Bowel Elimination

1. Identify factors that influence bowel elimination.

A. Development

A. Development1. Newborns and Infants

• meconium - the first fecal material passed by the newborn, normally up to 24 hours after birth; it is black, tarry, odorless, and sticky

• transitional stools

• follow meconium for about a week - greenish-yellow, contains mucus, loose

• infants

• pass stool frequently, after each feeding

• intestine is immature = stool is soft, liquid and frequent

• bacterial flora increase as intestines mature

• solid foods = stool becomes less frequent and firmer

• breast-fed - light yellow to golden feces

• formula-fed - dark yellow or tan stool, more formed2. Toddlers

• control of defecation

• starts at 1.5-2 years of age

• desire to control daytime BM starts when child becomes aware of:

• discomfort caused by a soiled diaper

• sensation that indicates the need for a BM

• typically attained by 2.5 y/o after toilet training3. School-Age Children and Adolescents

• have BM habits similar to adults

• patterns vary in frequency, quantity, and consistency

• may delay defecation because of an activity such as play4. Older Adults

• constipation

• significant health problem in older adults due to:

• reduced activity levels

• inadequate amount of fluid and fiber intake

• muscle weakness

• may be relieved by increasing fiber intake to 20-35 grams per day

• preventive measures for constipation:

• adequate roughage in the diet

• adequate exercise

• 6-8 glasses of fluid

• cup of hot water/tea at a regular time in the morning

• responding to gastrocolic reflex (i.e. 30 minutes after meals)

• gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after breakfast

• should be warned that consistent laxative use may cause constipation

• may also interfere with body’s electrolyte balance

• may decrease absorption of certain vitamins

• causes of constipation

• lifestyle habits

• serious malignant disorders

CLINICAL MANIFESTATIONS: COLORECTAL CANCER

RISK FACTORS Nonmodifiable • Age

• Race

• Family history

Modifiable • Cigarette smoking

• Poor diet (e.g., low in fiber and high in fat)

• Lack of physical activity

• Regular consumption of alcohol

SYMPTOMS • A change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days

• A feeling of needing to have a BM that is not relieved by doing so

• Rectal belleding or blood in the stool (often, though, stool will look normal)

• Cramping or steady abdominal pain

• Weakness and fatigue

• Unexpected weight loss

B. Diet• sufficient bulk (cellulose, fiber)

• necessary for adequate fecal volume

• inadequate fiber contributes to risk of developing

• obesity

• type 2 diabetes

• coronary artery disease

• colon cancer

• insoluble fiber

• promotes movement of material through digestive system and increases stool bulk

• ex: whole wheat flour, wheat bran, nuts, many vegetables

• soluble fiber

• forms a gel when mixed with water

• lowers blood cholesterol and glucose levels

• ex: oats, peas, beans, apples, citrus fruits, carrots, barley, psyllium

• drink plenty of water

• low-residue foods

• move more slowly

• need to increase fluid intake with such foods to increase rate of movement

• ex: rice, eggs, lean meats

• certain foods are difficult or impossible for some people to digest

• results in digestive upsets

• may cause passage of watery stools

• irregular eating

• impairs regular defecation

• foods that may influence bowel elimination

• spicy foods - diarrhea and flatus

• excessive sugar - diarrhea

• gas-producing foods - cabbage, onions, cauliflower, bananas, apples

• laxative-producing foods - bran, prunes, figs, chocolate, alcohol

• constipation-producing foods - cheese, pasta, eggs, lean meat

RECOMMENDED DAILY INTAKE OF FIBER

Men 50 and younger 38 grams

51 and older 30 grams

Women 50 and younger 25 grams

51 and older 21 grams

1. Fluid• body continues to reabsorb fluid from chyme even when fluid intake is inadequate or output is excessive

• reduced fluid intake slows passage and further increases fluid reabsorption

• healthy fecal elimination requires intake of 2,000-3,000 mL

• if chyme moves abnormally quickly, less fluid is absorbed - feces are soft or watery

C. Activity• stimulates peristalsis - facilitates movement of chyme along colon

• weak abdominal and pelvic muscles are ineffective in assisting defecation

• results from lack of exercise, immobility, or impaired neurologic functioning

• confined to bed = constipation

D. Psychological Factors• anxiety/anger - increased peristaltic activity causing nausea or diarrhea

• depression - slowed intestinal motility causing constipation

E. Defecation Habits• early bowel training may establish habit of defecating at a regular time

• when normal defecation reflexes are inhibited or ignored, reflexes tend to be progressively weakened

• when habitually ignored, urge to defecate is ultimately lost

• reasons adults/patients ignore reflexes

• pressures of time or work

• embarrassment about using a bedpan

• lack of privacy

• defecation too uncomfortable

F. Medications• drug side effects may interfere with normal elimination

• diarrhea

• constipation

• morphine, codeine (decrease GI activity through CNS effect)

• iron tablets - astringent effect, act more locally on bowel mucosa

• some medications directly affect elimination

• laxatives - medications that stimulate bowel activity and assist fecal elimination

• stool softeners facilitate defecation

• certain medications suppress peristaltic activity - treats diarrhea

• affect appearance of feces

• GI bleeding (e.g. aspirin products) - red or black

• iron salts - black

• antibiotics - gray-green

• antacids - whitish or white specks

• Pepto-Bismol - black stools

G. Diagnostic Procedures• some procedures (colonoscopy or sigmoidoscopy)

• require NPO

• cleansing enema

• normal defecation will not occur until eating resumes

H. Anesthesia and Surgery• general anesthesia

• normal colonic movements cease or slow by blocking parasympathetic stimulation

• regional/spinal anesthesia less likely to experience this problem

• surgery

• direct intestinal handling - causes temporary cessation of intestinal movement or ileum (lasts 24-48 hours)

• listen for bowel sounds - intestinal motility, important nursing assessment

I. Pathologic Conditions• spinal cord injuiries/head injuries - may decrease sensory stimulation for defecation

• impaired mobility

• may limit ability to respond to urge

• may cause constipation

• may cause client to experience fecal incontinence due to poorly functioning anal sphincters

J. Pain• discomfort when defecating - may cause client to suppress urge to defecate; may cause constipation

• narcotic analgesics for pain - may cause constipation

2. Review the common bowel diversions.

• ostomy - an opening for the gastrointestinal, urinary, or respiratory tract onto the skin

• Alternate feeding route• gastrostomy - an opening through the abdominal wall into the stomach• jejunostomy - a type of ostomy that opens through the abdominal wall into the jejunum

• Bowel ostomies - to divert and drain fecal material

• Ileostomy - a type of ostomy that opens into the ileum (small bowel)

• colostomy - a type of ostomy that opens into the colon (large bowel

• Classification

• by permanent or temporary status

• by anatomic location

• by construction of the stoma

• stoma - the opening created in the abdominal wall by the osmotic; generally red in color and moist

• may bleed when touched

• has no nerve endings

a. Permanence1. Temporary ostomies - allows distal diseased portion to heal

a. traumatic injuriesb. inflammatory conditions

2. Permanent ostomies - provide a means of elimination when the rectum or anus is nonfunctionala. birth defectsb. disease such as cancer of the bowel

b. Anatomic Location1. location influences the character and management of fecal drainage

a. the farther along, the more formed the stool, the more control over frequency of discharge2. length of time ostomy is in place also causes stool to become more formed

a. remaining functioning portions tend to compensate by increasing water absorption 3. ileostomy - empties from distal end of small intestine

a. produced liquid fecal drainageb. constant drainage, cannot be regulatedc. contains skin-damaging digestive enzymesd. appliance must be worn continuouslye. odor is minimal compared to colostomies

