeds,raw andgasformingfruitsandvegetables (apple,beans,cabbage, celery, onions, cherries,coconut, eggplant, melons,onions, wheat) 6.Content– ModifiedDiets Purpose High– FiberorHighResidue SodiumRestricted DiabeticDiet Toprevent andtreat constipationand diverticulitis Totreat cardiovascular, renal,andliverdisorder Tocontrol bloodsugar level Dietvarieswithindividual, severityofdiseasestype andextentofinsulin therapyreceived. Foods allowed fruits(apples, oranges) Fresh fruitsandvegetables Balanceddiet vegetables(broccoli, carrots,corn) NOCANNEDproducts, seafoods,anddairy products Usedietarylist exchange wholegrain(cereals, wheat,grain) o 1cuprice=1half burger o 1egg= ¼cottage cheese o 1tspmargarine= 2 tspmayonnaise 7. ElectrolyteReinforcedDiets HighPotassium HighCalcium HighPhosphorous Purpose Tomaintainskeletal andcardiacmuscle activity Toproviderigidityand structure tobones Totreat hypophosphatemia Foods allowed Coffee Dairyandmilk products Soft drinks Milk Greenleafyvegetables Chocolate Meat Small fishwithbones Milk Fruits(banana, cantaloupe, avocado, raisins, strawberry) Tuna Sardines Vegetables 1. BlandDiet Diettoallowstomachliningtoheal (doesnot stimulategastricsecretion) Indications o diarrhea o gastritis o indigestion o gall bladder disease o ulcer FoodsAllowed o mildflavour o softandsmoothintexture NotAllowed o Fibrous,hardmeats, herbsandspices, coffee,tea,citrusfruits, veryhot andcoldbeverages o strongflavouredvegetables(cabbage,onion,leek,cauliflower,turnip) 2. CandidiasisDiet Freeof: o Fruits o Sugar o FermentedFoods o Yeast 3. Acid– AshDiet Toalkalinizeurine Tosootheirritatedbladderorurethra Foods: Citrusfruitsandvegetables NotAllowed: Prunejuiceandcranberryjuice(bothproduceacidicurine) 4. Ash– AcidDiet ForUTI– toacidifyurine Giveprotein, meat, poultr 5. CultureRelatedDiets(ReligionandTheirDietaryPractices) HALAL KOSHER VEGAN Mormons Protestants Roman Catholic PurposeTomaintain dietary requirements ofMuslim Clients (Islamic) Tomaintaindietary requirementsofJewish Clients(Judaism/Jewish Faith) Foods Nopork Kosherfoodscannot be Full Vegetarian NoCoffee, NodairyProductsFasting preparedusingthe diet Alcohol, Tea andmeat during before utensilsthatwas Fasting communion preparedinanon– andduring Mayleadto Nopork kosherfood HolyWeek VB12 deficiency Milk andmeatarenot eatentogetherbut may Nocoffee, beeaten6– 12hrs apart alcohol, tea, Nogelatin Noalcohol Tomaintain (TheChurch (GreekOrthodox) dietary ofJesus requirements Christ ofthe ofSeventhDay latter-day AdventistClients saint) EnteralFeeding Enteralnutritionisadministeredtopreventorcorrect malnutritionandassociatedcomplications. It providesadequatenutritionviathegastrointestinal tract, through thedeliveryofcomplete supplementaryformulas. Indications o Patient unabletoswallow o Patient unableorunwillingtoconsumeadequatenutritionorally o Thepatient musthaveafunctioningGItract Contraindications o MalfunctioningGItract (i.e., short gut syndrome,severe acutepancreatitis) o Mechanical obstruction o Prolongedileus o SevereGIbleed o Severediarrhea/intractable vomiting o GItractfistula o TPNshouldbeconsidered insteadforpatientswith contraindications. RouteofAdministration - Therearefiveroutesofadministrationavailableforenteralfeeding.Therouteof administrationwill be determinedbythepredictedtherapy,recoverytimeand/ordisability. 1. Nasogastric(noseintostomach) Thisrouteisusedmost frequentlyduetoeaseofplacement ofthetube. Thisisfor short-termenteral feeding(usuallylessthanorequal to8-12weeks). 2. Nasoduodenal(noseintoduodenum) Thisroutebypassesthe stomach andadministersfeedingdirectlyintothesmall bowel. Themainadvantageofthisrouteislessriskofaspirationandisusedifgastricemptying isimpaired. 