Bowel Elimination
1.
Identify factors that influence bowel elimination.
A. Development
A.
Development
1. Newborns and Infants
• meconium - the first fecal material passed by the newborn, normally up to 24 hours after birth; it is black, tarry,
odorless, and sticky
•
•
transitional stools
•
follow meconium for about a week - greenish-yellow, contains mucus, loose
infants
•
•
•
•
•
•
pass stool frequently, after each feeding
intestine is immature = stool is soft, liquid and frequent
bacterial flora increase as intestines mature
solid foods = stool becomes less frequent and firmer
breast-fed - light yellow to golden feces
formula-fed - dark yellow or tan stool, more formed
Toddlers
2.
•
control of defecation
•
•
•
starts at 1.5-2 years of age
desire to control daytime BM starts when child becomes aware of:
•
•
discomfort caused by a soiled diaper
sensation that indicates the need for a BM
typically attained by 2.5 y/o after toilet training
School-Age Children and Adolescents
3.
•
•
•
4.
•
have BM habits similar to adults
patterns vary in frequency, quantity, and consistency
may delay defecation because of an activity such as play
Older Adults
constipation
•
•
•
•
•
significant health problem in older adults due to:
•
•
•
reduced activity levels
inadequate amount of fluid and fiber intake
muscle weakness
may be relieved by increasing fiber intake to 20-35 grams per day
preventive measures for constipation:
•
•
•
•
•
•
adequate roughage in the diet
adequate exercise
6-8 glasses of fluid
cup of hot water/tea at a regular time in the morning
responding to gastrocolic reflex (i.e. 30 minutes after meals)
gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after
breakfast
should be warned that consistent laxative use may cause constipation
•
•
may also interfere with body’s electrolyte balance
may decrease absorption of certain vitamins
causes of constipation
•
•
lifestyle habits
serious malignant disorders
CLINICAL MANIFESTATIONS: COLORECTAL CANCER
RISK FACTORS
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Nonmodifiable
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Modifiable
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SYMPTOMS
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B.
Age
Race
Family history
Cigarette smoking
Poor diet (e.g., low in fiber and high in fat)
Lack of physical activity
Regular consumption of alcohol
A change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for
more than a few days
A feeling of needing to have a BM that is not relieved by doing so
Rectal belleding or blood in the stool (often, though, stool will look normal)
Cramping or steady abdominal pain
Weakness and fatigue
Unexpected weight loss
Diet
•
•
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•
•
•
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sufficient bulk (cellulose, fiber)
•
necessary for adequate fecal volume
inadequate fiber contributes to risk of developing
•
•
•
•
obesity
type 2 diabetes
coronary artery disease
colon cancer
insoluble fiber
•
•
promotes movement of material through digestive system and increases stool bulk
ex: whole wheat flour, wheat bran, nuts, many vegetables
soluble fiber
•
•
•
forms a gel when mixed with water
lowers blood cholesterol and glucose levels
ex: oats, peas, beans, apples, citrus fruits, carrots, barley, psyllium
drink plenty of water
low-residue foods
•
•
•
move more slowly
need to increase fluid intake with such foods to increase rate of movement
ex: rice, eggs, lean meats
certain foods are difficult or impossible for some people to digest
•
•
results in digestive upsets
may cause passage of watery stools
irregular eating
•
impairs regular defecation
foods that may influence bowel elimination
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•
•
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spicy foods - diarrhea and flatus
excessive sugar - diarrhea
gas-producing foods - cabbage, onions, cauliflower, bananas, apples
laxative-producing foods - bran, prunes, figs, chocolate, alcohol
constipation-producing foods - cheese, pasta, eggs, lean meat
RECOMMENDED DAILY INTAKE OF FIBER
Men
50 and younger
38 grams
51 and older
30 grams
Women
1.
•
•
healthy fecal elimination requires intake of 2,000-3,000 mL
if chyme moves abnormally quickly, less fluid is absorbed - feces are soft or watery
stimulates peristalsis - facilitates movement of chyme along colon
weak abdominal and pelvic muscles are ineffective in assisting defecation
•
results from lack of exercise, immobility, or impaired neurologic functioning
confined to bed = constipation
anxiety/anger - increased peristaltic activity causing nausea or diarrhea
depression - slowed intestinal motility causing constipation
early bowel training may establish habit of defecating at a regular time
when normal defecation reflexes are inhibited or ignored, reflexes tend to be progressively weakened
when habitually ignored, urge to defecate is ultimately lost
reasons adults/patients ignore reflexes
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•
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pressures of time or work
embarrassment about using a bedpan
lack of privacy
defecation too uncomfortable
drug side effects may interfere with normal elimination
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diarrhea
constipation
•
•
morphine, codeine (decrease GI activity through CNS effect)
iron tablets - astringent effect, act more locally on bowel mucosa
some medications directly affect elimination
•
•
•
•
laxatives - medications that stimulate bowel activity and assist fecal elimination
stool softeners facilitate defecation
certain medications suppress peristaltic activity - treats diarrhea
affect appearance of feces
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•
•
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GI bleeding (e.g. aspirin products) - red or black
iron salts - black
antibiotics - gray-green
antacids - whitish or white specks
Pepto-Bismol - black stools
Diagnostic Procedures
•
H.
reduced fluid intake slows passage and further increases fluid reabsorption
Medications
•
G.
body continues to reabsorb fluid from chyme even when fluid intake is inadequate or output is excessive
Defecation Habits
•
•
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F.
21 grams
Psychological Factors
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•
E.
51 and older
Activity
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D.
25 grams
Fluid
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C.
50 and younger
some procedures (colonoscopy or sigmoidoscopy)
•
•
•
require NPO
cleansing enema
normal defecation will not occur until eating resumes
Anesthesia and Surgery
•
general anesthesia
•
normal colonic movements cease or slow by blocking parasympathetic stimulation
•
I.
regional/spinal anesthesia less likely to experience this problem
surgery
•
•
direct intestinal handling - causes temporary cessation of intestinal movement or ileum (lasts 24-48 hours)
listen for bowel sounds - intestinal motility, important nursing assessment
Pathologic Conditions
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•
J.
2.
spinal cord injuiries/head injuries - may decrease sensory stimulation for defecation
impaired mobility
•
•
•
may limit ability to respond to urge
may cause constipation
may cause client to experience fecal incontinence due to poorly functioning anal sphincters
Pain
•
•
discomfort when defecating - may cause client to suppress urge to defecate; may cause constipation
