Wound
1. Describe the differences in wounds healing by primary, secondary and tertiary
intention; and the phases of wound healing.
There are two types of wounds: those with loss of tissue and those without. A clean
surgical incision is an example of a wound with little tissue loss.
 Primary intention - Surgical wounds, sutured or stapled, are healed by primary
intention. The skin edges are approximated, or closed, and the risk of infection is
low. Healing occurs quickly, with minimal scar formation, as long as infection
and secondary breakdown is prevented.
 Secondary intention - A wound involving loss of tissue, such as a burn, pressure
ulcer, or severe laceration, heals by secondary intention. The wound is left open
until it becomes filled by scar tissue. It takes longer for a wound to heal by
secondary intention, and thus the chance of infection is greater. If scarring from
secondary intention is severe, there is often permanent loss of tissue function.
 Tertiary intention - Wound left open for several days, then wound edges are
approximated. Caused by wounds that are contaminated, and require observation
for signs of inflammation. Closure of wound is delayed until risk of infection is
resolved.
The three phases involved in the healing process of a full-thickness wound are
inflammatory, proliferative, and remodeling.
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

Inflammatory Phase – Body’s reaction to wound that begins within mins and lasts
3 days. Hemostasis makes platelets gather to stop bleeding, form clots and a fibrin
matrix to repair damaged tissue. Cells secrete histamine, resulting in redness,
edema, warmth, and throbbing. WBCs clean wound, and then collagen begins to
form scar tissue. In a clean wound the inflammatory phase accomplishes control
of bleeding and establishes a clean wound bed.
Proliferative Phase - Begins and lasts from 3 to 24 days. The main activities
during this phase are the filling of the wound with granulation tissue, contraction
of the wound, and the resurfacing of the wound by epithelialization. Wound
contracts to reduce the area that requires healing. In a clean wound the
proliferative phase accomplishes the following: the vascular bed is reestablished
(granulation tissue), the area is filled with replacement tissue (collagen,
contraction, and granulation tissue), and the surface is repaired (epithelialization).
Remodeling – 3 weeks to sometimes taking place for more than a year, depending
on the depth and extent of the wound. The collagen scar continues to reorganize
and gain strength for several months. However, a healed wound usually does not
have the tensile strength of the tissue it replaces. Collagen fibers undergo
remodeling or reorganization before assuming their normal appearance. Usually
scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color
than normal skin.
2. Describe complications of wound healing and the usual time of occurrence.
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


Hemorrhage - Bleeding from a wound site. Hemostasis occurs within several
minutes unless large blood vessels are involved or the client has poor clotting
function. Hemorrhage occurring after hemostasis indicates a slipped surgical
suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object
(e.g., a drain). Observe all wounds closely, particularly surgical wounds, in which
the risk of hemorrhage is great during the first 24 to 48 hours after surgery or
injury.
 Internal bleeding by looking for distention or swelling of the affected body
part, a change in the type and amount of drainage from a surgical drain, or
signs of hypovolemic shock. External bleeding is obvious because the
dressings covering the wound have bloody drainage.
Infection - Wound infection is the 2nd most common health care–associated
infection (nosocomial). Purulent material drains from it, even if a culture is not
taken or has negative results. Positive culture findings do not always indicate an
infection because many wounds contain colonies of noninfective resident bacteria.
Wounds with more than 100,000 (105) organisms per gram of tissue are infected.
The chances of wound infection are greater when the wound contains dead or
necrotic tissue, there are foreign bodies in or near the wound, and the blood
supply and local tissue defenses are reduced. Some contaminated or traumatic
wounds show signs of infection early, within 2 to 3 days. A surgical wound
infection usually does not develop until the 4th or 5th postoperative day.
 Fever, tenderness and pain at the wound site, and an elevated white blood
cell count. The edges of the wound appear inflamed. If drainage is present,
it is odorous and purulent, which causes a yellow, green, or brown color,
depending on the causative organism.
Dehiscence - The partial or total separation of wound layers when wound is not
healing properly. Most commonly occurs before collagen formation (3 to 11 days
after injury). A strategy to prevent dehiscence is to use a folded thin blanket or
pillow placed over an abdominal wound when the client is coughing. This
provides a splint to the area, supporting the healing tissue when coughing
increases the intraabdominal pressure.
 At risk for dehiscence: poor nutritional status, infection, or obesity.
Dehiscence involves abdominal surgical wounds and occurs after a sudden
strain, such as coughing, vomiting, or sitting up in bed. Clients often
report feeling as though something has given way. Increase in
serosanguineous drainage from a wound; be alert for the potential for
dehiscence.
Evisceration - Protrusion of visceral organs through a wound opening. The
condition is an emergency that requires surgical repair. When evisceration occurs,
the nurse places sterile towels soaked in sterile saline over the extruding tissues to