4. cecostomy - empties from the cecum5. ascending colostomy - empties from ascending colon

a. similar to an ileostomyb. drainage is liquid, cannot be regulated, digestive enzymes present

c. odor is a problem6. transverse colostomy - empties from transverse colon

a. malodorous, mushy drainageb. usually no control

7. descending colostomy - empties from descending colona. increasingly solid drainage

8. sigmoidostomy - empties from the sigmoid colona. normal/formed consistencyb. frequency of discharge can be regulatedc. may not need to wear an appliance at all timesd. odors can usually be controlled

c. Surgical Construction of the Stoma1. end or terminal colostomy - a type of colostomy that has a singe stoma created when one end of bowel

is brought out through an opening onto the anterior abdominal wall; the stoma is permanent2. loop colostomy - a type of colostomy where a loop of bowel is brought out onto the abdominal wall and

supported by a plastic bridge, or a piece of rubber tubing; the stoma has two ends: an active proximal end, and an inactive distal end

a. usually for emergenciesb. stoma is bulky and more difficult to manage

3. divided colostomy - consists of two edges of bowel brought out onto the abdomen but separated from each other; the proximal end is the colostomy and the distal end is the mucous fistula

a. used where spillage of feces into distal end needs to be avoided4. double-barreled colostomy - resembles a double-barreled shotgun; the proximal and distal loops of

bowel are sutured together for about 10 cm (4 in) and both ends are brought up onto the abdominal wall

3. Identify common causes and effects of the following bowel elimination problems.

a. constipation• constipation

• significant health problem in older adults due to:

• reduced activity levels

• inadequate amount of fluid and fiber intake

• muscle weakness

• may be relieved by increasing fiber intake to 20-35 grams per day

• preventive measures for constipation:

• adequate roughage in the diet

• adequate exercise

• 6-8 glasses of fluid

• cup of hot water/tea at a regular time in the morning

• responding to gastrocolic reflex (i.e. 30 minutes after meals)

• gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after breakfast

• should be warned that consistent laxative use may cause constipation

• may also interfere with body’s electrolyte balance

• may decrease absorption of certain vitamins

• causes of constipation

• lifestyle habits

• serious malignant disorders

b. diarrhea

• diarrhea - the passage of liquid feces and an increased frequency of defecation

• opposite of constipation

• results from rapid movement of fecal contents through the large intestine

• Symptoms

• stool is relatively unformed and excessively liquid

• finds it difficult or impossible to control the urge to defecate

• often accompanied by spasmodic cramps and increased bowel sounds

• persistent diarrhea irritates anal region and buttocks

• prolonged diarrhea results in fatigue, weakness, malaise, and emaciation

• Causes

• irritants in the intestinal tract - protective flushing; can create serious fluid and electrolyte losses (especially in infants, small children, and older adults)

• Clostridium difficile-associated disease

• produces mucoid and foul-smelling diarrhea

• highest risk: immunosuppressed persons, clients on chemotherapy, those who have recently used antimicrobial agents (fluoroquinolones)

• greatest risk: elderly

• infection control: hand hygiene with soap and water, contact precautions, cleaning of surfaces with bleach

CAUSE PHYSIOLOGICAL EFFECT

Psychological stress (e.g. anxiety) Increased intestinal motility and mucous secretion

Medications Inflammation and infection of mucosa due to overgrowth of pathogenic intestinal microorganisms

Antibiotics Irritation of intestinal mucosa

Iron Irritation of intestinal mucosa

Cathartics Incomplete digestion of food or fluid

Allergy to food, fluid, drugs Increased intestinal motility and mucous secretion

Intolerance of food or fluid Reduced absorption of fluids

Diseases of the colon (e.g., malabsorption syndrome, Crohn’s disease)

Inflammation of the mucosa often leading to ulcer formation

• increased risk for skin breakdown

• skin around anal region should be kept clean and dry; use zinc oxide

• use a fecal collector

• Also: spicy foods, excessive sugar, and anxiety/anger (^peristaltic activity) all can cause diarrhea

c. fecal impaction• fecal impaction - a mass or collection of hardened feces in the folds of the rectum; results from prolonged

retention and accumulation of fecal material

• severe impaction - accumulation well up into sigmoid colon and beyond

• Symptoms

• will experience passage of liquid fecal seepage and no normal stool

• frequent but nonproductive desire to defecate and rectal pain

• results in a generalized feeling of illness

• anorexia, distention of abdomen, nausea and vomiting may occur

• may be assessed by digital examination of the rectum

• Causes

• poor defecation habits

• constipation

• administration of medications such as anticholinergics and antihistamines

• barium used in radiologic examinations of upper and lower GI

• Treatment

• oil retention enema followed by a cleansing enema 2-4 hrs later, daily cleansing enemas, suppositories/stool softeners

• digital removal

d. bowel incontinence

bowel incontinence (fecal incontinence) - the loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter

• may occur at specific times or irregularly

• two types:

• partial - inability to control flatus or to prevent minor soiling

• major - inability to control feces of normal consistency

• associated with impaired functioning of anal sphincter or nerve supply (in neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle)

• prevalence increases with age

• emotionally distressing and may lead to social isolation

• Treatment

• repair of sphincter

• bowel diversion/colostomy

e. flatulence

• Primary sources

• action of bacteria on the chyme in the large intestine

• swallowed air

• gas that diffuses between the bloodstream and the intestine

• most swallowed gases are expelled by eructation/belching

• gas may accumulate in the stomach - gastric distention

• gases formed in the large intestine - absorbed into circulation• flatulence - the presence of excessive flatus in the intestines and leads to stretching and inflation of the

intestines (intestinal distention)

• Causes

• food (cabbage, onions)

• abdominal surgery

• narcotics

• Relief

• if gas is propelled by increased colon activity before it is absorbed, it is expelled through the anus

• use of a rectal tube to remove the gas

4. Develop 2 nursing diagnoses, interventions and outcomes for clients with elimination problems.

Dysfunctional gastrointestinal motility

Bowel incontinence

Constipation

Diarrhea

Risk for electrolyte imbalance

Impaired skin Integrity

Disturbed body image

Deficient knowledge, ostomy management

Nutrition

1. Discuss therapeutic diets and the rationale for the diet.

Clear liquid diet –

a. Includes minimum residue fluids that can be seen through. b. Examples are juices without pulp, broth, and Jell-O. c. Is often used as the first step to restarting oral feeding after surgery or an abdominal procedure. d. Can also be used for fluid and electrolyte replacement in people with severe diarrhea. e. Should not be used for an extended period as it does not provide enough calories and nutrients.

Full liquid diet –

Includes fluids that are creamy.

a. Some examples of food allowed are ice cream, pudding, thinned hot cereal, custard, strained cream soups, and juices with pulp.

b. Used as the second step to restarting oral feeding once clear liquids are tolerated. c. Used for people who cannot tolerate a mechanical soft diet. d. Should not be used for extended periods.

