perioperative phases
TRANSCRIPT
Unit: 3 perioperative phases Fundamental of Nursing
1
Perioperative Phases
Types of surgery.
Pre-operative phases.
Intra operative phases.
Post-operative phases
Perioperative:
Refers to the management and treatment of the client during the three
phases of surgery: preoperative, intraoperative, and postoperative.
1- Pre-operative (before surgery) refers to the time interval that begins
when the decision is made for surgery until the client is transferred to the
operating room (OR).
2- Intra-operative (during surgery) phase begins when the client is
transferred to the OR and ends with client transfer to a post anesthesia
care unit (PACU). When the client leaves the OR and is taken to a PACU.
3- Postoperative (after surgery) begins with admission of the patient to
the post anesthesia area and ends when healing is complete.
Surgical Intervention
Surgery is performed to correct an anatomical or physiological
defect or to provide therapeutic interventions.
Surgeries are categorized according to the degree of urgency
(timely intervention of surgery):
1. Emergency surgery is performed immediately to preserve function or
the life of the client.
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2. Elective surgery is performed when surgical intervention is the
preferred treatment for a condition that is not imminently life
threatening (but may ultimately threaten life or well-being).
Degree of risk
Surgery is also classified as major or minor according to the
degree of risk to the client.
Major surgery involves a high degree of risk, for a variety degree of
reasons; it may be complicated or prolonged, large losses of blood may
occur, such as open heart surgery and removal of kidney.
Minor surgery normally involves little risk, produces few complications
and is often performed in a (day surgery) such as breast biopsy, removal
of tonsils.
The degree of risk involved in a surgical procedure is affected by the
client's age, general health, nutritional status, use of medications, and
mental status.
Preoperative Phase:
A. Assessment
Preoperative assessment includes collecting and reviewing specific
client data to determine the client's needs both pre-and postoperatively.
Physical, psychological, and social needs are determined during
assessment.
1. Physical Assessment
1. General Survey.
2. Head and Neck.
3. Upper Extremities.
4. Anterior and Posterior Chest and Abdomen.
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5. Lower Extremities.
6. Physical Preparation
a. Skin Preparation
b. Nutrition
c. Gastrointestinal Preparation
d. Bowel Preparation
e. Urinary Elimination
f. Safety Precautions
g. Medications
h. E: Evaluation: Documentation of preoperative activities must be
entered in the client’s medical record on the appropriate forms.
2. Check the vital sings
3. Laboratory tests as physician prescribe.
Intra-operative Phase:
The intraoperative nurse is a vital member of the surgical team,
continually assessing the needs of the client.
Post-operative Phase: The primary goal of nursing care during the
immediate postoperative phase is to maintain the “A-B-Cs”: airway,
breathing, and circulation.
A: Assessment
This phase include the assessment of both Normal and Abnormal
Findings
Airway and Respiratory Status
a. Adequacy of airway and return of gag, cough, and swallowing
reflexes.
b. Type of artificial airway.
c. Rate, rhythm, and depth of respirations.
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d. Symmetry of chest wall movements and use of accessory
muscles.
e. Breath sounds.
f. Pulse oximeter readings.
g. Color of mucous membranes.
h. Amount and method of oxygen administration.
i. If awake, ability to deep breath and cough.
Circulatory Status
a. Apical and peripheral pulses.
b. Blood pressure (BP).
c. Nail bed and skin color and temperature.
d. Monitoring devices:
Cardiac monitor (ECG).
Pressure readings (arterial blood pressure or central venous
pressure)
Neurologic Status
a. Level of consciousness (Glasgow Coma Scale).
b. Eye opening.
c. Verbal response.
d. Motor response
Fluid and Metabolic Status
a. Intake and output.
b. Palpate for bladder distention.
c. Patency of intravenous (IV) infusion (type, rate, and amount).
d. Signs of dehydration (skin integrity and turgor) or overload
(edema).
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e. Patency, amount, and character of drainage (catheters, drains,
or tubes).
f. Inspect operative dressing (type, color and amount of
drainage).
g. Auscultation for bowel tones in all four quadrants and inspect
for abdominal distension
Level of Discomfort or Pain
a. Location, intensity, and duration.
b. Type, amount of analgesia administered and client’s response
Wound Management
a. Inspect the dressing.
b. Note type and amount of drainage.
c. If drainage is present, reassess in 15-minute intervals.
B: Nursing Diagnosis: Depending on the individual client’s needs, other
nursing diagnoses can be included in the plan of care.
1. Ineffective Airway Clearance related to:
Anesthesia (diminished cough reflex).
Increased pulmonary congestion Ineffective Breathing
Pattern related to Pain and Decreased energy/fatigue.
2. Deficient Fluid Volume related to:
Active fluid volume loss.
Inadequate fluid intake
3. Imbalanced Nutrition: Less Than Body Requirements related to:
Anesthesia.
Surgical manipulation of intestines
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4. Urinary Retention related to:
Anesthesia.
Surgical manipulation of the bladder Acute Pain related to:
Surgical incision
5. Risk for Infection related to:
Impaired skin integrity from surgical wound.
Deficient knowledge of wound or drainage tube care.
C: Outcome Identification and Planning
D: Interventions
1. Maintaining Respiratory Status.
2. Maintaining Circulatory Status.
3. Maintaining Neurologic Status.
4. Maintaining Fluid and Metabolic Status.
5. Managing Pain.
E: Evaluation
The client is conscious, oriented, and can move all extremities.
The client demonstrates full return of reflexes.
The client can clear the airway and cough effectively.
Vital signs have been stable or within baseline ranges for 30
minutes.
Intake and urinary output are adequate to maintain the circulating
blood volume.
The client is a febrile, or a febrile condition has been treated
accordingly.
Dressings are dry or have only minimal drainage.
Unit 4: Nutrition Fundamental of Nursing
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Nutrition
Nutrition: is the process by which the body metabolizes and utilizes
nutrients, encompasses all of the processes involved in consuming and
utilizing food for energy, maintenance, and growth.
These processes are ingestion, digestion, absorption, metabolism, and
excretion.
Digestion: refers to the mechanical and chemical processes that convert
nutrients into a physically absorbable state.
Absorption: is the process whereby the end products of digestion (i.e.,
individual nutrients) pass through the epithelial membranes in the small
and large intestines and into the blood or lymph systems.
Metabolism: is the aggregate of all chemical reactions and processes in
everybody cell, such as growth, generation of energy, elimination of
wastes, and other bodily functions as they relate to the distribution of
nutrients in the blood after digestion.
Excretion is the process of eliminating or removing waste products from
the body.
Nutrients
The body must have six types of nutrients to function efficiently
and effectively. These are water, carbohydrates, fats, proteins, vitamins,
and minerals. Nutrients are classified as energy nutrients, organic
nutrients, and inorganic nutrients.
The functions of the nutrients are interrelated. Intake in one
nutrient may lead to functional changes in another. Some examples of
interrelated functions include :
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(a) iron is better absorbed when vitamin C is present.
(b) calcium absorption depends on the presence of vitamin D.
Table (1) Classification of Nutrients
Classes Of Nutrients
Description Classes
Energy nutrients
Carbohydrates
Proteins
Fats
Organic nutrients
Carbohydrates
Proteins
Fats
Vitamins
Inorganic nutrients
Water
Minerals
Water: Virtually all body functions require water. Water is the major
constituent in every cell of the body. Approximately 55% to 65% of an
adult’s weight is water, and approximately 70% to 75% of an infant’s
weight is water. The body’s water content decreases with age.
Daily Requirements: The estimated water requirement for infants,
children, and adults is 1.5 mL/kcal of energy expenditure, a lactating
woman, who requires, on average, an additional 750 mL/day of water
during the first 6 months to match the amount of milk secreted.
Functions: Water has many functions in the body:
• Solvent: Water is the liquid in which many substances are dissolved to
form solutions.
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• Transporter: Water carries nutrients, wastes, and other materials
throughout the body and from each cell via blood, tissue fluids, and body
secretions.
•Regulator of body temperature: Water is excreted as perspiration when
the temperature goes up. Evaporation of perspiration cools the body.
• Lubricant: Water is a component of fluid within the joints, called
synovial fluid, which provides smooth movement of the many joints in
the body.