reduce chances of bacterial invasion and drying of the tissues. If the organs
protrude through the wound, blood supply to the tissues is compromised.
 Do not allow the client anything by mouth (NPO), observe the client for
signs and symptoms of shock, and prepare the client for emergency
surgery.
Fistulas - An abnormal passage between two organs or between an organ and the
outside of the body. Fistulas increase the risk of infection and fluid and electrolyte
imbalances from fluid loss. Chronic drainage of fluids through a fistula also
predisposes a person to skin breakdown.
 Most fistulas form as a result of poor wound healing or as a complication
of disease, such as Crohn's disease. Trauma, infection, radiation exposure,
and diseases such as cancer will prevent tissue layers from closing
properly and allow the fistula tract to form.
3. Explain the factors that impede or promote wound healing.
Intrinsic:
 Age - Increased age affects all phases of wound healing. A decrease in the
functioning of the macrophage leads to a delayed inflammatory response, delayed
collagen synthesis, and slower epithelialization.
 Nutritional Status - Deficiencies in any of the nutrients result in impaired or
delayed healing. Physiological processes of wound healing depend on the
availability of protein, vitamins (especially A and C), and the trace minerals zinc
and copper. Collagen is a protein formed from amino acids acquired by
fibroblasts from protein ingested in food. Vitamin C is necessary for synthesis of
collagen. Vitamin A reduces the negative effects of steroids on wound healing.
 Body Composition - Obese clients have a higher risk for complication because of
the constant strain placed on their wounds and the poor healing qualities of fat
tissue.
 Chronic Diseases - Patients with peripheral vascular disease are at risk for poor
tissue perfusion because of poor circulation. Oxygen requirements depend on the
phase of wound healing (e.g., chronic tissue hypoxia is associated with impaired
collagen synthesis and reduced tissue resistance to infection). Body extremities
are less sensitive to temperature and pain stimuli because of circulatory
impairment and local tissue injury, diabetic neuropathy.
Extrinsic:
 Infection - Wound infection prolongs the inflammatory phase; delays collagen
synthesis; prevents epithelialization; and increases the production of
proinflammatory cytokines, which leads to additional tissue destruction.
 Drug Therapy and Radiation – Risk of delayed or poor wound healing.
 Mobility - Patients unable to independently change positions are at risk for
pressure ulcer development.
 Smoking and Alcohol Intake - Patients with a history of excessive alcohol
ingestion are often malnourished, which delays wound healing.
 Type of Wound – Surgical, pressure sore, etc.
4. Identify different types of wound drainage, wound drainage systems and how to
empty a wound drainage device.
Serous - Clear, watery plasma
Purulent - Thick, yellow, green, tan, or brown
Serosanguineous - Pale, pink, watery; mixture of clear and red fluid
Sanguineous - Bright red; indicates active bleeding
Evacuator units such as a Hemovac or Jackson-Pratt exert a constant low pressure as long
as the suction device (bladder or container) is fully compressed. They are convenient
portable units that connect to tubular drains lying within a wound bed and exert a safe,
constant, low-pressure vacuum to remove and collect drainage. These types of drainage
devices are often referred to as self-suction. When the evacuator fills, measure output by
emptying the contents into a graduated cylinder and immediately reset the evacuator to
apply suction.
A Penrose drain lies under a dressing; at the time of placement a pin or clip is placed
through the drain to prevent it from slipping farther into a wound.
Unexpected findings:
 Poorly Approximated Edges
 Drainage after 3 Days
 Odor
 No Epithelialization of Edges
 Necrotic Tissue
 Exudate/Purulent Drainage
 Tissue bed excessively moist or dry
 Presence of Fistula
5. Identify various types of dressings, their purpose, and how to apply and secure
various types of dressings.
The dressing type depends on the assessment of the wound and the phase of wound
healing. For surgical wounds that heal by primary intention, it is common to remove
dressings as soon as drainage stops. In contrast, when dressing a wound healing by
secondary intention, the dressing material becomes a means for providing moisture to the
wound or assisting in debridement.
A dressing serves several purposes:
• Protects a wound from microorganism contamination
• Aids in hemostasis
• Promotes healing by absorbing drainage and debriding a wound
• Supports or splints the wound site
• Protects patients from seeing the wound (if perceived as unpleasant)
• Promotes thermal insulation of the wound surface
• Provides a moist environment
Most surgical gauze dressings have three layers: a contact or primary layer, an absorbent
layer, and an outer protective or secondary layer.
Wet to Dry Dressing - Mechanical Debridement
Dry Dressing - Protective
Transparent film dressing –
 Promotes moist environment
 Provides Direct Visualization
 Provides Barrier while allowing to wound to “breathe”
Hydrocolloid dressing –
 Adhesive and occlusive
 Gel molds to wound
 Auto debridement
Hydrogel dressing –
 Debrides the wound
 Soothes and Reduces Pain
 Conforms to wound size
Securing dressings  Adhesive Tape
 Latex Allergy
 Removal
 Montgomery Straps
 Gauze Roll
 Elastic Mesh
6. Determine what is appropriate and inappropriate to delegate regarding dressing
changes and wound management.
The NAP CAN:
 Apply Supportive Devices
 Delegation involves client observation and communication:
 Overall appearance of wound
 Level of pain
 Drainage from wound
 Mobility/Activity Level
 Use clean technique in keeping wound clean from body fluids or contamination
7. Discuss the risks and contributing factors to pressure ulcer formation.
Prolonged
Pressure
Impaired Blood
Flow
Impaired Cellular
Function
Tissue Ischemia
Tissue Death
Clients at Increased Risk:
 Impaired Mobility
 Advanced Age
 Decreased Sensory Perception
 Altered Level of Consciousness
 Bladder and/or Bowel Incontinence
 Poor Nutritional Status
 Chronic Illness
8. List the four stages of pressure ulcers.
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Stage I - Skin Intact, Non-blanching redness
Stage II - Partial thickness skin loss
Stage III - Full Thickness skin loss
Stage IV - Full Thickness skin loss with bone, muscle, tendons visible
Unstage-able - Wound bed cannot be visualized
9. Identify prevention strategies for pressure ulcers.
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
Identify at-risk population
Skin Assessment
 Baseline and per set schedule
 Visual Appearance
Ventilation
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The process of moving gases into and out of the
 Attention to pressure points
 Documentation
 Cannot be Delegated
Risk Assessment Scales
 Norton Scale
 Braden Scale (Focuses on LTC population)
Observation and Assessment
 Protective Skin Care
 Schedule Repositioning
 Support Surfaces
Nutrition
Education
Oxygenation
lungs
Perfusion
The ability of the cardiovascular system to pump
oxygenated blood to the tissues and return
deoxygenated blood to the lungs
Diffusion
Exchange of respiratory gases in the alveoli and
capillaries
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