No Concentrated Sweets (NCS) diet –

a. Is considered a liberalized diet for diabetics when their weight and blood sugar levels are under control. b. It includes regular foods without the addition of sugar. c. Calories are not counted as in ADA calorie controlled diets.

Diabetic or calorie controlled diet (ADA) –

a. These diets control calories, carbohydrates, protein, and fat intake in balanced amounts to meet nutritional needs, control blood sugar levels, and control weight.

b. Portion control is used at mealtimes as outlined in the ADA “Exchange List for Meal Planning.” c. Most commonly used calorie levels are: 1,200, 1,500, 1,800 and 2,000.

No Added Salt (NAS) diet –

a. Is a regular diet with no salt packet on the tray. b. Food is seasoned as regular food.

Low Sodium (LS) diet –

a. May also be called a 2 gram Sodium Diet. b. Limits salt and salty foods such as bacon, sausage, cured meats, c. canned soups, salty seasonings, pickled foods, salted crackers, etc. d. Is used for people who may be “holding water” (edema) or who have e. high blood pressure, heart disease, liver disease, or first stages of kidney disease.

Low fat/low cholesterol diet –

a. Is used to reduce fat levels and/or treat medical conditions that interfere with how the body uses fat such as diseases of the liver, gallbladder, or pancreas.

b. Limits fat to 50 grams or no more than 30% calories derived from fat. c. Is low in total fat and saturated fats and contains approximately 250-300 mg cholesterol.

High fiber diet –

a. Is prescribed in the prevention or treatment of a number of gastrointestinal, cardiovascular, and metabolic diseases. b. Increased fiber should come from a variety of sources including fruits, legumes, vegetables, whole breads, and

cereals.

Renal diet –

a. Is for renal/kidney people. b. The diet plan is individualized depending on if the person is on dialysis. c. The diet restricts sodium, potassium, fluid, and protein specified levels. d. Lab work is followed closely.

Mechanically altered or soft diet –

a. Is used when there are problems with chewing and swallowing. b. Changes the consistency of the regular diet to a softer texture. c. Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables. d. Is for people with poor dental conditions, missing teeth, no teeth, or a condition known as dysphasia.

Pureed diet –

a. Changes the regular diet by pureeing it to a smooth liquid consistency. b. Indicated for those with wired jaws extremely poor dentition in which c. chewing is inadequate. d. Often thinned down so it can pass through a straw. e. Is for people with chewing or swallowing difficulties or with the condition

f. of dysphasia. g. Foods should be pureed separately. h. Avoid nuts, seeds, raw vegetables, and raw fruits. i. Is nutritionally adequate when offering all food groups.

Food allergy modification –

a. Food allergies are due to an abnormal immune response to an otherwise harmless food. b. Foods implicated with allergies are strictly eliminated from the diet. c. Appropriate substitutions are made to ensure the meal is adequate. d. The most common food allergens are milk, egg, soy, wheat, peanuts, e. tree nuts, fish, and shellfish. f. A gluten free diet would include the elimination of wheat, rye, and barley. g. Replaced with potato, corn, and rice products.

Food intolerance modification –

a. The most common food intolerance is intolerance to lactose (milk sugar) because of a decreased amount of an enzyme in the body.

b. Other common types of food intolerance include adverse reactions to certain products added to food to enhance taste, color, or protect against bacterial growth.

c. • Common symptoms involving food intolerances are vomiting, diarrhea, abdominal pain, and headaches.

Tube feedings –

a. Tube feedings are used for people who cannot take adequate food or fluids by mouth. b. All or parts of nutritional needs are met through tube feedings. c. Some people may receive food by mouth if they can swallow safely and are working to be weaned off the tube feeding.

2. Enteral feeding:

Reasons Interventions Complications

Nasoenteric

Naso or oral gastric

NGT or OGT

Gastrostomy

PEG

Jejunostomy

PEJ

HOB >30, maintain for at least half hour afterwards

Check placement confirmed by x-ray, or aspirate fluids if pH <4, tube is probably in stomach

residual q4h and prior to medication administration

Flush with 30 mL of H20 q4h

keep securely taped

if indicated, food coloring to help indicate aspiration

stop continual feeding temporarily when turning or moving client

aspiration, hyperglycemia, abdominal distention, diarrhea, and fecal impaction

^report to primary care provider. Often, a change in formula or rate of admin can correct problems.

3. Define dysphagia and list causes.

Dysphagia = difficulty swallowing.

Clients at risk for dysphagia: older adults, those who have experienced stroke, clients with cancer who have had radiation therapy to the head and neck, and others with cranial nerve dysfunction

4. Complete the table for dysphagia:

Causes stroke, radiation therapy to the head or neck, cranial nerve dysfunction

Warning Signs pain while swallowing (odynophagia), unable to swallow, sensation of food getting stuck, drooling, being hoarse, regurgitation, frequent heartburn, unexpected weight loss, doughing or gagging when swallowing, having to cut food into smaller pieces

Complications malnutrition, weight loss and dehydration.

respiratory problems (aspiration.. pneumonia or upper respiratory infections)

5. Identify risk factors for aspiration.

Risk factors for aspiration:

Reduced LOC

Increased intragastric pressure

Tube feedings

Situations hindering elevation of upper body

Tracheostomy or endotracheal tube

Medication administeration

Wired jaws

Increased gastric residual

Incomplete lower esophageal sphincter

Impaired swallowing

Trauma/surgery of face, oral, neck

Depressed cough or gag reflexes

Decreased GI motility

Delayed gastric emptying

6. List nursing interventions to decrease aspiration.

Decrease aspiration:

Monitor resp rate, depth and effot.

Auscultate lung sounds frequently and before/after feedings

Check gag reflex before oral feedings

When feeding, watch for signs of impaired swallowing or aspiration – coughing, choking, spitting food, excessive drooling

Have suction machine available for high-risk clients in case of aspiration

Keep HOB elevated for at least half an hour afterward

Not presence of n&v or diarrhea

Listen to BS qh

Note any onset of abdominal distention or increased rigidity of abdomen

If tracheostomy, refer to speech pathologist for swallowing studies

If n&v, position on side

Feed slowly

7. Discuss risk factors related to poor nutrition intake.

Old age

Illness, physical or psychological

Multiple medications

Chronic alcohol intake

Low income

Social isolation

Physical disability

Involuntary weight loss or gain

Poor diet

Urinary Elimination

1. Identify factors that influence urinary elimination.

● Developmental Factors

○ Infants: 250-500mL, 20x a day, sp.gr: 1.008. colorless and odorless. ○ School-age children (5-10yr):

■ kidneys double in size -> urination 6-8x a day. ■ Enuresis: involuntary urination when control should be established.■ Nocturnal enuresis: bed-wetting

○ Older Adults■ prerenal failure: hypertension■ Intrarenal failure = hypertension, diabetes, toxins■ Post renal failure = outflow obstruction■ diminished excretory function ■ factors that impair renal function:

● arteriosclerosis● surgery

■ more susceptible to toxicity from medications due to decreased excretion■ Urinary frequency factors:

● men: enlarged prostate gland○ double void technique: empty bladder, after feeling done, try to void again

● women: weakness of muscle supporting bladder● decreased bladder capacity and ability to completely empty

○ retention of residual volume also predisposes to UTI. ● Psychosocial Factors

○ stress triggers ADH secretion ○ no time to pee, anxiety = no urination = higher risk of UTI

● Sociocultural factors○ different traditions of urinating

● Fluid and Food Intake (1.5-3L of fluid)○ alcohol and caffeine increase urine production (ETOH inhibits ADH)○ Beets and carotene can change urine color.