• Component of all cells: Water gives structure and form to the body.
• Hydrolysis: Water breaks apart substances, especially in metabolism.
• Feces: contains a small amount of water (insensible loss, except in cases
of diarrhea)
• Perspiration: varies with temperature, but some fluid is always lost
(insensible or sensible loss)
• Respiration: releases moisture with every breath (insensible loss)
Carbohydrates: Carbohydrates are made of the elements carbon,
hydrogen, and oxygen. Carbohydrates constitute the chief source of
energy for all body functions. Carbohydrates are classified according to
the number of saccharides (sugar units):
• Monosaccharide's (simple sugars) include glucose, galactose, and
fructose.
• Disaccharides (double sugars) include sucrose, lactose, and maltose.
• Polysaccharides (complex sugars) include glycogen, cellulose (fiber),
and starch.
Daily Requirements: It is recommended that carbohydrates make up
50% to 60% of an individual’s kcal intake per day. For example, if an
individual’s total energy requirement is 2,000 kcal, 50% of this number is
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1,000; this number is then divided by 4 for an estimated carbohydrate
requirement of 250 g/day.
Functions:
the primary source of energy for the body.
Carbohydrates are needed to oxidize fats completely and for
synthesis of fatty acids and amino acids.
Fats: Fats constitute the most concentrated source of energy in the diet,
providing 9 kcal per gram of fat.
Daily Requirements: It is recommended that fats make up no more than
25% to 30% of an individual’s caloric intake per day. For example,
assuming that one’s total energy requirement is 2,000 kcal/ day, one-
quarter (25%) of this would be 500 kcal. Dividing 500 kcal by 9 yields
an estimated fat requirement of 55.5 g/day.
Functions
• Provides a concentrated source of energy (more than twice the kcal of
carbohydrates)
• Assists in the absorption of fat-soluble vitamins
• Is a major component of cell membranes and myelin sheaths
• Improves the flavor of food and delays the stomach’s emptying time,
providing a feeling of satiety
• Protects and helps hold organs in place
• Insulates the body, thus assisting in temperature Maintenance.
Protein: are organic compounds that contain carbon, hydrogen, oxygen,
and nitrogen atoms; some proteins also contain sulfur. Protein is the only
nutrient that can build, repair, and maintain body tissues. The basic
building materials of protein are amino acids. The normal blood
concentration of amino acids is between 35 and 65 mg/dL.
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There are 20 identified amino acids, which are categorized as either
essential or nonessential:
• Nonessential amino acids can be synthesized (manufactured) in the
cells.
• Essential amino acids must be ingested in the diet because they cannot
be synthesized in the body.
Proteins are also classified as complete or incomplete.
• High-biological-value proteins (complete proteins) contain all of the
essential amino acids. Complete proteins are primarily animal proteins,
such as those in meat, poultry, fish, dairy products, and eggs.
• Low-biological-value proteins (incomplete proteins) most vegetables
are incomplete proteins.
Daily Requirements: A person must ingest a minimum of 20 to 30
grams of protein each day to prevent a net loss of body proteins. the
average adult’s daily requirement to be 0.8 g of protein for each kilogram
of body weight. Daily protein requirement is determined by multiplying
body weight in kilograms by 0.8.
Functions: The primary function of protein in the diet is to:
provide the amino acids necessary for the synthesis of body
proteins, which are used to build, repair, and maintain the body
tissues. Protein composes most of the muscles, skin, hair, nails,
brain, nerves, and internal organs.
Another function of protein is to assist in regulating fluid balance.
Protein is also used to build antibodies, which help defend the body
against disease and foreign substances.
Vitamins: are organic compounds regulate body processes. Vitamins are
needed in small quantities .They requirements are dependent on many
Unit 4: Nutrition Fundamental of Nursing
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factors, such as body size, amount of exercise, rate of growth, and
pregnancy.
Of the major vitamins, some are classified as either fat soluble or water
soluble.
Fat-soluble vitamins (vitamins A, D, E, and K) require the presence
of fats for their absorption from the GI tract and for cellular
metabolism and can be stored for longer periods of time in the
body’s fatty tissue and the liver.
Water-soluble vitamins (vitamin C and B complex vitamins)
require daily ingestion in normal quantities because these vitamins
are not stored in the body.
Minerals: Minerals are inorganic elements that help regulate body
processes and/or serve as structural components of the body. Like
vitamins, they have no fuel value.
Daily Requirements
Major minerals are required in amounts greater than 100 mg/ day.
Factors Affecting Nutrition
1. Age
Infants and children vary in weight and energy requirements. The
infant’s physiological development has implications for fluid, electrolyte,
and food intake that can predispose this age group to various imbalances.
2. Lifestyle
Eating is a social activity in most cultures. A person’s lifestyle may
have a major impact on food-related behaviors. Families with both
parents working or with children involved in sports and other activities
might find it difficult to sit down at the dinner table together for a home-
cooked meal.
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3. Ethnicity, Culture, and, religious practices.
Ethnic heritage and family nutritional patterns can have an impact
on food likes and dislikes.
4. Economics factors.
Economics is a major influence on food selection; fresh fruits and
vegetables and lean meats are expensive and are often substituted with
products that tend to be low in protein and high in starch.
5. Positive or negative experiences can become associated with certain
foods.
6. Radio and television shape attitudes toward foods.
7. Community resources can influence access to foods and, through
regulations, influence the quality of food.
Assessment of Nutritional Status
Assessment of the individual focuses on the intake and utilization
of food and fluid. This includes:
Nutritional history
Typical daily nutrient intake.
Types of snacks.
Eating times.
Quantity of food and fluids consumed.
Particular food preferences.
Use of nutrient, vitamin, and mineral supplements.
Condition of the skin.
Physical examination
1. Measure and weigh the patient and compare the findings with the
normal values on a standardized chart.
2. Observe the patient for clues to his nutritional status.
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3. Perform anthropometric arm measurements (Triceps skin-fold
thickness, Mid-arm circumference, Mid-arm muscle circumference),
These measurements provide information about the caloric reserves in
subcutaneous fat and indicate skeletal muscle mass
90% STANDARD MEASUREMENT
Men : 11.3mm Men : 12.5 mm
Triceps skin-fold thickness
Women: 4.9 mm Women: 16.5 mm
Men : 26.4 cm Men : 29.3 cm
Mid-arm circumference
Women: 25.7cm Women: 28.5cm
Men : 22.8cm
Men : 25.3 cm
Mid-arm muscle circumference
Women: 20.9cm
Women: 23.2cm
Compare the patient's percentage measurement with the standard.
A measurement less than 90% of the standard indicates caloric
deprivation.
A measurement over 90% indicates adequate or more than
adequate energy reserves.
Nursing process for patient with nutritional problems
Assessment must be performed logically and should include a
nutritional history, physical examination, and the results of laboratory
tests. Age and pregnancy determine some specific items to be included in
the nutritional assessment.
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Nutritional assessment for an infant should include:
• Height and weight
• Sleeping habits
• Type of feeding (breast- or bottle-fed)
• If breastfeeding, the mother’s nutritional status and use of alcohol,
tobacco, caffeine, and drugs; infant’s feeding schedule (how often fed and
for how long)
• If formula feeding, type, frequency, and method of preparation and
storage; feeding schedule; amount taken at each feeding
• Use of vitamin/mineral supplements
• If on solid foods, age at introduction, and any reactions or allergies
• Family attitudes about eating, food, and weight
The basic nutritional assessment for everyone over 1 year old should
include:
• Nutritional status
• Height and weight
• Meal and snack pattern (food record or 24-hour recall)
• Adequacy of intake based on the food guide pyramid
• Food allergies
• Physical activity
• Use of vitamin/mineral supplements
In addition to the basic nutritional assessment, during childhood dental
health is also assessed.
