Exam 3 Study Guide (32,37,38,14,15,16)
Chapter 32 Skin Integrity and Wound Care
Table 32-3 Types of wounds (1)
- Wound is a break of disruption in the normal integrity of the skin and tissue
- Disruption may range from a small cut on a finger to a 3rd degree burn
covering almost all of the body.
- Wounds may result from mechanical forces
- intentional or unintentional (based on how they were acquired), open or
closed, and acute or chronic (based on whether the wound follows the
normal, timely healing process or not). Pressure injuries may be further
classified as:
- (1) partial thickness where all or a portion of the dermis is intact;
- (2) full thickness where the entire dermis and sweat glands and hair
follicles are severed, which can expose bone, tendon, or muscle; or
- (3) unstageable, a full-thickness loss where the true depth cannot be
determined; may also involve deep tissue injury
- Intentional wounds
- Result of planned invasive therapy or treatment.
- Ex: surgery, intravenous, lumbar puncture
- Wound edges usually clean and bleeding is usually controlled
- Wound was made under sterile conditions with sterile
supplies and skin preparation
- Risk of infection decreased & healing is facilitated
- Unintentional
- Accidental wounds
- Occurs from unexpected trauma ( accidents, forcible
injury ( stabbing or gunshot) & burns
- Wound occurs in an unsterile environment,
contamination is likely
- Wound edges are usually jagged, multiple traumas are
common & bleeding is uncontrolled
- Factors create a high risk for infection and longer healing
time.
- An open wound occurs from intentional or unintentional trauma.
-
The skin surface is broken, providing a portal of entry for microorganisms.
Bleeding, tissue damage, and increased risk for infection and delayed healing
may accompany open wounds.
-
Examples include incisions and abrasions.
A closed wound results from a blow, force, or strain caused by trauma
-
such as a fall, an assault, or a motor vehicle crash.
The skin surface is not broken, but soft tissue is damaged, and internal injury
and hemorrhage may occur. Examples include ecchymosis and hematomas.
-
Acute wounds, such as surgical incisions, usually heal within days to weeks.
-
The wound edges are well approximated (edges meet to close skin surface)
and the risk of infection is low.
-
Acute wounds usually progress through the healing process without
interruption.
-
Chronic wounds, in contrast, do not progress through the normal sequence of repair.
The healing process is impeded.
-
The wound edges are often not approximated, the risk of infection is
increased, and the normal healing time is delayed (>30 days).
-
Chronic wounds remain in the inflammatory phase of healing (discussed in
the next section).
-
Chronic wounds include any wound that does not heal along the expected
continuum, such as wounds related to diabetes, arterial or venous
insufficiency, and pressure injuries.
TABLE 32-3 Types of Wounds
TYPE
CAUSE
Incision
Cutting or sharp instrument; wound edges in close approximation
and aligned
Contusion
Blunt instrument, overlying skin remains intact, with injury to
underlying soft tissue; possible resultant bruising and/or hematoma
Abrasion
Friction; rubbing or scraping epidermal layers of skin; top layer of
skin abraded
Laceration
Tearing of skin and tissue with blunt or irregular instrument; tissue
not aligned, often with loose flaps of skin and tissue
Puncture
Blunt or sharp instrument puncturing the skin; intentional (such as
venipuncture) or accidental
Penetrating
Foreign object entering the skin or mucous membrane and lodging in
underlying tissue; fragments possibly scattering throughout tissues
Avulsion
Tearing a structure from normal anatomic position; possible damage
to blood vessels, nerves, and other structures
Chemical
Toxic agents such as drugs, acids, alcohols, metals, and substances
released from cellular necrosis
Thermal
High or low temperatures; cellular necrosis as a possible result
Irradiation
Ultraviolet light or radiation exposure
Pressure ulcers
Compromised circulation secondary to pressure or pressure
combined with friction
Venous ulcers
Injury and poor venous return, resulting from underlying conditions,
such as incompetent valves or obstruction
Arterial ulcers
Injury and underlying ischemia, resulting from underlying
conditions, such as atherosclerosis or thrombosis
Diabetic ulcers
Injury and underlying diabetic neuropathy, peripheral arterial
disease, diabetic foot structure
Phases of Wound Healing (1)
The wound healing process can be divided into three or four phases, depending on the reference. In
this chapter, four phases will be discussed:
-hemostasis
- inflammation
- proliferation
- maturation.
-These four phases systematically lead to repair of the injury.If three stages are identified,
hemostasis is included as part of the inflammatory stage.
Hemostasis
●
-Hemostasis occurs immediately after the initial injury
●
-Involved blood vessels constrict and blood clotting begins through platelet activation and
clustering. After only a brief period of constriction, these same blood vessels dilate and
capillary permeability increases, allowing plasma and blood components to leak out into the
area that is injured, forming a liquid called exudate.
●
-The accumulation of exudate causes swelling and pain. Increased perfusion results in heat
and redness.
●
- If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury.
The platelets are also responsible for releasing substances that stimulate other cells to
migrate to the injury to participate in the other phases of healing.
INFLAMMATORY PHASE
●
The inflammatory phase follows hemostasis and lasts about 2 to 3 days.
●
White blood cells, predominantly leukocytes and macrophages, move to the wound.
Leukocytes arrive first to ingest bacteria and cellular debris.
●
About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area
and remain for an extended period. Macrophages are essential to the healing process. They
not only ingest debris, but also release growth factors that are necessary for the growth of
epithelial cells and new blood vessels.
●
These growth factors also attract fibroblasts that help to fill in the wound, which is necessary
for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and
swelling at the site of the injury.
●
During the inflammatory phase, the patient has a generalized body response, including a
mildly elevated temperature, leukocytosis (increased number of white blood cells in the
blood), and general malaise
PROLIFERATION PHASE
●
The proliferation phase is also known as the fibroblastic, regenerative, or connective tissue
phase. The proliferation phase lasts for several weeks.
●
New tissue is built to fill the wound space, primarily through the action of fibroblasts.
○
Fibroblasts are connective tissue cells that synthesize and secrete collagen and
produce specialized growth factors responsible for inducing blood vessel formation as
well as increasing the number and movement of endothelial cells.
●
Capillaries grow across the wound, bringing oxygen and nutrients required for continued
healing. Fibroblasts form fibrin that stretches through the clot.
●
A thin layer of epithelial cells forms across the wound, and blood flow across the wound is
reinstituted.
●
The new tissue, called granulation tissue, forms the foundation for scar tissue
development. It is highly vascular, red, and bleeds easily. In wounds that heal by first
intention, epidermal cells seal the wound within 24 to 48 hours, thus the granulation tissue is
not visible.
MATURATION PHASE
●
The final stage of healing, maturation (or remodeling) begins about 3 weeks after the injury,
possibly continuing for months or years.
●
Collagen that was haphazardly deposited in the wound is remodeled, making the healed
wound stronger and more like adjacent tissue.
●
New collagen continues to be deposited, which compresses the blood vessels in the healing
wound, so that the scar, an avascular collagen tissue that does not sweat, grow hair, or tan in
sunlight, eventually becomes a flat, thin line.
●
Scar tissue is less elastic than uninjured tissue. The strength of the scar tissue remains less
than that of normal tissue, even many years following injury and it is never fully restored.
Wounds that heal by secondary intention take longer to remodel and form a scar smaller
than the original wound.
●
If the scar is over a joint or other body structure, it may limit movement and cause disability
Wound Complications: Dehiscence vs. Evisceration (1)
-DEHISCENCE: partial/ total separation of tissues.
Wound layers due to excessive stress on wounds that is
not healed.
EVISCERATION: most serious complication of
dehiscence.
DEHISCENCE AND EVISCERATION
●
Dehiscence and evisceration (Fig. 32-2) are the most serious postoperative wound
complications.
●
Dehiscence is the partial or total separation of wound layers as a result of excessive stress
on wounds that are not healed.
●
Evisceration is the most serious complication of dehiscence. It occurs primarily with
abdominal incisions (Baranoski & Ayello, 2016; Hinkle & Cheever, 2018).
○
In evisceration, the abdominal wound completely separates, with protrusion of
viscera (internal organs) through the incisional area
○
Patients at greater risk for these complications include those who are obese or
malnourished, smoke tobacco, use anticoagulants, have infected wounds, or
experience excessive coughing, vomiting, or straining (Hinkle & Cheever, 2018).
○
An increase in the flow of (serosanguineous) fluid from the wound between
postoperative days 4 and 5 may be a sign of an impending dehiscence. The patient
may say that “something has suddenly given way.”
●
If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9%
sodium chloride solution and notify the health care provider.
○
Once dehiscence occurs, the wound is managed like any open wound. Dehiscence
and evisceration of an abdominal incision is a medical emergency.
○
Place the patient in the low Fowler’s position and cover the exposed abdominal
contents, as discussed previously, being sure to keep the exposed viscera moist.
○
Do not leave the patient alone, and be sure to provide reassurance and intravenous
pain medications as appropriate.
○
Notify the primary care provider immediately. This situation is an emergency that
requires prompt surgical repair, so the patient should be kept NPO (Baranoski &
Ayello, 2016; Hinkle & Cheever, 2018).
Stages of Pressure injuries (1)
1. Intact skin with non blanchable redness of a localized area, usually over a
bony prominence.
2. Blister, abrasion, shallow crater
3. Full thickness tissue loss- subcutaneous fat involved. Visible, but tendon or
muscle NOT exposed
4. Involves full thickness tissue. Loss with exposed bone, tendon, and muscle.
●
blanching (becoming pale and white) of the skin area under pressure may be an
early warning sign of potential injury development.
○
When pressure is relieved, blanching, which represents ischemia, is rapidly followed
by hyperemia, or reddening of the skin that occurs when pressure is removed.
○
The body literally floods the area with blood to nourish and remove wastes from the
cells.
○
The area appears red and feels warm, but blanches when slight pressure is applied.
○
After a patient who has been lying supine for 2 hours is repositioned onto the side,
any reddened area due to reactive hyperemia should fade within 60 to 90 minutes.
○
In patients with darkly pigmented skin, it may be best to assess for hyperemia by
touch; the skin feels warm.
○
●
Also, assess for some change in color relative to the surrounding skin.
If the pressure is not removed when this ischemia occurs, circulation is further impaired and
a pressure injury develops.
○
Appropriate intervention depends on early recognition of the stage of development
of the pressure injury.
○
Pressure injuries are commonly classified according to six stages (four numbered and
two unnumbered): stage 1, stage 2, stage 3, stage 4, unstageable, and deep
tissue pressure injury
●
When assessing pressure injuries, it is important to note that this staging system should be
used for pressure injuries only;
○
it does not apply to injuries that may occur secondary to moisture (such as IAD),
intertriginous dermatitis (an inflammatory condition that occurs in skin folds),
injuries related to medical adhesive, neuropathic (diabetic) ulcers, vascular ulcers,
mucosal membrane pressure injuries (with a history of medical device use at the
location of the injury), or injuries from traumatic wounds (such as burns, tears, or
abrasions; NPUAP, 2016b).
●
A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have
visible blanching; its color may differ from the surrounding skin. The area
may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
●
A stage 2 pressure injury involves partial-thickness loss of dermis and
presents as a shallow, open ulcer or a ruptured/intact serum-filled blister .
●
A stage 3 pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible and epibole (rolled wound edges) may occur,
but bone, tendon, or muscle is not exposed. Slough and/or eschar that may be
present do not obscure the depth of tissue loss. Ulcers at this stage may include
undermining and tunneling
●
Stage 4 injuries involve full-thickness tissue loss with exposed or palpable
bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be
present on some part of the wound bed; epibole, undermining, and/or
tunneling often occur.
○
When the clinician is unable to visualize the extent of tissue damage due to slough or
eschar, pressure injuries are classified as unstageable.
○
Slough is yellow, tan, gray, green, or brown dead tissue; eschar is tan,
brown, or black hardened dead tissue (necrosis) in the wound bed
■
Eschar and/or slough must be removed before the stage (3 or 4)
can be determined.
■
However, stable (dry, adherent, intact, without erythema or
fluctuance) eschar on the heels or ischemic limb should not be
removed or softened
○
Suspected deep-tissue injury presents as a persistent, nonblanchable purple or
maroon discoloration of intact or nonintact skin, or separation of the epidermis that
reveals a dark wound bed or blood-filled blister
○
It may initially present as a painful, firm, mushy, boggy, warmer, or cooler area as
compared to adjacent tissue
○
This type of injury typically results from intense and/or prolonged pressure and
shearing where the bone and muscle interface
●
BOX 32-3
●
Pressure Injury Stages
●
Pressure Injury
○
A pressure injury is localized damage to the skin and underlying soft tissue usually over
a bony prominence or related to a medical or other device. The injury can present as
intact skin or an open ulcer and may be painful. The injury occurs as a result of intense
and/or prolonged pressure or pressure in combination with shear. The tolerance of soft
tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion,
co-morbidities, and condition of the soft tissue.