3. Nasojejuenal (noseintojejunum) Thisroutebypassesthe stomach andadministersfeedingdirectlyintothesmall bowel. Themainadvantageofthisrouteislessriskofaspirationandisusedifgastricemptying isimpaired. 4. Gastrostomy(feedingtubeinsertedthrough abdominal wall intostomach) Thisisthepreferredmethodforlong-termenteral feeding.Preferredforpatientswho haveanintactgagreflex,havenormal emptyingofgastricandduodenal contentsand whosestomach isnot involvedintheprimarydisease. 5. Jejunostomy(feedingtubeisinsertedthrough abdominal wall intojejunum) Thisrouteisusedforlong-termenteral feedingforpatientswith impairedgastric emptying. NASOGASTRICTUBE(NGT) -commonlyusedtube: LEVINTUBE Purposes: -toprovide feeding(gastricgavage) -toirrigatestomach (gastriclavage) -Fordecompression -administrationofmeds -administersupplemental fluid -Insertionprocedure: 1. Informpatient andexplainprocedure. 2. PlaceinHFpositiontofacilitateinsertion. 3. Measurelengthoftubetobeinsertedstartingfromthetipofthenosetothetipoftheearlobe,tothexiphoid process). 4. Lubricatetipofcatheterwith water-solublelubricant toreducefriction.Oil basedlubricant maycause lipid pneumonia. 5. Hyperextendtheneck andgentlyadvancethecathetertowardthenasopharynx. 6. Tilt thepatient’ sheadforwardoncethetubereachestheoropharynx(throat)andaskthepatient toswallow orsipfluidastubeisadvanced. 7. SecuretheNGTbytapingittothebridgeofthenoseaftercheckingthetube’ splacement AdministeringTubeFeeding(gastricgavage) 1. Positionpt inSF 2. Assesstubeplacementandppatency - introduce5-20ml of airintoNGTandauscultateat theepigastricarea.Gurglingsoundindicatespatency -aspirategastriccontent (yellowish/greenish) -immersetipofthetubeinwater, nobubblesshouldbeproduced -measurepHofaspiratedfluid(acid) Note: themost effectivemethodofcheckingthe NGTplacement isradiograph verification. 3. Assessresidual feedingcontents. Toassessabsorptionofthelast feeding,shouldbelessthan50ml. 4. Introducefeedingslowlytopreventflatulence, crampingandvomiting. 5. Height oftubeshouldbe12inchesaboveinsertionpoint. 6. Instill 30-60ml ofwaterintotheNGTafterfeedingtocleansethelumenofthetube. 7. ClamptheNGTtoprevent entryofairintothestomach. 8. MaintainFowler’ spositionforatleast 30minstoprevent aspiration. 9. Document PotentialSideEffects SIDEEFFECT DIARRHEA NAUSEA/VOMITING/BL OATING REASON Feedingsareadministeredtooquickly Thepatient hasa lactoseintolerance(All formulasat WOHCarelactosefree) Acontaminatedformula isadministered(e. g.,formula ishungtoolonginsunortubing notcleansedproperly.) Useofantibioticsmayleadtoovergrowth ofC.difficiletoxinleadingtofrequent loose stools. Proteinmalnutrition(hypoalbuminemia) Malabsorptionstates Lack dietaryfibre. Feedingsareadministeredtooquickly. Intolerance toconcentrationand/or volume exists. ACTIONS Donot stopfeedingsunless specificallyorderedbythe physician. Investigatepotential causesand notifythephysiciananddietician. Ifvomitingoccurs, stopfeeding, turnpatienttotheside, assess needforsuctioningandnotify SIDEEFFECT CONSTIPATION MECHANICAL REASON Reducedgastricmotilityassociatedwith gastricretention. Feedingsaretoocold Paralyticileus Obstruction Inadequatebulk inthediet Associatedwithmedicationtherapy Reducedgastrointestinalmotility Associatedwithdecreasedlevel ofactivity Inadequatefluidintake Advancedage Skinand/ormucosal irritation Pressureagainst naresofnose ACTIONS physiciananddietician. Reassessfluidstatusandactivity level Notifyphysiciananddietician Hypoallergenictape Changedressingsonceperday withNormal Saline Securetapingoftube ParenteralNutrition Parenteral nutrition, orintravenousfeeding, isa methodofgettingnutritionintoyourbodythrough yourveins.Dependingonwhichveinisused,thisprocedureisoftenreferredtoaseithertotal parenteral nutrition (TPN)orperipheral parenteral