Inspiration - is an active process, stimulated by chemical receptors in the aorta.
Expiration - is a passive process that depends on the elastic recoil properties of the
lungs, requiring little or no muscle work.
Hyperventilation
Ventilation in excess of that required to
eliminate carbon dioxide produced by
cellular metabolism
Hypoventilation
Alveolar ventilation inadequate to meet the
body’s oxygen demand or to eliminate sufficient
carbon dioxide
Hypoxia
Inadequate tissue oxygenation at the
cellular level
Cyanosis
Blue discoloration of the skin and mucous
membranes
4 factors affecting oxygenation: Physiological, Developmental, Lifestyle, Environmental
Causes of hypoxia: (1) a decreased hemoglobin level and lowered oxygen-carrying
capacity of the blood; (2) a diminished concentration of inspired oxygen, which occurs at
high altitudes; (3) the inability of the tissues to extract oxygen from the blood, as with
cyanide poisoning; (4) decreased diffusion of oxygen from the alveoli to the blood, as in
pneumonia; (5) poor tissue perfusion with oxygenated blood, as with shock; and (6)
impaired ventilation, as with multiple rib fractures or chest trauma.
Signs & symptoms of hypoxia: apprehension, restlessness, inability to concentrate,
decreased level of consciousness, dizziness, and behavioral changes. The patient with
hypoxia is unable to lie flat and appears both fatigued and agitated. Vital sign changes
include an increased pulse rate and rate and depth of respiration.
1. Describe the impact of a client's level of health, age, lifestyle, and environment
on tissue oxygenation.
AGE:
• Infants and toddlers: upper respiratory infections (URIs), nasal congestion
•
•
•
School-aged children and adolescents: exposed to respiratory infections and
secondhand smoke; plus danger of starting cigarette smoking
Young to middle-aged adults: exposed to cardiopulmonary factors, unhealthy diet,
lack of exercise, stress, cigarette smoking, illegal substances; over-the-counter
(OTC) and prescription drugs not used as intended
Older adults: calcification of valves, SA node, and costal cartilages; osteoporosis;
atherosclerosis; enlarged alveoli, trachea, and bronchi.
LIFESTYLE:
Nutrition
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
•
•
Cardioprotective nutrition = Diets rich in fiber; whole grains; fresh fruits and vegetables; nuts;
antioxidants; lean meats; and omega-3 fatty acids.
Severe obesity decreases lung expansion, and increased body weight increases tissue oxygen demands.
Patients who are morbidly obese and/or malnourished are at risk for anemia.
Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon
dioxide retention.
Exercise
People who exercise for 30 to 60 minutes daily have a lower pulse rate and blood pressure, decreased
cholesterol level, increased blood flow, and greater oxygen extraction by working muscles.
 Thus those who do not exercise have higher pulse rates, blood pressures, and cholesterol levels; lower
blood flow; and lower oxygen extraction.
•
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
Smoking
 Associated with heart disease, COPD, and lung cancer
 The risk of lung cancer is 10 times greater for a person who smokes than for a
nonsmoker.
 Secondhand smoke is dangerous.
 Worsens peripheral vascular and coronary artery diseases.
Substance abuse
 Excessive use of alcohol and other drugs impairs tissue oxygenation.
Stress
 A continuous state of stress or severe anxiety increases the metabolic rate and
oxygen demand of the body.
 The body responds to anxiety and other stresses with an increased rate and
depth of respiration. Most people adapt, but some, particularly those with
chronic illnesses or acute life-threatening illnesses such as an MI, cannot
tolerate the oxygen demands associated with anxiety.
ENVIORNMENTAL:
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The incidence of pulmonary disease is higher in smoggy, urban areas than in rural
areas.
A patient’s workplace sometimes increases the risk for pulmonary disease.
 Coccidioidomycosis (Fungal disease caused by inhalation of spores, mostly
farmers.)
 Asbestosis (Lung disease that develops after exposure to asbestos. Are at risk
for developing lung cancer, and this risk increases with exposure to tobacco
smoke.)
 Talcum powder
 Dust
 Airborne fibers
2. Identify nursing care interventions in the primary care, acute care, and
restorative and continuing care settings that promote oxygenation.
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Vaccinations
 Influenza (children 6 months and older, those with chronic illnesses, healthcare
workers)
 Pneumococcal (over 65, at risk for pneumonia, those with chronic illnesses or
immunosuppression)
Healthy lifestyle
 Eliminating risk factors, eating right, regular exercise
Environmental pollutants
 Eliminating secondhand smoke, work chemicals, and pollutants (workers can
wear filter mask)
ACUTE:
• Dyspnea is difficult to measure and treat. Treatments are individualized, and more
than one therapy can be implemented. Breathing exercises improve ventilation,
oxygenation, and sensations of dyspnea.
• Airway maintenance requires mobilization of secretions by increased fluid intake,
humidification, or nebulization. The airway is patent when the trachea, bronchi,
and large airways are free from obstructions. Proper coughing techniques will
help to keep the airway patent and free from obstruction. The ability of a patient
to mobilize pulmonary secretions makes the difference between a short-term
illness and a long recovery involving complications. In patients with adequate
hydration, pulmonary secretions are thin, white, watery, and easily removable
with minimal coughing.
• Humidification is necessary for patients receiving more than 4 L/min of oxygen.
Bubbling oxygen through water adds humidity to oxygen.
• Nebulization adds moisture or medications to inspired air by mixing particles of
varying sizes with the air.
• Directed coughing is a deliberate maneuver that is effective when spontaneous
coughing is not adequate.
•
•
Diaphragmatic breathing/belly breathing is a technique that encourages deep
breathing to increase air to the lower lungs.
Chest physiotherapy is a group of therapies used to mobilize pulmonary
secretions. These include postural drainage, chest percussion, and vibration. You
will want to work collaboratively with respiratory therapists when using these
techniques.
3. Identify clinical indications that suggest the need for oral or tracheal suctioning.
Need based upon assessment and response of pathological condition:
1. Inspection of secretions
2. Auscultation of adventitious breath sounds in atypical locations
3. Routine q 1 to 2 hour suctioning not indicated
4. Can result in desaturation (lowering of oxygen)
Frequent procedure may result in:
Cardiac arrhythmias
Hypotension
Hypoxia
Airway trauma
Increased respiratory rate
Increased pulse
Increase blood pressure
Dyspnea
Adventitious breath sounds
Nasal secretions
Drooling
Gastric secretions/vomitus in mouth
Decreases in SaO2
Anxiety/apprehension
Behavior change/irritability
Pallor/cyanosis
Oropharyngeal
Nasopharyngeal
Nasotracheal
Secretions
removed from:
Posterior oral cavity
Posterior oral cavity
Lower airway
Sterile technique?
No
No
Yes
Cough Intact
Yes
No
No
Device
Tonsillar
suction
Size 5-12 Fr tube
Size 5-12 Fr tube
Measurement
tip
rigid
Nose>earlobe>sternal notch
4. Identify 3 parts of a tracheostomy tube.