●
●
Stage 1 Pressure Injury: Nonblanchable Erythema of Intact Skin
○
Intact skin with a localized area of nonblanchable erythema, which may appear
differently in darkly pigmented skin. Presence of blanchable erythema or changes in
sensation, temperature, or firmness may precede visual changes. Color changes do not
include purple or maroon discoloration; these may indicate deep tissue pressure injury.
●
●
Stage 2 Pressure Injury: Partial-Thickness Skin Loss With Exposed Dermis
○
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red,
moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat)
is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar
are not present. These injuries commonly result from adverse microclimate and shear
in the skin over the pelvis and shear in the heel. This stage should not be used to
describe moisture-associated skin damage (MASD) including incontinence-associated
dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive–related skin injury
(MARSI), or traumatic wounds (skin tears, burns, abrasions).
●
●
Stage 3 Pressure Injury: Full-Thickness Skin Loss
○
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation
tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be
visible. The depth of tissue damage varies by anatomical location; areas of significant
adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia,
muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar
obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
●
●
Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss
○
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle,
tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by
anatomical location. If slough or eschar obscures the extent of tissue loss, this is an
Unstageable Pressure Injury.
●
●
Unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss
○
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer
cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is
removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry,
adherent, intact without erythema or fluctuance) on the heel or ischemic limb should
not be softened or removed.
●
●
Deep Tissue Pressure Injury: Persistent Nonblanchable Deep Red, Maroon, or
Purple Discoloration
○
Intact or nonintact skin with localized area of persistent nonblanchable deep red,
maroon, or purple discoloration or epidermal separation revealing a dark wound bed or
blood-filled blister. Pain and temperature change often precede skin color changes.
Discoloration may appear differently in darkly pigmented skin. This injury results from
intense and/or prolonged pressure and shear forces at the bone–muscle interface. The
wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve
without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia,
muscle, or other underlying structures are visible, this indicates a full-thickness
pressure injury (unstageable, stage 3, or stage 4). Do not use DTPI to describe vascular,
traumatic, neuropathic, or dermatologic conditions.
●
Assessment of wound drainage (1)
-serous drainage: clear and watery
Sanguineous drainage- bright red
Serosanguineous drainage- pink to red
Purulent drainage- dark green or yellow
● Wound assessment involves inspection (sight and smell) and palpation for
appearance, drainage, odor, and pain.
● Drainage
○ The inflammatory response results in the formation of exudate which then drains
from the wound.
○
The exudate may contain fluid/serum, cellular debris, bacteria, and leukocytes ->
This exudate is called wound drainage
■
○
○
described as serous, sanguineous, serosanguineous, or, if infected, purulent
● Serous drainage is composed primarily of the clear, serous portion
of the blood and from serous membranes. Serous drainage is clear
and watery.
● Sanguineous drainage consists of large numbers of red blood cells
and looks like blood. Bright-red sanguineous drainage is indicative of
fresh bleeding, whereas darker drainage indicates older bleeding.
● Serosanguineous drainage is a mixture of serum and red blood
cells. It is light pink to blood tinged.
● Purulent drainage is made up of white blood cells, liquefied dead
tissue debris, and both dead and live bacteria. Purulent drainage is
thick, often has a musty or foul odor, and varies in color (such as dark
yellow or green), depending on the causative organism.
Drains may be inserted in or near a wound to promote drainage, reducing the risk of
abscess formation and promoting wound healing.
Assess the amount, color, odor, and consistency of wound drainage.
■ The amount and color depend on the wound location and size.
■ Typically, larger wounds have more drainage than smaller wounds.
■ Assess wound drainage on the wound, on the dressings, in drainage bottles
or reservoirs, or—depending on the location of the wound and the amount of
drainage—under the patient.
Presence of wound infections (1)
Results when the patient immune system fails to control growth of
microorganisms.
1.
2.
3.
-
Microorganisms invade a wound
Contaminated wound high risk for infection - increased in a surgical wound
Health care acquired infections
Purulent discharge - increased drainage, pain redness, swelling- increased
body temp- increase WBC count.
●
When infection is present
○
○
○
the wound is swollen and deep red.
It feels hot on palpation
drainage is increased and possibly purulent.
■
If dehiscence is impending or present
●
●
the wound edges are separated.
If the wound edges have separated and the wound is open, describe
the type of tissue in the wound: granulation, slough, or eschar
●
Assess for the presence of odor, but only after the wound has been cleaned. The presence of
odor can be indicative of certain types of bacteria.
Types of drainage systems (1)
●
TABLE 32-4 Common Types of Drains
TYPE: OPEN
PURPOSE
EXAMPLE
Gauze, iodoform gauze,
NuGauze—gauze dressings
packed loosely so the wound is
allowed to drain
Allow healing from base
of wound
Infected wounds, after
removal of
hemorrhoids
Penrose: open drainage system
consisting of a soft rubber tube
that provides a sinus tract
Drains blood and fluid
After incision and
drainage of abscess, in
abdominal surgery
TYPE: CLOSED
PURPOSE
EXAMPLE
Chest tube: mediastinal
placement (different from a chest
tube used in the pleural space)
Drains blood
After cardiac surgery
Hemovac: portable negative
pressure suction device
Drains blood and fluid
After abdominal,
orthopedic surgery
Jackson–Pratt (JP): bulb suction
device
Drains blood and fluid
After breast surgery or
mastectomy,
abdominal surgery
T-tube: T-shaped tube placed in
the common bile duct
Collects bile
After gallbladder
surgery
● OPEN DRAINAGE SYSTEMS
○ A Penrose drain is soft and flexible.
■ This drain does not have a collection device.
■ It empties into absorptive dressing material.
■ It promotes drainage passively, with the drainage moving from the area of
■
■
■
■
■
■
greater pressure, in the wound or surgical site, to the area of less pressure,
the dressing.
It is not sutured in place.
A sterile, large safety pin is often attached to the outer portion to prevent the
drain from slipping back into the incised area (Fig. 32-15).
Care is necessary to ensure that these drains are not dislodged during
dressing changes.
Sometimes the health care provider orders a Penrose drain that is to be
shortened each day.
To do so, grasp the end of the drain with sterile forceps, pull it out a short
distance while using a twisting motion, and cut off the end of the drain with
sterile scissors.
Place a new sterile pin at the base of the drain, as close to the skin as possible
○
○
● CLOSED DRAINAGE SYSTEMS
● Closed drainage systems
○ consist of a drainage tube that may be connected to an electrical suction device or
have a portable built-in reservoir to maintain constant low suction.
■ Examples include Jackson–Pratt drainage tubes (Fig. 32-16 on page 1080)
and Hemovacs (Fig. 32-17 on page 1080).
● These tubes are usually sutured to the skin.
● The closed drainage system prevents microorganisms from entering
the wound from saturated dressings.
●
●
●
●
●
●
Closed drainage systems also allow accurate measurement of
drainage.
Be sure to know which type of drain or tube was inserted during
surgery to ensure accurate assessments and interventions.
These systems must be emptied and the suction reestablished
according to the directions for each device.
This usually involves compressing the container while the port is
open, then closing the port after the device is compressed.
Skills 32-4 on pages 1106–1108 and 32-5 on pages 1109–1111 outline
the procedures for caring for Jackson–Pratt and Hemovac drains.
Wear gloves when emptying the drainage and do not touch the open
port to avoid contaminating the port. If the device ever fully expands,
meaning no suction is being applied, empty the device and reengage
the suction.
Color classifications of open wounds (1)
RYB Wound Classification
A color classification system termed RYB (red-yellow-black) can be used for wound assessment and to help
direct treatment for open wounds, or healing by secondary intention (Hess, 2013; Krasner, 1995; Stotts,
1990). This classification, with related interventions, is based on the assessment of wound color. However,
many wounds have red, yellow, and black components and are categorized as mixed wounds (see Figure).
When all colors are present, the wound is treated first for the most serious color: black, followed by yellow,
and finally red.
R = Red = Protect
Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue.
Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist
dressings, and changing of the dressing only when necessary, and/or based on product manufacturer’s
recommendations.
Y = Yellow = Cleanse
Yellow in the wound may indicate the presence of exudate (drainage) or slough, and requires wound
cleaning. These wounds are characterized by oozing from the tissue covering the wound, often accompanied
by purulent drainage. Drainage can be whitish yellow, creamy yellow, yellowish green, or beige. To cleanse
these wounds, nursing interventions include the use of wound cleansers and irrigating the wound.
B = Black = Debride
Black in the wound may indicate the presence of an eschar (necrotic tissue), which is usually black but may
also be brown, gray, or tan. The eschar requires debridement (removal) before the wound can heal. These
wounds are often cared for by advanced practice nurses who are educated in the care of more complex
wounds. After debridement, the wound is treated as a yellow wound and then, as healing progresses, a red
wound.
Pressure injury assessment tools (1)
●
●
●
Norton Scale: physical and mental conditions, activity, mobility, and incontinence (Norton,
McLaren, & Exton-Smith, 1962/1975)
Waterlow Scale: age and gender (sex), build and weight, continence, skin type, mobility,
nutrition, and special population-specific risks (Waterlow, 1985)
*****Braden Scale: mental status, continence, mobility, activity, and nutrition (Braden &
Maklebust, 2005; Fig. 32-7)
○ With these tools, a numeric score is assigned to each assessment area.
○ The degree of risk is based on the patient’s total score.
○ Using the Braden scale, a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to
14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk (Braden &
Maklebust, 2005).
○ Patients may have additional risk factors and/or other health problems not measured
by the chosen assessment scale.
○
Therefore, good nursing judgment may reveal the need for a higher intensity of
preventive
intervention than what may be identified by the scale alone
Effects of applying heat vs. cold (1)
Effects of Applying Heat
●
●
●
●
●
●
●
●
●
Assess: the patient for undesired response, including localized
redness, blistering, and pain, hypotension, and changes in
consciousness.
vDilates peripheral blood vessels
vIncreases tissue metabolism
vReduces blood viscosity and increases capillary permeability
vReduces muscle tension and promotes relaxation
vHelps relieve pain, muscle spasms and joint stiffness.
v
vDo not apply heat to an open wound immediately after the trauma, during hemorrhage, over
noninflammatory edema, to an acutely inflamed area, a localized malignant tumor, the testes, or the
abdomen of a pregnant woman, or over metallic implants
● The application of local heat dilates peripheral blood vessels
○ increases tissue metabolism
○ reduces blood viscosity
○ increases capillary permeability
●
●
●
●
○ reduces muscle tension
○ and helps relieve pain.
Vasodilation-> increases local blood flow.
In turn, the supply of oxygen and nutrients to the area is increased, and venous
congestion is decreased.
○ As local blood flow increases, the viscosity of blood is reduced.
○ Increased capillary permeability improves the delivery of leukocytes and
nutrients, while also facilitating the removal of wastes and prolonging clotting
time.
○ These actions, combined with increased tissue metabolism, accelerate the
inflammatory response to promote healing.
○ Heat reduces muscle tension to promote relaxation and helps to relieve muscle
spasms and joint stiffness.
○ Heat also helps relieve pain by stimulating specific nerve fibers, closing the gate
that allows the transmission of pain stimuli to centers in the brain.
■ Because of these local physiologic effects, heat in various forms is used to
treat infections, surgical wounds, inflamed tissue, arthritis, joint and
muscle pain, dysmenorrhea, and chronic pain.
The systemic effects of extensive, prolonged heat
○ increased cardiac output
○ Sweating
○ increased pulse rate
○ and decreased blood pressure.
■ This response occurs when heat is applied to a large body area, increasing
the blood flow to that area while decreasing it to another part of the body,
in effect, causing hypovolemic shock.
Effects of Applying Cold
○
○
○
○
○
○
vConstricts peripheral blood vessels
vReduces muscle spasms
vPromotes comfort by slowing the transmission of pain stimuli
vCold reduces blood flow to tissue and reduces the formation of edema and inflammation
v
vDo not use cold for open wounds or for patients with impaired peripheral circulation or
adverse reactions to cold.
○
Assess for localized responses including Pallor, cyanosis,
numbness, and pain
○
○ The local application of cold constricts peripheral blood vessels, reduces muscle
spasms, and promotes comfort.
○ Cold reduces blood flow to tissues and decreases the local release of painproducing substances such as histamine, serotonin, and bradykinin.
■ This action in turn reduces the formation of edema and inflammation.
■ Decreased metabolic needs and capillary permeability, combined with
increased coagulation of blood at the wound site, facilitate the control of
bleeding and reduce edema formation.
○ Cold also reduces
■ muscle spasm
■ alters tissue sensitivity (producing numbness)
■ and promotes comfort by slowing the transmission of pain stimuli.
○ Cold, for these effects, is used after direct trauma for
■ dental pain
■ for muscle spasms,
■ after sprains
■ and to treat some chronic pain syndromes.