nutrition(PPN). Thisformofnutritionisusedtohelppeoplewhocan’ t orshouldn’ t gettheircorenutrientsfrom food. It isoftenusedforpeoplewith: Crohn’ sdisease cancer short bowel syndrome ischemic bowel disease It alsocanhelppeoplewith conditionsthat resultfromlowbloodflowtotheirbowels. Parenteral nutritiondeliversnutrientssuch assugar,carbohydrates, proteins,lipids, electrolytes, and traceelementstothebody.Thesenutrientsarevital inmaintaininghigh energy, hydration, andstrengthlevels. Somepeopleonlyneedtoget certaintypesofnutrientsintravenously. CHAPTER9 INTERVENTIONSTOPROMOTEBOWELANDBLADDERELIMINATION KeyTerms Urination Defecation Laxatives Enema Urinarycatheterization Let’ sStart! PhysiologyofDefecation Peristalticwavesmovethefecesintothesigmoidcolonandtherectum. Sensorynervesinrectumarestimulated. Individual becomesawareofneedtodefecate. Fecesmoveintotheanal canal whentheinternal andexternal sphincterrelax. External anal sphincterisrelaxedvoluntarilyiftimingisappropriate. Expulsionofthefecesassistedbycontractionof theabdominal musclesandthediaphragm. Movesthefecesthroughtheanal canal andexpelledthroughanus. Facilitatedbythighflexionanda sittingposition. FactorsthatInfluenceFecalElimination Developmentalstage Diet Medications Diagnosticprocedures Fluid Anesthesia Activity Psychologicfactors Surgery Pathologicconditions Defecationhabits Pain CharacteristicsofFeces Color: yelloworgoldenbrown(duetothebilepigmentderivativeknownasstercobilinfecal urobilinogen. Odor:aromaticupondefecation(duetoindoleandscatole, whichareproductsof fermentationand putrefactioninthelargeintestine. Amount: dependonthebulkofthefoodintake. Approximately150to300gperday. Consistency: soft, formed Shape: cylindrical Frequency: Variable;usual range1-2perdayto1every2-3days AlterationontheCharacteristicsofStool 1. AlcoholicStool. Gray,paleorclay-coloredstool duetoabsenceofstercobilincausedbybiliary obstruction. 2. Hematochezia.Passageofstool with brightredblood. Itisduetolowergastrointestinal bleeding. 3. Melena.Passageofblack, tarrystool duetoupperGI bleeding. 4. Steatorrhea. Greasy, bulk, foul-smelling stool. It is due to presence of undigested fats like in hepatobiliary-pancreaticobstructions/disorders. CommonFecalEliminationProblems 1. Constipation Referstothepassageofsmall, dry,hardstoolsorthepassageofnostool forperiodoftime NursingInterventionstoPreventandRelieveConstipation 1. Adequate fluid intake, between1,500 to 2,000 ml/day. This isthe most effective measure to relieveconstipation. 2. High fiber diet. To provide bulk to the stool. High fiber foods include fresh or cooked fruits and vegetables with their skin, whole grain fresh, breads and cereals, fruits, and vegetable juices. 3. Establish regularpatternofdefecation. For some people, ingestion of food orfluid first thing inthemorningstimulatesanurgetodefecate.Overtime, apatternofbowel eliminationevery morning can be established and is considered a normal pattern for that person. Some people are ritualistic, using the same method to promote a regular pattern of bowel elimination, whereas others have no set pattern except to respond to the defecation urge whereverit occurs. 4. Respondimmediatelytotheurgeto defecate. Thedefecationreflex andthe urgeto defecate subside after a few minutes if the initial urge isignored. The feces then, remainin therectum until anothermasscolonicmovementpropelsmorestool intotherectum, whichmaynot be forseveral hoursorlonger. 5. Minimize stress. Stress triggers the sympathetic nervous system, causing decreased peristalsis. 6. Adequateactivityandexercisepromotemuscletoneandfacilitateperistalsis. 