narcotic analgesics for pain - may cause constipation
Review the common bowel diversions.
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•
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•
a.
•
ostomy - an opening for the gastrointestinal, urinary, or respiratory tract onto the skin
Alternate feeding route
• gastrostomy - an opening through the abdominal wall into the stomach
• jejunostomy - a type of ostomy that opens through the abdominal wall into the jejunum
Bowel ostomies - to divert and drain fecal material
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•
Ileostomy - a type of ostomy that opens into the ileum (small bowel)
colostomy - a type of ostomy that opens into the colon (large bowel
Classification
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•
•
by permanent or temporary status
by anatomic location
by construction of the stoma
•
stoma - the opening created in the abdominal wall by the osmotic; generally red in color and moist
•
•
may bleed when touched
has no nerve endings
Permanence
1.
2.
b.
Temporary ostomies - allows distal diseased portion to heal
a. traumatic injuries
b. inflammatory conditions
Permanent ostomies - provide a means of elimination when the rectum or anus is nonfunctional
a. birth defects
b. disease such as cancer of the bowel
Anatomic Location
1. location influences the character and management of fecal drainage
a. the farther along, the more formed the stool, the more control over frequency of discharge
2. length of time ostomy is in place also causes stool to become more formed
a. remaining functioning portions tend to compensate by increasing water absorption
3. ileostomy - empties from distal end of small intestine
a. produced liquid fecal drainage
b. constant drainage, cannot be regulated
c. contains skin-damaging digestive enzymes
d. appliance must be worn continuously
e. odor is minimal compared to colostomies
4. cecostomy - empties from the cecum
5. ascending colostomy - empties from ascending colon
a. similar to an ileostomy
b. drainage is liquid, cannot be regulated, digestive enzymes present
c. odor is a problem
6. transverse colostomy - empties from transverse colon
a. malodorous, mushy drainage
b. usually no control
7. descending colostomy - empties from descending colon
a. increasingly solid drainage
8. sigmoidostomy - empties from the sigmoid colon
a. normal/formed consistency
b. frequency of discharge can be regulated
c. may not need to wear an appliance at all times
d.
c.
3.
odors can usually be controlled
Surgical Construction of the Stoma
1. end or terminal colostomy - a type of colostomy that has a singe stoma created when one end of bowel
is brought out through an opening onto the anterior abdominal wall; the stoma is permanent
2. loop colostomy - a type of colostomy where a loop of bowel is brought out onto the abdominal wall and
supported by a plastic bridge, or a piece of rubber tubing; the stoma has two ends: an active proximal end,
and an inactive distal end
a. usually for emergencies
b. stoma is bulky and more difficult to manage
3. divided colostomy - consists of two edges of bowel brought out onto the abdomen but separated from
each other; the proximal end is the colostomy and the distal end is the mucous fistula
a. used where spillage of feces into distal end needs to be avoided
4. double-barreled colostomy - resembles a double-barreled shotgun; the proximal and distal loops of
bowel are sutured together for about 10 cm (4 in) and both ends are brought up onto the abdominal wall
Identify common causes and effects of the following bowel elimination problems.
a.
constipation
•
constipation
•
•
•
•
•
•
•
•
•
reduced activity levels
inadequate amount of fluid and fiber intake
muscle weakness
may be relieved by increasing fiber intake to 20-35 grams per day
preventive measures for constipation:
•
•
•
•
•
•
adequate roughage in the diet
adequate exercise
6-8 glasses of fluid
cup of hot water/tea at a regular time in the morning
responding to gastrocolic reflex (i.e. 30 minutes after meals)
gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after
breakfast
should be warned that consistent laxative use may cause constipation
•
•
may also interfere with body’s electrolyte balance
may decrease absorption of certain vitamins
causes of constipation
•
•
b.
•
•
•
•
significant health problem in older adults due to:
lifestyle habits
serious malignant disorders
diarrhea
diarrhea - the passage of liquid feces and an increased frequency of defecation
opposite of constipation
results from rapid movement of fecal contents through the large intestine
Symptoms
•
•
•
•
•
stool is relatively unformed and excessively liquid
finds it difficult or impossible to control the urge to defecate
often accompanied by spasmodic cramps and increased bowel sounds
persistent diarrhea irritates anal region and buttocks
prolonged diarrhea results in fatigue, weakness, malaise, and emaciation
Causes
•
•
irritants in the intestinal tract - protective flushing; can create serious fluid and electrolyte losses (especially in
infants, small children, and older adults)
Clostridium difficile-associated disease
•
•
•
•
produces mucoid and foul-smelling diarrhea
highest risk: immunosuppressed persons, clients on chemotherapy, those who have recently used antimicrobial
agents (fluoroquinolones)
greatest risk: elderly
infection control: hand hygiene with soap and water, contact precautions, cleaning of surfaces with bleach
CAUSE
PHYSIOLOGICAL EFFECT
Psychological stress (e.g. anxiety)
Increased intestinal motility and mucous secretion
Medications
Inflammation and infection of mucosa due to overgrowth of
pathogenic intestinal microorganisms
Antibiotics
Irritation of intestinal mucosa
Iron
Irritation of intestinal mucosa
Cathartics
Incomplete digestion of food or fluid
Allergy to food, fluid, drugs
Increased intestinal motility and mucous secretion
Intolerance of food or fluid
Reduced absorption of fluids
Diseases of the colon (e.g., malabsorption syndrome,
Crohn’s disease)
Inflammation of the mucosa often leading to ulcer formation
•
increased risk for skin breakdown
•
•
•
skin around anal region should be kept clean and dry; use zinc oxide
use a fecal collector
Also: spicy foods, excessive sugar, and anxiety/anger (^peristaltic activity) all can cause diarrhea
c.
fecal impaction
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•
•
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fecal impaction - a mass or collection of hardened feces in the folds of the rectum; results from prolonged
retention and accumulation of fecal material
severe impaction - accumulation well up into sigmoid colon and beyond
Symptoms
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•
•
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frequent but nonproductive desire to defecate and rectal pain
results in a generalized feeling of illness
anorexia, distention of abdomen, nausea and vomiting may occur
may be assessed by digital examination of the rectum
Causes
•
•
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•
poor defecation habits
constipation
administration of medications such as anticholinergics and antihistamines
barium used in radiologic examinations of upper and lower GI
Treatment
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d.
will experience passage of liquid fecal seepage and no normal stool
oil retention enema followed by a cleansing enema 2-4 hrs later, daily cleansing enemas, suppositories/stool
softeners
digital removal
bowel incontinence