○ Exposure to prolonged or extensive environmental cold produces systemic effects
of increased
■ blood pressure, shivering, and goose bumps.
● Although shivering is a normal body response to cold, prolonged
cold may cause tissue injury.
Chapter 37 Urinary Elimination
Table 37-1 Additional terms used to describe urinary problems (1)
Medications affecting color of urine (1)
Medications have numerous effects on urine production and elimination. Of
gravest concern are the many prescription and nonprescription drugs known to be
nephrotoxic (capable of causing kidney damage). Abuse of analgesics, such as
aspirin or ibuprofen, can cause nephrotoxicity. Some antibiotics, such as
gentamicin, can be nephrotoxic as well.
Diuretics, which commonly are used in the treatment of hypertension and other
disorders, prevent the reabsorption of water and certain electrolytes in the tubules.
Depending on the dose of the drug, diuretics cause moderate to severe increases in
production and excretion of dilute urine.
Cholinergic medications stimulate contraction of the detrusor muscle and produce
urination. Some analgesics and tranquilizers suppress the central nervous system,
interfering with urination by diminishing the effectiveness of the neural reflex.
Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red
color.
Diuretics can lighten the color of urine to pale yellow.
Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine.
The antidepressant amitriptyline or B-complex vitamins can turn urine green or
blue-green.
Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can
lead to brown or black urine.
Promoting Normal Urination (education) (2)
normal urination includes interventions to support normal voiding habits, fluid
intake, strengthening of muscle tone, stimulating urination and resolving urinary
retention, and assisting with toileting
Patient education/general care guidelines for urinary diversion (2)
-A urinary diversion involves the surgical creation of an alternate route for
excretion
ileal conduit involves a surgical resection of the small intestine, with
transplantation of the ureters to the isolated segment of small bowel. This separated
section of the small intestine is then brought to the abdominal wall, where urine is
excreted through a stoma, a surgically created opening on the body surface.
A cutaneous ureterostomy is another type of incontinent cutaneous urinary
diversion in which the ureters are directed through the abdominal wall and attached
to an opening in the skin. These cutaneous diversions are usually permanent, and
the patient wears an external appliance to collect the urine because elimination of
the urine from the stoma cannot be controlled voluntarily.
continent urinary diversion (CUD) (e.g., the Indiana pouch): ureters are
diverted into a segment of ileum and cecum in an Indiana pouch. This is a surgical
alternative that uses a section of the intestine to create an internal reservoir that
holds urine, with the creation of a catheterizable stoma. The external stoma or
outlet must be catheterized at regular intervals to drain the urine that has collected
in this reservoir
General care guidelines:
patient needs physical and psychological support before and after surgery
Inspect the patient’s stoma regularly. It should be dark pink to red and moist (Fig.
37-18). A pale stoma may indicate anemia, and a dark or purple-blue stoma may
reflect compromised circulation or ischemia. Bleeding around the stoma and its
stem should be minimal. Notify the primary care provider promptly if bleeding
persists or is excessive, or if color changes occur in the stoma.
Note the size of the stoma, which usually stabilizes within 6 to 8 weeks. Most
stomas protrude 1/2 to 1 in from the abdominal surface and may initially appear
swollen and edematous. The edema usually subsides after 6 weeks. If an
abdominal dressing is in place over the surgical incision, check it frequently for
drainage and bleeding. The dressing is usually removed after 24 hours.
Keep the skin around the stoma site (peristomal area) clean and dry. If care is not
taken to protect the skin around the stoma, irritation or infection may occur. A
leaking appliance frequently causes skin erosion. Candida or yeast infections can
also occur around the stoma if the area is not kept dry.
Measure the patient’s fluid intake and output. Careful monitoring of the patient’s
urinary output is necessary to detect fluid imbalances and adequate functioning of
the diversion.
Keep the patient as free of odors as possible. If the patient has an external
appliance, empty the appliance frequently.
Patients with urinary diversions created using a portion of the gastrointestinal tract
will experience the presence of mucus in the urine (Schreiber, 2016). The segment
of the gastrointestinal tract continues to produce mucus as part of its normal
functioning. This mucus production does not decrease over time, but is usually not
a problem for patients with an ileal conduit (Stott & Fairbrother, 2015). Mucus
may be a problem for patients with a continent urinary diversion; mucus retention
in the pouch can block the catheter used to empty the pouch. Working with an
enterostomal nurse, these patients are taught to irrigate the pouch with normal
saline solution weekly using clean technique to clear mucus from the continent
urinary diversion (Stott & Fairbrother, 2015).
Monitor the return of intestinal function and peristalsis. Initially after surgery,
peristalsis is inhibited. Remember, patients with urinary diversions created using a
portion of the gastrointestinal tract had a bowel resection as part of the procedure.
Encourage the patient to participate in care and to look at the stoma. Patients
normally experience emotional depression during the early postoperative period.
Help the patient to cope by listening, explaining, and being available and
supportive. A visit from a representative of the local ostomy support group may be
helpful. Patients usually begin to accept their altered body image when they are
willing to look at the stoma, make neutral or positive statements concerning the
ostomy, and express interest in learning self-care.
EDUCATION
--Patient education is essential for independence in self-care. Teaching can begin
before surgery so that the patient has adequate time to absorb information.
Explain each aspect of care to the patient and what the patient’s role will be when
beginning self-care. As the patient assumes responsibility for self-care, teach the
patient how to make the necessary observations, to be aware of indications of
problems, and to recognize when to seek assistance. For these goals to be met, the
patient and/or family member should be able to do the following:
MAINTAINING NORMAL VOIDING HABITS
If the patient’s voiding habits are adequate, provide care or teach the patient to
maintain these habits to ensure comfort and satisfactory urine output. Attention to
the following variables is helpful:
Schedule: Some patients report urinating on demand in no apparent pattern. Others
have inflexible patterns that have developed over the years and become anxious if
these are interrupted. Some patients need assistance to urinate and may experience
urgency. Nursing actions should support the patient’s usual urinating pattern as
much as possible.
Urge to void: Assist the patient to void when the patient first feels the urge to void.
Routinely delaying urination may result in difficulty initiating a stream and/or
urinary stasis. Urinary stasis can contribute to the development of UTIs.
Privacy: Many adults and children cannot urinate in the presence of another
person. Unless the patient is extremely weak and requires assistance, provide
privacy in the health care facility and in the home.
Position: Helping patients assume their usual voiding position may be all that is
necessary to resolve an inability to urinate. Some male patients cannot use a urinal
while lying down or sitting; encourage them to void while standing at the bedside
unless this is contraindicated. Similarly, some female patients cannot void easily
on a bedpan but respond favorably with a bedside commode.
Hygiene: Patients who are confined to bed find it difficult to perform their usual
genital hygiene. Careful cleansing of the perineal and genital areas is needed for
patient comfort and to prevent infection. This is easily accomplished for patients
on bedrest by using warmed, moistened disposable washcloths and skin cleanser or
by pouring warm, soapy water over the perineal area while the patient is still on the
bedpan, followed by clear water.
Because people customarily wash their hands after toileting and hand hygiene
prevents transmission of microorganisms, offer patients confined to bed a
moistened towelette or soap and water to wipe their hands after removing the
bedpan or urinal.
-Explain the reason for the urinary diversion and the rationale for treatment.
-surgical creation of an alternate route for excretion of urine.
Ileal conduit> stoma
Cutaneous ureterostomy- permanent
Continent urinary diversion (CUD) - indiana pouch
-clean urine specimens can be obtained from stoma
- specimen for cultures should never be obtained directly from the urostomy
appliance.
-Demonstrate self-care behaviors that effectively manage the diversion.
-Describe follow-up care and existing support resources.
-Report where supplies may be obtained in the community.
-Verbalize related fears and concerns.
-Demonstrate a positive body image
Physical assessment of urinary functioning (1)
Pg 1348 Examination of bladder- urethral meatus and urine, skin
-palpation of kidneys → deep palpation → done by advanced health professionals
Assessment of bladder may be indicated when patients experience difficulty voiding or other alterations in
elimination.
●
●
●
●
●
●
●
●
***vKidneys: Palpation of the kidneys is usually performed by an advanced health care
practitioner as part of a more detailed assessment.
vUrinary bladder: Palpate and percuss the bladder or use a bedside scanner.
oBedside scanner: portable bladder ultrasound device creates an image of the pts bladder and
calculates urine volume present. It is noninvasive and painless. Postvoid residual: is the amount
of urine remaining in the bladder after voiding, if less than 50 mL indicates adequate bladder
emptying. Greater than 100 mL indicates the bladder is not emptying correctly.
vUrethral orifice: Inspect for signs of infection, discharge, or odor
vSkin: Assess for color, texture, turgor, and excretion of wastes.
Urine: Assess for color, odor, clarity, and sediment
Physical assessment of urinary functioning includes an examination of the urinary bladder, if indicated
urethral meatus, skin, & urine.
○ Kidney are normally well protected by considerable fat and connective tissue, making
palpation difficult.
○ Palpation of the kidneys is usually performed as part of a more detailed assessment.
○ Technique requires deep palpation and is generally assessed by advanced health care
professionals -> advanced practice nurse or health care provider
Bladder
○ Assessment of the bladder may be indicated when patients experience difficulty voiding
○ Bladder is normally positioned below the symphysis pubic cannot be palpated or percused
when empty. When the bladder is normally positioned below the symphysis pubis and may
reach to just below the umbilicus
○ Before palpating the bladder, always inquire as to when the patient last voided.
○ Observe the lower abdominal wall, noting any swelling, and palpate this area for tenderness.
■ If distended, ote the smoothness and roundness of the bladder; measure the height of
the edge of the bladder above the symphysis pubis.
○
○
○
●
Bedside scanner is another commonly used method to assess the fullness of the bladder.
Portable bladder ultrasound devices create an image of the pts bladder & calculate urine
volume present in the bladder.
■ Noninvasive and painless.
○ Bladder scan can be performed at the bedside, pose no risk for infection and is safer
alternative to catheterization to determine bladder urine volume.
■ Results are most accurate when the pt is in supine position during scanning.
Urethral orifice
○ Inspect the urethral orifice for any signs of inflammation, discharge, or foul odor.
○ In females -> urethral meatus is a slit-like opening below the clitoris and above the vaginnal
ofice.
■ Place female pt in the dorsal recumbent position with the inner labia retracted for
good visualization of the meatus.
○ Males -> the meatus is at the tip of the penis.
■ Male pt is uncircumcised, retract the foreskin to visualize the meatus
●
SKIN INTEGRITY AND HYDRATION
○ Because problems with urinary functioning may result in disturbances in hydration and
excretion of body wastes, assess the skin carefully for color, texture, and turgor.
○ Assess the integrity of the skin in the perineal area. Problems with incontinence may result in
severe excoriation (abrasion of the epidermis).
●
Urine Characteristics
○
○
Assess the patient’s urine for color, odor, clarity, and the presence of any sediment.
Note any abnormalities. In select patients, monitor the pH and specific gravity of the urine
■ (which is a measure of the density of urine compared with the density of water)
■ and check the urine for abnormal constituents such as protein, blood, glucose, ketone
bodies, and bacteria
Urine specimen collection (1)
●
●
●
Powerpoint
○ Routine urinalysis: collect into appropriate container with pts name, date and time, package it
appropriately, send to lab, 10 mL of urine
○ Clean-catch or midstream specimens: pt voids and discards a small amount of urine then
continues voiding in a sterile specimen container, stops and removes container and continues
to void.
■ Culture and sensitivity test is positive if it shows at least 100,000 organisms per
milliliter of urine. The presence of bacteria with symptoms of dysuria, urinary
frequency or urgency, cloudy urine with a foul odor indicates a UTI, red blood cells
and nitrates may also be present, need 3 mL for collection
■
○ Sterile specimens from indwelling catheter: when collecting a urine specimen form an
indwelling catheter the specimen should be obtained from the catheter itself using the special
port for specimens. A specimen should not be collected from the drainage bag because it can
result in an inaccurate analysis. Use sterile technique
○ Urine specimen from a urinary diversion: catheterize the stoma, insert urinary catheter no
more than 2-3 inches
○ 24-hour urine specimen: have the pt empty their bladder, discard this urine and then collect all
urine voided for the next 24 hours. Keep urine on ice. Post signs on the pts bathroom
indicating a 24 hour urine is in progress with date and time.
○ Specimens from infants and children: plastic disposable collection bags are available for
collecting urine specimens from infants and young children who have not achieved voluntary
bladder control
○ Point-or-care urine testing: used to detect glucose, protein, bilirubin, bacteria, and blood. It’s
a diagnostic kit with a plastic strip that changes color once it touches the urine.
Routine Urinalysis
○ A sterile urine specimen is not required for a routine urinalysis.
○ Collect urine by having the patient void into a clean bedpan, urinal, or receptacle (e.g., a
specimen hat in the toilet bowl).
○ Take care to avoid contamination with feces.