7. Assume setting or semi squatting position. This position allows gravity to assist the elimination of feces and makes it easier for the client to contract the abdominal and pelvic muscles, thereby applying external pressure to the large intestine and encouraging evacuation. 8. Administer laxatives as ordered. Laxatives stimulate peristalsis and promote defecation. Avoid overuse of laxatives because natural defecation reflexes are inhibited, rebound constipationoccurs. TypesofLaxatives 1. Chemical Irritants. They provide chemical stimulation to intestinal wall, thereby increasing peristalsis. E.g., Dulcolax(Bisacodyl), castoroil, Senokot (Senna) 2. Stool Lubricants. Theylubricatefecesandfacilitatetheexpulsion.E.g., mineral oil 3. Stool Softeners.Theysoftenthestool andfacilitatesexpulsion.E.g., Colace(Nadecussate) 4. Bulk Formers. Theyincreasethe bulk ofthefeces, increasingmechanical pressure anddistentionofthe intestine, thereby, increasingperistalsis. E.g.,Metamucil (psylliumhydrophilicmucilloid) 5. Osmotic Agents. They attack fluids from the intestinal capillaries to the stool. E.g., Milk of Magnesia (MagnesiumHydroxide) Duphalac(lactulose 2. FecalImpaction Isthe massorcollectionofhardened, putty-like fecesinthe foldsofthe rectum. The stool is lodged or stuckintherectum;thepersonisunabletovoluntarilyevacuatethestool. Assessment 1. Absenceof bowel movement for3to5days. 2. Passageofliquidfecal seepage. 3. Hardenedfecalmassispalpatedduringdigital examinationoftherectum. 4. Nonproductivedesiretodefecateandrectal pain. 5. anorexia, bodymalaise 6. Subjective feelingofabdominalfullnessorbloating;apparent abdominal distention. 7. Nauseaandvomiting. NursingInterventionstoRelieveFecalImpaction 1. Manual extractionorfecal disimpactionasordered. 2. increasedfluidintake 3. Sufficient bulk indiet. 4. Adequateactivityandexercise 3. Diarrhea Referstofrequentevacuationofwaterystools. It isassociatedwithincreasedgastrointestinal motility, andarapidpassageoffecal contentsthroughthelowergastrointestinal tract. NursingInterventionstoRelieveDiarrhea 1. Replace fluidandelectrolytelosses. 2. Providegoodperianal care.Diarrheal stool isoftentimeshighlyacidic. Thiscausesanal sorenessandirritationintheperianal area. 3. Promoterest.Toreduceperistalsis. 4. Diet. Small amountofblandfoods Lowfiberdiet BRAT(banana, riceam,apple,toast) Avoidexcessivelyhotorcoldfluids(thisarestimulants) Potassium-rich foodsandfluids(e.g., banana,Gatorade) Antidiarrheal medicationsasordered. CAUTION:Donot administerantidiarrheal atthestart ofdiarrhea.Diarrhea isthebody’ sprotective mechanismtoriditselfofbacteriaandtoxins 4. Flatulence Isthepresenceofexcessivegasintheintestines, (alsotympanities).Thismaybedueto swallowedair,bacterial actioninthelarge intestineanddiffusionfromblood. CommoncausesofFlatulence 1. Constipation 2. Medicationsthat decreaseintestinal motility(e.g.,Codeine, barbiturates) 3. Anxiety 4. Eatinggasformingfoods, e.g.;cabbage,onions, root crops, legumes 5. Rapidfoodorfluidingestion 6. Improperuseofdrinkingstraw. 7. Excessivedrinkingofcarbonatedbeverages 8. Gumchewing,candysucking,smoking 9. Abdominal surgery.Thiscausesdecreasedperistalsis NursingInterventionstorelieveFlatulence a. Avoidgasformingfoods. b. Providewarmfluidstodrink. Toincreaseperistalsis c. Earlyambulationamongpost operativeclients d. Adequateactivityandexercise. e. Limit carbonatedbeverages, useofdrinkingstrawsandchewinggum. f. Rectal tubeinsertion. 