perioperative phases

Unit: 3 perioperative phases Fundamental of Nursing

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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


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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:


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• 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


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.


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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


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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.


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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


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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.


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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


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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.


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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


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)


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• 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:


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.


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.


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 .


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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,


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


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.


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


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.


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.


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.


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.


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


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


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


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.


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.

perioperative phases

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