■ If a woman is menstruating when a urine sample is obtained, note this on the
laboratory slip because red blood cells may appear in the urine.
■ When patients are voiding into a bedpan or collection device on the toilet, instruct
them not to place toilet tissue into the urine.
○ Using aseptic technique, pour the urine into an appropriate container; label it with the
patient’s name, date, and time of collection; package it appropriately; and send it to the
laboratory for examination.
■ Do not leave urine standing at room temperature for a long period before sending it
to the laboratory; if the specimen is not processed or refrigerated within 1 hour of
collection, changes in the appearance and composition of the urine may occur
(Fischbach & Dunning, 2015).
Clean-Catch or Midstream Specimen
○ A clean-catch specimen of urine is required in some situations.
○ Most health care facilities specify that a clean-catch specimen be collected during midstream.
○
○
○
○
○
This means that the patient voids and discards a small amount of urine; continues voiding in
a sterile specimen container to collect the urine; stops voiding into container; removes
container and continues voiding; then discards the last amount of urine in the bladder.
The first small amount of urine voided helps to flush away any organisms near the meatus
because the findings may be inaccurate if these organisms enter the specimen.
In addition, it is generally thought that urine voided at midstream is most characteristic of the
urine the body is producing.
A patient who can carry out the technique properly may collect their own clean-catch
midstream urine specimen and often prefers to do so
The nurse provides the appropriate equipment and instructions for the procedure
●
Sterile Specimen
○ Sterile urine specimens may be obtained by catheterizing the patient’s bladder or by taking
the specimen from an indwelling catheter already in place. (Refer to the Catheterizing the
Patient’s Bladder discussion and Skills 37-5 [on pages 1391–1398] and 37-6 [on pages 1398–
1405].)
○ When it is necessary to collect a urine specimen from a patient with an indwelling catheter,
the specimen should be obtained from the catheter itself using the special port for specimens.
○ A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could
result in an inaccurate analysis.
○ Always observe sterile technique while collecting a urine specimen from an indwelling
catheter.
○ Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container,
nonsterile gloves, and possibly a clamp.
○ The size of the syringe for the specimen depends on the specific laboratory test. A urine
culture requires about 3 mL, whereas routine urinalysis requires at least 10 mL of urine.
○ Also, check the catheter to determine if an access port for specimen removal is present.
Wearing gloves protects the nurse from any contact with the specimen.
○ If urine is not present in the tube, clamp the tube below the access port briefly (not to exceed
30 minutes) to allow urine to accumulate
○ . Clean the access port with an antiseptic swab, and carefully attach the syringe to the port
(Fig. 37-7). Aspirate urine into the syringe, remove the syringe, release the clamp if one was
used, and transfer the specimen to the appropriate container. Label the specimen with the
patient’s name, date, and time of collection; then package and transport the specimen
according to facility policy.
●
Urine Specimens from a Urinary Diversion
○ Urine specimens can be obtained from urinary diversions.
○ Clean urine specimens can be obtained from a urinary diversion appliance into a clean
container for a routine urinalysis (Williams, 2012).
○ Specimens for culture should never be obtained directly from the urostomy appliance
(Mahoney et al., 2013).
○ If a urine sample is needed for culture and sensitivity, it can be obtained by two methods.
○ The preferred method is to catheterize the stoma. Remove the stoma appliance and clean the
stoma site with solution, based on facility policy (Mahoney et al., 2013).
○ Using sterile technique, insert the urinary catheter no more than 2 to 3 in into the stoma site.
○ If there is resistance, rotate the catheter gently until it slides forward. If there is continued
resistance, do not force the catheter any further (Mahoney et al., 2013; Williams, 2012).
○ After collection of a sufficient amount of urine, remove the catheter and reapply the stoma
appliance.
○ If a urinary catheter is not available, a specimen may still be obtained (Mahoney et al., 2013).
○ Remove the stoma appliance and clean the stoma site with solution, based on facility policy
(Mahoney et al., 2013).
○
○
●
Discard the first few drops of urine by allowing urine to drip onto sterile gauze (Mahoney et
al., 2013).
Hold a sterile specimen cup under the stoma to collect urine. After collection of a sufficient
amount of urine, reapply the stoma appliance.
24-Hour Urine Specimens
○
○
○
○
○
○
○
○
○
○
For some laboratory studies, 24-hour specimen collection is required.
The patient and the entire nursing team must understand the importance of collecting all the
urine voided in a 24-hour period.
Post a sign on the patient’s bathroom door as a helpful reminder not to discard urine.
Initiate a collection at a specific time (which is recorded) by asking the patient to empty the
bladder.
Discard this urine and then collect all urine voided for the next 24 hours.
At the end of the 24 hours, ask the patient to void. Add this urine to the previously collected
urine, and then send the entire specimen to the laboratory.
Depending on the type of examination, the urine from each voiding may be kept in a
separately marked container and the time of each voiding recorded, or all urine voided may be
collected in a common receptacle.
The laboratory usually specifies whether a preservative is used to retard decomposition and
whether the specimen is to be refrigerated or kept on ice.
In some situations, the patient may be required to collect the specimen at home.
It is very important for the patient and the patient’s caregivers to understand the specific
collection, storage, timing, and transportation instructions for the prescribed test.
●
Specimens from Infants and Children
○ Plastic disposable collection bags are available for collecting urine specimens from infants
and young children who have not achieved voluntary bladder control (Fig. 37-8 on page
1354).
Types of Urinary Incontinence (1)
Pg 1361
Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by treatable factors,
such as confusion secondary to acute illness, infection, and as a result of medical treatment, such as the use of
diuretics or intravenous fluid administration.
Stress incontinence (discussed earlier in the chapter) occurs when there is an involuntary loss of urine related
to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or
other physical activities. Childbirth, menopause, obesity, or straining from chronic constipation can also result
in urine loss. The leakage usually does not occur when the person is supine.
Urge incontinence is the involuntary loss of urine that occurs soon after feeling an urgent need to void
(urgency). These patients experience a loss of urine before getting to the toilet and an inability to suppress the
need to urinate.
A diagnosis of mixed incontinence indicates that there is urine loss with features of two or more types of
incontinence.
Overflow incontinence, or chronic retention of urine, is the involuntary loss of urine associated with
overdistention and overflow of the bladder. The signal to empty the bladder may be underactive or absent, the
bladder fills, and dribbling occurs. It may be due to a secondary effect of some drugs, fecal impaction, or
neurologic conditions.
Functional incontinence is urine loss caused by the inability to reach the toilet because of environmental
barriers, physical limitations, loss of memory, or disorientation.
Patients with reflex incontinence experience emptying of the bladder without the sensation of the need to void.
Spinal cord injuries may lead to this type of incontinence.
Total incontinence is a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical
malformation. Urination cannot be controlled due to an anatomic abnormality.
●
The National Association for Continence (NAFC, 2015a) and the U.S. Department of Health and
Human Services (U.S. Department of Health and Human Services [USDHHS], 2012) identify
numerous types of urinary incontinence.
● Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by
treatable factors, such as confusion secondary to acute illness, infection, and as a result of
medical treatment, such as the use of diuretics or intravenous fluid administration.
● Stress incontinence (discussed earlier in the chapter) occurs when there is an involuntary loss of
urine related to an increase in intra-abdominal pressure. This commonly occurs during
coughing, sneezing, laughing, or other physical activities. Childbirth, menopause, obesity, or
straining from chronic constipation can also result in urine loss. The leakage usually does not
occur when the person is supine.
● Urge incontinence is the involuntary loss of urine that occurs soon after feeling an urgent need
to void (urgency). These patients experience a loss of urine before getting to the toilet and an
inability to suppress the need to urinate.
● A diagnosis of mixed incontinence indicates that there is urine loss with features of two or more
types of incontinence.
● Overflow incontinence, or chronic retention of urine, is the involuntary loss of urine associated
with overdistention and overflow of the bladder. The signal to empty the bladder may be
underactive or absent, the bladder fills, and dribbling occurs. It may be due to a secondary
effect of some drugs, fecal impaction, or neurologic conditions.
● Functional incontinence is urine loss caused by the inability to reach the toilet because of
environmental barriers, physical limitations, loss of memory, or disorientation.
● reflex incontinence experience emptying of the bladder without the sensation of the need to
void. Spinal cord injuries may lead to this type of incontinence.
● Total incontinence is a continuous and unpredictable loss of urine, resulting from surgery,
trauma, or physical malformation. Urination cannot be controlled due to an anatomic
abnormality.
● Urinary incontinence is treatable. Appropriate interventions can significantly reduce the
symptoms of urinary incontinence and even prevent its occurrence.
○ Transient: appears suddenly and lasts 6 months or less (infection)
○ Mixed: urine loss with features of two or more types of incontinence
○ Overflow: overdistention and overflow of bladder (drugs, fecal impaction, neurologic
conditions)
○ Functional: caused by factors outside the urinary tract or inability to reach the toilet
due to physical limitations
○ Reflex: emptying of the bladder without sensation of need to void (spinal cord injuries)
○ Total: continuous, unpredictable loss of urine (surgery, trauma, physical malformation)
○ Stress: involuntary loss of urine related to an increase in intra-abdominal pressure
(coughing, sneezing, laughing)
Box 37-4 Caring for a hemodialysis access (1)
CARING FOR A HEMODIALYSIS ACCESS
●
Perform hand hygiene and put on PPE, if indicated.
●
Identify the patient.
● Close the curtains around the bed and close the door to the room, if possible. Explain what you are going
to do, and why you are going to do it to the patient.
● Question the patient about the presence of muscle weakness and cramping, changes in temperature, and
abnormal sensations.
● Inspect the area over the access site for continuity of skin color, muscle strength, and the patient’s ability
to perform range of motion in the extremity/body part with the hemodialysis access.
Palpate over the access site, feeling for a thrill or vibration. Palpate pulses above and below the site.
Palpate the continuity of the skin temperature along and around the extremity. Check capillary refill.
Auscultate over the access site with bell of stethoscope, listening for a bruit or vibration.
Do not measure blood pressure, perform a venipuncture, or start an IV on the access arm.
●
●
●
●
Remove PPE, if used. Perform hand hygiene.
● Hemodialysis
○
○
○
○
○
involves a machine that does the work healthy kidneys normally perform by filtering harmful
wastes, electrolytes, and fluid from the blood that would normally be eliminated in the
patient’s urine (Fig. 37-20).
Patients receive a vascular access in order to receive hemodialysis.
This vascular access, an arteriovenous (AV) fistula (a surgically created connection between
an artery and a vein; Fig. 37-21A) or AV graft (a surgically created path between an artery
and a vein using a flexible, synthetic tube; Fig. 37-21B) allows for easy access to the
bloodstream.
A temporary or permanent double-lumen central venous catheter can also be used to provide
vascular access for hemodialysis (Robson, 2013).
These vascular accesses are the point at which blood is removed from the patient’s body for
dialysis and then returned (Mayo, 2013).
Chapter 38 Bowel Elimination
Process of peristalsis (1)
●
●
●
●
●
●
vPeristalsis is under control of the autonomic nervous system.
○ oParasympathetic nervous system stimulates movement (rest and digest), Sympathetic system
inhibits movement (fight or flight).
vContractions occur every 3 to 12 minutes.
vMass peristalsis sweeps occur one to four times each 24-hour period.
vOne-third to one-half of food waste is excreted in stool within 24 hours.
vBearing down to defecate increases pressure in the abdominal and thoracic cavities which decreases
blood flow to the heart and temporarily lowering cardiac output. Once bearing down is stopped the
blood is returned to the heart which can cause the heart rate to go down and pts have syncope termed
Valsalva maneuver and can be contraindicated in pts with cardiovascular problems.
○ Varies amount pt some pts will have a Bowel Movement two or three times a week others
two or three times a day
Peristalsis
○
○
○
○
○
○
○
○
Anatomic nervous system -> innervates muscle of the colon.
The parasympathetic nervous system stimulates movement, while the sympathetic
system inhibits movement.
Contractions of the circular and longitudinal muscles of the intestine
Mass peristaltic sweeps occur one to four times each 24-hour period in most people,
propelling the fecal mass forward.
■ This movement is different from the frequent peristaltic rushes that occur in the
small intestine.
Mass peristalsis often occurs after food has been ingested, accounting for the urge to defecate
that often occurs after meals.
■ Timing nursing interventions to evacuate bowel contents with this natural urge to
defecate is bmphelpful.
■ One third to one half of ingested food waste is normally excreted in the stool within
24 hours, and the remainder within the next 24 to 48 hours.
After passing through the sigmoid colon, the waste products enter the rectum, where they are
stopped from exiting by the anal sphincters
The internal sphincter in the anal canal and the external sphincter at the anus control the
discharge of feces and flatus (intestinal gas).
■ The internal sphincter consists of involuntary smooth muscle tissue that is innervated
by the autonomic nervous system.
■ Motor impulses are carried by the sympathetic system (thoracolumbar) and inhibitory
impulses by the parasympathetic system (craniosacral).