5. FecalIncontinence Is the involuntary elimination of bowel contents; it is often associated with neurologic, mental or emotional impairments. Clients with cerebral cortex injury may be unable to perceived distended rectum, or are unable to initiate the motorresponserequiredtoinhibit defecationvoluntarily. People whohave sustained sacral spinal cord injury experience impaired nerve supplyto therectum andanal sphincterstopostponedefecation. Clientswho are disoriented or confused mayhave lost the social inhibition that preventsimmediate fecal evacuation. Diarrhea predisposes a person to fecal incontinence. Sometimes, the volume of feces is so large and the defecation urge so intense that the person cannot maintain sphincter contraction long enoughtoaccesstoilet facilitiesandremovethenecessaryclothing NursingDiagnosis:ClientswithFecalEliminationProblems: 1. Constipationrelatedto: a. Inadequatefiberindiet g. Delayed defecation when urge is b. Immobility/inadequatephysical activity c. Inadequatefluidintake present h. Use of d. Painondefecation e. Changeinroutine(diet intake) prescribed constipating medication (narcotic analgesic, iron, antacidandanticholinergic) f. Abuseoflaxatives 2. Perceivedconstipationrelatedto: a. Alteredthoughtprocess b. Familyhealth beliefs c. Knowledgedeficitaboutnormalprocesses 3. Diarrhearelatedto: a. Dietaryalteration b. Stress/anxiety e. Spoiledfood f. Tubefeeding c. Inflammation/irritationofthebowel d. Drugside effects g. Allergy 4. Potential fluidvolumedeficitrelatedto: a. Diarrhea ENEMAS b. Abnormal fluidlossthroughostomy c. Potential impairedskinintegrityrelatedto: a. Prolongeddiarrhea b. Bowel incontinence c. Bowel diversionostomy Purposes: Relieve constipation and fecal impaction Relieveflatulence Administermedication TYPESOFENEMAS 1. CLEANSINGENEMA Evac uate feces in preparation for diagnostic procedureorsurgery Stimulates peristalsis by irritating the colon and rectum and or by distending the intestine with the volumeoffluidintroduced A. HIGHcleansingenema: cleanseasmuchofthecolonaspossible;1000ml ofsolutionisadministeredinadults. B. LOWcleansing enema: to cleanse the rectum and sigmoid colon only; 500 ml of solution is administered in adults. 2. CARMINATIVE Toexpel flatus -60-80ml of fluidisintroduced. 3. RETENTIONENEMA Introducesoil intotherectumandsigmoidcolon;oil isretainedinthecolonfor1-3hours Softensfecesandlubricatestherectumandanal canal tofacilitatepassageofstool 4. RETURNFLOWENEMA/HARRISFLUSH/COLONICIRRIGATION Donealsotoexpel flatus 300-500ml offluidisintroducedintoandout ofthelargeintestine. Solutioncontainerisloweredsothatthefluidbacksoutthroughtherectal tubecontainer. Theinflow-outflowprocessisrepeated5-6times Replace the solutionseveraltimesasitbecomesthick withfeces Proceduremaytake15-20minstobeeffectiv SOLUTIONSUSED NON-RETENTION RETENTION -Tapwater(500-1000ML) Carminativeenema -Soapsuds(20ml ofcastilesoapin 500-1000ml ofwater) Oil (90-120ofmineral oil, oliveor cottonseedoil) -Normalsaline(9ml ofNaCl to1000ml ofwater) -HypertonicSolution/Fleetenema (90-120ml) HTOFSOL. 18inchesaboverectum 12inchesaboverectum TEMPOFSOL 115-125F 105-110F TIMEREQUIRED 5-10mins 1-3hours Nursingconsiderationswhenadministeringenema: Checkthedoctor’ sorder Provideprivacy Promoterelaxationtofacilitateinsertionoftube Positionthepatient (adult: left lateral position;children: dorsalrecumbent) Identifyappropriatecathetersize: Adult:fr22-32 Children: fr14-18 Infant: fr12 Lubricate5cm(2in)oftherectal tube Allowsolutiontoflowthroughthetubetoexpelairbeforeinsertion. Insert 7-10cm(3-4inches) of rectal tube ingentle rotationmotiontoprevent irritationofanal and rectal tissues Introducesolutionslowlytoprevent suddenstimulationofperistalsis Change the positionto distribute solutionwell inthe colon(high enema), if low, remain in left side-lying position. Ifabdominalcrampsoccur,temporarilystoptheflowof solutionbyclampingthetube Aftertheprocedure,pressthebuttockstoinhibittheurge todefecate Assist patienttothetoilet Doperianal care Document UrinaryElimination AnatomyandPhysiologyoftheUrinarySystem The major role of the urinary systemisto maintainhomeostasis by maintaining