In addition to the basic nutritional assessment, the following is assessed
for the adolescent client:
• Use of alcohol, tobacco, caffeine, and drugs
• Use of fad diets
The following is assessed for the adult client:
Unit 4: Nutrition Fundamental of Nursing
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• Use of alcohol, tobacco, caffeine, and drugs
• Use of fad diets
• Prescribed restricted diet
In addition to the basic nutritional assessment, the followingis assessed
for elderly clients:
• Undesirable change in weight
• Dentition and swallowing
• Appetite
• Adequacy of daily intake of food
• Ability to self-feed
• Prescribed restricted diet
• Use of alcohol, tobacco, caffeine, and drugs
In addition to the basic nutritional assessment, the following is assessed
for the pregnant client:
• Weight and rate of weight gain
• Diet changes in response to pregnancy
• Cravings for foods or nonfoods (pica)
• Intake of supplemental vitamins/minerals
• Feeding plans (breast or formula)
• Use of alcohol, caffeine, tobacco, or drugs.
Subjective Data
Subjective data are obtained through a nutritional history by asking
clients questions. Several methods are used in collecting these subjective
data: 24-hour recall, food-frequency questionnaire, food record, and diet
history. Although the history data may indicate adequate nutrition.
Unit 4: Nutrition Fundamental of Nursing
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24-Hour Recall The 24-hour recall requires client identification of
everything consumed in the previous 24 hours. It is performed easily and
quickly by asking pertinent questions.
Food-Frequency Questionnaire The food-frequency method gathers
data relative to the number of times per day, week, or month that the
client eats particular foods, such as cholesterol and saturated fat.
Food Record The food record provides quantitative information
regarding all foods consumed, with portions weighed and measured for
three consecutive days.
Objective Data
A physical examination may elicit findings that suggest nutritional
imbalance. The measurement of a client’s intake and output and daily
weight are critical assessments, especially for hospitalized clients.
Physical Examination
A physical assessment requires decision making, problem solving,
and organization. ‘The nurse should be aware of rapidly proliferating
tissues such as hair, skin, eyes, lips, and tongue that usually show nutrient
deficiencies sooner than other tissues 'Essential components of
anthropometric measurements(height, weight, and skin folds) are also
discussed. Intake and Output (I&O)
Anthropometric Measurements
Anthropometric measurements (measurements of the size, weight,
and proportions of the body) evaluate the client's calorie-energy
expenditure balance, muscle mass, body fat, and protein reserves based
on height, weight, skin folds, and limb and girth circumferences. The
Unit 4: Nutrition Fundamental of Nursing
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body mass index (BMI) determines whether a person's weight is
appropriate for height and is calculated using a simple formula:
BMI =Weight/kgHeight/m
Skin fold Measurement
indicates the amount of body fat. This information is beneficial in
promoting health and determining risks and treatment modalities
associated with chronic illness and surgery.
1. To measure the triceps fold, locate the midpoint of the upper arm.
Grasping the skin on the back of the upper arm, place the calipers 1 cm
below fingers, and measure the thickness to the nearest millimeter.
2. For a sub scapular skin fold measurement, grasp the skin below the
scapula with three fingers, angle the fold about45_ laterally to the
scapula, place the caliper 1 cm above fingers, and read the measurement.
Mid-Upper-Arm Circumference: The measurement of mid-upper-arm
circumference (MAC) serves as an index for skeletal muscle mass and
protein reserve. Instruct the client to relax and flex the forearm; with a
measuring tape, measure the circumference at the midpoint of the upper
arm (see Figure 2).
Abdominal-Girth Measurement: An abdominal girth measurement
serves as an index as to whether abdominal distention is increasing,
decreasing, or remaining the same. With an indelible pen, place an X on
the client’s abdomen at the point of greatest distention. Using a
measuring tape, measure the abdomen’s circumference. This
measurement should be performed at the same time each day and
consistently recorded in either inches or centimeters.
Unit 4: Nutrition Fundamental of Nursing
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FIGURE 1 Measuring Triceps Skin fold, at Midpoint of the Upper Arm
FIGURE 2 Measuring the Mid-Upper-Arm Circumference
FIGURE 3 Measuring the Sub scapular Skin fold
Unit 4: Nutrition Fundamental of Nursing
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Laboratory Tests Several laboratory tests provide information about a
client’s nutritional status. These include the protein indices of serum
albumin, pre albumin, and serum transferrin; hemoglobin; total
lymphocyte count; blood urea nitrogen (BUN); and urine creatinine.
Hemoglobin is a measurement of the oxygen- and iron carrying capacity
of the blood. Total lymphocyte count may reflect protein-calorie
malnutrition, which inhibits lymphocyte synthesis. Blood urea nitrogen is
a nitrogen balance study that indicates the degree to which protein is
being depleted or replaced, and urine creatinine excretion indicates the
amount of creatinine eliminated by the kidneys.
Nursing diagnoses
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: More Than Body Requirements
Risk for Imbalanced Nutrition: More Than Body Requirements
Other possible nursing diagnoses related to nutritional problems include
the following:
Disturbed Body Image
Ineffective Breastfeeding
Impaired Dentition
Deficient Knowledge (specify)
Impaired Oral Mucous Membrane
Acute Pain, Chronic Pain
Feeding Self-Care Deficit
Chronic Low Self-Esteem
Risk for Impaired Skin Integrity.
Unit 4: Nutrition Fundamental of Nursing
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Planning/Outcome Identification
The plan is individualized to meet the client’s specific needs. These
needs may include achieving desired weight, correcting nutritional
deficiencies, maintaining a special diet, preventing nutritional disorders
secondary to a particular therapy, or improving nutrition to promote
health and prevent disease.
Goals for clients with nutritional alterations might be as follows:
Client will maintain intake and output balance.
Client will comply with diet therapy, avoiding high-sodium foods.
Client will gain 2 pounds in 4 weeks.
Implementation
Includes monitoring the client’s weight and intake, diet therapy,
and feeding. Client teaching occurs with each intervention to maximize
the effectiveness of nutritional therapy.
The Nursing Interventions Classification (NIC) consists of specific
interventions for clients with impaired nutrition, such as Behavior
Management: Over activity/Inattention, Eating Disorders Management,
enteral Tube Feeding, Nausea Management, and Nutrition Management.
These interventions identify the specific nursing activities for each
classification.
Standard hospital diets
The types of standard diets used by the hospitals are:
1. Clear Liquid Diet.
Uses
-This diet is indicated for the postoperative patient's first feeding when
it is necessary to fully ascertain return of gastrointestinal function.
-It may also be used during periods of acute illness, in cases of food
intolerance, and
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-To reduce colon fecal matter for diagnostic procedures.
-The diet is limited to fat-free broth or bouillon, flavored gelatin,
water, fruit drinks without pulp, fruit ice, Popsicles, tea, coffee or
coffee substitutes, and sugar.
-No cream or creamers reused.
-Carbonated beverages may be included when ordered by the
physician; however, they are often contraindicated.
2. Full Liquid Diet.
Uses
This diet is used when a patient is unable to chew or swallow
solid food because of extensive oral surgery, facial injuries,
esophageal strictures, and carcinomas of the mouth and esophagus.
3.Soft Diets
-Soft diets transition patients from a liquid diet to a regular diet.
-Patients prescribed a soft diet are restricted to foods that can be mashed
with a fork. This includes cooked fruits and vegetables, bananas, soft
eggs and tender meats.
-A mechanical soft diet allows most foods as long as they can be
chopped, ground, mashed or pureed to a soft texture.
4. Regular Diet/Normal or house diets
Uses
-It is used to maintain or achieve the highest level of nutrition in patients
who do not have special needs related to illness or injury.
-While regular diets do not have portion or choice restrictions, they are
altered to meet the needs of the patient's age, condition and personal
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beliefs. For example, a pregnant woman may require more calories and
different nutrients than a young child would need.
5. Restricted Diets
-Restricted diets encompass a variety of special diets that limit the
amount of calories, fat, salt and other substances based on the patient's
medical needs. For example,
-A restricted-fat diet allows only low-fat versions of milk, cheese, cereal
and ice cream but does not place limits on the amount of fresh fruits and
vegetables a patient may consume.
-A restricted diet can also modify the other types of diets. For example, a
post-operative patient with heart disease may be prescribed a low-fat full
liquid diet.
5. Parenteral Nutrition
Parenteral nutrition (PN) is a method of providing nutrients to the
body by an IV route. The nutrients are a very complex admixture
containing proteins, carbohydrates, fats, electrolytes, vitamins, trace
minerals, and sterile water in a single container.
The goals of PN are to improve nutritional status, establish a
positive nitrogen balance, maintain muscle mass, promote weight
maintenance or gain, and enhance the healing process.