3 These two divisions of the autonomic nervous system function antagonistically in a
dynamic equilibrium.
■ The external sphincter at the anus has striated muscle tissue and is under voluntary
control.
■
○
○
○
○
○
The levator ani muscle reinforces the action of the external sphincter and is
controlled voluntarily.
Defecation refers to the emptying of the large intestine.
Two centers govern the reflex to defecate, one in the medulla and a subsidiary one in
the spinal cord.
■ When parasympathetic stimulation occurs, the internal anal sphincter relaxes
and the colon contracts, allowing the fecal mass to enter the rectum.
The rectum becomes distended by the fecal mass, the primary stimulus for the
defecation reflex.
■ Rectal distention leads to an increase in the intrarectal pressure, causing the
muscles to stretch and thereby stimulating the defecation reflex and
subsequently the urge to eliminate.
The external anal sphincter, which is under voluntary control, is constricted or
relaxed at will.
■ During the act of defecation, several additional muscles aid in the process.
Voluntary contraction of the muscles of the abdominal wall by holding one’s
breath, contracting the diaphragm, and closing the glottis increases intraabdominal pressure up to four or five times the normal pressure, which helps
expel feces.
■ Simultaneously, the muscles on the pelvic floor contract and aid in expulsion
of the fecal mass.
■ Defecation is eased by flexing the thigh muscles, which increases abdominal
pressure, and by the sitting position, which increases downward pressure on
the rectum.
■ If the urge to defecate is ignored, defecation often can be delayed voluntarily
by contracting the external anal sphincter and pelvic floor muscles.
When a person bears down to defecate, the increased pressures in the abdominal and
thoracic cavities result in decreased blood flow to the atria and ventricles, thus
temporarily lowering cardiac output. Once bearing down ceases, the pressure is
lessened, and a larger than normal amount of blood returns to the heart.
■ This act may cause the heart rate to slow and result in syncope in some
patients. Therefore, this technique of bearing down,
■ termed the Valsalva maneuver,-> may be contraindicated in people with
cardiovascular problems and other illnesses.
● The act of defecation is usually painless. If the bowels move at regular
intervals and the stools are formed and soft, functional problems
involving frequency of elimination seldom occur.
■ Many people become concerned if they do not have a daily bowel movement.
■ However, normal elimination patterns can vary widely among people.
● Although many adults pass one stool each day, other healthy people
have more frequent or less frequent bowel movements. Some people
have a bowel movement two or three times a week; others, two or
three times a day.
Variables influencing bowel elimination
●
Developmental considerations
○ Age affects what a person eats and the body’s ability to digest nutrients ad eliminate wastes.
● Developmental considerations: age
● Daily patterns: different times, positions and place, changes in patterns can lead to
constipation
● Food and fluid: high fiber diet promotes peristalsis
●
●
●
●
Activity and muscle tone: regular exercise improves GI mobility
Lifestyle: feelings that bowel is a “dirty” process or rituals
Psychological variables: anxiety causes diarrhea
Pathologic conditions: pt reports stool being ribbon-like a tumor may be obstructing
normal passage; bulky, greasy and foul smelling can mean cystic fibrosis.
● Medications: anticoagulants/aspirin GI bleeds (black stools)
● Diagnostic studies: colonoscopy and bowel cleansing
● Surgery and anesthesia: direct manipulation of bowel during abdominal surgery inhibits
peristalsis known as postoperative paralytic ileus.
○
○
○
○
●
Stools of an infant are markedly different from those of an older adult
Pt are often reluctant to discuss their bowel habits and stool characteristics
Nurses need to be familiar with bowel concerns pertinent to each developmental group
Infant
■ Stool characteristics depends on whether the infant is being fed brest milk or formula
● Breast milk is easier to for infants intestines to break down and absorb
● Breastfed babies -> more frequent stools
○ Stools are yellow to golden and loose, have a little odor.
○ Stool of formula fed infants vary from yellow to brown, paste like
consistency-> strong odor bc of decomposition of protein.
○ Stools of both breastfed and formula fed infants may have curds and
mucous.
● Infants have no control over their bowel elimination
○ Toddler -> ages of 18-24 months, the nerve fibers innervating the internal & external anal
sphincters become fully developed -> voluntary control of defecation becomes possible.
■ Voluntary defecation requires intact muscular, sensory, and nervous structures
■ Successful bowel training also include awareness by the toddler of the need to
defecate
● Ability to communicate this need, the wish to please the significant person
involved in bowel training, & praise and reinforcement for the toddlers
successful behavior.
● Daytime bowel control is normally attained by 30 months of age, but the age
varies with each child.
■ Helps parents to understand that physiologic maturity is the first priority for
successful bowel training.
■ Discourage use of punishment or shame for lack of readiness to become toilettrained or for elimination accidents.
■ Toddles that are toilet trained -> regress and experience soiling when hospitalized;
scolding or acting disgusted only reinforces this behavior
■ Constructive approach by seeking the underlying cause.
○ School aged child, adolescent, and adult
■ Emphasize that the use of over-the-counter laxatives and enemas can have
serious consequences and that any problems prompting such use need to be
evaluated.
● Irritable bowel syndrome (IBS), which is common in the adult
population, can present with constipation, diarrhea, or both. The
symptoms may be brought on by diet, stress, depression, or anxiety.
○ Older adults
■ Constipations is often a chronic problem for older adults.
■ Rectal receptors in adults have a decreased response to stretching -> decreased urge
to move the bowels despite a large amount of stool in the rectum.
● Diarrhea
● fecal impaction -prolonged retention or an accumulation of fecal material
that forms a hardened mass in the rectum
● Fecal incontinence - involuntary or inappropriate passing of stool or flatus
can result from physiologic or lifestyle changes
Daily patterns
■ Most people have individual patterns of bowel elimination involving
● Frequency
● Timing considerations
● Positions
● Place
■ Changes in any of these patterns may upset a persons routine and lead to constipation
●
■
■
●
Ppl defecate after breakfast, -> gastrocolic & duodenocolic reflexes cause
mass propulsive movement of the large intestine.
● If urge to defecate is ignored because the person finds the time or place
inconvenient, feces remain in the rectum until the defecation reflex is
initiated again.
● Water continues to be absorbed from the unexpelled feces, which makes the
stool dry, hard, and painful to pass.
When people defecate, most people assume the squatting or slightly forward-sitting
position with the thighs flexed.
● In either position, increased pressure is placed on the abdomen, as well as
downward pressure on the rectum; both facilitate defecation
Obtaining the same results when seated on a bedpan is difficult.
Embarrassment may further inhibit defecation. In addition, for
most people, defecation is a private affair experienced easily only
in the comfort of one’s own bathroom. Defecation may be difficult
in a shared hospital room with only a curtain for privacy.
Food and Fluid
○ Both the type and the amount of foods eaten and the amount of fluids ingested affect
elimination.
○ A high-fiber diet of 25 to 30 g of fiber and a daily fluid intake of 2,000 to 3,000 mL
facilitate bowel elimination.
■ High-fiber foods, such as whole grains and bran, dried peas and beans, and fresh
fruits and vegetables, increase the bulk in fecal material.
■ Bulkier feces increase the pressure on the intestinal wall, which serves as a stimulus
for peristalsis
■ As a result, feces move more quickly through the colon, allowing less time for water
to be reabsorbed.
■ Subsequently, the stool is soft and easy to pass. When the stool moves quickly
through the colon there is also less time for toxins to be absorbed from feces by the
colon
■ Many believe that these toxins play an important role in promoting the development
of colon cancer.
● Therefore, preventing their absorption by the colon is a key part of colon
cancer prevention.
○ People digest and tolerate foods differently.
■ This variation is determined in part by one’s culture.
● For example, travelers to a foreign country who eat native foods or drink the
water may suffer severe indigestion and elimination problems, such as
diarrhea.
○ Food intolerance may alter bowel elimination possibly resulting in
■ Diarrhea
■ Gaseous
■ Distention
■ and cramping
● For example, people who lack the enzyme lactase, which helps to break
down the simple sugar lactose found in milk and milk products, cannot
digest milk; this is called lactose intolerance.
○ These people often experience excessive intestinal gas and diarrhea when they ingest milk, as
the small intestine pulls fluid into the bowel through osmosis to assist in moving the dairy
product out of the body.
○ Certain foods have been associated with specific effects on bowel elimination. These include:
■ Constipating foods: processed cheese, lean meat, eggs, pasta, rice, white bread,
iron and calcium supplements (Day, Wills, & Coffey, 2014)
■ Foods with laxative effect: certain fruits and vegetables (e.g., prunes), bran,
chocolate, spicy foods( taco bell) , alcohol, coffee
●
●
●
●
■ Gas-producing foods: onions, cabbage, beans, cauliflower
Activity and muscle tone
○ Regular exercise improves gastrointestinal motility and muscle tone, whereas inactivity
decreases both.
○ Adequate tone in the abdominal muscles, diaphragm, & perineal muscles
■ Essential for ease of defecation.
■ Pt on prolonged bedrest or those with decreased mobility are prime candidates for
constipation
Lifestyle
○ Individuals, family, & sociocultural variables influence a persons usual elimination habits
○ Long term effects of bowel training may result in a persons
■ Acceptance of bowel elimination as a normal life process
■ Preoccupation with bowel elimination
■ Feeling that bowel elimination is a “dirty” process.
○ Rituals associated with bowel elimination, cleanliness considerations, the language used to
talk about bowel elimination or reluctance to discuss it
■ Individual responses to involuntary passage of flatus (gas), and so onnn, vary widely
among people
○ Persons daily schedule, occupation, leisure activities may contribute to a habit of defecating
at regular times or an irregular pattern.
Psychological Variable
○ Psychological stress affects the body in many ways
○ People, anxiety seems to have a direct effect on gastrointestinal motility, and diarrhea
accompanies periods of high anxiety.
○ Fight or flight response, when the body mobilizes itself for intense action, blood is shunted
away from the stomach and intestines, resulting in a slowing of gastrointestinal motility
○ People who chronically worry and those with certain personality types who tend to hold onto
problems & negative feelings may experience frequent constipation.
Pathologic Conditions
○ Numerous pathologic processes may change a persons usual bowel elimination habits.
○ Changes in stool characteristics or frequency may be one of the first clinical manifestations of
a disease
■ Evaluation may lead to diagnosis of disease
■ Similarly, a parents report that a child's stool are frequent, bulky, greasy, and foul
smelling suggests cystic fibrosis.
■ Requires further evaluation and consultation with a health care provider, especially if
other clinical manifestations are present.
○ Medications may also influence the appearance of the stool for a variety of reasons
■ Any drug with the potential to cause GI bleeding ( anticoagulants, asprinn, products)
may cause the stool to appear pink to red to black.
■ Iron salts results in a black stool from the oxidation or iron.
■ Bismuth subsalicylate used to treat diarrhea can also cause black stools
■ Antacids may cause a while discoloration or speckling in the stool.
■ Antibiotics may cause green-grey color related to impaired digestion.
○ Diarrhea and constipation are also common signs of potential disease processes.
■ Diarrhea or constipation may result from pathologic conditions such as diverticulitis
(inflammation and/or infection of a diverticulum, a small, bulging pouch in the
colon).
■ Diarrhea may result from bacterial and viral infection, malabsorption syndromes (the
inability of the digestive system to absorb one or more of the major vitamins,
minerals, or nutrients), neoplastic diseases (tumors), diabetic neuropathy (damage to
nerve cells), hyperthyroidism, and uremia (retention of urea in the blood).
○ Outbreaks of food poisoning can result in severe gastrointestinal symptoms, including
diarrhea.
■ For example, infections caused by certain types of Escherichia coli, particularly
dangerous for young children (under 10 years of age) and older adults, can progress
●
quickly to life-threatening hematologic and renal complications (Grossman & Porth,
2014).
■ Severe abdominal cramping followed by watery or bloody diarrhea may signal a
microbial infection, which can be confirmed by a stool sample.
■ Supportive treatment, careful monitoring, and attentive nursing care are essential.
○ Constipation may be the result of conditions such as diseases within the colon or rectum and
injury to, or degeneration of, the spinal cord and megacolon (extremely dilated colon).
■ Changes in color, contents, odor, and appearance of stool may be related to
conditions that traumatize the stomach or intestines, or that interfere with normal
digestion.
■ Thus, stool assessment is an important diagnostic task for the nurse.
○ Intestinal obstruction occurs when blockage prevents the normal flow of intestinal contents
through the intestinal tract
■ Mechanical obstructions result from pressure on the intestinal walls.
■ Common causes of mechanical obstruction are tumors of the colon or rectum,
diverticulum, adhesions from scar tissue, stenosis, strictures, and hernia and volvulus
(twisting of a part of the colon).
■ Nonmechanical obstructions result from an inability of the intestinal musculature to
move the contents through the bowel.