bodyfluid composition andvolume.Thecomponentsoftheurinarysystemareasfollows: kidneys, ureters,urinarybladdersandurethra. TheKidneys The kidneys are two bean-shaped organs located retroperitoneally at the level of the twelftg thoracic andthirdlumbarvertebra. Theright kidneyisslightlylowerthanthe left kidneydueto thepresenceof theliveronthe right sideofthe abdomen. The kidneys are divided into renal cortex, medulla and pelvis. The medulla is composed of series of pyramids. Functional units of the kidneys are the nephrons. The nephrons are composed of glomerulus and the renal tubules. Theglomerulusisaturfof semi-permeablecapillaries,surroundedbytheBowman’ scapsule. Thethree regionsof therenal tubules areas follows: proximal convolutedtubules, loopof Henleand the distal convolutedtubules. Theprimaryfunctionofthenephronsisformationofurine. About1200ml ofbloodflowstothekidneysperminute, whichis20-25%ofthecardiacoutput. Through theformationofurine, thekidneysremovewasteproductsfromthebody,regulatefluidvolume, maintainelectrolytesconcentration, bloodpressureandpHwithinthebody. The glomerular filtration rate (GFR) is125 ml/min. Fromthis, the kidneys form0.5 to 1 ml per minute, 60 MLperhour, approximately1500ml perdayofurine. TheUreters The ureters are two small tubes about 25 cm long. They transport urine from the renal pelvis to the urinarybladder. The ureters enter the urinary bladder obliquely and is guarded by ureter vesicular sphincter. These two factorsprevent refluxofurineasthe bladdercontracts. TheUrinaryBladder Theurinarybladderservesasreservoirforurine. It is composed of three layers of detrusor muscles. Contraction of these muscle expels urine from the bladder. Thebladderisguardedbyinternal urethral sphincterinthejunctionof itsopeningintotheurethra. The trigone is triangular region in the floor of the bladder that is marked by the openings for the two uretersandtheinternal urethral orifice. Theapproximatemaximumcapacityofthebladderis1000ml ofurine. TheUrethra Theurethraisthepassagewayof theurineintotheexternal environment. The internal urethral sphincter is an involuntary muscle, while the external urethral sphincter is a voluntarymuscle. Thefemaleurethra is1½to2 ½incheswhile themale urethra is5½to 6½inchesupto8 inches inlength. Theshorterurethra amongfemalesincreasepropensitytourinarytractinfection. UrineFormation Threestepsofformationofurinebythekidneysareasfollows: a. Glomerular filtration. Water and solutes move from the blood to the glomerular capsule. The fluid that entersthecapsuleiscalledglomerularfiltrate. b. Tubular reabsorption. It is the movement of the substance from the filtrate in the kidney tubulesinto the bloodintheperitubularcapillaries.Only1%of the filtrateremainsinthe tubulesandbecomesurine. Water and other substances that are useful to the body are reabsorbed. Water is reabsorbed by osmosis,whilemost solutesarereabsorbedbyactivetransport. c. Tubular secretion. It isthe transport of substances fromthe blood into the renal tubules. Potassium and hydrogen are primarily eliminated from the body. Ammonia, uric acid, some f=drug metabolites are likewise eliminated. Micturition It is the act of expelling urine from the bladder. Synonymous to urination or voiding The parasympathetic nervous system initiates voiding. Whereas the sympathetic nervous system inhibits voiding. The micturition reflex is involuntary, but it can be inhibited by higher brain centers. NormalCharacteristicsoftheUrine Color amber/straw Odor aromatic-uponvoiding Transparency Clear pH slightlyacidic(range:4.6-8averageof6) Specificgravity 1.010-1.025(thisismeasuresbyurinometer) ProblemsinUrinaryElimination A. AlteredUrineComposition PresenceofRBC PresenceofWBC PresenceofPus