Oral airway
 Prevents obstruction of the trachea by displacement of the tongue into the
oropharynx
Endotracheal and tracheal airways
 Short-term use to ventilate, relieve upper airway obstruction, protect against
aspiration, clear secretions
Tracheostomy
 Long-term assistance, surgical incision made into trachea
Tracheostomy - Artificial surgical opening into the trachea
 Temporary
 Prolonged mechanical ventilation
 Secretions which cannot be cleared routinely
 Permanent
 Disease (trauma, laryngeal cancer) that will permanently affect airway
Parts of a Tracheostomy:
 Outer Cannula
 Keeps stoma open
 Is never removed!!!
 May be secured with trach ties
 Inner Cannula
 Removed for cleaning
 May be disposable
 Obturator
 Used to insert trach tube
 ALWAYS KEEP AT BEDSIDE IN THE EVENT OF ACCIDENTAL
TRACH DISLODGEMENT
5. Differentiate between cuffed and uncuffed tracheal tubes.
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
Cuffed trach tube:
 Prevents aspiration
 Must check cuff pressure regularly to avoid over inflation
 Cuff pressure should not exceed 20 mmHg
Uncuffed trach tube:
 Children
6. Discuss safety precautions for the client with a tracheostomy.
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
Preventing Accidental Tracheostomy Dislodgement
 Keep replacement tube of equal or smaller size at bedside
 Have obturator immediately available at bedside
 Emergency equipment available at bedside including oxygen and manual
resuscitator
 Use assistance to stabilize trach tube when changing trach ties
Emergency Management of Dislodgement
 Call for help
 Place head of bed at 45°
 Insert obturator into new trach (if available) or dislodged trach
 Lubricate with water soluble lubricant
 Insert tube at 45° angle to neck
 If unsuccessful, place suction catheter into stoma to allow for air entry
 If still unsuccessful, cover stoma and use bag-valve-mask to ventilate
7. Explain sterile open tracheal suctioning and tracheostomy care.
Performed every 8 to 12 hours to remove secretions and provide skin care to stoma.