bowel incontinence (fecal incontinence) - the loss of voluntary ability to control fecal and gaseous discharges
through the anal sphincter
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•
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may occur at specific times or irregularly
two types:
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partial - inability to control flatus or to prevent minor soiling
major - inability to control feces of normal consistency
associated with impaired functioning of anal sphincter or nerve supply (in neuromuscular diseases, spinal
cord trauma, and tumors of the external anal sphincter muscle)
prevalence increases with age
emotionally distressing and may lead to social isolation
Treatment
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e.
bowel diversion/colostomy
flatulence
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Primary sources
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action of bacteria on the chyme in the large intestine
swallowed air
gas that diffuses between the bloodstream and the intestine
most swallowed gases are expelled by eructation/belching
gas may accumulate in the stomach - gastric distention
•
gases formed in the large intestine - absorbed into circulation
flatulence - the presence of excessive flatus in the intestines and leads to stretching and inflation of the
intestines (intestinal distention)
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Causes
•
4.
repair of sphincter
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food (cabbage, onions)
abdominal surgery
narcotics
Relief
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•
if gas is propelled by increased colon activity before it is absorbed, it is expelled through the anus
use of a rectal tube to remove the gas
Develop 2 nursing diagnoses, interventions and outcomes for clients with elimination problems.

Dysfunctional gastrointestinal motility

Bowel incontinence

Constipation

Diarrhea

Risk for electrolyte imbalance

Impaired skin Integrity

Disturbed body image

Deficient knowledge, ostomy management
Nutrition
1.
Discuss therapeutic diets and the rationale for the diet.
Clear liquid diet –
a.
b.
c.
d.
e.
Includes minimum residue fluids that can be seen through.
Examples are juices without pulp, broth, and Jell-O.
Is often used as the first step to restarting oral feeding after surgery or an abdominal procedure.
Can also be used for fluid and electrolyte replacement in people with severe diarrhea.
Should not be used for an extended period as it does not provide enough calories and nutrients.
Full liquid diet –
Includes fluids that are creamy.
a.
b.
c.
d.
Some examples of food allowed are ice cream, pudding, thinned hot cereal, custard, strained cream soups, and
juices with pulp.
Used as the second step to restarting oral feeding once clear liquids are tolerated.
Used for people who cannot tolerate a mechanical soft diet.
Should not be used for extended periods.
No Concentrated Sweets (NCS) diet –
a.
b.
c.
Is considered a liberalized diet for diabetics when their weight and blood sugar levels are under control.
It includes regular foods without the addition of sugar.
Calories are not counted as in ADA calorie controlled diets.
Diabetic or calorie controlled diet (ADA) –
a.
b.
c.
These diets control calories, carbohydrates, protein, and fat intake in balanced amounts to meet nutritional needs,
control blood sugar levels, and control weight.
Portion control is used at mealtimes as outlined in the ADA “Exchange List for Meal Planning.”
Most commonly used calorie levels are: 1,200, 1,500, 1,800 and 2,000.
No Added Salt (NAS) diet –
a.
b.
Is a regular diet with no salt packet on the tray.
Food is seasoned as regular food.
Low Sodium (LS) diet –
a.
b.
c.
d.
e.
May also be called a 2 gram Sodium Diet.
Limits salt and salty foods such as bacon, sausage, cured meats,
canned soups, salty seasonings, pickled foods, salted crackers, etc.
Is used for people who may be “holding water” (edema) or who have
high blood pressure, heart disease, liver disease, or first stages of kidney disease.
Low fat/low cholesterol diet –
a.
b.
c.
Is used to reduce fat levels and/or treat medical conditions that interfere with how the body uses fat such as diseases
of the liver, gallbladder, or pancreas.
Limits fat to 50 grams or no more than 30% calories derived from fat.
Is low in total fat and saturated fats and contains approximately 250-300 mg cholesterol.
High fiber diet –
a.
b.
Is prescribed in the prevention or treatment of a number of gastrointestinal, cardiovascular, and metabolic diseases.
Increased fiber should come from a variety of sources including fruits, legumes, vegetables, whole breads, and
cereals.
Renal diet –
a.
b.
c.
d.
Is for renal/kidney people.
The diet plan is individualized depending on if the person is on dialysis.
The diet restricts sodium, potassium, fluid, and protein specified levels.
Lab work is followed closely.
Mechanically altered or soft diet –
a.
b.
c.
d.
Is used when there are problems with chewing and swallowing.
Changes the consistency of the regular diet to a softer texture.
Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables.
Is for people with poor dental conditions, missing teeth, no teeth, or a condition known as dysphasia.
Pureed diet –
a.
b.
c.
d.
e.
f.
g.
h.
i.
Changes the regular diet by pureeing it to a smooth liquid consistency.
Indicated for those with wired jaws extremely poor dentition in which
chewing is inadequate.
Often thinned down so it can pass through a straw.
Is for people with chewing or swallowing difficulties or with the condition
of dysphasia.
Foods should be pureed separately.
Avoid nuts, seeds, raw vegetables, and raw fruits.
Is nutritionally adequate when offering all food groups.
Food allergy modification –
a.
b.
c.
d.
e.
f.
g.
Food allergies are due to an abnormal immune response to an otherwise harmless food.
Foods implicated with allergies are strictly eliminated from the diet.
Appropriate substitutions are made to ensure the meal is adequate.
The most common food allergens are milk, egg, soy, wheat, peanuts,
tree nuts, fish, and shellfish.
A gluten free diet would include the elimination of wheat, rye, and barley.
Replaced with potato, corn, and rice products.
Food intolerance modification –
a.
b.
c.
The most common food intolerance is intolerance to lactose (milk sugar) because of a decreased amount of an enzyme in
the body.
Other common types of food intolerance include adverse reactions to certain products added to food to enhance taste,
color, or protect against bacterial growth.
• Common symptoms involving food intolerances are vomiting, diarrhea, abdominal pain, and headaches.
Tube feedings –
a.
b.
c.
2.
Tube feedings are used for people who cannot take adequate food or fluids by mouth.
All or parts of nutritional needs are met through tube feedings.
Some people may receive food by mouth if they can swallow safely and are working to be weaned off the tube feeding.
Enteral feeding:
Reasons
Interventions
Complications
Nasoenteric
HOB >30, maintain for at least half hour
afterwards
aspiration, hyperglycemia, abdominal
distention, diarrhea, and fecal impaction
Check placement
confirmed by x-ray,
or aspirate fluids if pH <4, tube is
probably in stomach
^report to primary care provider. Often, a
change in formula or rate of admin can
correct problems.
Naso or oral gastric
NGT or OGT
residual q4h and prior to medication
administration
Gastrostomy
Flush with 30 mL of H20 q4h
PEG
keep securely taped
if indicated, food coloring to help indicate
aspiration
Jejunostomy
PEJ
3.
stop continual feeding temporarily when
turning or moving client
Define dysphagia and list causes.
Dysphagia = difficulty swallowing.
Clients at risk for dysphagia: older adults, those who have experienced stroke, clients with cancer who have had radiation therapy to
the head and neck, and others with cranial nerve dysfunction
4.
Complete the table for dysphagia:
Causes
stroke, radiation therapy to the head or neck, cranial nerve dysfunction
Warning Signs
pain while swallowing (odynophagia), unable to swallow, sensation of food getting stuck, drooling,
being hoarse, regurgitation, frequent heartburn, unexpected weight loss, doughing or gagging
when swallowing, having to cut food into smaller pieces
Complications
malnutrition, weight loss and dehydration.
respiratory problems (aspiration.. pneumonia or upper respiratory infections)
5.
Identify risk factors for aspiration.
Risk factors for aspiration:

Reduced LOC

Increased intragastric pressure

Tube feedings

Situations hindering elevation of upper body

Tracheostomy or endotracheal tube

Medication administeration
6.

Wired jaws

Increased gastric residual

Incomplete lower esophageal sphincter

Impaired swallowing

Trauma/surgery of face, oral, neck

Depressed cough or gag reflexes

Decreased GI motility

Delayed gastric emptying
List nursing interventions to decrease aspiration.
Decrease aspiration:
7.

Monitor resp rate, depth and effot.

Auscultate lung sounds frequently and before/after feedings

Check gag reflex before oral feedings

When feeding, watch for signs of impaired swallowing or aspiration – coughing, choking, spitting food, excessive
drooling

Have suction machine available for high-risk clients in case of aspiration

Keep HOB elevated for at least half an hour afterward

Not presence of n&v or diarrhea

Listen to BS qh

Note any onset of abdominal distention or increased rigidity of abdomen

If tracheostomy, refer to speech pathologist for swallowing studies

If n&v, position on side

Feed slowly
Discuss risk factors related to poor nutrition intake.