● Medications○ Urinary Retention (Box 1 pg 749)

■ Anticholinergic medications, such as Atropine, Robinul, and Pro-Banthine. ■ Antidepressant and antipsychotic agents, such as tricyclic antidepressants and MAO inhibitors.

● aminotryptaline (blueish tinge) ■ Antihistamine: Pseudoephedrine (Actifed and Sudafed)■ Antihypertensives: hydralazine (Apresoline) and methyldopate (Aldomet)■ Antiparkinsonism: levadopa, trihexyphenidyl (artane), and benzotropine mesylate (Cogentin)■ Beta-adrenergic blockers, such as propranolol (Inderal)■ Opiods: hydrocodone (Vicodin) ■ Anesthetics ■ Peridium decreases urinary tract (turns urine orange)

● Muscle Tone○ good muscle tone important to maintain stretch and contractility of bladder.

● Pathologic Conditions○ Diseases of nephrons○ Abnormal amounts of protein or RBC’s in urine.○ Heart and circulatory disorders. ○ Kidney stones○ enlarged prostate

● Surgical and Diagnostic Procedures

2. Identify common causes and effects of the following urinary elimination problems.

a. frequency● Polyuria

○ increase fluid intake○ Diuretics, lots of ETOH○ Presence of thirst, dehydration, and weight loss. ○ History of diabetes or kidney disease. ○ some stages of renal failure

● Oliguria, anuria (<500mL in 24 hr)○ Decreased fluid intake○ dehydration○ hypotension, shock, or heart failure○ history of kidney disease or renal failure or decrease perfusion to kidneys (high BUN, creatinine,

edema, hypertension)

b. nocturia● Frequency of nocturia (2 or 3 times a night)

○ pregnancy

○ increased fluid intake○ UTI

c. urgency● Urgency - sudden desire to urinate immediately

○ stress○ UTI○ enlarged prostate

d. dysuria● Dysuria - pain or difficulty

○ UTI○ hematuria, pyuria (pus in urine)

e. incontinence● Incontinence - involuntary urination of adults

○ bladder inflammation or CVA○ difficult access to toilet (impaired mobility)○ leakage when coughing, laughing, sneezing ○ cognitive impairment○ SCI

f. urinary retention● Retention

○ distended bladder on palpation and percussion ○ discomfort, restlessness, frequency, small urine volume○ recent anesthesia/ surgery○ perineal swelling○ medications○ lack of privacy or other factors inhibiting micturition

g. neurogenic bladder● Neurogenic Bladder

○ impaired neurologic function (SCI) ○ does not perceive fullness therefore unable to control urinary sphincters○ self-catheterization (q4h)

3. Describe appropriate care for a patient with a Foley catheter.

Indications for Foley● Acute urinary retention or bladder outlet obstruction● Need for accurate output in critically ill clients● Peri-operative use for selected surgical procedures● To assist in healing of open sacral or perineal wounds in incontinent clients● Client requires prolonged immobilization ● To improve comfort for end of life care

Foley Care● Care:

○ Urinary catheters is indicated○ Hand hygiene○ Must be continuously connected to the drainage bag○ NO breach in system○ Routine daily meatal hygiene & after BM○ Urinary catheter bag should be emptied regularly into a clean container○ Securement device○ No dependent loops

4. List nursing interventions that may prevent a urinary tract infection.

● Prevent infections○ Drink 8 glasses of water a day○ Practice frequent voiding○ Avoid harsh cleansing products.○ Avoid tight-fitting pants○ Wear cotton rather than nylon (enhances ventilation)○ Wipe from front to back○ take showers rather than baths (bacteria in bath water)

● Acidifying urine○ Foods such as:

■ eggs, cheese, meat, whole grains, cranberries, plums, and tomatoes increase the acidity of urine. ● acidifying the urine of clients reduce risk of UTI and calculus formation.

5. Describe interventions to manage urinary incontinence.

● Client education○ Continence (bladder) training

■ client resists urge or sensation to urinate and only void according to a timetable to gradually stabilize the bladder and diminish urgency.

● also provides larger voided volumes and longer intervals between voiding. ■ Habit training

● scheduled toileting, have client void at regular intervals○ no delay voiding of urge occurs○ used in children with urinary dysfunction

■ Prompted voiding● prompting or reminding client when to void.

○ Pelvic Muscle Exercises○ Maintaining Skin Integrity

● Maintain elimination habits○ medications usually interfere with normal voiding habits○ assist client to maintain habits (assisting with toilet PRN)

● Fluid intake (2-3L/day) ○ promote increased fluid intake -> increased urine production -> more stimulation of micturition reflex. ○ keep bladder flushed out and decreases risk of sediment or other obstructions○ 1500 mL of measurable fluid is adequate for most adults

■ may be c/i for clients with kidney or heart failure.

6. Review the common urinary diversions.

● Continent (indicated by bladder cancer) ○ Kock Pouch

○ new bladder out of ileum○ Nipple valve which permits external catheter to drain

○ Neobladder ○ Intact urethra**○ A small part of the small intestine is made into a reservoir or pouch, which is connected to

the urethra. ○ Closely matches normal urination

● Incontinento Suprapubic catheter

urethral trauma, short-term 2-3 weekso Ureterostomy

Detaches one or both ureters from the bladder, and brings them to the surface of the abdomen with the formation of a stoma to divert the flow of urine away from the bladder when the bladder is not functioning or has been removed.

Birth defects, malfunction of bladder, SCI, bladder cancero Nephrostomy

Flow of urine is diverted directly from the kidneys to the abdominal wall. Usually temporary but may be permanent for cancer pts.

o Vesicostomy urethra no longer functioning, bladder attached directly to skin

o Ileal conduit aka bricker’s loop the ureters are detached from the bladder and joined to a short length of the small intestine (ileum) The ureters drain freely. One end of the ileum piece is sealed off and the other end is brought to the surgace of the abdomen to form the stoma. An ostomy bag is worn over the stoma to collect urine.

7. Develop 2 nursing diagnoses, interventions and outcomes for clients with urinary problems.

Disturbed body image : shame r/t incontinence

Urinary incontinence

Pain

Risk for infection

Toileting self care deficit

Impaired urinary elimination

QSEN - Ensuring Healthcare Quality and Safety

1. What does it mean to give quality care?

Quality care is STEEEP: safe, timely, effective, efficient, equitable, patient-centered

2. Define a high reliability organization.High Reliability organization:

Organizations that continually look at themselves and ask are we giving the best care possible? Do we provide an environment for safe care?