Clinical Indications
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a. The patient's intake is insufficient to maintain an anabolic state
(e.g., severe burns, malnutrition, short bowel syndrome, acquired
immunodeficiency syndrome [AIDS], sepsis, and cancer).
b. The patient's ability to ingest food orally or by tube is impaired
(e.g., paralytic ileus, Crohn's disease with obstruction, post-
radiation enteritis, severe hyper emesis gravidarum in pregnancy).
c. The patient is unwilling or unable to ingest adequate nutrients (e.g.,
anorexia nervosa, postoperative elderly patients).
d. The underlying medical condition precludes being fed orally or by
tube (e.g., acute pancreatitis, high enterocutaneous fistula).
e. Preoperative and postoperative nutritional needs are prolonged
(e.g., extensive bowel surgery).
6. Therapeutic Diets
Therapeutic diets are used to treat disease or illness. Like restricted
diets, they can also be used to modify another type of hospital diet.
Types of therapeutic diets include:
a. Modification of calorie intake, such as with patients that need a
high calorie diet to promote weight gain;
b. Modification of certain nutrients including protein and
carbohydrates; or diets that encourage an increased fluid intake.
Examples of therapeutic diets
a. Diabetic Diet
-The diabetic diet aims to control the amount of food the patients eat,
especially foods that dramatically affect blood sugar,
-To help manage the disease.
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-The diet also aims to promote a healthy weight because this improves
blood sugar management.
b. Dash Diet
-It is a therapeutic diet used to treat high blood pressure.
-The diet contains high amounts of potassium, magnesium, calcium and
fiber to help lower your blood pressure.
-It also recommends limit intake of sodium to 1,500 mg a day.
-The DASH diet is considered an overall healthy diet and has also been
shown to be helpful for those wishing to lose weight and prevent the
onset of diabetes.
c. Dialysis Diet
-People with chronic kidney failure may need to go on dialysis to help
their body's clear the waste products in their blood.
-Limits foods high in sodium, potassium and phosphorous.
-Fruits and vegetables contain potassium and the amount you eat will be
limited.
-Limit the amount of meat and dairy products because these foods are
high in phosphorous.
Unit 5: Fluids and Electrolytes Fundamental of Nursing
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Fluids and Electrolytes
Lecture outlines:
Physiology of Fluid and acid-base Balance.
Factors affecting Fluid and Electrolyte Balance.
Fluid Volume Assessment.
Physiology of Fluid and acid-base Balance.
The body normally maintains a balance between the amount of
fluid taken in and the amount excreted. Health promotion requires
maintenance of body fluid and acid-base balance.
Fluid compartments
The body’s fluid is contained within three compartments: cells,
blood vessels, and the tissue space (space between the cells and blood
vessels). Fluids move constantly from one compartment to another to
accommodate the cells metabolic needs.
Types of body fluids
a. Intracellular fluid: within the cell.
b. extracellular fluid (ECF): fluid outside the cells:
1. Intravascular fluid: within blood vessels.
2. Interstitial fluid: between cell
Key terms used in explaining the movement of molecules in body fluids
are:
• Solute: Substance dissolved in a solution
• Solvent: Liquid that contains a substance in solution
Unit 5: Fluids and Electrolytes Fundamental of Nursing
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• Permeability: Capability of a substance, molecule, or ion to diffuse
through a membrane (covering of tissue over a surface, organ, or
separating spaces).
• Semipermeable: Selectively permeable (All membranes in the body
allow some solutes to pass through the membrane without restriction but
will prevent the passage of other solutes).
Cells have permeable membranes that allow fluid and solutes to pass
into and out of the cell.
Permeability allows the cell to acquire the nutrients it needs from ECF
to carry on metabolism and to eliminate metabolic waste products.
Blood vessels have permeable membranes that bathe and feed the cells.
The intravascular fluid of arterioles carries oxygen and nutrients to the
cells.
The venules take in the waste products from the cells’ metabolic
activity.
Cells and capillaries form a mesh like structure that creates a tissue
space between cells and the vascular system to allow cellular access to
the vascular system.
Interstitial space promotes access of the cells to the arterioles and
venules.
Body water distribution
Water is the largest single constituent of the body, representing 45% to
75% of the body’s total weight.
About two-thirds of the body fluid is intracellular.
The remaining one-third is extracellular, with one-fourth of this fluid
being intravascular and three-fourths being interstitial fluid.
Unit 5: Fluids and Electrolytes Fundamental of Nursing
3
Bones are made up of nearly one-third water, while the muscles and
brain cells contain 70% water.
Body fat is essentially free of water; therefore, the ratio of water to
body weight is greater in leaner people than in obese people.
Water is present in all body tissues and cells and serves two main
functions:
1. To act as a solvent for the essential nutrients so that they can be used
by the body and,
2. To transport nutrients and oxygen from the blood to the cells and
remove waste material and other substances from the cells back to the
blood so they can be excreted by the body.
3. Water is also needed by the body to:
a. Give shape and form to the cells.
b. Regulate body temperature.
c. Act as a lubricant in joints.
d. Cushion body organs.
e. Maintain peak physical performance
Factors affecting fluid and electrolytes balance:
The balance of fluids and electrolytes in the body is dependent on
many factors and will vary with such elements as age and lifestyle.
Age
Body water distribution is relative to body size. The smaller the
body, the larger the fluid content:
• Adult, 60% water
• Child, 60%–77% water
• Infant, 77% water
• Embryo, 97% water
Unit 5: Fluids and Electrolytes Fundamental of Nursing
4
In older adults, body water diminishes because of tissue loss; the
percentage of total body weight that is fluid may be reduced to 45% to
50% in persons over age 65. Caution must be used when administering
diuretics, especially diuretics, to older adults to prevent diuretic-induced
electrolyte disturbances.
Lifestyle
Loss of body fluids can result from stress, exercise, or a warm or
humid environment.
Stress leads to increased blood volume and decreased urine production.
Sweating and exercise cause the body to lose water and sodium, thus
necessitating electrolyte replacement and intensifying the thirst
response. Warm climates can exert a similar effect.
An individual’s diet will also determine fluid and electrolyte levels.
Adequate intake of fluids, carbohydrates, potassium, calcium, sodium,
fats, and protein is essential in helping the body maintain homeostasis
and function properly.
Dehydration is one of the most common yet most serious fluid
imbalances that can occur from poor monitoring of diet.
One nursing goal is to ensure that all clients understand the role water
plays in health and to see that clients understand how to maintain
adequate hydration status.
Fluid volume assessment
Health history
The nursing history should elicit data specific to fluids:
• Lifestyle (Sociocultural and economic factors, stress, exercise)
• Dietary intake (recent changes in the amount and types of fluid and
food, increased thirst)
Unit 5: Fluids and Electrolytes Fundamental of Nursing
5
• Religion (whether illness has had an effect on beliefs or religion; query
whether the client would like a visit from a religious counselor)
• Weight (sudden gain or loss)
• Fluid output (recent changes in the frequency or amount of urine
output)
• GI disturbances (prolonged vomiting, diarrhea, anorexia, ulcers,
hemorrhage)
• Fever and diaphoresis.
• Draining wounds, burns, trauma
• Disease conditions that could upset homeostasis (renal disease,
endocrine disorders, neural malfunction, pulmonary disease)
• Therapeutic programs that can produce imbalances (special diets,
medications, chemotherapy, administration of IV fluid, gastric or
intestinal suction)
Physical examination
The nurse performs a complete physical examination and identifies
all abnormalities because fluid alterations may affect any body system.
Daily Weight
Vital Signs
Measurement of vital signs provides the nurse with information
regarding the client’s fluid, electrolyte, and acid-base status and the
body’s compensatory response for maintaining balance.
An elevated temperature places the client at risk for dehydration
caused by an increased loss of body fluid.
Changes in the pulse rate, strength, and rhythm are indicative of fluid
alterations.
Fluid volume alterations may cause the following pulse changes:
Unit 5: Fluids and Electrolytes Fundamental of Nursing
6
a. Fluid volume deficit (FVD): increased pulse rate and weak pulse
volume.
b. Fluid volume excess (FVE): increased pulse volume and third heart
sound
Respiratory changes are assessed by inspecting the movement of the
chest wall, counting the rate, and auscultating the lungs.