Old age

Illness, physical or psychological

Multiple medications

Chronic alcohol intake

Low income

Social isolation

Physical disability

Involuntary weight loss or gain

Poor diet
Urinary Elimination
1.
Identify factors that influence urinary elimination.
●
Developmental Factors
○
Infants: 250-500mL, 20x a day, sp.gr: 1.008. colorless and odorless.
○
School-age children (5-10yr):
■
kidneys double in size -> urination 6-8x a day.
■
Enuresis: involuntary urination when control should be established.
■
Nocturnal enuresis: bed-wetting
○
Older Adults
■
prerenal failure: hypertension
■
Intrarenal failure = hypertension, diabetes, toxins
■
Post renal failure = outflow obstruction
■
diminished excretory function
■
factors that impair renal function:
●
arteriosclerosis
●
surgery
■
■
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●
●
●
●
●
●
2.
more susceptible to toxicity from medications due to decreased excretion
Urinary frequency factors:
●
men: enlarged prostate gland
○
double void technique: empty bladder, after feeling done, try to void again
●
women: weakness of muscle supporting bladder
●
decreased bladder capacity and ability to completely empty
○
retention of residual volume also predisposes to UTI.
Psychosocial Factors
○
stress triggers ADH secretion
○
no time to pee, anxiety = no urination = higher risk of UTI
Sociocultural factors
○
different traditions of urinating
Fluid and Food Intake (1.5-3L of fluid)
○
alcohol and caffeine increase urine production (ETOH inhibits ADH)
○
Beets and carotene can change urine color.
Medications
○
Urinary Retention (Box 1 pg 749)
■
Anticholinergic medications, such as Atropine, Robinul, and Pro-Banthine.
■
Antidepressant and antipsychotic agents, such as tricyclic antidepressants and MAO inhibitors.
●
aminotryptaline (blueish tinge)
■
Antihistamine: Pseudoephedrine (Actifed and Sudafed)
■
Antihypertensives: hydralazine (Apresoline) and methyldopate (Aldomet)
■
Antiparkinsonism: levadopa, trihexyphenidyl (artane), and benzotropine mesylate (Cogentin)
■
Beta-adrenergic blockers, such as propranolol (Inderal)
■
Opiods: hydrocodone (Vicodin)
■
Anesthetics
■
Peridium decreases urinary tract (turns urine orange)
Muscle Tone
○
good muscle tone important to maintain stretch and contractility of bladder.
Pathologic Conditions
○
Diseases of nephrons
○
Abnormal amounts of protein or RBC’s in urine.
○
Heart and circulatory disorders.
○
Kidney stones
○
enlarged prostate
Surgical and Diagnostic Procedures
Identify common causes and effects of the following urinary elimination problems.
a.
frequency
●
Polyuria
○
increase fluid intake
○
Diuretics, lots of ETOH
○
Presence of thirst, dehydration, and weight loss.
○
History of diabetes or kidney disease.
○
some stages of renal failure
●
Oliguria, anuria (<500mL in 24 hr)
○
Decreased fluid intake
○
dehydration
○
hypotension, shock, or heart failure
○
history of kidney disease or renal failure or decrease perfusion to kidneys (high BUN, creatinine,
edema, hypertension)
b.
nocturia
●
Frequency of nocturia (2 or 3 times a night)
○
pregnancy
○
increased fluid intake
○
UTI
c.
urgency
●
Urgency - sudden desire to urinate immediately
○
stress
○
UTI
○
enlarged prostate
d.
dysuria
●
Dysuria - pain or difficulty
○
UTI
○
hematuria, pyuria (pus in urine)
3.
e.
incontinence
●
Incontinence - involuntary urination of adults
○
bladder inflammation or CVA
○
difficult access to toilet (impaired mobility)
○
leakage when coughing, laughing, sneezing
○
cognitive impairment
○
SCI
f.
urinary retention
●
Retention
○
distended bladder on palpation and percussion
○
discomfort, restlessness, frequency, small urine volume
○
recent anesthesia/ surgery
○
perineal swelling
○
medications
○
lack of privacy or other factors inhibiting micturition
g.
neurogenic bladder
●
Neurogenic Bladder
○
impaired neurologic function (SCI)
○
does not perceive fullness therefore unable to control urinary sphincters
○
self-catheterization (q4h)
Describe appropriate care for a patient with a Foley catheter.
Indications for Foley
●
Acute urinary retention or bladder outlet obstruction
●
Need for accurate output in critically ill clients
●
Peri-operative use for selected surgical procedures
●
To assist in healing of open sacral or perineal wounds in incontinent clients
●
Client requires prolonged immobilization
●
To improve comfort for end of life care
Foley Care
●
Care:
○
○
○
○
○
○
○
○
4.
Urinary catheters is indicated
Hand hygiene
Must be continuously connected to the drainage bag
NO breach in system
Routine daily meatal hygiene & after BM
Urinary catheter bag should be emptied regularly into a clean container
Securement device
No dependent loops
List nursing interventions that may prevent a urinary tract infection.
●
●
5.
Prevent infections
○
Drink 8 glasses of water a day
○
Practice frequent voiding
○
Avoid harsh cleansing products.
○
Avoid tight-fitting pants
○
Wear cotton rather than nylon (enhances ventilation)
○
Wipe from front to back
○
take showers rather than baths (bacteria in bath water)
Acidifying urine
○
Foods such as:
■
eggs, cheese, meat, whole grains, cranberries, plums, and tomatoes increase the acidity of urine.
●
acidifying the urine of clients reduce risk of UTI and calculus formation.
Describe interventions to manage urinary incontinence.
●
Client education
○
Continence (bladder) training
■
client resists urge or sensation to urinate and only void according to a timetable to gradually stabilize
the bladder and diminish urgency.
●
also provides larger voided volumes and longer intervals between voiding.
■
Habit training
●
scheduled toileting, have client void at regular intervals
○
no delay voiding of urge occurs
○
used in children with urinary dysfunction
Prompted voiding
●
prompting or reminding client when to void.
○
Pelvic Muscle Exercises
○
Maintaining Skin Integrity
Maintain elimination habits
○
medications usually interfere with normal voiding habits
○
assist client to maintain habits (assisting with toilet PRN)
Fluid intake (2-3L/day)
○
promote increased fluid intake -> increased urine production -> more stimulation of micturition reflex.
○
keep bladder flushed out and decreases risk of sediment or other obstructions
○
1500 mL of measurable fluid is adequate for most adults
■
may be c/i for clients with kidney or heart failure.
■
●
●
6.
Review the common urinary diversions.
●
●
7.
Continent (indicated by bladder cancer)
○
Kock Pouch
○
new bladder out of ileum
○
Nipple valve which permits external catheter to drain
○
Neobladder
○
Intact urethra**
○
A small part of the small intestine is made into a reservoir or pouch, which is connected to
the urethra.
○
Closely matches normal urination
Incontinent
o
Suprapubic catheter

urethral trauma, short-term 2-3 weeks
o
Ureterostomy

Detaches one or both ureters from the bladder, and brings them to the surface of the abdomen with
the formation of a stoma to divert the flow of urine away from the bladder when the bladder is not
functioning or has been removed.

Birth defects, malfunction of bladder, SCI, bladder cancer
o
Nephrostomy

Flow of urine is diverted directly from the kidneys to the abdominal wall.

Usually temporary but may be permanent for cancer pts.
o
Vesicostomy

urethra no longer functioning, bladder attached directly to skin
o
Ileal conduit

aka bricker’s loop

the ureters are detached from the bladder and joined to a

short length of the small intestine (ileum)

The ureters drain freely.

One end of the ileum piece is sealed off and the other end is

brought to the surgace of the abdomen to form the stoma.

An ostomy bag is worn over the stoma to collect urine.
Develop 2 nursing diagnoses, interventions and outcomes for clients with urinary problems.
Disturbed body image : shame r/t incontinence
Urinary incontinence
Pain
Risk for infection
Toileting self care deficit
Impaired urinary elimination
QSEN - Ensuring Healthcare Quality and Safety
1.
What does it mean to give quality care?
Quality care is STEEEP: safe, timely, effective, efficient, equitable, patient-centered
2.
Define a high reliability organization.
High Reliability organization:

Organizations that continually look at themselves and ask are we giving the best care possible? Do we provide
an environment for safe care?
3.
State at least 2 indicators of the quality of nursing care within an institution.