3. State at least 2 indicators of the quality of nursing care within an institution.

All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informatics

The six competencies:o Safeo Timelyo Effectiveo Efficiento Equitableo Patient-centered

4. A local hospital is being evaluated on whether it gives quality care. Which of the following would the evaluating agency find in a successful evaluation? (select all that apply)

A. Care is provided in a timely mannerB. The hospital regularly reviews policies for their effectivenessC. The cost of care is lower than other hospitals in the areaD. Physicians review all policies for medical usefulnessE. Care is given without regard for ability to payF. Patients are actively involved in decisions about their own care

Patient-Centered Care

1. List at least 3 techniques to provide patient-centered care.1. Open visiting hours2. Family Zones – comfortable places for family to visit. Lots in PEDs.3. Views of nature – views, plants, painting of something natural 4. Noise reduction5. Decrease environment stressors6. “we are guests in their lives”

2. Describe the benefits of quality and safety in providing patient-centered care.

3. The nurse asks the diabetic patient when she would like her AM care, before or after breakfast. This is an example of providing:

A. Safe careB. Patient-centered care XC. Evidence-based practiceD. Care using teamwork

Teamwork and Collaboration

1. Complete the following chart:

How is it practiced? How does it help teamwork?

Benefits

Open Communication

assertive communication… honest, direct, and appropriate while being open to ideas and respescting the rights of others

Values perspectives, expertise and unique contributions of all team members

Prevents errors.. minimizes miscommunication with colleagues

Mutual Respect Skilled communicators focus on finding solutions and achieving desirable outcomes

Seek to protect and advance collaborative relationships among colleagues

Invite and hear all relevant perspectives Call upon goodwill and mutual respect to build

consensus and arrive at common

Values perspectives, expertise and unique contributions of all team members

Teamwork, benefits the patient, the team, and the organization.

understanding Demonstrate congruence between words and

actions, holding others accountable for doing the same

Shared Decision-Making

Emotional intelligence… ability to form work relationships with colleagues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of others

Values perspectives, expertise and unique contributions of all team members

Benefits the patient, the team, and the organization.

With emotional intellifence, the nurse is viewed as mature, approachable, and easygoing

2. Define the elements of SBAR.

SBAR: Situation – What is going on with the patient? Background – What is the clinical background or context? Assessment – What do I think the problem is? Recommendation – What would I recommend?

3. List the activities of the rapid response team and define how these enhance quality and safety in health care.

Rapid Response Team: When a pt demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the

bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death

Critical care nurse, respiratory therapist, and physician (critical care or hospitalist) backup Proactively evaluate high-risk ward patients Educate and act as liaison to warm staff

4. What is the purpose of using the SBAR format?A. It makes report and shift changes go faster B. It ensures the unit is compliant with Magnet requirementsC. It ensures complete and organized communication between shiftsD. It maintains Safe, Better, Appropriate and Reliable care.

Evidence-Based Practice

1. List the steps (in order) of the EBP proces.

1. Collect the most relevant and best evidence2. Critically appraise the evidence3. Integrate the evidence with one’s own clinical expertise, patient preferences and values in making a practice decision

or change4. Evaluate the results of the practice decision or change

2. List elements that can be used as evidence in EBP.a. Established research methodsb. Systematic research, randomized clinical trials, descriptive studies, qualitative research, c. Experts in the health care fieldd. staff educators, CNSs, NPs, the medical staff, pharmacistse. Anything that helps you answer the question

3. Describe how a nurse would critique evidence to determine its usefulness to a particular clinical setting.a. It is not just enough to find the articles you want, but you need to ask yourself whether or not they hold any merit.b. Ask yourself whether or not the article deals with you questionc. Interpret the evidenced. Apply what you have learned in your patient caree. Observe how evidence is used to make policy and procedure changes to improve patient caref. Evaluate the decision

4. Define the 4 elements of a PICO question.a. PICO Format

i. Patient population of interestii. Intervention of interestiii. Comparisoniv. Outcome

1. Define bundles and describe how they improve quality and safety in health care. Bundles: groupings of best practices with respect to a disease process that individually improve care, but

when applied together result in substantially greater improvement. o Central line bundleo VAP bundleo Catheter-associated UTI bundleo Surgical site infection

Quality Improvement

1. Define never events and give examples. Never events

o Objects left in after surgery, air embolism, blood incompatibility, pressure ulcers, falls

2. Describe strategies a health care organization uses in quality improvement. Nursing sensitive measure

o Affected by the supply of nursing staff, the skill level of the nursing staff, and the education/certification of nursing staff

o Central line infections, falls, IV infiltrations Test of change (PDSA)

o Plan, Do, Study, Act

3. What is the significance of reporting and investigating never events?A. To guarantee they never happen againB. To figure out who is responsible so they can be disciplinedC. To identify human factors that contributed to the eventD. To write them up in research for other hospitals to learn from

4. Which of the following are elements of Joint Commission Patient Safety goals? (Select all that apply)A. Hand hygieneB. Time outs before surgeryC. Use of unit dose syringesD. Cost containmentE. The use of 3 patient identifiers - need only 2

Safety

1. Define the concept of human factors and its role in patient safety.Human factors: humans make mistakes. What can we do to avoid them.

2. List measures to increase safety in medication administration.Safety in Medication Administration:

Two patient identifiers Patient armbands – pt, allergies. Look-alike and sound-alike drugs Medication reconciliation

o Good faith effort Involve the patient Decrease tolerance of risk

3. Define national patient safety indicators; and describe the 6 safety goals.1. Identify patients correctly

i. 2 patient identifiersii. Never room numberiii. Special attention when giving blood

2. Improve staff communicationi. Critical test results

3. Use medications safelyi. Unit dose and prefilled syringes when possibleii. Medication reconcilliation

4. Prevent infectioni. Hand hygieneii. MDRO risk assessmentiii. Catheter guidelines

5. Identify patient safety risks6. Prevent mistakes in surgery

i. Time outsii. Verify correct patient, correct procedure, correct site

Healthcare Informatics

1. List the elements of EHRs and how they contribute to quality and safety. EHRs

o Respond to alertso Use for communicationo Decision support toolso Up-to-the-minute information

2. Describe concerns about the use of EHRs in health care. EMR concerns (eye contact, decreased critical thinking, system offline, patient privacy)

3. Describe how consumers use informatics and the benefits and challenges for nurses. Consumer use

o Increased medical knowledge by consumer increases the need for assessment of resources

o Social media for patient care

o Home monitoring

Diabetes

1. Discuss the classifications and risk factors for developing diabetes.Classification

Type One (10%)

o Inherited with environmental trigger

o Autoimmune - beta cell destruction

Born with or develop during

early childhood

Type Two (90%)

o Genetic & lifestyle

Insulin resistance – the pancrease will respond by producing more insulin and then the beta cells get exhausted

Insulin deficiency

Gestational Diabetes

o Occurs in 2%–5% of pregnancies

o Inadequate insulin secretion & responsivenes

o Many will not have diabetes after pregnancy, some will develop type 2 diabetes

2. List the complications of diabetes and appropriate preventative measures.Complications from DM:

Hypoglycemia

o Blood glucose level < 60 mg/dL (normal BGluc 70-110)

o Diet therapy: glucose/carbohydrate replacement

o Drug therapy: glucagon, 50% dextrose

o Prevention strategies for:

Insulin excess

Deficient food intake

Exercise

Alcohol

Hyperglycemia

o Blood glucose level > 200 mg/dL

Causes microvascular changes leading to vascular disease and neuropathies

o Results from Insulin deficiency

Hyperglycemia

Polyuria

Polydipsia

Polyphagia

Development of ketone bodies

Dehydration

Hemoconcentration

Hypovolemia

Hyperviscosity

Hypoperfusion

Hypoxia

o Treatment/prevention:

oral and/or insulin therapy

Therapeutic diet – low glycemic foods etc

Diabetic ketoacidosis (DKA)

o Serum glucose >300 mg/dl

o Common in type 1, rare in type 2

o Results from inadequate insulin

o Acidosis results from ketone production of fat breakdown for energy demands

o Symptoms

Polyuria, polydipsia

Hyperventilation, Kussmual respirations

Dehydration

Fruity odor of ketones, fatigue

GI symptoms

o Interventions include ICU admission

Monitor for manifestations

Assessment of airway, LOC, hydration status, blood glucose level

Management of fluid & electrolytes

Drug therapy goal: to lower serum glucose by 75 - 150 mg/dL/hr

Manage of acidosis

Client education & prevention

NPO

Hyperosmolar hyperglycemic syndrome (HHS)

o Severe hyperglycemia with little or no ketones

o Causes profound dehydration & shock

o Glucose levels are in excess of 600 mg/dL

o Older adults with type 2 DM who are still producing some insulin

o Symptoms

confusion , coma, febrile, polydipsia, nausea, weight loss

o Interventions

Monitoring

Fluid therapy: rehydrate & restore normal blood glucose levels within 36 to 72 hr

IV insulin therapy often needed to reduce blood glucose levels

NPO

Foot ulcers

o Interventions and foot care practices

Cleanse & inspect feet daily

Wear properly fitting shoes

Avoid walking barefoot

Trim toenails regularly

Report non-healing breaks in the skin

Periodontal disease

3. Discuss teaching topics and priorities for a patient newly diagnosed with diabetes mellitus type 2.

Goals of treatment

o Provide the individual with adequate tools to achieve glycemic control

o Prevent, delay or arrest the microvascular(neuro-, renal-, retinalopathy) & macrovascular complications of DM

o Minimize hypoglycemia

o Optimize BMI

Diet considerations for Type 2 diabetic:

o Hypocaloric diet = weight loss & better glycemic control

o Modification of eating habits

o Adjust CHO to glucose levels

o Restrict ETOH intake

4. List the medication classifications used in the treatment of the client with diabetes:Oral Drug Therapy: probably too much information. None of this was discussed in lec

Drug Classification Generic/Trade Names Nursing Considerations Adverse EffectsSulfonylurea agents - antidiabetic

Tolbutamide (Modenol, Novobutamide, Orinase)Glimepiride (Amaryl)

Directly stimulates beta cells to produce insulin. Adjunct to diet and exercise

No common adverse effects.. Dizziness, headache, possible leukopenia

Meglitinide analogs- antidiabetic

Nateglinide (Starlix) Repaglinide (Prandin, Gluconorm)

St. the release of insulin. Use alone or with metformin for nonIDDM

No common.. flu like symptoms, hypoglycemia, URI

Alpha-glucosidase inhibitors

Acarbose (Precose) Delays absorption of sugars from intestinal tract. Adjunct to diet and exercise

Diarrhea, flatulence, andominal distention

Biguanides Metformin (Fortamet, Glucophage, Glumetza, Riomet)

Increase binding of insulin and potentiate insulin action. Adjunct to diet and exercise.

N&v, abdominal pain, bitter or metallic tastem diarrhea, bloatedness, anorexia

Thiazolidinedione agents Piolitazone hydrochloride (Actos)

Decreases hepatic glucose output and increases glucose uptake in skel muscle and fat. Adjunct to diet

Upper respiratory tract infection

Dipeptidyl peptidase inhibitors

Exenatide (Byetta, Bydureon) Mimicks incretin, enhances insulin secretion. Slows gastric empyting. With d/ex

No common. Jittery, n&v, gi upset , hypoglycemia

5. List signs and symptoms of hypo- and hyperglycemia.

Hypoglycemia:

Warm

Weakness or fatigue

Confusion or difficulty thinking

Shaky, nervous, anxious

Seizures, loss of consciousness

Sweaty, hungry, tingling

Hyperglycemia:

Always tired

Crave extra liquids (polydipsia)

o Dehydration

Hemoconcentration

Hypovolemia

Hyperviscosity

Hypoperfusion

Hypoxia

Frequent urination (polyuria)

Numbness and tingling of feet

Always hungry (polyphagia)

Unexplained weight loss

Blurred vision

Sexual dysfunction

6. Discuss the appropriate therapeutic diet for a patient with diabetes.

Diet Considerations:

Type 1

o Consistency in timing & amount of calories

o Adjust insulin for departures from meal plan

o Frequent, smaller meals rather than quantity

Type 2

o Hypocaloric diet = weight loss & better glycemic control

o Modification of eating habits

o Adjust CHO to glucose levels

o Restrict ETOH intake

Medical nutritional therapy:

ADA

o 50-60% CHO 45-60 grams per meal

o 15-20% PRO

o 20-30% FAT

Discourage refined & simple sugars

Encourage complex CHOs & fiber

Alcohol consumption

Glycemic index

o Consumption of high-glycemic index foods results in higher & more rapid increases in glucose levels than the consumption of low-glycemic index foods

o High BMIs linked to obesity, heart disease & DM

o Consumption of low-glycemic index foods results in lower & sustained increases in blood glucose & lower insulin demands on beta-cells

o People who eat low glycemic index foods tend to have lower body fat

7. Discuss the different types of insulin and appropriate times to administer.

Drug Classification Generic/Trade Names Nursing Considerations Adverse Effects

Rapid-actingLispro (Humalog)Aspart (Novolog)Glulisine (Apidra)

Onset: <15 minutesPeak: 1-2 hoursDuration: 3-6 hours

hypoglycemia

Short-actingRegular (Novolin R, Humulin R)

Onset: 30-60 minutesPeak: 2-4 hoursDuration: Up to 24 hr

^

Intermediate-acting NPH (Novolin N, Humulin N, ReliOn)

Onset: 2-4 hoursPeak: 4-8 hoursDuration: 10-18 hrs

^

Long-acting Glargine (Lantus)Detemir (Levemir)

Onset: 1-2 hoursPeak: Usually noneDuration: Up to 24 hr

^

Combinations Novolin 70/30, Humulin 70/30

Humalog 75/25, Novolog 70/30, Humalog 50/50

Onset: 30-60 minutesPeak: 2-10 hrsDuration: 10-18 hrs

Onset: 10-30 minutesPeak: 1-6 hrsDuration: 10-24 hrs

^

Skin

1. Identify risk factors for skin impairment:

Risk Factor Assessment Data Nursing InterventionGenetics color, allergies, acne, excema Monitor skin care practices

Age wrinkles - skin is drier, less sebum. Skin is thinner, decreased subQ tissue and collagen.

old age – increased healing time due to decreased circulation

monitor continence status, immobility-related risk factors, help position, assess nutritional status, teaching about skin and wound assessment, signs of infection, how to use topical meds, how to turn/reposition every 2 hours

Illness Arterial illnesses (deceases o2 to tissues).. peripheral artery disease >> thin, shiny skin with no hair.