● Examples of causes of nonmechanical obstruction include diseases that
weaken or paralyze the intestinal walls such as muscular dystrophy, diabetes
mellitus, and Parkinson’s disease.
● Manipulation of the bowel during surgery may also result in paralytic ileus.
The effects of surgery are further detailed later in the chapter.
Medications
○ Medication are available that can promote peristalsis ( laxatives) or inhibit peristalsis
(antidiarrheal medications)
○ Opioids-> common cause of medication - induced constipation and can result in significant
distress for the patient.
○ Enteric neurons control major body function such as bowel control.
■ Opioids- binding receptors are found in the enteric neurons in the gastrointestinal
tract.
■ The binding of the opioids to these receptor sites interrupts peristalsis, causing
slowed movement of stool through the colon, resulting in increased reabsorption of
fluid in the large intestine.
■ Antacids containing aluminum,iron sulfate, and anticholinergic medications
● Decrease gastrointestinal motility, w/ the potential to also cause constipation
○ Many medications can cause diarrhea as a side effect.
■ For example, diarrhea is a potential adverse effect of treatment with
antibiotics such as amoxicillin clavulanate.
■ In this situation, using antidiarrheal drugs is not recommended because its
use would prolong the exposure of the intestinal mucosa to the irritating
effect of the antibiotic.
■ Medications with magnesium, such as over-the-counter antacids, can also
cause diarrhea.
● Metformin, a common medication used to treat type 2 diabetes
mellitus, can cause diarrhea.
● The resulting diarrhea can often become bothersome or severe
enough with these and other medications that the drugs may need to
be discontinued.
○ Because antibiotics are used so extensively in the health care setting, many patients
are at risk for infection with Clostridium difficile,
■ a health care–acquired infection (HAI)
■ When a patient is receiving treatment with broad-spectrum antibiotics, there
is a disruption in the normal intestinal flora, allowing the microorganism to
flourish within the intestine.
C. difficile causes intestinal mucosal damage and inflammation, resulting in
diarrhea and abdominal cramping.
■ C. difficile spores are shed in feces and are relatively resistant to
disinfectants.
■ These microorganisms can be spread on the hands of health care providers
after contact with equipment or surfaces contaminated with the
microorganism
■ It is important to institute contact precautions for infected patients.
■ Consider environmental surfaces and items close to the patient, such as the
side rails and overbed table, to be contaminated. Intensified environmental
cleaning is required
Diagnostic studies
○ Diagnostic studies may affect a patient’s usual bowel elimination pattern.
■ For example, patients may need to fast for diagnostic studies.
○ The ingestion of barium during diagnostic procedures, such as a barium enema,
■ may result in constipation or impaction if it is not completely eliminated after
the procedure.
■ In addition, the stress of hospitalization and waiting for the results of studies,
combined with changes in food intake, can severely alter a patient’s usual
elimination patterns.
○ The bowel preparation used for bowel cleansing before certain diagnostic studies of
the gastrointestinal tract can interfere with the normal timing of a patient’s bowel
movements.
Surgery and Anesthesia
○ Direct manipulation of the bowel during abdominal surgery inhibits peristalsis,
causing a condition termed postoperative paralytic ileus
■ This temporary stoppage of peristalsis normally lasts 3 to 5 days. During this
time, food and oral fluids are usually withheld.
■ Many times, the patient is receiving opioids for pain relief, which can
exacerbate the situation.
○ If this condition persists, distention and symptoms of acute obstruction
may occur, possibly resulting in the need for surgical intervention.
■ Inhaled general anesthetic agents also inhibit peristalsis by
blocking the parasympathetic impulses to the intestinal
musculature.
■ However, local and regional anesthetics have little effect on peristalsi
■
●
●
Effect of medications on stool (1)
● Medications may also influence the appearance of the stool for a variety of reasons.
● Any drug with the potential to cause gastrointestinal bleeding (e.g., anticoagulants, aspirin
products) may cause the stool to appear pink to red to black.
● Iron salts result in a black stool from the oxidation of iron.
● Bismuth subsalicylate used to treat diarrhea can also cause black stools.
● Antacids may cause a white discoloration or speckling in the stool.
● Antibiotics may cause a green-gray color related to impaired digestion.
○
○
○
Medication are available that can promote peristalsis ( laxatives) or inhibit peristalsis
(antidiarrheal medications)
Opioids-> common cause of medication - induced constipation and can result in significant
distress for the patient.
Enteric neurons control major body function such as bowel control.
■ Opioids- binding receptors are found in the enteric neurons in the gastrointestinal
tract.
■
●
●
●
●
●
●
●
●
●
●
The binding of the opioids to these receptor sites interrupts peristalsis, causing
slowed movement of stool through the colon, resulting in increased reabsorption of
fluid in the large intestine.
■ Antacids containing aluminum,iron sulfate, and anticholinergic medications
● Decrease gastrointestinal motility, w/ the potential to also cause constipation
○ Many medications can cause diarrhea as a side effect.
■ For example, diarrhea is a potential adverse effect of treatment with
antibiotics such as amoxicillin clavulanate.
■ In this situation, using antidiarrheal drugs is not recommended because its
use would prolong the exposure of the intestinal mucosa to the irritating
effect of the antibiotic.
■ Medications with magnesium, such as over-the-counter antacids, can also
cause diarrhea.
● Metformin, a common medication used to treat type 2 diabetes
mellitus, can cause diarrhea.
● The resulting diarrhea can often become bothersome or severe
enough with these and other medications that the drugs may need to
be discontinued.
○ Because antibiotics are used so extensively in the health care setting, many patients
are at risk for infection with Clostridium difficile,
■ a health care–acquired infection (HAI)
■ When a patient is receiving treatment with broad-spectrum antibiotics, there
is a disruption in the normal intestinal flora, allowing the microorganism to
flourish within the intestine.
■ C. difficile causes intestinal mucosal damage and inflammation, resulting in
diarrhea and abdominal cramping.
■ C. difficile spores are shed in feces and are relatively resistant to
disinfectants.
■ These microorganisms can be spread on the hands of health care providers
after contact with equipment or surfaces contaminated with the
microorganism
■ It is important to institute contact precautions for infected patients.
■ Consider environmental surfaces and items close to the patient, such as the
side rails and overbed table, to be contaminated. Intensified environmental
cleaning is required.
***Aspirin, anticoagulants: pink to red to black stool
Iron salts: black stool
Bismuth subsalicylate (pepto-bismol) used to treat diarrhea can also cause black stools.
Antacids: white discoloration or speckling in stool
Antibiotics: green-gray color
Opioids are a common cause of medication induced constipation
Antacids containing aluminum, iron sulfate, and anticholinergic medications can cause
constipation.
Amoxicillin clavulanate (antibiotics) adverse effect is diarrhea. Many pts are at risk for
Clostridium difficile a HAI due to broad-spectrum antibiotic use.
Inhaled general anesthetic agents also inhibit peristalsis
Local and regional anesthetics have little effect on peristalsis ***
Physical assessment of the abdomen (1)
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●
vThe sequence for abdominal assessment proceeds from inspection, auscultation, and percussion to
palpation.
oInspection and auscultation are performed before palpation because palpation may disturb normal
peristalsis and bowel mobility
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vInspection: observe contour for the presence of distention (inflation) or protrusion (projection),
noting any masses, scars, or areas of distention
vAuscultation: listen for bowel sounds in all 4 quadrants using clockwise approach with the
diaphragm of a stethoscope
oNote frequency and character, audible clicks, and flatus. High-pitched, gurgling, and soft sounds (530 sounds/min)
oDescribe bowel sounds as audible, hypoactive, hyperactive, absent or infrequent.
vPercussion and palpations: performed by advanced practice professionals, palpate the area of pain
last..
Abdomen
○ sequence for abdominal assessment proceeds from inspection, auscultation, and percussion to
palpation
○ Inspection auscultation are performed before palpation because palpation because palpation
may disturb normal peristalsis and bowel motility.
○ Advanced health care providers usually perform percussion & deep palpation of the abdomen,
as this is an advanced assessment skill.
○ Place the pt comfortably in supine position with the abdomen exposed, chest and pubic area
draped, and the knees slightly flexed.
○ Encourage the pt to urinate prior to the examination so that the bladder is empty.
Inspection
○ Observe the contour of the abdomen,nothing any masses, scars, or areas of distention.
○ Peristalsis is usually not visible except in very thin patients.
○ When an intestinal obstruction is present, the visible waves of peristalsis to the point of the
obstruction may be observed on the abdomen
○ Observe the contour of the abdomen
○ Significant findings may include the presence of distention ( inflation) or protrusion
(projection)
Auscultation
○ Using the diaphragm of a warmed stethoscope, listen for bowel sounds in all abdominal
quadrants, using a systemic, clockwise approach.
○ If the patient has a nasogastric (NG) tube in place, disconnect it from suction during this
assessment to allow for accurate interpretation of sounds.
■ Keep in mind that the timing of the patient’s most recent meal or a full bladder may
also affect the examination.
■ Note the frequency and character of bowel sounds, intermittent audible clicks and
gurgles produced by the movement of air and flatus in the gastrointestinal tract.
■ They are usually high-pitched, gurgling, and soft, indicating bowel motility and
peristalsis.
○ Their frequency may range from 5 to 30 bowel sounds per minute, depending on the rate of
peristalsis
○ Significant findings include:
■ hypoactive bowel sounds
● a diminished rate of sounds
■ hyperactive bowel sounds
● intense with increased frequency
■ Inaudible
● absent or infrequent bowel sounds.
■ Hypoactive bowel sounds indicate diminished bowel motility, commonly caused
by abdominal surgery or late bowel obstruction.
■ Hyperactive bowel sounds indicate increased bowel motility, commonly caused by
diarrhea, gastroenteritis, or early/partial bowel obstruction.
■ Decreased or absent bowel sounds, evidenced only after listening for 2 minutes
or longer, signify the absence of bowel motility, commonly associated with
peritonitis, paralytic ileus, and/or prolonged mobility
●
○ Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible.
Palpation
○ Perform light palpation in each quadrant.
○ Use warm hands and bend the patient’s knees if possible
○ Watch the patient’s face for nonverbal signs of pain during palpation
○ Palpate each quadrant in a systematic manner, noting muscular resistance, tenderness,
enlargement of the organs, or masses.
○ If the patient complains of abdominal pain, palpate the area of pain last. If the patient’s
abdomen is distended, note the presence of firmness or tautness.
Types of direct visualization studies and diets (1)
Esophagogastroduodenoscopy (EGD): visual exam of the esophagus, the stomach,
and the duodenum
NO red dye foods
Fasting: 6-12 hours before exam
Colonoscopy: visual exam of the large intestine from the anus to the ileocecal
valve
Oral prep involved, clear liquid diet, no red dye foods
NPO: 6-8 hours before exam
Sedated before exam
Sigmoidoscopy: visual exam of the sigmoid colon, rectum, and anal canal
Enema
Wireless capsule endoscopy: is minimally invasive, pt swallows a capsule about
the size of a vitamin, which contains a small camera that emits a radio signal.
Takes 2 pictures per second for a total of 55,000 images in 8 hours. NPO 10-12
hours prior and 2 hours after.
Scheduling diagnostic testing (1)
Follow a logical sequence when more than one test is required for accurate
diagnosis.
v1: fecal occult blood test
v2: barium studies (should precede UGI)
v3: endoscopic examinations
**Noninvasive procedures take precedence over invasive procedures**
(least invasive to most invasive. Except in emergency situations)
Nasogastric tubes (1)
Pg 1444--The NG tube is passed through the nasopharynx into the stomach.
***Oral hygiene needs to be performed as often as every 2-4 hours to prevent
drying of tissues and to relieve thirst
An NG tube is a pliable single- or double-lumen (inner open space) tube that is
hollow, allowing for the removal of gastric secretions and installation of solutions
such as medications or feedings into the stomach.
-nutritional support
-NG tubes may be inserted to decompress or drain the stomach of fluid or
unwanted stomach contents such as poison or medication and air, and when
conditions are present in which peristalsis is absent.
-Tubes for decompression typically are attached to suction. Suction can be applied
intermittently or continuously. When the underlying condition has been resolved
and/or the NG tube is no longer indicated, the tube is removed.
--Decompression should be reserved for patients with conditions such as a
prolonged postoperative ileus or a small bowel obstruction
--Can be connected to suction intermittently or continuously
Decompression: irrigation with 30-60 mL of NS Q4H-Q8H to maintain patency
Used to allow the gastrointestinal tract to rest before or after abdominal surgery to
promote healing
Inserted to monitor gastrointestinal bleeding
Ex: paralytic ileus, obstruction by tumor or hernia.
Placement needs to be verified via X-ray it is the most
accurate method
A misplaced feeling tube in the lungs or pulmonary tissue
places the patient at risk for aspiration.
Types of ostomies (1)
Ostomy: a term for surgically formed opening from the inside
of an organ to the outside.