Changes in the rate and depth may cause respiratory acid-base
imbalances or may be indicative of a compensatory response in
metabolic acidosis or alkalosis.
Blood pressure measurements can be used to assess the degree of FVD.
FVD can lower the blood pressure with or without orthostatic
hypotension.
A narrow pulse pressure (less than 20 mm Hg) may indicate FVD that
occurs with severe hypovolemia.
Intake and Output
Measure and record the client’s intake and output for a 24- hour
period to assess for an actual or potential imbalance
Edema:
The detectable accumulation of increased interstitial fluid. Edema
may be localized (confined to a specific area) or generalized (occurring
throughout the body’s tissue)
Skin Turgor
Is the normal resiliency of the skin. When the skin is pinched and
released, it springs back to a normal position because of the outward
pressure exerted by the cells and interstitial fluid.
Unit 5: Fluids and Electrolytes Fundamental of Nursing
7
Buccal (Oral) Cavity
Inspect the buccal cavity. With FVD, there is a decrease in saliva,
which causes sticky, dry mucous membranes and dry cracked lips. The
tongue has longitudinal furrows
Eyes
Inspect the eyes. FVD causes sunken eyes, dry conjunctiva, and
decreased or absent tearing. Puffy eyelids (periorbital edema or
papilledema) are characteristic of FVE; the client may also have a history
of blurred vision.
Jugular and Hand Veins
Circulatory volume is assessed by measuring venous filling of the
jugular and hand veins.
Neuromuscular System
Fluid and electrolyte imbalances may cause neuromuscular
alterations, the muscles lose their tone and become soft and
underdeveloped, and reflexes are diminished.
Diagnostic and laboratory data
Biochemical assessment is another essential source of objective
data. Laboratory results can be used to detect imbalances before clinical
symptoms are assessed in the physical examination.
Nursing Diagnosis
‘‘Fluid volume, pressure, and levels of sodium and albumin are keys to
maintaining fluid balances between the intracellular and extracellular
(intravascular and interstitial) spaces. In order to make a nursing
diagnosis, the nurse must be able to interpret assessment and biochemical
data and draw conclusions relative to the client’s imbalance.
Unit 5: Fluids and Electrolytes Fundamental of Nursing
8
Excess Fluid Volume
Excess fluid volume (EFV) exists when the client has increased
interstitial and intravascular fluid retention and edema. EFV is related to
the excess fluid either in tissues of the extremities (peripheral edema) or
in lung tissues (pulmonary edema).
Factors that put the client at risk for EFV are:
• Excessive intake of fluids (e.g., IV therapy, sodium)
• Increased loss or decreased intake of protein (chronic diarrhea, burns,
kidney disease, malnutrition)
• Compromised regulatory mechanisms (kidney failure)
• Decreased intravascular movement (impaired myocardial contractility)
• Lymphatic obstruction (cancer, surgical removal of lymph nodes,
obesity)
• Medications (steroid excess)
• Allergic reaction
Assessment findings in the client with FVE include:
1. acute weight gain;
2. decreased serum osmolality,
3. protein and albumin,
4. blood urea nitrogen (BUN),
5. hemoglobin (Hb), and hematocrit (HCT); and,
6. signs and symptoms of edema.
7. The clinical manifestations of edema are relative to the area of
involvement; either pulmonary or peripheral .
Unit 5: Fluids and Electrolytes Fundamental of Nursing
9
Deficient Fluid Volume
Deficient fluid volume (DFV) exists when the client experiences
vascular, interstitial, or intracellular dehydration.
The degree of dehydration is classified as mild, marked, severe, or
fatal on the basis of the percentage of body weight lost.
There are three types of dehydration based on the proportion of fluid
and particles in the intracellular and extracellular spaces:
Isotonic dehydration(hypovolemia): refers to the loss of both fluid and
particles in the vascular space that occurs with vomiting, diarrhea, and
bleeding; it is the most common form of dehydration, especially in infants
and children.
Hypertonic dehydration: refers to a greater loss of fluid than particles in
the vascular space when the body tries to maintain a normalized isotonic
state by pulling fluids from the intracellular space into the vascular space;
it occurs in:
diabetic ketoacidosis.
renal insufficiency, and,
the administration of hypertonic solutions.
Hypotonic dehydration: refers to a greater loss of particles than fluid in
the vascular space when the body tries to maintain a normal isotonic state
by pushing fluids from the vascular space into the intracellular space,
causing the cells to swell; it occurs in:
chronic disease states and,
with the administration of hypotonic solutions.
Unit 5: Fluids and Electrolytes Fundamental of Nursing
10
Assessment findings in the client with DFV include:
1. Thirst and weight loss.
2. With marked dehydration, the mucous membranes and skin are dry.
3. poor skin turgor;
4. low-grade temperature elevation;
5. tachycardia; respirations 28 or greater; a decrease (10–15 mm Hg) in
systolic blood pressure; slowing in venous filling;
6. a decrease in urine (less than 25 mL per hour); concentrated urine;
7. elevated HCT, Hb, and BUN; and an acid blood pH (less than 7.4).
Severe dehydration
is characterized by the symptoms of marked dehydration:
1. the skin becomes flushed skin.
2. The systolic blood pressure continues to drop (60 mm Hg or below).
3. behavioral changes (restlessness, irritability, disorientation, and
delirium).
The signs of fatal dehydration are anuria and coma that leads to death.
Nursing Diagnoses for patient with Fluid Alteration Excess Fluid
Volume Related to:
Excessive fluid intake secondary to excess sodium intake.
Compromised regulatory mechanism (renal and cardiac dysfunction).
Inaccurate intravenous infusion rate
Deficient Fluid Volume Related to
Excessive fluid loss secondary to vomiting, blood loss, surgical
drains and tubes, diarrhea, and diuretics.
Unit 5: Fluids and Electrolytes Fundamental of Nursing
11
Risk for Deficient Fluid Volume Related to:
Extremes of age (very young or old) and weight.
NPO and fluid restrictions.
Increased fluid output from normal routes: vomiting, diarrhea, urine.
Increased fluid losses from drainage or suction routes: wounds, drains,
indwelling tubes (e.g., urine catheter, nasogastric suction).
Loss of plasma associated with severe trauma and burns.
Disorders that impair fluid intake or absorption (immobility,
unconsciousness).
Chronic disorders: congestive heart failure, pulmonary edema, chronic
obstructive lung disease, renal failure, diabetes, cancer, transplant
candidates.
Planning and Outcomes
1. Maintain fluid and electrolyte balance.
2. Free from any complications
Implementation
1. Monitor daily weight.
2. Measure the vital signs.
3. Check intake and output.
4. accurately calculated the IV infusion rate to maintain the client’s
hydration.
Evaluation
1. The client’s vital signs within normal limits.
2. The IV site free from erythema, edema, and purulent drainage.
Unit 6: Oxygenation Fundamental of nursing
1
Oxygenation
Physiology of Oxygenation
The function of the respiratory system is gas exchange, oxygen
from inspired air diffuses from alveoli in the lungs into the blood in
pulmonary capillaries. Carbon dioxide produced during cell metabolism
diffuses from the blood into the alveoli and is exhaled. The organs of the
respiratory system facilitate this gas exchange and protect the body from
foreign matter such as particulates and pathogens.
Factors Affecting Respiratory Function
1. Age
2. Environment
3. Lifestyle
4. Health status
5. Medications
6. Stress
Alterations in respiratory function
A. Hypoxia
Hypoxia is a condition of insufficient oxygen anywhere in the
body, from the inspired gas to the tissues.
Hypoventilation that is inadequate alveolar ventilation, can lead to
hypoxia.
Hypoxemia refer to reduced oxygen in the blood.
Cyanosis bluish discoloration of the skin, nail beds, and mucus
membranes, due to reduced hemoglobin-oxygen saturation.
Unit 6: Oxygenation Fundamental of nursing
2
B. Altered Breathing Patterns
Tachypnea is rapid rate
Bradypnea is an abnormally slow respiratory rate
Apnea is the cessation of breathing
Hyperventilation is an increased movement of air into and out of
the lungs.
Orthopnea is the inability to breathe except in an upright or
standing position.