4.
All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary
team, emphasizing evidence-based practice, quality improvement approaches and informatics
The six competencies:
o
Safe
o
Timely
o
Effective
o
Efficient
o
Equitable
o
Patient-centered
A local hospital is being evaluated on whether it gives quality care. Which of the following would the evaluating
agency find in a successful evaluation? (select all that apply)
A.
B.
C.
D.
E.
F.
Care is provided in a timely manner
The hospital regularly reviews policies for their effectiveness
The cost of care is lower than other hospitals in the area
Physicians review all policies for medical usefulness
Care is given without regard for ability to pay
Patients are actively involved in decisions about their own care
Patient-Centered Care
1.
List at least 3 techniques to provide patient-centered care.
1. Open visiting hours
2. Family Zones – comfortable places for family to visit. Lots in PEDs.
3. Views of nature – views, plants, painting of something natural
4. Noise reduction
5. Decrease environment stressors
6. “we are guests in their lives”
2.
Describe the benefits of quality and safety in providing patient-centered care.
3.
The nurse asks the diabetic patient when she would like her AM care, before or after breakfast. This is an
example of providing:
A. Safe care
B. Patient-centered care X
C. Evidence-based practice
D. Care using teamwork
Teamwork and Collaboration
1.
Complete the following chart:
How is it practiced?
Open
Communication
assertive communication… honest, direct, and
appropriate while being open to ideas and
respescting the rights of others
Mutual Respect

Shared DecisionMaking
2.
Skilled communicators focus on finding
solutions and achieving desirable outcomes

Seek to protect and advance collaborative
relationships among colleagues

Invite and hear all relevant perspectives

Call upon goodwill and mutual respect to build
consensus and arrive at common
understanding

Demonstrate congruence between words and
actions, holding others accountable for doing
the same
Emotional intelligence… ability to form work
relationships with colleagues, display maturity in a
variety of situations, and resolve conflicts while
taking into consideration the emotions of others
Define the elements of SBAR.
SBAR:
How does it help
teamwork?
Values perspectives,
expertise and unique
contributions of all team
members
Values perspectives,
expertise and unique
contributions of all team
members
Benefits
Values perspectives,
expertise and unique
contributions of all team
members
Benefits the patient, the team,
and the organization.
Prevents errors.. minimizes
miscommunication with
colleagues
Teamwork, benefits the patient,
the team, and the organization.
With emotional intellifence, the
nurse is viewed as mature,
approachable, and easygoing




3.
Situation – What is going on with the patient?
Background – What is the clinical background or context?
Assessment – What do I think the problem is?
Recommendation – What would I recommend?
List the activities of the rapid response team and define how these enhance quality and safety in health care.
Rapid Response Team:

When a pt demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the
bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer,
cardiac arrest, or death

Critical care nurse, respiratory therapist, and physician (critical care or hospitalist) backup

Proactively evaluate high-risk ward patients

Educate and act as liaison to warm staff
4.
What is the purpose of using the SBAR format?
A. It makes report and shift changes go faster
B. It ensures the unit is compliant with Magnet requirements
C. It ensures complete and organized communication between shifts
D. It maintains Safe, Better, Appropriate and Reliable care.
Evidence-Based Practice
1.
List the steps (in order) of the EBP proces.
1.
2.
3.
4.
Collect the most relevant and best evidence
Critically appraise the evidence
Integrate the evidence with one’s own clinical expertise, patient preferences and values in making a practice decision
or change
Evaluate the results of the practice decision or change
2.
List elements that can be used as evidence in EBP.
a. Established research methods
b. Systematic research, randomized clinical trials, descriptive studies, qualitative research,
c. Experts in the health care field
d. staff educators, CNSs, NPs, the medical staff, pharmacists
e. Anything that helps you answer the question
3.
Describe how a nurse would critique evidence to determine its usefulness to a particular clinical setting.
a. It is not just enough to find the articles you want, but you need to ask yourself whether or not they hold any merit.
b. Ask yourself whether or not the article deals with you question
c. Interpret the evidence
d. Apply what you have learned in your patient care
e. Observe how evidence is used to make policy and procedure changes to improve patient care
f.
Evaluate the decision
4.
Define the 4 elements of a PICO question.
a. PICO Format
i. Patient population of interest
ii. Intervention of interest
iii. Comparison
iv. Outcome
1.
Define bundles and describe how they improve quality and safety in health care.

Bundles: groupings of best practices with respect to a disease process that individually improve care, but
when applied together result in substantially greater improvement.
o
Central line bundle
o
VAP bundle
o
Catheter-associated UTI bundle
o
Surgical site infection
Quality Improvement
1.
Define never events and give examples.

Never events
o
Objects left in after surgery, air embolism, blood incompatibility, pressure ulcers, falls
2.
Describe strategies a health care organization uses in quality improvement.

Nursing sensitive measure
o
Affected by the supply of nursing staff, the skill level of the nursing staff, and the
education/certification of nursing staff
o
Central line infections, falls, IV infiltrations

Test of change (PDSA)
o
Plan, Do, Study, Act
3.
What is the significance of reporting and investigating never events?
A.
To guarantee they never happen again
B.
C.
D.
4.
To figure out who is responsible so they can be disciplined
To identify human factors that contributed to the event
To write them up in research for other hospitals to learn from
Which of the following are elements of Joint Commission Patient Safety goals? (Select all that apply)
A. Hand hygiene
B. Time outs before surgery
C. Use of unit dose syringes
D. Cost containment
E. The use of 3 patient identifiers - need only 2
Safety
1.
Define the concept of human factors and its role in patient safety.
Human factors: humans make mistakes. What can we do to avoid them.
2.
List measures to increase safety in medication administration.
Safety in Medication Administration:

Two patient identifiers

Patient armbands – pt, allergies.

Look-alike and sound-alike drugs

Medication reconciliation
o
Good faith effort

Involve the patient

Decrease tolerance of risk
3.
Define national patient safety indicators; and describe the 6 safety goals.
1. Identify patients correctly
i. 2 patient identifiers
ii. Never room number
iii. Special attention when giving blood
2. Improve staff communication
i. Critical test results
3. Use medications safely
i. Unit dose and prefilled syringes when possible
ii. Medication reconcilliation
4. Prevent infection
i. Hand hygiene
ii. MDRO risk assessment
iii. Catheter guidelines
5. Identify patient safety risks
6. Prevent mistakes in surgery
i. Time outs
ii. Verify correct patient, correct procedure, correct site
Healthcare Informatics
1.
List the elements of EHRs and how they contribute to quality and safety.

EHRs
o
Respond to alerts
o
Use for communication
o
Decision support tools
o
Up-to-the-minute information
2.
Describe concerns about the use of EHRs in health care.

EMR concerns (eye contact, decreased critical thinking, system offline, patient privacy)
3.
Describe how consumers use informatics and the benefits and challenges for nurses.

Consumer use
o
Increased medical knowledge by consumer increases the need for assessment of resources
o
Social media for patient care
o
Home monitoring
Diabetes
1.
Discuss the classifications and risk factors for developing diabetes.
Classification

Type One (10%)
o
Inherited with environmental trigger
o
Autoimmune - beta cell destruction

Born with or develop during
early childhood

Type Two (90%)
o

2.
Genetic & lifestyle

Insulin resistance – the pancrease will respond by producing more insulin and then the
beta cells get exhausted

Insulin deficiency
Gestational Diabetes
o
Occurs in 2%–5% of pregnancies
o
Inadequate insulin secretion & responsivenes
o
Many will not have diabetes after pregnancy, some will develop type 2 diabetes
List the complications of diabetes and appropriate preventative measures.
Complications from DM:

Hypoglycemia

o
Blood glucose level < 60 mg/dL (normal BGluc 70-110)
o
Diet therapy: glucose/carbohydrate replacement
o
Drug therapy: glucagon, 50% dextrose
o
Prevention strategies for:

Insulin excess

Deficient food intake

Exercise

Alcohol
Hyperglycemia
o
Blood glucose level > 200 mg/dL

o
Results from Insulin deficiency

o

Causes microvascular changes leading to vascular disease and neuropathies
Hyperglycemia

Polyuria

Polydipsia

Polyphagia

Development of ketone bodies

Dehydration

Hemoconcentration

Hypovolemia

Hyperviscosity

Hypoperfusion

Hypoxia
Treatment/prevention:

oral and/or insulin therapy

Therapeutic diet – low glycemic foods etc
Diabetic ketoacidosis (DKA)
o
Serum glucose >300 mg/dl
o
Common in type 1, rare in type 2
o
Results from inadequate insulin
o
Acidosis results from ketone production of fat breakdown for energy demands
o
Symptoms
o


Polyuria, polydipsia

Hyperventilation, Kussmual respirations

Dehydration

Fruity odor of ketones, fatigue

GI symptoms
Interventions include ICU admission

Monitor for manifestations

Assessment of airway, LOC, hydration status, blood glucose level

Management of fluid & electrolytes

Drug therapy goal: to lower serum glucose by 75 - 150 mg/dL/hr

Manage of acidosis

Client education & prevention

NPO
Hyperosmolar hyperglycemic syndrome (HHS)
o
Severe hyperglycemia with little or no ketones
o
Causes profound dehydration & shock
o
Glucose levels are in excess of 600 mg/dL
o
Older adults with type 2 DM who are still producing some insulin
o
Symptoms

o

3.
Interventions

Monitoring

Fluid therapy: rehydrate & restore normal blood glucose levels within 36 to 72 hr

IV insulin therapy often needed to reduce blood glucose levels

NPO
Foot ulcers
o

confusion , coma, febrile, polydipsia, nausea, weight loss
Interventions and foot care practices

Cleanse & inspect feet daily

Wear properly fitting shoes

Avoid walking barefoot

Trim toenails regularly

Report non-healing breaks in the skin
Periodontal disease
Discuss teaching topics and priorities for a patient newly diagnosed with diabetes mellitus type 2.

Goals of treatment
o
Provide the individual with adequate tools to achieve glycemic control

o
Prevent, delay or arrest the microvascular(neuro-, renal-, retinalopathy) & macrovascular
complications of DM
o
Minimize hypoglycemia
o
Optimize BMI
Diet considerations for Type 2 diabetic:
o
Hypocaloric diet = weight loss & better glycemic control
o
Modification of eating habits
o
Adjust CHO to glucose levels
o
Restrict ETOH intake
4.
List the medication classifications used in the treatment of the client with diabetes:
Oral Drug Therapy: probably too much information. None of this was discussed in lec
Drug Classification
Sulfonylurea agents antidiabetic
Generic/Trade Names
Tolbutamide (Modenol,
Novobutamide, Orinase)
Glimepiride (Amaryl)
Nursing Considerations
Directly stimulates beta cells to
produce insulin. Adjunct to diet
and exercise
Adverse Effects
No common adverse effects..
Dizziness, headache, possible
leukopenia
Meglitinide analogs
- antidiabetic
Nateglinide (Starlix)
Repaglinide (Prandin,
Gluconorm)
Acarbose (Precose)
St. the release of insulin. Use
alone or with metformin for
nonIDDM
Delays absorption of sugars
from intestinal tract. Adjunct to
diet and exercise
Increase binding of insulin and
potentiate insulin action. Adjunct
to diet and exercise.
Decreases hepatic glucose
output and increases glucose
uptake in skel muscle and fat.
Adjunct to diet
No common.. flu like
symptoms, hypoglycemia, URI
Mimicks incretin, enhances
insulin secretion. Slows gastric
empyting. With d/ex
No common. Jittery, n&v, gi
upset , hypoglycemia
Alpha-glucosidase
inhibitors
Biguanides
Metformin (Fortamet,
Glucophage, Glumetza,
Riomet)
Piolitazone hydrochloride
(Actos)
Thiazolidinedione agents
Exenatide (Byetta, Bydureon)
Dipeptidyl peptidase
inhibitors
5.
List signs and symptoms of hypo- and hyperglycemia.
Hypoglycemia:

Warm

Weakness or fatigue

Confusion or difficulty thinking

Shaky, nervous, anxious

Seizures, loss of consciousness

Sweaty, hungry, tingling
Hyperglycemia:

Always tired

Crave extra liquids (polydipsia)
o
Dehydration

Hemoconcentration

Hypovolemia
Diarrhea, flatulence, andominal
distention
N&v, abdominal pain, bitter or
metallic tastem diarrhea,
bloatedness, anorexia
Upper respiratory tract
infection
6.

Hyperviscosity

Hypoperfusion

Hypoxia

Frequent urination (polyuria)

Numbness and tingling of feet

Always hungry (polyphagia)

Unexplained weight loss

Blurred vision

Sexual dysfunction
Discuss the appropriate therapeutic diet for a patient with diabetes.
Diet Considerations:

Type 1

o
Consistency in timing & amount of calories
o
Adjust insulin for departures from meal plan
o
Frequent, smaller meals rather than quantity
Type 2
o
Hypocaloric diet = weight loss & better glycemic control
o
Modification of eating habits
o
Adjust CHO to glucose levels
o
Restrict ETOH intake
Medical nutritional therapy:

7.
ADA
o
50-60% CHO 45-60 grams per meal
o
15-20% PRO
o
20-30% FAT

Discourage refined & simple sugars

Encourage complex CHOs & fiber

Alcohol consumption

Glycemic index
o
Consumption of high-glycemic index foods results in higher & more rapid increases in glucose levels than
the consumption of low-glycemic index foods
o
High BMIs linked to obesity, heart disease & DM
o
Consumption of low-glycemic index foods results in lower & sustained increases in blood glucose & lower
insulin demands on beta-cells
o
People who eat low glycemic index foods tend to have lower body fat
Discuss the different types of insulin and appropriate times to administer.
Drug Classification
Rapid-acting
Short-acting
Generic/Trade Names
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Regular (Novolin R, Humulin R)
Nursing Considerations
Onset: <15 minutes
Peak: 1-2 hours
Duration: 3-6 hours
Onset: 30-60 minutes
Peak: 2-4 hours
Duration: Up to 24 hr
Adverse Effects
hypoglycemia
^
Intermediate-acting
NPH (Novolin N, Humulin N,
ReliOn)
Onset: 2-4 hours
Peak: 4-8 hours
Duration: 10-18 hrs
^
Long-acting
Glargine (Lantus)
Detemir (Levemir)
^
Combinations
Novolin 70/30, Humulin 70/30
Onset: 1-2 hours
Peak: Usually none
Duration: Up to 24 hr
Onset: 30-60 minutes
Peak: 2-10 hrs
Duration: 10-18 hrs
Humalog 75/25, Novolog 70/30,
Humalog 50/50
^
Onset: 10-30 minutes
Peak: 1-6 hrs
Duration: 10-24 hrs
Skin
1.
Identify risk factors for skin impairment:
Risk Factor
Genetics
Assessment Data
color, allergies, acne, excema
Nursing Intervention
Monitor skin care practices
Age
wrinkles - skin is drier, less sebum.
Skin is thinner, decreased subQ
tissue and collagen.
monitor continence status, immobilityrelated risk factors, help position,
assess nutritional status, teaching
about skin and wound assessment,
signs of infection, how to use topical
meds, how to turn/reposition every 2
hours
Assess nutrtional status, fluids,
circulation
old age – increased healing time
due to decreased circulation
Illness
Arterial illnesses (deceases o2 to
tissues).. peripheral artery disease
>> thin, shiny skin with no hair.
Poor nutrition
muscle atrophy, decreased subQ
tissue, decreased skin integrity
Assess nutrition status
Circulation
need good circulation for
o2/nutrients/etc and goo venous
return to remove waste
Compression socks, ankle exercises
Pressure
Bed or wheelchair bound = higher
chance of skin breakdown
Repostion/turn every 2 hours
Medications
photosensitive medications =
reation >burning, stinging, blisters.
RetinA, birth control
Teach how to use and possible side
effects/interactions, increased risk for
skin impairment
Long term corticosteroid usage =
skin is thinner (especially on
forearem) and has purple
echymosis
2.
Describe the pressure ulcer staging system.