Sigmoid colostomyDescending colostomy
Transverse colostomy
Ascending colostomy-
Ileostomy: area between the ileum of the small intestine to be
eliminated through the stoma. Liquid
Colostomy: Formed feces in the colon to exit the stoma. (the opening of the
ostomy attached to the skin).
--Can be temporary or permanent. Temporary allow the intestine to repair itself
after inflammatory disease or injury. Permanent can be due to cancer
Colostomy care (1)
Pg 1447-patient with an ostomy needs physical and psychological support both
preoperatively and postoperatively.
Support can come from the patient’s significant others, members of the
health care team, and from people who have had similar experiences.
Help the patient cope by listening, explaining, and being available and
supportive. A visit from a representative of the local ostomy support group
may be helpful. Patients usually begin to accept their altered body image
when they are willing to look at the stoma, make neutral or positive
statements concerning the ostomy, and express interest in learning self-care
-Keep the patient as free of odors as possible; empty the appliance frequently.
Candida or yeast infections can also occur around the stoma if the area is not
kept dry.
-Inspect the patient’s stoma regularly.
-Note the size, which should stabilize within 6 to 8 weeks.
-It should be dark pink to red and moist
-A pale stoma may indicate anemia, a dark/purple may indicate ischemia.
-Keep the skin around the stoma site clean and dry.
-Measure the patient’s fluid intake and output.
Check the ostomy appliance for the quality and quantity of discharge.
Initially after surgery, peristalsis may be inhibited. As peristalsis returns, stool will
be eliminated from the stoma.
**Record intake and output every 4 hours for the first 3 days after surgery. If the
patient’s output decreases while intake remains stable, report the condition
promptly.
-Explain each aspect of care to the patient and self-care role.
Patient teaching is one of the most important aspects of colostomy care and
should include family members and/or people identified by the patient to include in
care, when appropriate. Teaching can begin before surgery so that the patient has
adequate time to absorb information.
-Encourage patients to care for and look at ostomy.
Patients normally experience emotional depression during the early
postoperative period. Help the patient cope by listening, explaining, and being
available and supportive.
Chapter 14 Assessing
Five types of nursing assessments (2)
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Comprehensive initial: occurs once the pt is admitted to a health care facility. There are policies in
place specifying the time interval which this assessment must be completed. The purpose of this
assessment is to establish a complete database for problem identification and care planning.
Focused: nurse gathers data about a specific problem that has been identified. What are your S/S?
When did they start? What makes s/s better? Worse? Focus is on the problem.
Emergency: pt presents with physiologic or psychological crisis. Life threatening problem. Ex. stab
wounds, unresponsive pt.
Time-lapsed: compare pts current status to the baseline data obtained earlier.
Assessment of communities and special populations
Initial assessment
○ Performed shortly after the pt is admitted to a health care facility or service
○ Purpose of this assessment is to establish a complete database for problem identification and
care planning
○ Nurse collects data concerning all aspects of the pts health, establishing priorities for ongoing
focus assessments and creating a reference baseline for future comparison.
Focus assessment
○ Nurses gathers data about a specific problems that has already been identified
■ What are your signs/symptoms
■ When did they start
●
●
■ Were you doing anything different than usual when they started
■ What makes your symptoms better?worse?
■ Are you taking any remedies ( medical/natural) for your symptoms
○ May be done during the initial assessment if the pts health problems surface-> routinely part
of ongoing data collection
○ Another purpose of the focused assessment is to identify new or overlooked problems.
○ Quick priority assessment are
■ Short
■ Focused
■ Prioritized assessments ( most important information you need to have first)
Emergency Assessment
○ When a patient presents with a physiologic or psychological crisis, ->the nurse performs an
emergency assessment
■ to identify life-threatening problems.
■ A long-term care facility resident who begins choking in the dining room, a bleeding
patient brought to the emergency department with a stab wound, an unresponsive
patient in the rehabilitation unit, and a factory worker threatening violence are all
candidates for an emergency assessment.
■ In the first example, the source of the choking is assessed;
■ in the second, the blood loss and wound characteristics;
■ in the third, airway, breathing, and circulation; and in the fourth, the potential for
immediate harm
■ ABC’s -> airway, breathing, circulation!!!
Time Lapsed
○ The time-lapsed assessment is scheduled to compare a patient’s current status to
the baseline data obtained earlier
○ Most patients in residential settings and those receiving nursing care over longer
periods of time, such as homebound patients with visiting nurses, are
scheduled for periodic time-lapsed assessments to reassess their health
status and to make necessary revisions in the care plan.
○ This assessment can be comprehensive or focused.
Objective Data vs. Subjective Data (2)
● Subjective data
○ are information perceived only by the affected person; these data cannot be
perceived or verified by another person.
○ Examples of subjective data are feeling nervous, nauseated, or chilly, and
●
●
●
experiencing pain. Subjective data also are called symptoms or covert data.
Objective data
○ Objective data are observable and measurable data that can be seen, heard, felt, or
measured by someone other than the person experiencing them.
○ Objective data observed by one person can be verified by another person observing
the same patient.
■ Examples of objective data are an elevated temperature reading (e.g., 101°F),
skin that is moist, and refusal to look at or eat food. Objective data also are
called signs or overt data. Table 14-2 compares subjective and objective data.
○ Paying attention to both subjective and objective data promotes clinical reasoning
because often the two types of data complement and clarify one another.
Objective data
○ Observable and measurable data that can be seen, heard, or felt by someone other than the
person experiencing them
○ For example, elevated temperature, skin moisture, vomiting
Subjective data
○ Information perceived only by the affected person
○
For example, pain experience, feeling dizzy, feeling anxious
TABLE 14-2 Comparison of Objective and Subjective Data
OBJECTIVE DATA
SUBJECTIVE DATA
32-year-old man
“I’m beginning to feel better about myself now that I’m
losing weight and I seem to have more energy.”
Height: 5′8″
Weight:
9/18/19—224 lb
2/4/20—202 lb
Posterior, left midcalf is
warm and red.
“My leg hurts when I walk.”
Patient observed fidgeting
with bed covers; facial
features are tightly drawn.
“I’m so afraid of what they might find when they cut me
open tomorrow.”
Characteristics of Data (1)
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●
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Purposeful
Prioritized
Complete
Systematic
Factual and accurate
Relevant
Purposeful. ->When preparing for data collection, identify the purpose of the nursing assessment
(comprehensive, focused, emergency, time-lapsed) and then gather the appropriate data. The
circumstances of the patient’s situation may also dictate the nature and amount of data you collect.
Prioritized-> It is essential to get the most important information first.
Complete-> As much as possible, identify all the patient data needed to understand a patient health
problem and develop a care plan to maximize the patient’s health and well-being.
○ For example, knowing that a patient has lost weight is not fully meaningful until you discover
■ (1) if the weight loss was intentional or unintentional
■ (2) if it was related to a change in eating or exercise patterns or to some underlying
pathologic condition
■ (3) how the patient views and is responding to the weight loss.
Systematic ->Using a systematic way to gather data, you will always know if you’ve missed
something important.
Factual and accurate->Both you and the patient, as well as family members and other caregivers,
may intentionally or unintentionally misrepresent or distort patient information.
○ For example, a patient who values being thin may describe a weight gain of several pounds as
the onset of obesity. If you are concerned with accuracy and factual reality, you will
continually verify what you hear with what you observe, using other senses and validating all
questionable data.
○ At the outset of data collection, it is crucial that you determine whether the patient or
●
●
caregiver who is supplying the data is reliable.
○ If you suspect that your own personal bias or stereotyping may be influencing your data
collection, you should consult with another nurse.
○ You should also describe observed behavior rather than interpreting the behavior. For
example: “Patient frequently is observed lying with his face to the wall. Attempts to engage
him in conversation fail. He refused lunch today and ate only soup for dinner.” In contrast,
the statement “Patient is depressed” is an interpretation of the patient’s behavior, not a factual
statement. Recording the patient’s behaviors factually allows other health care professionals
to explore causes of the behavior with the patient.
Relevant -> Because recording comprehensive data can be very time consuming, one challenge facing
you as a nurse is to determine what types of and how much data to collect for each patient. As
described throughout this chapter, the aim is to record concisely all pertinent data. Often, only
experience will teach you what data are needed in specific cases.
Recorded in a standard manner ->Data cannot be efficiently used unless you record the information
according to the facility’s policy so that all caregivers can easily access what you learned.
Sources of Data (1)
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●
Patient: AAOx4 vs. Data from pts with limited mental or communication capacity, such as young
children and elders with dementia, cannot be relied on as accurate
Family and significant others
Patient record: review record prior to seeing pt
Medical history, physical examination, progress notes: written by physicians or nurse practitioners and
they focus on pathologic conditions and treatments
Consultations: note from GI, Ortho, Cardiologist
Reports of laboratory and other diagnostic studies: X-ray
Reports of therapies by other health care professionals: nutrition, physical therapy, speech therapy
Nursing and other health care literature: nursing journals to understand diseases
Patient -> primary and usually the best source of information.
○ Unless specified otherwise, the data recorded in the nursing history are assumed to have been
collected from the patient.
○ Most patients are willing to share information when they know it is helpful for planning their
care.
○ Although subjective data collected from the patient are usually accurate, you should be alert
for certain difficulties.
■ For example, a patient who is acutely ill may not be able to communicate adequately
if the pain is severe or if consciousness is altered.
■ An emotionally upset patient may distort information; for example, patients who are
fearful because they think their illness may threaten their work or life may deny
certain symptoms or deliberately give misleading facts.
■ If you become aware that a patient’s report of symptoms differs from physical
findings or data obtained from other sources, note this and explore the cause of the
discrepancy.
○ Data from patients with limited mental or communication capacity, such as young children
and older adults with dementia, cannot be relied on as accurate.
■ However, learn early to avoid the mistake of too quickly judging that a family
member is a better source of information than the patient.
■ Children and people with decreased mental capacity or impaired verbal ability
should be encouraged to respond to interview questions as best as they can.
■
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●
Automatically turning to a family member, friend, or caregiver for information
communicates powerfully that you either have no time for the patient to express his
or her needs or mistakenly doubt the patient’s ability to communicate these needs.
Family and significant others
○ Family members, friends, and caregivers are especially helpful sources of data when the
patient is a child or has limited capacity to share information with the nurse.
○ Partners can supply information concerning their spouses.
○ Friends often accompany a patient to a health facility and can supply useful information.
Take care to determine that the patient does not object to you gathering data from family and
friends, and also that family and friends want to participate
■ Also, everyone involved should clearly understand the confidentiality of this data.
Whenever data are gathered from support people, indicate this in the nursing history.
Patient record
○ this review helps to focus the nursing assessment and to confirm and amplify information
obtained from other sources.
○ You should review records early when gathering data—in some instances, before the first
contact with the patient.
○ The patient’s health record or chart, which lists such information as age, sex, occupation,
religious preference, next of kin, and financial status, is one type of record. The health record
includes information entered by various health care professionals such as physicians, social
workers, dietitians, physiotherapists, and laboratory technicians.
■ Consists of
● Medical history, physical examination, & progress notes
● Consultation
● Reports lab and other diagnostic studies
● Reports of therapies by other health care professionals.
Assessing therapy
○ Nurses can also gain valuable data about patients from technologies such as cardiac and
respiratory monitors.
■ For example, a patient’s bedside monitoring can provide round-the-clock information
on blood pressure, heart rate, respirations, and cardiac activity.
Other Health Care Professionals
○ Nurses can learn a great deal about a patient’s normal health habits and patterns and response
to illness by talking with other nurses, physicians, social workers, and others on the health
care team (Fig. 14-5).
○ Although such communication is always important, it is especially critical when patients are
transferred from home to an institution or from one hospital or institution to another.
○ The only way to ensure continuity of care is to make special efforts to share pertinent
information.
Nursing and Other Health Care Literature
○ To obtain a comprehensive patient database, it may be necessary to consult the nursing and
related literature on specific health problems.
■ For example, a nurse who has not cared for a patient with Paget’s disease before
should read about the clinical manifestations of the disease and its usual progression
to know what to look for when assessing the patient.
■ In addition to information about medical diagnoses, treatment, and prognosis, a
literature review offers nurses important information about nursing diagnoses,
developmental norms, and psychosocial and spiritual practices that is helpful when
assessing and caring for patients.
Four phases of a nursing Interview (1)
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vPreparatory phase: look over pts chart
vIntroduction: introduce yourself to pt, provide orientation to facility,
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vWorking phase: longest phase, nurse works together with pt to meet the pts physical and
psychosocial needs.
vTermination: conclusion, change of shift, pt is being discharged home.
Chapter 15 Diagnosing
Be familiar with formulating nursing diagnosis (5)
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vDescribes patient problems nurses can treat independently
In the presence of known problems, predict the most common and most dangerous
complications and take immediate action to (a) prevent them, and (b) manage them in case
they cannot be prevented.
