HOSA Clinical Nursing Notes PDF

HOSA Clinical Nursing Section 1: Basic Care (20%) A. Vital Signs Vital Signs: these include temperature, pulse, respiration and blood pressure. They must all be within normal limits to sustain life. The Graphic Method: Shows a large amount of information → easily accessible for healthcare pr...

HOSA Clinical Nursing Section 1: Basic Care (20%) A. Vital Signs Vital Signs: these include temperature, pulse, respiration and blood pressure. They must all be within normal limits to sustain life. The Graphic Method: Shows a large amount of information → easily accessible for healthcare professionals Record of vital signs → help provided diagnoses and respond to rapidly changing situations Method can record: date, temperature, pulse rate, respiratory rate, blood pressure and other important information Frequent Vital Signs: Vital signs taken every 5, 10 or 15 minutes when patient is in serious condition Body Temperature Body Temperature: heat inside a person’s body - balanced between heat produced and lost Oral body temperature - usually around 37 degrees Can be measured in C or F Signs of elevated temperature ○ Flushed face ○ Hot skin ○ Bright eyes ○ Restlessness ○ Chills ○ Thirst Normal body temperature is lowest in the morning and highest in the evening Newborns normal body temperature is generally higher than adults  A person with a fever (pyrexia) are said to be febrile ○ Fever usually is accompanied by illness, signifies the body fighting an infection Fever Terminology Intermittent fever: a temperature that alternates between a fever and a normal/subnormal reading Remittent fever: a temperature that rises several degrees above normal and returns to normal/near normal Constant fever: stays elevated Crisis: a sudden drop from fever to normal temperature Lysis: when an elevated temperature gradually returns to normal Relapsing fever: fever that returns to normal for at least a day and then occurs again Lowered Body Temperature Hypothermia: body temperature is significantly below normal (may cause death, can be caused by overexposure to the elements - such as cold water) Lowered body temperature can be desirable in some situations as it slows metabolism, decreasing the body’s need for oxygen. Clinical hypothermia: is used to perform some surgical procedures Accidental hypothermia: is life threatening, needs immediate treatment Thermometers Most commonly, electronic thermometers are used, however disposable thermometers can be used as they are convenient while travelling. Where to Measure Body Temperature Oral (O) - mouth Rectal (R) - anus Axillary (Ax) - armpit Tympanic (TM) - ear canal Temporal (TA) - forehead For all areas, except temporal, always ensure the entire sensor of the thermometer is covered by tissue. To ensure the thermometer is sanitary, cover the probe with paper or plastic. Oral Measures temperature within the sublingual arteries Measurement More accurate than axillary but less accurate than rectal Wait before measuring if patient has eaten hot or cold Don’t measure orally if patient is confused, unconscious or uncooperative, patient may accidentally bite Patients that breathe through the mouth cannot have oral measurement Rectal Highly accurate Measurement May be uncomfortable Used for unconscious patients Cannot be used after rectal surgery, or in conditions such as diarrhea, colitis or cancer of the rectum Axillary Least accurate (probe isn’t tightly enclosed between skin) Measurement Used frequently on newborns Only use this method if any other method is impossible or undesirable Tympanic Measures thermal radiation given off by tympanic membrane and ear canal Measurement Fast recording of temperature Ideal spot for measuring core temperature Temporal Newer method → scanner Artery Scanner moves across forehead, calculates peak body temperature (by Measurement measuring temperature in the artery via infrared technology) Quickest, non-invasive method Said to be more accurate than the tympanic method Pulse Pulse: heartbeats produce a wave of higher-pressure blood causing pulsation through the arteries, the wave/vibration is the pulse. Pulse should occur rhythmically. Regulation of Pulse: Rate Pulse rate: how often a person’s heart beats per minute (heart rate - HR) Normal adult heart rate → 60-80 beats per minute Newborn → 120-140 BPM Pulse rate changes during sleep, exercise, extreme emotion or due to disease Fever or overactive thyroid gland → faster pulse rate Tachycardia: a pulse rate consistently above 100 BPM ○ Can signify heart disease, heart failure, hemorrhage Bradycardia: a pulse rate consistency below 55 BPM ○ May be natural for well conditioned athletes ○ Can also be caused by an abnormal condition