Clinical Indications:
 Soiled/loose tracheostomy ties or tracheostomy dressing
 Unstable tracheostomy tube
 Excessive secretions

Document:
 Type and size of trach tube
 Frequency and extent of care
 Client tolerance
 Any complications
8. Differentiate between various oxygen delivery masks and describe proper use
and remaining interventions to promote oxygenation.
An oxygen mask is a device used to administer oxygen, humidity, or heated humidity. It
fits snugly over the mouth and nose and is secured in place with a strap. There are two
primary types of oxygen masks: those delivering low concentrations of oxygen and those
delivering high concentrations.

Nasal Cannula
 Flow rate up to 6 L/min
 >4L/min causes airway drying; requires humidifier
 >4L/min does not significantly increase % oxygen delivery



 Monitor nares and ears for skin breakdown q 8 hr
Simple Face Mask
 Administers oxygen, humidity or heated humidity
 Short term use
 Low flow oxygen
 Delivers concentrations of 30 to 60%
 Contraindicated in clients with carbon dioxide retention (ie: COPD)
Non-rebreather Mask
 Face mask with reservoir
 High concentration of oxygen
 May deliver 80-90% oxygen with flow rate of 10 L/min
 Nurse must ensure bag is inflated; does not collapse on expiration
Venturi Mask
 Capable of delivering higher oxygen concentrations
 Delivers concentrations of 24 to 55% with oxygen flow rates of 2 to 14 L/min
 Flow control meter
O2 Device
O2 Flow Rate
FIO2
Advantages
Disadvantages
Nasal
Cannula
1-6 L/min
24-44%
Safe-simple
Easily tolerated
Inexpensive
Can’t use with nasal obstruction
Drying
FI02 changes with breathing pattern
Plastic Face
mask with
reservoir bag
(NRM)
6+ L/min
60-95%
High
concentrations
of oxygen
Risk of suffocation
Uses o2 supply fast
No humidity
Venturi
Mask
4-12 L/min
Follow
directions
24-60%
Controls
O2
concentration
Use humidity
Interferes with eating/talking
•
•
•
Cardiac rehab helps the patient to achieve and maintain an optimal level of health.
Maintenance of adequate systematic hydration helps to keep mucus clear, to thin
and water it down. Unless otherwise noted, a patient should have water intake of
1500 to 2000 mL/day.
Numerous coughing techniques can be used to help the patient maintain a patent
airway.
 Cascade cough: the patient takes a slow, deep breath and holds it for 2
seconds while contracting expiratory muscles. The patient opens the mouth
and performs a series of coughs throughout exhalation, progressively lowering
lung volumes
 Huff cough: the patient simulates a natural cough reflex that is effective for
clearing the airway
•
•
 Quad cough: patients without abdominal muscle control use this while
breathing out with a maximal effort
Pursed-lip breathing: deep inspiration and prolonged expiration through pursed
lips to prevent alveolar collapse
Diaphragmatic breathing: requires the patient to relax intercostal and accessory
muscles while taking deep inspirations
Bowel Elimination
1. Discuss normal age-related changes in the GI tract.
Infant: Have a small stomach capacity and less secretion of digestive enzymes. Food
passes quickly through an infant's intestinal tract because of rapid peristalsis. The infant
is unable to control defecation because of a lack of neuromuscular development. This
neuromuscular development usually does not take place until 2 to 3 years of age.
Older Adults: Systemic changes in the function of digestion and absorption of nutrients
result from changes in older patients’ cardiovascular and neurological systems rather than
their GI system. For example, arteriosclerosis causes decreased mesenteric blood flow,
thus decreasing absorption from the small intestine. In addition, peristalsis decreases, and
esophageal emptying slows. Older adults often experience changes in the GI system that
impair digestion and elimination. Older adults also lose muscle tone in the perineal floor
and anal sphincter.
2. Discuss physiological/psychological factors that influence the elimination process
and nursing measures that promote normal elimination.
Normal Elimination:
 Hydration
 Eases passage of intestinal contents
 1400-2000ml/day
 Fiber
 Provides “bulk”
 High fiber foods
Inhibitors:
 Dietary Intolerance
 Lactose
 Gluten
 Celiac Disease
 Autoimmune disorder
 Privacy
 Work/School
 “Stage fright”
 Psychological
 Depression
 Personal Habits
 Physical Ability
 Co-Morbidities/conditions
 HTN/CHF
 Parkinson’s, spinal cord injury, chronic bowel disease, pain, pregnancy
 Medications
 Polypharmacy
3. Describe the nursing implications for common diagnostic examinations of the GI
tract.




Fecal occult blood
 Hemoccult
Blood tests
 Pancreatic disease
 Elevated Amylase
 Carcino-embryonic antigen (CEA)
 Liver disease
 Elevated Total bilirubin
 Elevated Alkaline phosphatase
Plain x-ray
Upper GI: Barium Swallow
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Lower GI: Barium Enema
Ultrasound
Computerized Tomography Scan
Magnetic Resonance Imaging
Enteroclysis
Endoscopy
Colonoscopy
Flexible Sigmoidoscopy
4. Describe
common
physiological
alterations
in
elimination
and
utilize critical thinking in the provision of care to clients with alterations in
bowel elimination.
Constipation
A symptom, not a disease; infrequent stool
and/or hard, dry, small stools that are difficult
to eliminate
Impaction
Results from unrelieved constipation; a collection of
hardened feces wedged in the rectum that
a person cannot expel
Diarrhea
an increase in the number of stools and the
passage of liquid, unformed feces
Incontinence
Inability to control passage of feces and gas to the
anus
Flatulence
Accumulation of gas in the intestines causing
the walls to stretch
Hemorrhoids
Dilated, engorged veins in the lining of the rectum
Nursing Assessments:
 Nursing history
 Physical assessment
 Dietary intake
 Medication Review
 Laboratory tests
 Diagnostic exams
 Elimination “routines” or schedule
 Daily activity
 Collaboration of health team and family
5. Discuss indications for a NG tube; the various types of NG tubes; and how to
insert and maintain an NG tube for gastric decompression.

Purpose
 Decompression


 Compression
 Lavage
 Enteral feedings; medication administration
Risks
 Aspiration of gastric contents
 Trauma
 Fluid and Electrolyte imbalance
Contraindications to NG insertion
 Head, facial or neck trauma
 Suspicion/history of alcoholism
 Recent nasal surgery
Salem Sump:
•
•
•
•
Double lumen
Sump
 Air vent (blue pigtail)
Indications
 Gastric decompression
 Lavage
Advantage
 Does not adhere to gastric mucosa
Levin Tube:
•
•
•
Single lumen
No pigtail air vent
Indications
 Gastric decompression
 Enteral tube feeding
How to Insert NG Tube:







Provider order
Hand Hygiene
Inform client what to expect
Measure for correct length
Client positioning
Verify tube placement
 Ask client to talk
 Inspect posterior pharynx for coiled tube
 Chest x-ray confirmation
 Air bolus: Auscultate over stomach
Aspirate syringe to obtain gastric content
 Observe color of gastric secretions
 Measure pH of contents
 Should be pH of 4 or less for gastric contents
 pH of 5.5 or greater is associated with respiratory secretions
Ongoing Nursing Care:
 Anchor tube securely
 Attach to suction as ordered
 Pigtail of Salem sump is always kept elevated
 Proper patient positioning; comfort
 Initiate NPO status; monitor I+O’s
 Provide frequent mouth/nares care (q 2 hr)

Assess GI and Respiratory status
6. Discuss indications and proper method of administering a cleansing enema.
Cleansing enemas promote the complete evacuation of feces from the colon. They act by
stimulating peristalsis through the infusion of a large volume of solution or through local
irritation of the mucosa of the colon. They include tap water, normal saline, soapsuds
solution, and low-volume hypertonic saline. Each solution has a different osmotic effect,
influencing the movement of fluids between the colon and interstitial spaces beyond the
intestinal wall. Infants and children receive only normal saline because they are at risk for
fluid imbalance.

Promote defecation
 Constipation, impaction
 Diagnostic/surgical prep

Types
 Isotonic (NS Enema), hypertonic (Fleet Enema), hypotonic (Tap water)
 Soap suds, oil retention
7. Discuss nursing care measures required to care for clients with a bowel diversion
including instruction on the proper procedure for pouching an ostomy.



Ostomies require a pouch to collect fecal material. An effective pouching system
protects the skin, contains fecal material, remains odor free, and is comfortable
and inconspicuous. A person wearing a pouch needs to feel secure in participating
in any activity.
Many pouching systems are available. To ensure that a pouch fits well and meets
the client's needs, consider the location of the ostomy, type and size of the stoma,
type and amount of ostomy drainage, size and contour of the abdomen, condition
of the skin around the stoma, physical activities of the client, client's personal
preference, age and dexterity, and cost of equipment. A wound ostomy continence
nurse (WOCN) is a nurse specially educated to care for ostomy clients; the
WOCN collaborates with staff nurses to be sure the client uses the correct
pouching system. For example, referral to a WOCN is appropriate when planning
the care of a client who has a high-output ostomy that requires a pouch
modification.
A pouching system consists of a pouch and skin barrier. Some pouching systems,
such as Squibb-ConvaTec, Hollister, Coloplast, and Smith & Nephew, are
attached to the client's skin from the product's adhesive surface, whereas other
pouching systems, such as VIP, are nonadhesive systems. Pouches come in one-
and two-piece systems that are disposable or reusable. Some pouches have the
opening precut by the manufacturer; others require the stoma opening to be
custom cut to the client's specific stoma size.
Urinary Elimination
1. Identify factors that commonly influence urinary elimination and common GU
alterations.
Normal adult urine output averages 1200 to 1500 mL/day.


Brain structures influence bladder function
 Voluntary
 Involuntary
Voiding
 Bladder contraction + Urethral sphincter and pelvic floor muscle relaxation
 Stretching of bladder wall
 Signals sent to the brain
o Voluntary response: void or ignore
 When ready to void
o external sphincter relaxes
o detrusor muscle contracts
o bladder empties
Factors Affecting Elimination:

Disease Processes
 Those affecting urine volume and quality
 Pre-renal
o Impaired blood flow to and through kidneys
 Renal
o Kidney disease
• ESRD (End stage renal disease) and Uremic Syndrome
 Post-renal
o Obstruction/impaired lower urinary tract
 Those impairing mobility
 Neuromuscular
 Joint disease
 Spinal cord injury
 Those impairing continence
 Decreased sensation
 Loss of voluntary control




Fluid Balance
Surgical Procedures
Diagnostic Procedures
Foods
 Color change and odor
 Beets, berries, asparagus
Medications
 Diuretics
 Antihistamines
 Anticholinergics
Sociocultural factors
 Privacy/access
 Alcohol and caffeine intake
Psychological factors
 Anxiety
 Stress



GU Alterations:
 Urinary Retention
 An accumulation of urine due to the inability of the bladder to completely
empty
 Urinary Incontinence
 Involuntary leakage of urine
2. Explain how to obtain a nursing history for a client with urinary elimination
problems.
Skin and Mucosal Membranes
Assess:
-Hydration
-Skin breakdown
Kidneys
Flank pain may occur with infection or
inflammation
Bladder
Distended bladder rises above
symphysis pubis
Urethral Meatus
Observe for:
-Discharge
-Inflammation
-Lesions
3. Describe characteristics of normal and abnormal urine.
Normal Urine:
 Color
 Pale-straw to amber color
 Odor
 Ammonia in nature
 Clarity
 Transparent unless pathology is present
 Amount
 Intake and output
 Graduated cylinder for EACH client
 Output: 1200 – 1500 mL/day
Abnormal Urine:
 Color
 Bleeding from the kidneys or ureters causes urine to become dark red;
bleeding from the bladder or urethra causes a bright red urine. Various
medications and foods also change urine color. For example, Pyridium, a
urinary analgesic, colors the urine bright orange. Eating beets, rhubarb, or
blackberries causes red urine. Special dyes used in intravenous diagnostic
studies eventually discolor urine. Dark amber urine is the result of high
concentrations of bilirubin caused by liver dysfunction. Document and report
any abnormal color or sediment, especially if the cause is unknown.
 Odor
 Stagnant urine has an ammonia odor, which is common in clients who are
repeatedly incontinent. A sweet or fruity odor occurs from acetone or
acetoacetic acid (by-products of incomplete fat metabolism) seen with
diabetes mellitus or starvation.
 Clarity
 Urine that stands in a container becomes cloudy. Freshly voided urine in
clients with renal disease will appear cloudy or foamy because of high protein
concentrations. Urine also appears thick and cloudy as a result of bacteria and
white blood cells.
 Amount
 Output diminished (Oliguria), 40 mL/24hrs
4. Describe the nursing implications of common diagnostic tests of the urinary
system.