Dyspnea (difficult of breathing) or shortness of breathing
C. Obstructed Airway completely or partially.
Assessing Oxygenation
1. Determine client history and acute and chronic health problems:
Clients with carbon dioxide retaining chronic obstructive
pulmonary disease (COPD) will need lower amounts of oxygen so as not
to obliterate their hypoxic respiratory drive. They be on oxygen and need
long-term continuous therapy.
2. Assess the client's baseline respiratory signs:
including airway, respiratory pattern, rate, depth, and rhythm, noting
indications of increased work of breathing. This will help determine the
client's need for oxygen as well as response to the therapy.
3. Check the extremities and mucous membranes closely for color:
This gives some indication of oxygenation, although problems with
circulation and tissue perfusion can alter these factors also.
Unit 6: Oxygenation Fundamental of nursing
3
4. Review arterial blood gas (ABG) and pulse oximetry results.
These are the most important determinants of the effectiveness of the
pulmonary system and determine the need for therapy as well as changes
in therapy.
5. Note lung sounds for crackles.
Secretions will interfere with airway patency and diffusion of oxygen
and carbon dioxide across the alveolar-capillary bed.
Diagnoses
Impaired Gas Exchange
Ineffective Breathing Pattern
Risk for Injury
Ineffective Airway Clearance
Planning
Equipment Needed
• Stethoscope
• Oxygen source—portable or in-line
• Oxygen flow meter
• Oxygen delivery device: nasal cannula, mask.
• Oxygen tubing
• Pulse oximetry
• Humidifier and distilled or sterile water.
Client Education
1. Explain to the client the reason for oxygen therapy.
2. Help the client understand the importance of leaving the delivery
system on.
Unit 6: Oxygenation Fundamental of nursing
4
3. Use pictures to help clients understand their lungs and airway so
they will be more likely to cooperate with the therapy.
4. Make sure clients know what signs and symptoms to report that
indicate therapy is not effective and needs to be changed.
5. Reinforce safety issues-make sure they understand that oxygen
supports combustion.
6. Show clients methods to increase oxygenation such as deep
breathing, coughing, and changes in positioning
Implementation
Nasal Cannula
1.Wash hands to reduces the transmission of microorganisms.
2.Verify from the order to ensures correct dosage and route.
3.Explain procedure and hazards to the client. Remind smoker clients for
not smoking while O2 is in use.
4.Fill humidifier to fill line with distilled water to prevents drying of the
client's airway and thins any secretions
Evaluation
• Oxygen levels returned to normal in blood and tissues as evident by
oxygen saturation ≥ 92%; skin color normal for client.
• Respiratory rate, pattern, and depth are within the normal range.
• The client understands the rationale for the therapy.
Documentation Nurses' Notes
Recording of oxygen saturation and respiratory status.
• Note method of oxygen delivery and rate.
• Document client's response to treatment.
• Note and record changes in mental status.
Unit 7: Urinary elimination Fundamental of Nursing
1
Urinary Elimination
Lecture outlines:
Overview of Urinary Elimination
Factors Affecting Voiding
Characteristics of Urine
Altered Urine Production
Abnormal of Urinary elimination
Assessing clients with urinary elimination
Overview of Urinary Elimination
The physiological mechanisms that govern urinary elimination are
complex and not yet completely understood. Continence in the adult
requires anatomic integrity of the urinary system, nervous control of the
detrusor muscle, and a competent sphincter mechanism. Urinary
incontinence occurs when abnormalities of one or more of these factors
cause an uncontrolled loss of urine that produces social, physiological, or
hygienic difficulties for the client.
Urination
Micturition, voiding, and urination all refer to the process of
emptying the urinary bladder. Urine collects in the bladder until pressure
stimulates special sensory nerve endings in the bladder wall called stretch
receptors. This occurs when the adult bladder contains between 250 and
450 mL of urine. In children, a considerably smaller volume, 50 to 200
mL, stimulates these nerves.
Unit 7: Urinary elimination Fundamental of Nursing
2
Factors Affecting Voiding
Numerous factors affect the volume and characteristics of the urine
produced and the manner in which it is excreted.
1. Age
- Control over bladder can begin as early as 18 months of age but is
typically not mastered until age 4.
- Nighttime control usually takes longer to achieve, and boys typically
take longer to develop control over elimination than girls.
2. Fluid and Food Intake
- Certain fluids, such as alcohol, increase fluid output by inhibiting the
production of antidiuretic hormone.
- Fluids that contain caffeine (e.g., coffee, tea, and cola drinks) also
increase urine production.
- Some foods and fluids can change the color of urine. For example,
beets can cause urine to appear red; foods containing carotene can
cause the urine to appear yellower than usual.
3. Medications
Diuretics (e.g., chlorothiazide and furosemide) increase urine
formation by preventing the reabsorption of water and electrolytes from
the tubules of the kidney into the bloodstream.
4. Muscle Tone
- Good muscle tone is important to maintain the stretch and
contractility of the detrusor muscle so the bladder can fill
adequately and empty completely.
- Clients who require a retention catheter for a long period may have
poor bladder muscle tone because continuous drainage of urine
prevents the bladder from filling and emptying normally. Pelvic
muscle tone also contributes to the ability to store and empty urine.
Unit 7: Urinary elimination Fundamental of Nursing
3
5. Pathologic Conditions
- Diseases of the kidneys may affect the ability of the nephrons to
produce urine.
- Abnormal amounts of protein or blood cells may be present in the
urine, or the kidneys may virtually stop producing urine altogether,
a condition known as renal failure.
- Heart and circulatory disorders such as heart failure, shock, or
hypertension can affect blood flow to the kidneys, interfering with
urine production.
6. Surgical and Diagnostic Procedures
- The urethra may swell following a cystoscopy, and surgical
procedures on any part of the urinary tract may result in some
postoperative bleeding; as a result, the urine may be red or pink
tinged for a time.
- Spinal anesthetics can affect the passage of urine because they
decrease the client's awareness of the need to void. Surgery on
structures adjacent to the urinary tract (e.g., the uterus) can also
affect voiding because of swelling in the lower abdomen.
Characteristics of Urine
Characteristic Normal Abnormal
Amount in 24
hours
(adult)
1,200-1,500 mL Under 1,200 mL A large
amount over intake
Color, clarity Straw, amber
Transparent
Dark amber, Cloudy, Dark
orange, Red or dark brown,
Mucous plugs, viscid, thick
Odor Faint aromatic Offensive
Sterility No microorganisms
present Microorganisms present
Unit 7: Urinary elimination Fundamental of Nursing
4
PH 4.5-8 Over 8
Under 4.5
Specific
gravity 1.010-1.025
Over 1.025
Under 1.010
Glucose Not present Present
Ketone bodies
(acetone) Not present Present
Blood Not present Occult (microscopic)
Bright red
Altered Urine Production
Although people's patterns of urination are highly individual, most
people void about 5 to 6 times a day. People usually void when they first
awaken in the morning, before they go to bed, and around mealtimes.
Polyuria
- Polyuria (or diuresis) refers to the production of abnormally large
amounts of urine by the kidneys, often several liters more than the
client's usual daily output.
- Polyuria can follow excessive fluid intake, a condition known as
polydipsia, or may be associated with diseases such as diabetes
mellitus, and chronic nephritis.
- Polyuria can cause excessive fluid loss, leading to intense thirst,
dehydration, and weight loss.
Oliguria and Anuria
The terms oliguria and anuria are used to describe decreased urinary
output.
Oliguria is low urine output, usually less than 500 mL a day or 30 mL
an hour for an adult.
Unit 7: Urinary elimination Fundamental of Nursing
5
Although oliguria may occur because of abnormal fluid losses or a lack
of fluid intake, it often indicates impaired blood flow to the kidneys or
impending renal failure and should be promptly reported to the primary
care provider. Restoring renal blood flow and urinary output promptly
can prevent renal failure and its complications.
Anuria refers to a lack of urine production.
Frequency and Nocturia
Urinary frequency is voiding at frequent intervals, that is, more than 4
to 6 times per day.
An increased intake of fluid causes some increase in the frequency of
voiding.
Conditions such as urinary tract infection, stress, and pregnancy can
cause frequent voiding of small quantities (50 to 100 mL) of urine.
Nocturia,
is voiding two or more times at night.
Urgency Urgency is the sudden strong desire to void.