Stage I: Intact skin with non-blanchable redness. Darkly pigmented skin may not have visible blanching

Stage II: Partial thickness loss of dermis; shallow open ulcer, red pink wound bed, without slough. May present as intact
or open/ruptured bulla

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present. May include undermining
& tunneling

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some
parts of the wound bed. May include undermining & tunneling
3.
Differentiate primary, secondary and tertiary wound healing.
Healing by first intention - primary wound healing

Wound closed by approximation of margins or wound created & closed in the OR

First choice for clean, fresh well-vascularized wounds

Indications: onset <24h, clean, viable tissue, approximation of skin edges is achievable

Treated with: irrigation, débribement, margins approximated using simple methods

Scar depends on: initial injury, amount of contamination, accuracy of closure

Fastest healing & most cosmetically pleasing
Healing by second intention - secondary wound healing

Wound is left open & closed by epithelialization & myofibroblasts

Wound heals without surgical intervention

Indicated in infected or contaminated wound

Presence of granulation tissue

Complications: wound contracture & hypertrophic scarring
Healing by third intention - tertiary wound healing

4.
For managing wounds that:
o
bacterial count contraindicates primary closure
o
subsequent repair of a wound initially left open or not previously treated
o
a crush component with tissue devitalized
Complete the following.
Wound
Exudate Type
What is it?
Color?
Consistency
Serous
Serum or plasma
clear or
straw
watery
Purulent
Pus. Filled with
leuokocytes, dead
tissue, bacteria
(alive or dead)
green or
yellow
Thicker than serous
Serosanguineous
serum and
sanguineous(RBCs)
tends to
be light
red
moderately thin
RBCs
dark red
moderately thick, may have clots
Pus and blood
reddish?
thick
(ex, fluid in blister
or burn)
(seen in surgical
incisions)
Sanguineous
(seen in open
wounds)
Purosanguineous
(seen in new
wound that is
infected)
5.
Describe the difference between an arterial and a venous wound
Arterial (Insufficiency ulcers)
Wound Characteristics
remember..good arterial blood
flow!
Venous (stasis ulcers) MAINLY
BAD arterial blood flow

Ruddy color base

Pale base color when elevated

Shallow wound

Shiny, taut skin

Irregular margins

Punched out appearance


Minimal exudate
Moderate to heavy
exudate

Cool skin temperature

Warm skin temperature

Pain with rest & exercise

Minimal to severe pain

Pedal pulses diminished or absent

Pedal pulses present

Lateral

Medial
Nursing care
6.
Likely to have emboli, VET
incompetent venous valves
(varicose veins)
Describe ways the nurse can enhance wound healing.
Order special mattresses, reposition and turn clients regularly, moist wound healing, nutrition and fluids, prevent infection,
positioning
Untreated Wounds
o
Control bleeding by
o
applying direct pressure
o
elevating the extremity
o
Prevent infection by
o
Cleaning or flushing
o
Covering the wound with a clean dressing
o
If severe, assess for shock
Treated Wounds
o
Assess the wound, record drainage, measure the size, integrity of skin surrounding area, clinical signs of infection
7.
Identify assessment data pertinenet to skin integrity, pressure sores and wounds.

Location – related to a bony prominence

Type of wound – stage of ulcer

Size – in centimeters (length, width and depth in order). Insert sterile swab at the deepest part of the wound then
measure it against a measuring guide, undermining, tunneling

Wound bed – color and location of necrosis (dead tissue) or eschar. Healthy is pink.

Exudate – type, note color, amount

Odor – can indicate infection.

Wound margins – condition and integrity of surrounding skin. Approximated? Erythemic?

Pain – most of the time there is no sensation. Don’t normally medicate for wound care

Cause
8.
Write at least 2 nursing diagnoses, expected outcomes and interventions associated with impaired skin
integrity.
Risk for impaired skin integrity r/t urinary and fecal incontinence or r/t decreased mobility or r/t decreased nutrional intake.
Impaired skin integrity r/t impaired mobility, decreased nutrtional intake AEB stage II pressure ulcer
Imbalanced nutrition (less/more than body requirements) r/t increased intake, decreased absorption AEB weight loss or weight
gain
Risk for infection r/t a break in the skin
Pain, Acute or chronic r/t to the wound AEB pt complaint
Impaired physical mobility r/t increased BMI, decreased muscle tone AEB decreased movement in bed
Ineffective tissue perfusion r/t decresed Hgb hct AEB cool extremities
Sleep
1.
Briefly discuss mechanisms that regulate sleep.
Sleep regulation

Biological process. 24 hours cycle. Indoginous. (built in)

Internal clock.. hypothalamus. SCN. Reticular activating system to shut us off and turn us on
o
3-6 months old babies able to regulate sleep better

Circadian. Around the day

NREM – 80% of sleep
o
1- very light sleep. Couple of minutes. Might wake self back up at this time
o
2- light sleep. 10-15 minutes. HR, RR, BP all start decreasing
o
3- deep sleep
o
4- deep sleep (difference ¾ is the amount of delta waves) Paradoxcycal sleep (looks like awake on EEG)

Beta = highest frequency, awake. Theta = drowsy. Delta = asleep.

REM
o
Every 90 minutes. Lasts up to 30 minutes. More dreams.

4-5 sleep cycles a night. Most need this amount to wake up refreshed.

Each cycle consists of NREM and REM.

Even though we are asleep. We can still respond to meaningful stimuli (wake for child crying, fire alarm.. but will sleep
through sprinklers, garbage truck)
2.
Explain the functions of sleep and the effect it has on health and well-being.
Functions of sleep:

Not completely understood

Restores normal levels of activity and normal balance among parts of the nervous system

Necessary for protein synthesis, which allows repair processes to occue

Lack of sleep = become emotionally irritable, have poor concentration, and experience difficulty making decisions

Glial cells shrink while we are asleep.. they think that the CSF and lymph fluid can wash the brain out.
3.
Identify factors that affect sleep and related nursing assessments and interventions.

Illness – pain, COPD- difficulty lying down (become short of breath), women decreased estrogen making them more
restless, BPH and CHF have nocturia

Environment – too noisy or quiet, temperature (most people like it cooler), dark or too dark, comfortable: pillows,
blankets.

Lifestyle – shift work, irregular routines, travel a lot through different time zones

Emotional stress – norep stimulates CNS which makes it harder to go to sleep (stressing out before sleep over daily
life)

Stimulants and alcohol – caffeine and nicotine should be avoided 2-3 hours before bed. As well as ritalin, cocaine,
meth.

Diet – high BMI have a more difficult time falling asleep and staying asleep.

Smoking – stimulant. Smokers are light sleepers

Motivation – staying up all night for studying.. body eventually falls asleep

Medications – beta blockers have insomnia and bad dreams.. in the day time more sleep. Narcotics – decrease REM
sleep and make more drowsy in the day.