Whether problems are present or not, look for evidence of risk factors (things that evidence
suggests contribute to health problems). If you identify risk factors, you aim to reduce or
control them, thereby preventing the problems themselves.
In all situations, ensure that safety and learning needs are met, and promote optimum
function and independence.
○ As nurses interpret and analyze patient data, they may identify health problems that
are better treated by physicians (medical diagnoses) or by nurses working with other
health care professionals (collaborative problems). In such a case, the nurse reports
the findings to the physician or other appropriate health care professionals and
works collaboratively with them to resolve the problem.
Problem-Focused Nursing Diagnoses
○ A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable
human response to a health condition/life process that exists in an individual, family, group,
or community. This type of nursing diagnosis has four components: label, definition, defining
characteristics, and related factor.
Risk Nursing Diagnoses
○ A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual,
family, group, or community for developing an undesirable human response to health
conditions/life processes.
Health Promotion Nursing Diagnoses
○ A health promotion nursing diagnosis is a clinical judgment concerning motivation and
desire to increase well-being and to actualize human health potential. These responses are
expressed by a readiness to enhance specific health behaviors, and can be used in any health
state. Health promotion responses may exist in an individual, family, group, or community.
○ NANDA-I also recognizes syndromes. A syndrome is a clinical judgment concerning a
specific cluster of nursing diagnoses that occur together and are best addressed together and
through similar interventions. Chronic pain syndrome is an example (2018, pp. 35–36).
● TABLE 15-3 Formulation of Nursing Diagnosis Statements
DEFINITION
PURPOSE
EXAMPLE
Problem
Etiology
Identifies what is
unhealthy about
the patient,
indicating the
need for change
(clear, concise
statement of the
patient’s health
problem)
Suggests the
patient outcomes
(expectations for
change)
Identifies the
factors that are
maintaining the
unhealthy state or
response
(contributing or
causative factors)
Suggests the
appropriate
nursing measures
Bathing self-care
deficit
↓
related to (R/T)
↓
Fear of falling in
the tub and
obesity
↓
as evidenced by
(AEB)
↓
Defining
characteristics
Identify the
subjective and
objective data that
signal the
existence of the
problem (cues that
reflect the
existence of a
problem)
Suggest evaluative
criteria
Strong body and
urine odor,
unclean hair: “I’m
afraid I’ll fall in
the tub and break
something.” (5 ft 4
in, 170 lb)
Examples:
Two-part diagnostic statement: Bathing self-care deficit R/T fear of falling in tub and
obesity
Three-part diagnostic statement: Bathing self-care deficit R/T fear of falling in tub and
obesity, AEB strong body and urine odor, unclean hair, statement of fearing fall in tub,
and height and weight: 5 ft 4 in, 170 lb
●
Problem
○ The purpose of the problem statement is to describe the health state or health problem of the
patient as clearly and concisely as possible.
○ Because this section of the nursing diagnosis identifies what is unhealthy about the patient
and what the patient would like to change in his or her health status, it suggests patient
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outcomes. NANDA-I recommends the use of quantifiers or descriptors to limit or specify the
meaning of a problem statement.
○ For example, the descriptor “anticipatory” placed before the concept “grieving” clarifies the
nursing diagnosis for a pregnant couple informed prenatally that their child will most likely
be stillborn and who are already grieving the death of their child. Some common descriptors
are listed in Table 15-4.
Etiology
The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors
believed to be related to the problem as either a cause or a contributing factor.
○ Because the etiology identifies the factors that maintain the unhealthy patient state and
prevent the desired change, the etiology directs nursing intervention.
○ Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective.
○ For example, a diabetic patient who is frequently admitted to the hospital with hyperglycemia
and who has a poor history of dietary and pharmacologic management is diagnosed to be
noncompliant.
Mistakenly assuming that the noncompliance is related to a knowledge deficit, the nurse channels all
nursing activities and energies into teaching the patient how to manage the diabetes.
○ However, this would be useless if the noncompliance were actually a result of the patient’s
decreased will to live, an etiology that would necessitate a different group of nursing
interventions.
Defining Characteristics
○ The subjective and objective data that signal the existence of the actual or possible health
problem are the third component of the nursing diagnosis.
○ NANDA-I has identified defining characteristics for each accepted nursing diagnosis;
familiarity with these characteristics helps nurses recognize clusters of significant data. It is
important to remember that the defining characteristics are part of assessment.
○ Although they are written last in the formal diagnosis, they are considered first. Table 15-3
defines the components of a nursing diagnosis statement and shows how they affect patient
outcomes, nursing measures, and evaluation.
○ Table 15-5 (on page 376) shows a NANDA-I diagnosis and all of its components. Other
examples of sample nursing diagnosis statements are found throughout the book.
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Purposes of the diagnosing step (1)
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vIdentify how an individual, group, or community responds to actual or potential health and life
processes.
vIdentify factors that contribute to, or cause, health problems (etiologies).
vIdentify resources or strengths on which the individual, group, or community can draw to prevent or
resolve problems.
vIn the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from
the nursing assessment.
vActual or potential health problems that can be prevented or resolved by independent nursing
intervention are termed nursing diagnoses.
Types of Nursing Diagnoses
○ NANDA-I describes three types of nursing diagnoses: problem focused, risk, and health
promotion.
Problem-Focused Nursing Diagnoses
○ A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable
human response to a health condition/life process that exists in an individual, family, group,
or community. This type of nursing diagnosis has four components: label, definition, defining
characteristics, and related factor.
●
●
Risk Nursing Diagnoses
○ A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual,
family, group, or community for developing an undesirable human response to health
conditions/life processes.
Health Promotion Nursing Diagnoses
○ A health promotion nursing diagnosis is a clinical judgment concerning motivation and
desire to increase well-being and to actualize human health potential. These responses are
expressed by a readiness to enhance specific health behaviors, and can be used in any health
state. Health promotion responses may exist in an individual, family, group, or community.
■ NANDA-I also recognizes syndromes. A syndrome is a clinical judgment
concerning a specific cluster of nursing diagnoses that occur together and are best
addressed together and through similar interventions. Chronic pain syndrome is an
example (2018, pp. 35–36).
Four components of a diagnosis (1) ( add more if possible)
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●
vLabel: Provides a name for a diagnosis
oImpaired urinary elimination
vDefinition: Provides a clear, precise description, based on data collected
oDysfunction in urine elimination
vDefining characteristics: cluster of signs and symptoms that indicate the presence of a diagnostic
label
oDysuria, frequent voiding, hesitancy, nocturia, urinary incontinence
vRelated factor: Factors that appear to show some type of patterned relationship with the nursing
diagnoses. Related to multiple causality
Chapter 16 Outcomes
Three elements of comprehensive planning (1)
Initial: Developed by the nurse who performs the nursing history and physical
assessment
Addresses each problem listed in the prioritized nursing diagnoses
Identifies appropriate patient goals and related nursing care
Ongoing: is carried out by any nurse who interacts with the patient.
keep the plan up to date to facilitate the resolution of health problems, manage risk
factors, and promote function.
Adjusting pt outcomes and developing new outcomes as needed are performed in
ongoing planning.
vDischarge: is best carried out by the nurse who has worked most closely with the
patient and family, possibly in conjunction with a nurse or social worker with a
broad knowledge of existing community resources.
In acute care settings comprehensive discharge planning begins when the pt is
admitted.
Uses teaching and counseling skills effectively to ensure that home care behaviors
are performed competently
Maslow’s Hierarchy of Human Needs (1)
basic needs must be met before a person can focus on higher ones, patient needs
may be prioritized according to the following hierarchy:
1.Physiologic needs- oxygen, water, food, elimination, rest
2.Safety needs-hand hygiene, protecting pt from potential or actual harm, making
sure IV pumps are working.
3.Love and belonging needs- including family and friends in care of pt, nursepatient relationships
4.Self-esteem needs-making pt feel good about themselves, respecting pts values
and beliefs,
5.Self-actualization needs- focus on the pts strengths and possibilities, encourage
pt to do things for themselves.
For example, a geriatric patient who is incontinent of urine and sitting in a wet
disposable brief (physiologic need) will be unable to participate fully in a music
therapy diversional activity (self-esteem need) until the more basic need is met.
Types of nursing interventions (1)
Nurse-initiated: actions performed by a nurse without a physician’s order, its an
autonomous action based on nursing diagnosis
Physician-initiated: actions initiated by a physician in response to a medical
diagnosis but carried out by a nurse under doctor’s orders, both the physician and
nurse are legally responsible for these interventions. Nurses under no
circumstances should implement a questionable intervention.
Collaborative: treatments initiated by other providers and carried out by a nurse
Physical therapy, respiratory therapy, occupational therapy.
Pg 394--397--A nurse-initiated intervention is an autonomous action based on scientific
rationale that a nurse executes to benefit the patient in a predictable way related to
the nursing diagnosis and projected outcomes.
nursing interventions are actions performed by the nurse to:
Monitor patient health status and response to treatment
Reduce risks
Resolve, prevent, or manage a problem
Promote independence with activities of daily living
Promote optimum sense of physical, psychological, and spiritual well-being
Give patients the information they need to make informed decisions and be
independent
Nurse-initiated interventions do not require a health care provider’s (or other
team member’s) order. Nurse-initiated interventions, like patient goals, are
derived from the nursing diagnosis. But whereas the problem statement of the
diagnosis suggests the patient goals, it is the cause of the problem (etiology) that
suggests the nursing interventions
An intervention is initiated by a physician in response to a medical diagnosis but
is carried out by a nurse in response to a doctor’s order. For example, a physician
examining a patient brought into the emergency department after a motor vehicle
accident might ask the nurse to administer a medication to relieve pain and to
schedule the patient for radiographs and other diagnostic tests. The nurse who
performs these interventions is implementing physician-initiated interventions.
Both the physician and nurse are legally responsible for these interventions, and
nurses are expected to be knowledgeable about how to execute these interventions
safely and effectively. Nurses who question the appropriateness of physicianinitiated interventions are legally responsible to seek clarification of the order with
responsible parties. Under no circumstances should a nurse implement a
questionable intervention, even at the urging of a physician or other professional.
Chapter 7 addresses nurses’ legal responsibility for their actions.
Nurses also carry out treatments initiated by other providers such as pharmacists,
respiratory therapists, or physician assistants; these are collaborative
interventions.
For example, nurses caring for a patient after a motor vehicle accident may
eventually implement interventions written by a physical therapist, occupational
therapist, or other member of the health care team.
Types of Institutional Plans of Care (2)
Nursing Care Plans: is the written guide that directs the efforts of the nursing team
working with the pt to meet their health goals. Formats of Care plans.
Computerized plans of care: electronic medical record
Concept map plans of care: a diagram of pt problems and interventions. They help
organize pt data
Change of shift reports: information about the pt is being communicated to
oncoming shift, hand-off, SBAR (situation, background, assessment,
recommendation) helps you stay organized and prevents omissions in tx
Multidisciplinary (collaborative) plans of care: tools used in case management to
communicate the standardized, interdisciplinary care plans for pts. To provide a
high-quality, cost-effective care for pts, families, and groups. Emphasis is on
clearly stating expected pt outcomes and the specific times within which it is
reasonable to achieve these outcomes.
Student plans of care: aimed to assist students how to use the five steps of the
nursing process
Parts of a measurable outcome (1)
Subject: the pt or some part of the pt
Verb: the action the pt will perform
Conditions: particular circumstances in or by which the outcome is to be achieved.
Not every outcome specifies conditions.
Performance criteria: the expected pt behavior or other manifestation described in
observable, measurable terms.
Target time: when the pt is expected to be able to achieve the outcome. The target
time or time criterion may be a realistic, actual date or other statement indicating
time, such as before discharge, after viewing film, or whenever observed.
EX: During the next 24-hour period, the pts fluid intake will total at least
2,000 mL
EX: At the next visit, (date), the pt will correctly demonstrate relaxation
exercises.
Standards to apply to outcome identification and planning (1)
The primary purpose of the outcome identification and planning step of the nursing
process is to design a plan of care with and for the patient that, once implemented,
results in the prevention, reduction, or resolution of patient health problems and the
attainment of the patient’s health expectations, as identified in the patient
outcomesA patient outcome is an expected conclusion to a patient health problem,
or in the event of a wellness diagnosis, an expected conclusion to a pts health
expectation.
The law: state’s nurse practice act outlines the scope of nursing practice. State
Board of Nursing also outlines what you are and are not allowed to do.
National practice standards: American Nurses Association
Specialty professional organizations: American Association of Critical Care
Nurses, Emergency Nurses Association they develop standards for specialty care.
The Joint Commission: is a powerful accrediting body has developed detailed
standards that must be followed to keep accreditation.
The Agency for Healthcare Research and
Quality (AHRQ): This organization develops,
reviews, and updates clinical guidelines to aid
health care providers to prevent, diagnose,
and manage clinical conditions.
Your employer: Each facility usually
develops its own unique set of standards,
polices and procedures on how nursing care
should be given