There may or may not be a great deal of urine in the bladder, but the
person feels a need to void immediately.
Urgency accompanies psychological stress and irritation of the trigon
and urethra.
It is also common in people who have poor external sphincter control
and unstable bladder contractions. It is not a normal finding.
Dysuria
Dysuria means voiding that is either painful or difficult.
It can accompany a stricture (decrease in caliber) of the urethra,
urinary infections, and injury to the bladder and urethra.
Unit 7: Urinary elimination Fundamental of Nursing
6
Often clients will say they have to push to void or that burning
accompanies or follows voiding.
The burning may be described as severe, like a hot poker, or more
subdued, like sunburn.
Often, urinary hesitancy (a delay and difficulty in initiating voiding) is
associated with dysuria.
Enuresis
Enuresis is involuntary urination in children beyond the age when
voluntary bladder control is normally acquired, usually 4 or 5 years of
age.
Nocturnal enuresis often is irregular in occurrence and affects boys
more often than girls.
Diurnal (daytime) enuresis may be persistent and pathologic in origin.
Abnormal of Urinary elimination
Urinary incontinence and urinary retention are the most common
causes of altered urinary elimination patterns. Urinary incontinence is the
uncontrolled loss of urine that constitutes a social or hygienic problem.
Urinary retention
is the inability to completely evacuate urine from the bladder
during micturition.
Urinary incontinence
There are two primary types of urinary incontinence, acute and chronic.
1. Acute urinary incontinence is a transient and reversible loss of urine.
It may occur during an acute illness or after an injury.
Common causes of acute urinary incontinence include:
a. urinary tract infection,
b. atrophic vaginitis,
Unit 7: Urinary elimination Fundamental of Nursing
7
c. Polyuria related to diabetes, acute confusion, immobility, and
sedation.
d. Medications that increase or decrease bladder or urethral sphincter
tone also may contribute to acute incontinence.
2. Chronic Urinary Incontinence
There are four predominant types of chronic urine loss:
a. Stress urinary incontinence (SUI): is the uncontrolled loss of urine
caused by physical exertion in the absence of a detrusor muscle
contraction.
b. Instability incontinence
The loss of urine caused by a premature or hyperactive contraction of the
detrusor in the person with normal sensations of the lower urinary tract,
these unstable detrusor contractions initially cause a precipitous desire to
urinate followed by urinary leakage unless the opportunity to toilet is
immediately available. In those without sensations of bladder filling and
impending urination, the contraction is followed by urinary incontinence
that is often described as unpredictable.
c. Functional incontinence
The loss of urine caused by altered mobility, dexterity, access to the
toilet.
These conditions are worsened in an unfamiliar environment, such as a
hospital, where side rails are raised on beds and sedatives are used to
enhance sleep.
Difficulty in reaching the toilet due to environmental factors (e.g.,
stairs, poor lighting, and toilet height, narrow doors that are impassable
to wheelchairs or walkers) also produces functional incontinence when
Unit 7: Urinary elimination Fundamental of Nursing
8
the obstacles render the person unable to enter the bathroom with
reasonable ease.
d. Extra urethral incontinence
The uncontrolled loss of urine that exists when the sphincter
mechanism has been bypassed, the three causes of extra urethral
incontinence are ectopia, a congenital defect in which leaks occur from
a source outside the urethra; a fistula, an acquired passage allowing
urinary leakage; or a surgical bypass of the urinary bladder, such as the
ideal conduit.
The severity of extra urethral incontinence varies from a dribbling
leakage superimposed on an otherwise normal voiding pattern to a
continuous urine loss that replaces any recognizable voiding pattern.
Assessing clients with urinary elimination
A complete assessment of a client's urinary function includes the
following:
Nursing history
Physical assessment of the genitourinary system, hydration status, and
examination of the urine
Relating the data obtained to the results of any diagnostic tests and
procedures
Nursing History
The nurse determines the client's normal voiding pattern and
frequency, appearance of the urine and any recent changes, any past or
current problems with urination, the presence of an ostomy, and factors
influencing the elimination pattern.
Unit 7: Urinary elimination Fundamental of Nursing
9
Physical Assessment
Complete physical assessment of the urinary tract usually includes
percussion of the kidneys to detect areas of tenderness.
Palpation and percussion of the bladder are also performed.
assess the skin for color, texture, and tissue turgor as well as the
presence of edema.
Mobility and dexterity are evaluated by observation or by asking the
client to perform simple tasks.
Pelvic support is assessed in the woman because it is associated with
pelvic muscle weakness.
Assessing Urine
Normal urine consists of 96% water and 4% solutes.
Organic solutes include urea, ammonia, creatinine, and uric acid.
Diagnostic Tests
1. urinalysis is obtained and evaluated for nitrites, leukocytes,
hemoglobin, glucose, and specific gravity.
2. Urine culture and sensitivity testing are completed and the client is
treated for urinary tract infection.
Unit 8: Bowel Elimination Fundamental of Nursing
Bowel Elimination
Elimination of the waste products of digestion from the body is
essential to health. The excreted waste products are referred to as feces or
stool.
Defecation: Defecation is the expulsion of feces from the anus and
rectum; it is also called a bowel movement. The frequency of defecation
is highly individual, varying from several times per day to two or three
times per week.
Feces: Normal feces are made of about 75% water and 25% solid
materials. Normal feces require a normal fluid intake; feces that contain
less water may be hard and difficult to expel.
Characteristics of Stool
Characteristics Normal Abnormal
Color Adult: brown
Infant: yellow
Clay or white, Black
or tarry Red, Pale
Orange or green
Consistency Formed, soft, semisolid, moist Hard, dry, Diarrhea
Shape
Cylindrical (contour of
rectum) about 2.5 cm (1 in.)'in
diameter in adults
Narrow, pencil-
shaped, or string like
stool
Amount Varies with diet (about 100-
400 g per day)
Odor
Aromatic: affected by ingested
food and person's own
bacterial flora
Pungent
Constituents Small amounts of undigested Pus Mucus Parasites
Unit 8: Bowel Elimination Fundamental of Nursing
roughage, sloughed dead
bacteria and epithelial cells,
fat, protein, dried constituents
of digestive juices (e.g., bile
pigments, inorganic matter)
Blood Large
quantities of fat
Foreign objects
Factors That Affect Defecation
Defecation patterns vary at different stages of life. Circumstances
of diet, fluid intake and output, activity, psychological factors, lifestyle,
medications and medical procedures, and disease also affect defecation.
1. Age
A client’s age or developmental level will affect control bowel
patterns. Infants initially lack a pattern to their elimination.
Control bowel movements can begin as early as 18 months of age but
is typically not mastered until age 4.
Nighttime control usually takes longer to achieve, and boys typically
take longer to develop control over elimination than girls.
Control of elimination is generally constant throughout the adult years,
with the exception of illness and pregnancy stages, when temporary
loss of control, urgency, and retention may develop.
2. Diet
Sufficient bulk (cellulose, fiber) in the diet is necessary to provide
fecal volume.
Bland diets and low-fiber diets are lacking in bulk and therefore create
insufficient residue of waste products to stimulate the reflex for
defecation.
Low-residue foods, such as rice, eggs, and lean meats, move more
slowly through the intestinal tract.
Unit 8: Bowel Elimination Fundamental of Nursing
Increasing fluid intake with such foods increases their rate of
movement.
Certain foods are difficult or impossible for some people to digest.
This inability results in digestive upsets and, in some instances, the
passage of watery stools.
Irregular eating can also impair regular defecation.
Individuals who eat at the same times every day usually have a
regularly timed, physiologic response to the food intake and a regular
pattern of peristaltic activity in the colon.
Spicy foods can produce diarrhea and flatus in some individuals.
Excessive sugar can also cause diarrhea. Other foods that may
influence bowel elimination include the following:
Gas-producing foods, such as cabbage, onions, cauliflower, bananas,
and apples
Laxative-producing foods, such as bran, prunes, figs, chocolate, and
alcohol
Constipation-producing foods, such as cheese, pasta, eggs, and lean
meat
3. Fluid
Inadequate fluid intake, resulting in hard feces.
Healthy fecal elimination usually requires a daily fluid intake of 2,000
to 3,000 ml.