Assess nutrtional status, fluids, circulation

Poor nutrition muscle atrophy, decreased subQ tissue, decreased skin integrity

Assess nutrition status

Circulation need good circulation for o2/nutrients/etc and goo venous return to remove waste

Compression socks, ankle exercises

Pressure Bed or wheelchair bound = higher chance of skin breakdown

Repostion/turn every 2 hours

Medications photosensitive medications = reation >burning, stinging, blisters. RetinA, birth control

Long term corticosteroid usage = skin is thinner (especially on forearem) and has purple echymosis

Teach how to use and possible side effects/interactions, increased risk for skin impairment

2. Describe the pressure ulcer staging system.

Stage I: Intact skin with non-blanchable redness. Darkly pigmented skin may not have visible blanching

Stage II: Partial thickness loss of dermis; shallow open ulcer, red pink wound bed, without slough. May present as intact or open/ruptured bulla

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present. May include undermining & tunneling

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. May include undermining & tunneling

3. Differentiate primary, secondary and tertiary wound healing.

Healing by first intention - primary wound healing

Wound closed by approximation of margins or wound created & closed in the OR

First choice for clean, fresh well-vascularized wounds

Indications: onset <24h, clean, viable tissue, approximation of skin edges is achievable

Treated with: irrigation, débribement, margins approximated using simple methods

Scar depends on: initial injury, amount of contamination, accuracy of closure

Fastest healing & most cosmetically pleasing

Healing by second intention - secondary wound healing

Wound is left open & closed by epithelialization & myofibroblasts

Wound heals without surgical intervention

Indicated in infected or contaminated wound

Presence of granulation tissue

Complications: wound contracture & hypertrophic scarring

Healing by third intention - tertiary wound healing

For managing wounds that:

o bacterial count contraindicates primary closure

o subsequent repair of a wound initially left open or not previously treated

o a crush component with tissue devitalized

4. Complete the following.

Wound Exudate Type

What is it? Color? Consistency

Serous

(ex, fluid in blister or burn)

Serum or plasma clear or straw

watery

Purulent Pus. Filled with leuokocytes, dead tissue, bacteria (alive or dead)

green or yellow

Thicker than serous

Serosanguineous

(seen in surgical incisions)

serum and sanguineous(RBCs)

tends to be light red

moderately thin

Sanguineous

(seen in open wounds)

RBCs dark red moderately thick, may have clots

Purosanguineous

(seen in new wound that is infected)

Pus and blood reddish? thick

5. Describe the difference between an arterial and a venous wound

Arterial (Insufficiency ulcers) Venous (stasis ulcers) MAINLY

Wound Characteristics remember..good arterial blood flow!

Pale base color when elevated

Shiny, taut skin

Punched out appearance

Minimal exudate

Cool skin temperature

Pain with rest & exercise

Pedal pulses diminished or absent

Lateral

BAD arterial blood flow

Ruddy color base

Shallow wound

Irregular margins

Moderate to heavy exudate

Warm skin temperature

Minimal to severe pain

Pedal pulses present

Medial

Nursing care Likely to have emboli, VET incompetent venous valves (varicose veins)

6. Describe ways the nurse can enhance wound healing.

Order special mattresses, reposition and turn clients regularly, moist wound healing, nutrition and fluids, prevent infection, positioning

Untreated Woundso Control bleeding by

o applying direct pressure o elevating the extremity

o Prevent infection byo Cleaning or flushingo Covering the wound with a clean dressing

o If severe, assess for shock

Treated Woundso Assess the wound, record drainage, measure the size, integrity of skin surrounding area, clinical signs of infection

7. Identify assessment data pertinenet to skin integrity, pressure sores and wounds.

Location – related to a bony prominence

Type of wound – stage of ulcer

Size – in centimeters (length, width and depth in order). Insert sterile swab at the deepest part of the wound then measure it against a measuring guide, undermining, tunneling

Wound bed – color and location of necrosis (dead tissue) or eschar. Healthy is pink.

Exudate – type, note color, amount

Odor – can indicate infection.

Wound margins – condition and integrity of surrounding skin. Approximated? Erythemic?

Pain – most of the time there is no sensation. Don’t normally medicate for wound care

Cause

8. Write at least 2 nursing diagnoses, expected outcomes and interventions associated with impaired skin integrity.

Risk for impaired skin integrity r/t urinary and fecal incontinence or r/t decreased mobility or r/t decreased nutrional intake.

Impaired skin integrity r/t impaired mobility, decreased nutrtional intake AEB stage II pressure ulcer

Imbalanced nutrition (less/more than body requirements) r/t increased intake, decreased absorption AEB weight loss or weight gain

Risk for infection r/t a break in the skin

Pain, Acute or chronic r/t to the wound AEB pt complaint

Impaired physical mobility r/t increased BMI, decreased muscle tone AEB decreased movement in bed

Ineffective tissue perfusion r/t decresed Hgb hct AEB cool extremities

Sleep

1. Briefly discuss mechanisms that regulate sleep.

Sleep regulation

Biological process. 24 hours cycle. Indoginous. (built in)

Internal clock.. hypothalamus. SCN. Reticular activating system to shut us off and turn us on

o 3-6 months old babies able to regulate sleep better

Circadian. Around the day

NREM – 80% of sleep

o 1- very light sleep. Couple of minutes. Might wake self back up at this time

o 2- light sleep. 10-15 minutes. HR, RR, BP all start decreasing

o 3- deep sleep

o 4- deep sleep (difference ¾ is the amount of delta waves) Paradoxcycal sleep (looks like awake on EEG)

Beta = highest frequency, awake. Theta = drowsy. Delta = asleep.

REM

o Every 90 minutes. Lasts up to 30 minutes. More dreams.

4-5 sleep cycles a night. Most need this amount to wake up refreshed.

Each cycle consists of NREM and REM.

Even though we are asleep. We can still respond to meaningful stimuli (wake for child crying, fire alarm.. but will sleep through sprinklers, garbage truck)

2. Explain the functions of sleep and the effect it has on health and well-being.

Functions of sleep:

Not completely understood

Restores normal levels of activity and normal balance among parts of the nervous system

Necessary for protein synthesis, which allows repair processes to occue

Lack of sleep = become emotionally irritable, have poor concentration, and experience difficulty making decisions

Glial cells shrink while we are asleep.. they think that the CSF and lymph fluid can wash the brain out.

3. Identify factors that affect sleep and related nursing assessments and interventions.

Illness – pain, COPD- difficulty lying down (become short of breath), women decreased estrogen making them more restless, BPH and CHF have nocturia

Environment – too noisy or quiet, temperature (most people like it cooler), dark or too dark, comfortable: pillows, blankets.

Lifestyle – shift work, irregular routines, travel a lot through different time zones

Emotional stress – norep stimulates CNS which makes it harder to go to sleep (stressing out before sleep over daily life)

Stimulants and alcohol – caffeine and nicotine should be avoided 2-3 hours before bed. As well as ritalin, cocaine, meth.

Diet – high BMI have a more difficult time falling asleep and staying asleep.

Smoking – stimulant. Smokers are light sleepers

Motivation – staying up all night for studying.. body eventually falls asleep

Medications – beta blockers have insomnia and bad dreams.. in the day time more sleep. Narcotics – decrease REM sleep and make more drowsy in the day.