PresenceofBacteria PresenceofAlbumin PresenceofProtein PresenceofGlucose PresenceofKetones Hematuria UrinaryTract Infection Pyuria Bacteriuria Albuminuria Proteinuria Glycosuria Ketonuria DiabeticKetoacidosis B. AlteredUrineProduction 1. Polyuria. The production of excessive amount of urine, such as a more than 100ml/hr. or 2500 ml/day(alsodieresis) 2. Oliguria. The production of decreased amount of urine, such as less than 30 ml/hr. or less than 500 ml/24hrs 3. Anuria. The absence of production of urine by the kidneys such as a 0 to 10 ml/hr. (also urinary suppression) C. AlteredUrinaryFrequency 1. Frequency. Voidingat frequent intervals 2. Nocturia. Increasedfrequencyat night. 3. Urgency. The strong feeling that the personwants tovoid. There mayormaynot be great amount of urineinthebladder. 4. Dysuria. Voidingthat iseitherpainful ordifficult. 5. Hesitancy. Difficultyininitiatingvoiding. 6. Enuresis.Repeatedinvoluntaryvoidingbeyond4-5yearsofage. 7. Pollakiuria.Frequent, scantyurination 8. Urinaryincontinence. a. Total incontinence.Acontinuousandunpredictablelossofurine. b. Stress incontinence. The leakage of less than 50 ml of urine because of sudden increase in intra-abdominalpressure,e.g., whenonecoughs, sneezes,laughsorexertsphysically. c. Urge incontinence. Follows a sudden strong desire to urinate and leads to involuntary detrusor contraction. d. Functional incontinence.Theinvoluntaryunpredictablepassageof urine. e. Reflex incontinence. Is an involuntary loss of urine occurring at somewhat predictable intervals whenspecificbladdervolumeisreached. 9. Retention. The accumulationofurineinthe bladderwith associatedinability of the bladder toempty itself. 250-450ml ofurineinthebladdertriggersmicturitionreflex. ClinicalSignsofUrinaryRetention a. Discomfortinthepubicarea b. Bladderdistention(palpation&percussion) Smooth, firm, ovoidmassat the suprapubic area Massarisingout ofthepelvis. Dullnessonpercussion c. Inabilitytovoidorfrequent voidingofsmall volumes(25-50ml ata time) d. Adisproportionatelysmall amount of output inrelationtofluidintake. e. Increasingrestlessnessandfeelingof needtovoid. NursingInterventionstoInduceVoiding 1. Provide privacy. This is the most effective nursing measuretoinducevoiding. 2. Providefluidstodrink. 3. Assist the patient in the anatomical position of voiding. 4. Serve clean, warm, and dry bedpan (female), urinal (male) 5. Allow the patient to listen to the sound of running water. 6. Danglefingersinwarmwater 7. Promoterelaxation. 8. Provideadequatetimeforvoiding. 9. Perform Crede’ s maneuver as ordered. This is done byapplyingpressureonthesuprapubicarea. 10. Administercholinergic, e.g., Urecholine (Bethanechol)asordered. 11. Last resort: Urinary catheterization. This is the last resort because it is one of the most common causesofnosocomial infection. UrinaryCatheterization Purposes: Relievebladderdistension Instill medicationsintothebladder Irrigatethebladder Measurehourlyurineoutput accurately Collect urinespecimen Empty bladder in preparation for diagnostic procedureandsurgery Nursingconsiderations: Verifydoctor’ sorderandidentifythepatient Explainprocedureandprovideprivacy Doperineal care Useappropriatecathetersize: Male: 16-18 Female: 12-14 Position: Male>supinewith legsabducted Female>dorsal recumbent Donsterilegloves Locatemeatus: Male---tipofglanspenis Female---betweenclitorisandvaginal orifice Cleansethemeatuswithantisepticsolutionfromfront toback Lubricatecatheterwithwater-solublesolution Insert the catheterandadvanceuntil urineflowsthroughthetubing Anchorthecatheterbyinflatingtheballoonwith 5-10ml of sterilewater Anchorthetubing: Male---laterallyupwardoverthelowerabdomentoprevent penoscrotal pressure female--inneraspectofthethigh