If chyme moves abnormally quickly through the large intestine,
however, there is less time for fluid to be absorbed into the blood; as a
result, the feces are soft or even watery.
4. Activity
Activity stimulates peristalsis, thus facilitating the movement of chyme
along the colon.
Unit 8: Bowel Elimination Fundamental of Nursing
Weak abdominal and pelvic muscles are often ineffective in increasing
the intra-abdominal pressure during defecation or in controlling
defecation.
Weak muscles can result from lack of exercise, immobility, or
impaired neurologic functioning.
Clients confined to bed are often constipated.
5. Psychological Factors
anxious or angry is increased peristaltic activity and subsequent nausea
or diarrhea. In contrast,
depressions slowed intestinal motility, resulting in constipation.
6. Defecation Habits
If a person ignores this urge to defecate, water continues to be
reabsorbed, making the feces hard and difficult to expel.
When the normal defecation reflexes are inhibited or ignored, these
conditioned reflexes tend to be progressively weakened.
When habitually ignored, the urge to defecate is ultimately lost.
Adults may ignore these reflexes because of the pressures of time or
work.
Hospitalized' clients may suppress the urge because of embarrassment
about using a bedpan, because of lack of privacy, or because defecation
is too uncomfortable.
7. Medications
large doses of certain tranquilizers and repeated administration of
morphine and codeine, cause constipation because they decrease
gastrointestinal activity through their action on the central nervous
system.
Laxatives are medications that stimulate bowel activity and so assist
fecal elimination.
Unit 8: Bowel Elimination Fundamental of Nursing
Medications also affect the appearance of the feces.
- aspirin products can cause the stool to be red or black.
- Iron salts lead to black stool because of the oxidation of the iron;
- antibiotics may cause a gray-green discoloration; and
- antacids can cause a whitish discoloration or white specks in the stool.
8. Diagnostic Procedures
Before certain diagnostic procedures, such as visualization of the
colon (colonoscopy), the client is restricted from ingesting food or fluid.
The client may also be given a cleansing enema prior to the examination.
In these instances normal defecation usually will not occur until eating
resumes.
9. Anesthesia and Surgery
General anesthetics cause the normal colonic movements to cease or
slow by blocking parasympathetic stimulation to the muscles of the
colon. Clients who have regional or spinal anesthesia are less likely to
experience this problem.
Surgery that involves direct handling of the intestines can cause
temporary cessation of intestinal movement. This condition, called
ileus, usually lasts 24 to 48 hours. Listening for bowel sounds that
reflect intestinal motility is an important nursing assessment following
surgery.
10. Pathologic Conditions
Spinal cord injuries and head injuries can decrease the sensory
stimulation for defecation. Impaired mobility may limit the client's ability
to respond to the urge to defecate and the client may experience
constipation. Or, a client may experience fecal incontinence because of
poorly functioning anal sphincters.
Unit 8: Bowel Elimination Fundamental of Nursing
11. Pain
Clients who experience discomfort when defecating (e.g., following
hemorrhoid surgery) often suppress the urge to defecate to avoid the
pain. Such clients can experience constipation as a result.
Clients taking narcotic analgesics for pain may also experience
constipation as a side effect of the medication.
Fecal Elimination Problems
Four common problems are related to fecal elimination:
constipation, diarrhea, bowel incontinence, and flatulence.
Constipation
Constipation may be defined as fewer than three bowel movements
per week. This infers the passage of dry, hard stool or the passage of no
stool. It occurs when the movement of feces through the large intestine is
slow, thus allowing time for additional reabsorption of fluid from the
large intestine. The person may also have a feeling of incomplete stool
evacuation after defecation. However, it is important to define
constipation in relation to the person's regular elimination pattern. Some
people normally defecate only a few times a week; other people defecate
more than once a day. Careful assessment of the person's habits is
necessary before a diagnosis of constipation is made.
Many causes and factors contribute to constipation. Among them are
the following:
Insufficient fiber intake
Insufficient fluid intake
Insufficient activity or immobility
Irregular defecation habits
Unit 8: Bowel Elimination Fundamental of Nursing
Change in daily routine
3q1Chronic use of laxatives or enemas
Irritable bowel syndrome (IBS)
Pelvic floor dysfunction or muscle damage
Poor motility or slow transit
Neurological conditions (e.g., Parkinson's disease), stroke, or paralysis
Emotional disturbances such as depression or mental confusion
Medications such as opioids, iron supplements, antihistamines,
antacids, and antidepressants.
Constipation can cause health problems for some clients. In children it
is often associated with urinary tract infections.
Fecal Impaction
Fecal impaction is a mass or collection of hardened feces in the folds
of the rectum.
Impaction results from prolonged retention and accumulation of fecal
material.
In severe impactions the feces accumulate and extend well up into the
sigmoid colon and beyond.
Fecal impaction can be recognized by the passage of liquid fecal
seepage (diarrhea) and no normal stool.
The liquid portion of the feces seeps out around the impacted mass.
Impaction can also be assessed by digital examination of the rectum,
during which the hardened mass can often be palpated.
The causes of fecal impaction are usually poor defecation habits and
constipation.
The barium used in radiologic examinations of the upper and lower
gastrointestinal tracts can also be a causative factor. Therefore, after
Unit 8: Bowel Elimination Fundamental of Nursing
these examinations, laxatives or enemas are usually taken to ensure
removal of the barium.
Diarrhea
Diarrhea refers to the passage of liquid feces and an increased
frequency of defecation.
It is the opposite of constipation and results from rapid movement of
fecal contents through the large intestine.
Rapid passage of chyme reduces-the time available for the large
intestine to reabsorb water and electrolytes
The person with diarrhea finds it difficult or impossible to control the
urge to defecate for very long.
Diarrhea and the threat of incontinence are sources of concern and
embarrassment.
Bowel Incontinence
Bowel incontinence, also called fecal incontinence, refers to the loss of
voluntary ability to control fecal and gaseous discharges through the
anal sphincter.
The incontinence may occur at specific times, such as after meals, or it
may occur irregularly. Two types of bowel incontinence are described:
partial and major.
1. Partial incontinence: is the inability to control flatus or to prevent
minor soiling.
2. Major incontinence: is the inability to control feces of normal
consistency.
Fecal incontinence is generally associated with impaired functioning of
the anal sphincter or its nerve supply, such as in some neuromuscular
Unit 8: Bowel Elimination Fundamental of Nursing
diseases, spinal cord trauma, and tumors of the external anal sphincter
muscle.
Fecal incontinence is an emotionally distressing problem that can
ultimately lead to social isolation.
Several surgical procedures are used for the treatment of f ceiling
continence. These include repair of the sphincter and fecal diversion or
colostomy.
Flatulence
There are three primary sources of flatus:
a. Action of bacteria on the chyme in the large intestine,
b. Swallowed air.
c. Gas that diffuses between the blood stream and the intestine.
Most gases that are swallowed are expelled through the mouth by
eructation (belching). However, large amounts of gas can accumulate
in the stomach, resulting in gastric distention.
The gases formed in the large intestine are chiefly absorbed through
the intestinal capillaries into the circulation. Flatulencies the presence
of excessive flatus in the intestines and leads to stretching and inflation
of the intestines (intestinal distention).
If excessive gas cannot be expelled through the anus, it may be
necessary to insert a rectal tube to remove it.
Assessing of clients with bowel elimination
1. taking a nursing history;
2. physical examination of the abdomen, rectum, and anus; and
inspecting the feces.
3. review any data obtained from relevant diagnostic tests.
Unit 8: Bowel Elimination Fundamental of Nursing
Fecal Elimination Problems
What problems have you had or do you now have with your bowel
movements (constipation, diarrhea, excessive flatulence, seepage, or
incontinence)?
When and how often does it occur?
What do you think causes it (food, fluids, exercise, emotions,
medications, disease, surgery)?
What have you tried to solve the problem, and how effective was it?
Diagnostic Studies: Diagnostic studies of the gastrointestinal tract
include direct visualization techniques, indirect visualization techniques,
and laboratory tests for abnormal constituents.
Laboratory tests also may be obtained for select cases of fecal
incontinence. A stool culture may be analyzed for ova and parasites,
electrolytes, or culture when dietary intolerance or a GI infection is
thought to be causing diarrhea and related incontinence.