Pre-test considerations
 Consent
 Allergies
 Bowel prep
 Fluid restrictions
 Anesthesia/sedation
Post-test considerations
 Assessing I&O
 Observing characteristics of urine (color, clarity, presence of blood)
 Encouraging fluid intake, especially if using radiopaque dye
5. Identify nursing diagnoses appropriate for clients with alterations in urinary
elimination and measures to promote normal micturation and reduce episodes of
incontinence.
Nursing Diagnosis’s:
 Social isolation
 Disturbed body image
 Urinary incontinence (functional, stress, urge, overflow)
 Pain (acute, chronic)
 Risk for infection
 Toileting self-care deficit
 Impaired skin integrity
 Impaired urinary elimination
 Constipation
 Urinary retention
Plan:
The plan of care for urinary elimination alterations must include realistic and
individualized goals along with relevant outcomes. The nurse and the patient need to
collaborate in setting goals and outcomes and ultimately in choosing nursing
interventions. A general goal is often normal urinary elimination; but sometimes the
individual goal differs, depending on the problem. The goals are short or long term. For
example, urinary retention following surgery requires a short-term goal: “Patient will
have normal voiding with complete bladder emptying within 24 hours.” Relevant
expected outcomes for this goal include the following:
 Patient will void within 4 hours.
 Urinary output of 300 mL or greater will occur with each voiding.
 Patient's bladder is not distended to palpation.
Make sure that goals are reasonably achievable and relevant to the patient's situation.
6. Discuss nursing measures to reduce urinary tract infection.
Urinary Tract Infection:
 Bacteria
 Enters the ascending urethra
 Most common health care related infection
 40% of all HAI’s
How they happen:
 Hospital acquired UTI result from:
 E. coli most common bacteria
 Poor hand hygiene
 Improper catheter care
 Improper catheterization technique
 Catheterization
 Perineal care
Prevention:
 Teaching
 Maintain normal elimination practices & habits
 Adequate fluid intake
 Promote complete bladder emptying
 Acidify urine
One of the most important considerations is to prevent infection of the urinary system.
Good perineal hygiene that includes cleaning the urethral meatus after each voiding or
bowel movement is essential. A minimal daily fluid intake of 1200 to 1500 mL dilutes
urine, promotes regular micturition, and flushes the urethra of microorganisms. Voiding
after intercourse; not using excessive soap or taking bubble baths; wearing cotton
underwear; and drinking enough fluids, especially fluids high in acid ash such as apple or
cranberry juice help prevent UTI.
Tips for prevention for patient with catheter:
 Hand hygiene.
 Spigot does not touch anything
 Use sterile tech to collect specimens
 Do not touch ends of catheter
 If tube accidently disconnects, clean before reconnect
 Urine measure device for EACH client
 Drainage bag below bladder
 Drain all urine from tubing to drainage bag when ambulating
 Avoid prolonged kinking or clamping of the tubing.
 Empty drainage bag <8 hrs
 Encourage fluid intake
 Cranberry juice



Remove catheter ASAP
Tape or secure the catheter
Perineal hygiene per agency policy (q 4-8 hr) and after defecation
When to clean:
 Pericare and cleansing first 4” of catheter
 Every 8 hours or less
 After defecation
7. Explain technique for inserting and caring for sterile urinary catheters, and how
to obtain urine specimens.
Condom Catheters:
 Incontinent Male
 Comatose Male
 Spontaneous and complete emptying of bladder
 Non-invasive, external device
 Non Sterile
Straight Catheters:
 Single use
 Intermittent bladder drainage
Foley Catheters:
 Remains in place
 Continuous drainage
 Indwelling
Indwelling Triple Lumen:




Removes blood, pus or sediment from obstructing bladder
Measurement of urine output
Catheter irrigations and instillations
Healthcare provider order
Sizes:
• French
• Larger the number, the larger the lumen
• Use the smallest size possible
 Various sizes
 Infants
5-6 Fr
 Children
8-10 Fr
 Young Girl
12 Fr
 Women
14-16 Fr
 Men
16-18 Fr
Urine Specimens for Catheters:
 Specimen can be collected from drainage bag ONLY WHEN IMMEDIATELY
inserted
 Do not puncture balloon lumen
 Needle-free system
 Cannot be Delegated
Nutrition
1. Discuss nursing diagnoses related to nutritional problems.






Risk for aspiration
Diarrhea
Deficient knowledge
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: more than body requirements
Risk for imbalanced nutrition: more than body requirements