Insomnia is the number one sleep problem

o Difficulty falling or staying asleep. More than 1 week is chronic. r/t stress and it is intermittent. Risk factors.. age stress and higher in females esp in menopause. Investigate their sleep patterns, environment, sleep positively

Activity and Exercise

1. Define the role of the nurse in activity and exercise.

Assessing: history, physical examination of body alignment, gait, appearance, and movement of joints, capabilities and limitations for movement, muscle mass, and strength, activity tolerance, problems related to immobility, and physical fitness.

2. Discuss the systemic effects of immobility.

Musculoskeletal system● disuse osteoporosis

○ without exercise, bones demineralize● Disuse atrophy● Contractures:

○ permanent shortening of the muscle ● Stiffness and pain in the joints

○ ankylosed: permanently immobile○ excess calcium deposited in joints.

CV system● Diminished cardiac reserve

○ reduces ANS balance, reduces heart’s capacity to respond to any metabolic demands above basal levels.■ tachycardia with minimal exertion.

● Increase use of the Valsalva maneuver○ Valsalva maneuver: holding breath and straining against a closed glottis.

● Orthostatic hypotension● Venous vasodilation and stasis

○ Immobile person: skeletal muscles no longer assist in pumping blood back to heart against gravity.■ blood pools and causes vasodilation and engorgement. ■ valve incompetence

● Dependent edema ● Thrombus formation

Respiratory system● Decreased respiratory movement

○ intercostal joints become fixed in an expiratory phase of respiration, further limiting the potential for maximal ventilation.

■ produces shallow breathing and reduced vital capacity (additional inhalation passed maximum inhalation)

● Pooling of respiratory secretions● Atelectasis● Hypostatic pneumonia

GI system● constipation due to decreased peristalsis + decreased abdominal and perineal muscles = impaction ● embarrassment of using a bedpan leads to postponement of defecation leads to weakened and suppressed defecation

reflex ● some clients use Valsalva maneuver excessively which increases intra-abdominal and thoracic pressure and places

stress on heart and circulatory system.

Metabolic system● Decreased metabolic rate● Negative nitrogen balance

○ negative balance between protein anabolism and catabolism■ more catabolism of proteins than intake

● Anorexia○ decreased caloric intake due to decreased metabolic rate (less energy needed)

● Negative calcium balance ○ greater amounts of calcium are extracted from bone than can be replaced

GU system● Urinary stasis

○ urine pools due to gravity ● Renal calculi

○ calcium salts are no longer in balance and form stones. ● Urinary retention

○ bladder distention and occasionally urinary incontinence ● Urinary infection

○ static urine○ improper perineal care/ indwelling catheter○ urinary reflex (backward flow)

Integumentary system● Reduced skin turgor● Skin breakdown

Psychoneurological ● Decline in mood-elevating substances such as endorphins ● Increased dependence on others

○ may lower person’s self-esteem■ frustration and exaggerated emotional reactions

● Decreased variety of stimuli ○ time perception deteriorates○ problem-solving and decision making deteriorate due to lack of intellectual stimulation.

● Anxiety

3. Describe the benefits of activity

● Musculoskeletal system○ Size, shape, tone, and strength of muscles are maintained with exercise and increased with strenuous exercise.

■ Strenuous exercise causes hypertrophy and increased efficiency of muscular contraction. ○ Exercise increases:

■ joint nourishment■ joint flexibility■ stability■ ROM

○ Bone density and strength is maintained through weight-bearing and high-impact movements. ■ maintains balance between osteoblasts and osteoclasts.

● CV system○ increases strength of heart muscle contraction○ increases blood supply to the heart and muscles○ lowering BP○ improved O2 uptake○ improved HR variability○ improved circulation○ reduces stress

● Respiratory system○ Benefits:

■ improves gas exchange■ increases toxin elimination through deeper breathing■ improves O2 to brain

● enhances problem solving and emotional stability■ prevents pooling of secretions■ decreases breathing effort and risk for infection

○ Special considerations:■ LE exercise forms for treating COPD patients■ yoga breathing and postures with asthma are helpful

● GI system○ Improves appetite○ increases GI tract tone○ facilitates peristalsis○ can help relieve constipation

● Metabolic/Endocrine system○ increases metabolic rate○ increases use of triglycerides and fatty acids

■ resulting in lower serum triglycerides, A1C levels, and cholesterol.■ make cells more responsive to insulin

● GU system○ promotes efficient blood flow = excretion of bodily wastes more effectively.

○ prevents stasis of urine and therefore flushes out bacteria = less UTI● Immune system

○ exercise allows for lymph fluid to be more efficiently pumped through the lymphatic system. ○ moderate exercise enhances immunity, strenuous exercise may reduce immune function.

● Psychoneurological System○ exercise can elevate mode and relieve stress and anxiety.○ MoA:

■ exercise increases levels of neurotransmitters ■ exercise increases levels of endorphins■ increases level of O2 to brain inducing euphoria■ muscular exertion releases stored stress associated with accumulated emotional demands.

○ Relaxation response (RR): physiological state that can be elicited through deep relaxation breathing with emphasis on prolonged exhalation.

■ Emphasis on exhalation recruits PNS “rest and digest” reflex. ■ Progressive contraction and relaxation of muscles throughout body until feels relaxed. ■ These can be done by anyone at anytime.

● Cognitive function○ Induces cells in brain to strengthen and build neuronal connections. ○ Enhances decision-making, problem-solving, planning, and paying attention. ○ Brain Gym and cross-lateral movements helpful to enhance cognitive functions.

■ Shown to help ADD< ADHD, learning disorders, and mood disorders.

4. Complete the following chart on the hazards of immobility:

Assessment Problem Desired outcome

Interventions

Metabolic *measure height and weight*palpate skin

Weight loss due to muscle atrophy and loss of subQ fat. Generalized edema due to low blood protein levels

weight control, self-care

Nutrition

Cardiovascular *Auscultate the heart*Measure BP*Palpate and observe sacrum, legs and feet*Palpate peripheral pulses*Measure calf muscle circumferences*Observe calf muscle for redness, tenderness, and swelling

Increased HR

Ortho. HypotensionPeriph. Edema

Weak periph pulses

EdemaThombophlebitis

circulation prevent complications of immobility

Musculoskeletal *Measure arm and leg circumferences*Palpate and observe body joints*Take goniometric measurements of joint ROM

Decreased muscle mass

Stiffness or pain in joints

Decreased joint ROM, joint contractures

Joint movement, activity, mobility

ROM exercises, ambulate, prevent complications of immobility

Elimination *Measure fluid intake and output*Inspect urine*Palpate urinary bladder

*Observe stool*Auscultate bowel sounds

DehydrationCloudy, dark= ^SGravDistended bladder due to urinary retention

hard, dry small stooldecreased intestinal motility

Elimination Foley, laxative

Integumentary *Inspect skin Break in skin integrity physiological consequence

position appropriately, move and turn clients in bed

Respiratory *Observe chest movements*Auscultate chest

Asymmetric chest movements, dyspneaDiminished breath sounds, crackles, weezes, and ^resp rate

resp status incentive spirometer,cough and deep breathing, position 30+

Psychoneurological

*Observe behaviors, affect, and cognition*Monitor development skills in children

Anger, flat affect, crying, confusion, anxiety, cog function .. sleep or appetite disturbances

stress level, self-care,

Coping strategies, stress relief, meds