Insomnia is the number one sleep problem
o
Difficulty falling or staying asleep. More than 1 week is chronic. r/t stress and it is intermittent. Risk factors..
age stress and higher in females esp in menopause. Investigate their sleep patterns, environment, sleep
positively
Activity and Exercise
1.
Define the role of the nurse in activity and exercise.
Assessing: history, physical examination of body alignment, gait, appearance, and movement of joints, capabilities and limitations
for movement, muscle mass, and strength, activity tolerance, problems related to immobility, and physical fitness.
2.
Discuss the systemic effects of immobility.
Musculoskeletal system
●
disuse osteoporosis
○
without exercise, bones demineralize
●
Disuse atrophy
●
Contractures:
○
permanent shortening of the muscle
●
Stiffness and pain in the joints
○
ankylosed: permanently immobile
○
excess calcium deposited in joints.
CV system
●
Diminished cardiac reserve
○
reduces ANS balance, reduces heart’s capacity to respond to any metabolic demands above basal levels.
■
tachycardia with minimal exertion.
●
Increase use of the Valsalva maneuver
○
Valsalva maneuver: holding breath and straining against a closed glottis.
●
Orthostatic hypotension
●
Venous vasodilation and stasis
○
Immobile person: skeletal muscles no longer assist in pumping blood back to heart against gravity.
■
blood pools and causes vasodilation and engorgement.
■
valve incompetence
●
Dependent edema
●
Thrombus formation
Respiratory system
●
Decreased respiratory movement
○
intercostal joints become fixed in an expiratory phase of respiration, further limiting the potential for maximal
ventilation.
■
produces shallow breathing and reduced vital capacity (additional inhalation passed maximum
inhalation)
●
Pooling of respiratory secretions
●
Atelectasis
●
Hypostatic pneumonia
GI system
●
constipation due to decreased peristalsis + decreased abdominal and perineal muscles = impaction
●
embarrassment of using a bedpan leads to postponement of defecation leads to weakened and suppressed defecation
reflex
●
some clients use Valsalva maneuver excessively which increases intra-abdominal and thoracic pressure and places
stress on heart and circulatory system.
Metabolic system
●
Decreased metabolic rate
●
Negative nitrogen balance
○
negative balance between protein anabolism and catabolism
■
more catabolism of proteins than intake
●
Anorexia
○
decreased caloric intake due to decreased metabolic rate (less energy needed)
●
Negative calcium balance
○
greater amounts of calcium are extracted from bone than can be replaced
GU system
●
Urinary stasis
○
urine pools due to gravity
●
Renal calculi
○
calcium salts are no longer in balance and form stones.
●
Urinary retention
○
bladder distention and occasionally urinary incontinence
●
Urinary infection
○
static urine
○
improper perineal care/ indwelling catheter
○
urinary reflex (backward flow)
Integumentary system
●
Reduced skin turgor
●
Skin breakdown
Psychoneurological
●
●
●
●
3.
Decline in mood-elevating substances such as endorphins
Increased dependence on others
○
may lower person’s self-esteem
■
frustration and exaggerated emotional reactions
Decreased variety of stimuli
○
time perception deteriorates
○
problem-solving and decision making deteriorate due to lack of intellectual stimulation.
Anxiety
Describe the benefits of activity
●
●
●
●
●
●
●
●
Musculoskeletal system
○
Size, shape, tone, and strength of muscles are maintained with exercise and increased with strenuous exercise.
■
Strenuous exercise causes hypertrophy and increased efficiency of muscular contraction.
○
Exercise increases:
■
joint nourishment
■
joint flexibility
■
stability
■
ROM
○
Bone density and strength is maintained through weight-bearing and high-impact movements.
■
maintains balance between osteoblasts and osteoclasts.
CV system
○
increases strength of heart muscle contraction
○
increases blood supply to the heart and muscles
○
lowering BP
○
improved O2 uptake
○
improved HR variability
○
improved circulation
○
reduces stress
Respiratory system
○
Benefits:
■
improves gas exchange
■
increases toxin elimination through deeper breathing
■
improves O2 to brain
●
enhances problem solving and emotional stability
■
prevents pooling of secretions
■
decreases breathing effort and risk for infection
○
Special considerations:
■
LE exercise forms for treating COPD patients
■
yoga breathing and postures with asthma are helpful
GI system
○
Improves appetite
○
increases GI tract tone
○
facilitates peristalsis
○
can help relieve constipation
Metabolic/Endocrine system
○
increases metabolic rate
○
increases use of triglycerides and fatty acids
■
resulting in lower serum triglycerides, A1C levels, and cholesterol.
■
make cells more responsive to insulin
GU system
○
promotes efficient blood flow = excretion of bodily wastes more effectively.
○
prevents stasis of urine and therefore flushes out bacteria = less UTI
Immune system
○
exercise allows for lymph fluid to be more efficiently pumped through the lymphatic system.
○
moderate exercise enhances immunity, strenuous exercise may reduce immune function.
Psychoneurological System
○
exercise can elevate mode and relieve stress and anxiety.
○
MoA:
■
exercise increases levels of neurotransmitters
■
exercise increases levels of endorphins
■
increases level of O2 to brain inducing euphoria
■
muscular exertion releases stored stress associated with accumulated emotional demands.
○
Relaxation response (RR): physiological state that can be elicited through deep relaxation breathing with
emphasis on prolonged exhalation.
■
Emphasis on exhalation recruits PNS “rest and digest” reflex.
■
Progressive contraction and relaxation of muscles throughout body until feels relaxed.
●
4.
■
These can be done by anyone at anytime.
Cognitive function
○
Induces cells in brain to strengthen and build neuronal connections.
○
Enhances decision-making, problem-solving, planning, and paying attention.
○
Brain Gym and cross-lateral movements helpful to enhance cognitive functions.
■
Shown to help ADD< ADHD, learning disorders, and mood disorders.
Complete the following chart on the hazards of immobility:
Assessment
Problem
Desired
outcome
Interventions
Metabolic
*measure height and weight
*palpate skin
weight control,
self-care
Nutrition
Cardiovascular
*Auscultate the heart
*Measure BP
*Palpate and observe sacrum,
legs and feet
*Palpate peripheral pulses
*Measure calf muscle
circumferences
*Observe calf muscle for
redness, tenderness, and
swelling
Weight loss due to muscle atrophy and loss of
subQ fat.
Generalized edema due to low blood protein
levels
Increased HR
circulation
prevent complications of
immobility
Joint
movement,
activity,
mobility
ROM exercises, ambulate,
prevent complications of
immobility
Elimination
Foley, laxative
physiological
consequence
position appropriately, move and
turn clients in bed
resp status
incentive spirometer,cough and
deep breathing, position 30+
stress level,
self-care,
Coping strategies, stress relief,
meds
Musculoskeletal
Elimination
*Measure arm and leg
circumferences
*Palpate and observe body joints
*Take goniometric
measurements of joint ROM
*Measure fluid intake and output
*Inspect urine
*Palpate urinary bladder
*Observe stool
*Auscultate bowel sounds
Integumentary
*Inspect skin
Respiratory
*Observe chest movements
*Auscultate chest
Psychoneurological
*Observe behaviors, affect, and
cognition
*Monitor development skills in
children
Ortho. Hypotension
Periph. Edema
Weak periph pulses
Edema
Thombophlebitis
Decreased muscle mass
Stiffness or pain in joints
Decreased joint ROM, joint contractures
Dehydration
Cloudy, dark= ^SGrav
Distended bladder due to urinary retention
hard, dry small stool
decreased intestinal motility
Break in skin integrity
Asymmetric chest movements, dyspnea
Diminished breath sounds, crackles, weezes,
and ^resp rate
Anger, flat affect, crying, confusion, anxiety,
cog function .. sleep or appetite disturbances