Readiness for enhanced nutrition
Feeding self-care deficit
Impaired swallowing
2. Compare and contrast various therapeutic and diet progressions.
Therapeutic Diets:
• High Fiber
• Low Sodium
• Low Cholesterol
• Diabetic
• Regular
Diet Progressions:
 Clear Liquid
 Full Liquid
 Pureed
 Mechanical Soft
 Soft/low Residue
Clear Liquid - Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit
juices, gelatin, fruit ices, popsicles
Full Liquid - As for clear liquid, with addition of smooth-textured dairy products (e.g.,
ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable
juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt
Pureed - As for clear and full liquid, with addition of scrambled eggs; pureed meats,
vegetables, and fruits; mashed potatoes and gravy
Mechanical Soft - As for clear and full liquid and pureed, with addition of all cream
soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes,
pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups,
peanut butter, eggs (not fried)
Soft/Low Residue - Addition of low-fiber, easily digested foods such as pastas,
casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes,
and cookies without nuts or coconut
High Fiber - Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and
dried fruits
Low Sodium - 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no added
salt to severe sodium restriction (500-mg sodium diet), which requires selective food
purchases
Low Cholesterol - 300 mg/day cholesterol, in keeping with American Heart Association
guidelines for serum lipid reduction
Diabetic - Nutrition recommendations by the American Diabetes Association: focus on
total energy, nutrient and food distribution; include a balanced intake of carbohydrates,
fats, and proteins; varied caloric recommendations to accommodate patient's metabolic
demands
Regular - No restrictions, unless specified
3. Discuss the nursing care for the client with dysphagia.
Difficulty Swallowing:
Neurogenic
Myogenic
Obstructive
Warning Signs:
Cough while eating
Change in voice tone or quality
Facial grimaces
Repetitive throat clearing
Runny nose/tearing eyes
Increased Secretions
Pocketing of food
People at risk:
 Decreased Level of Consciousness/Alertness
 Decreased Gag Reflex
 Decreased Cough Reflex
 Difficulty Managing Saliva
Complications:
 Aspiration Pneumonia
 Dehydration
 Impaired Nutritional Status
 Weight Loss
 Decreased Independence
 Adaptive utensils
Special Precautions:
 Communication
 Thickened liquids
 Education
 Positioning
 Verbal cues
 Feed slowly/Small bites
Early and ongoing assessment of patients with swallowing difficulties and use of a
valid dysphagia screening tool increase quality of care and decrease incidence of
aspiration pneumonia. Dysphagia screening includes medical record review; observation
of a patient at a meal for change in voice quality, posture, and head control; percentage of
meal consumed; eating time; drooling or leakage of liquids and solids; cough during/after
a swallow; facial or tongue weakness; palatal movement; difficulty with secretions;
pocketing; choking; and presence of voluntary and dry cough.
4. Compare and contrast various types of gastro-intestinal tubes.
Type
Location
Uses
Nasogastric
Nares to stomach
Short term management
nutritional problems
Nasointestinal
Nares to intestine
Risk for aspiration
Gastrostomy
Percutaneous endoscopic
gastrostomy (PEG)
Surgically placed into
the stomach through
the abdominal wall
For extended length of time;
Can’t tolerate nasoenteric feed;
Nasoenteric interferes with
rehabilitation
Percutaneous endoscopic
jejeunostomy (J-Tube)
Type of Gastrostomy
tube
5. State the indications for enteral nutrition.
•
Supplemental or primary source of nutrition
of
•
•
•
 Meet nutritional needs
Physiologically efficient
Less expensive
Ease of delivery
Indications:
 Cancer
 Gastrointestinal Disorders
 Inadequate Oral Intake
 Dysphagia
 Critical Illness and/or Trauma
 Neurologic and muscular disorders
6. Describe the procedure for initiating and maintaining tube feedings.
Feeding tubes are inserted through the nose (nasogastric or nasointestinal), surgically
(gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy
or jejunostomy [PEG or PEJ]).
Enteral nutrition (EN) - provides nutrients into the GI tract. It is the preferred method of
meeting nutritional needs if a patient is unable to swallow or take in nutrients orally yet
has a functioning GI tract. Enteral nutrition provides physiological, safe, and economical
nutritional support. Patients with enteral feedings receive formula via nasogastric, jejunal,
or gastric tubes. Patients with a low risk of gastric reflux receive gastric feedings;
however, if there is a risk of gastric reflux, which leads to aspiration, jejunal feeding is
preferred. After an enteral tube is inserted, verification of tube placement by x-ray film
examination needs to occur before the patient receives the first enteral feeding.
7. Discuss EBP to determine NG tube feeding tube placement.
Historically nurses verified feeding tube placement by injecting air through the tube
while auscultating the stomach for a gurgling or bubbling sound or asking the patient to
speak. Auscultation has repeatedly been shown to be ineffective in detecting tubes
accidentally placed in the lung. Some patients are able to speak despite placement of
feeding tubes in the lung. Furthermore, auscultation is not effective in distinguishing
between gastric and intestinal placement for feeding tubes. The measurement of pH of
secretions withdrawn from the feeding tube helps to differentiate the location of the tube.
At present the most reliable method for verification of placement of small-bore feeding
tubes is x-ray film examination.
Stomach
Stomach
8. Describe the risks and complications of enteral feedings.
Risks:
• Aspiration Pneumonia
• Diarrhea
Intestinal
•
•
•
•
Constipation
Abdominal Cramping
Delayed Gastric Emptying
 Check for residual
Fluid and Electrolyte Imbalances
 Overload
 Dehydration
Complications:
• Tube Occlusion/Obstruction
 Irrigate before after meds, feedings
• Tube Displacement
 Mark tubing at exit site
Nursing Interventions:
• Airway Patency
• Patient Comfort
 Gagging
 Irritation to nares/mucosa
 Patient Positioning
 Elevate HOB
 Right side lying
Dosage Calculations
IV flow rate:
 X gtt/min= (mL to infuse * gtt factor) / minutes
Examples:
 Infuse 75 mL/hour. Gtt factor = 10
 13 gtt/min= (75 mL * 10) / 60 minutes
 Infuse 1000 mL/6 hours. Gtt factor 10
 (1000 mL * 10) / 360 minutes = 28 gtt/min
Heparin:
Oral Medications:
Safe Medication:
18.2kg