Regulation of Pulse: Volume Pulse volume: varies with blood volume in arteries, strength of heart contractions, and elasticity of blood vessels Normal pulse → felt with moderate finger pressure Full/rebounding pulse → difficult to obliterate (destroy) Weak pulse → difficult to feel Regulation of Pulse: Rhythm Pulse rhythm: the spacing of beats Intermittent/irregular pulse: when pulse skips a beat When pulse is regular in rhythm by irregular in force, it may be due to a disease or condition Measuring Pulse: Palpation Feeling with fingers → radial, temporal, mandibular, carotid and femoral pulse Palpate with first, second and third fingers (never the thumb as it has its own pulse)  Count the pulsations against time to determine pulse rate in BPM. Measuring Pulse: Auscultation Apical pulse: counted using a stethoscope which amplifies sound ○ Diaphragm is placed over the heart’s apex on the chest ○ “Lub dub” sound for each heartbeat, arises due to the opening and closing of heart valves Measuring Pulse: Locations Radial pulse Most convenient Apical pulse Always used for children under 2 years, or when it appears that the heart has stopped Apical-radial pulse Takes both pulses, is ordered when it is suspected that the patient’s heart is not effectively pumping Pedal pulse Can determine circulation of blood to lower extremities Carotid pulse Used commonly or when other pulses are not palpable Measuring Pulse: Doppler Ultrasonic vascular doppler device: can be used to detect peripheral pulses with conductive gel Respiration Rate and Depth of Breath Normal Respiratory Rates at Various Ages AGE AVERAGE RATE OF RESPIRATION (per minute) Newborn 30-80 Early childhood 20-40  Late childhood 15-25 Adulthood Men 12-18 Women 16-20 Breathing Eupnea: normal breathing Tachypnea: present with abnormally rapid breathing (more than 20-24 breaths per minute) Bradypnea: occurs with less than 10 breaths per minute We sigh/yawn to cleanse the lungs and expand small airways and alveoli that are unused in ordinary breathing Some drugs, poisons, conditions or pressure on the brain's respiratory center decreases respiration rate Kussmaul’s respirations: characterized by laboured breathing caused by diabetic acidosis and diabetic ketoacidosis Respiration Sounds Snoring: occurs when the air passageway is partially blocked, commonly caused by a limp tongue in the throat Stertorous breathing: occurs when air passes through secretions in the air passages, common before death (also known as the death rattle) Dyspnea Dyspnea: difficult or painful breathing May be caused by strenuous exercise, obesity, acute pneumonia, etc. Orthopnea: if the patient can only breathe in an upright position Asthma: a condition that causes difficulty breathing due to spasms and edema of bronchi Adult breath to heartbeat = 1:15 Respiration usually increases slower than pulse rate - except in respiratory diseases Cheynes-Stokes respirations: are slow and shallow at first, gradually growing faster and deeper then tapering off until the stop entirely  ○ Cycle may repeat after several seconds ○ Serious condition that usually precedes death Blood Pressure What is Blood Pressure? Blood Pressure: a measure of pressure exerted by the blood as it flows through the arteries. Determined by cardiac output and peripheral resistance. Cardiac Output: combination of heart rate and stroke volume over one minute Peripheral Resistance: resistance of blood vessels to the flow of blood Affects blood pressure and work required for the heart to pump blood Arteriosclerosis and atherosclerosis increase resistance to blood flow Systole and Diastole Systole: highest point of blood pressure, measuring systolic blood pressure (SBP) Diastolic Blood Pressure (DBP): heart relaxes and the lowest pressure obtained before the heart beats again Normal Blood Pressure Pulse pressure → usually between ⅓ and ½ of the systolic pressure Average systolic pressure (age 20) = 115 to 120 Average diastolic pressure (age 20) = 75 to 80 Some people have lower blood pressures, which are also considered normal Hypertension: high than recommended blood pressure Hypotension: very low blood pressure ○ An indication of hemorrhage or shock Measuring Blood Pressure  Direct measurement of blood pressure: inserts a probe into the patient’s artery for constant measurement Sphygmomanometer: uses an inflatable bladder enclosed in a cuff cutting off blood flow, then listening for the pulse as pressure is released ○ Palpation is possible with this method if stethoscope is unavailable Aneroid manometer: allows the observation of heartbeats as the pressure needle bounces Electronic machines may also measure blood pressure automatically How to take blood pressure: https://www.youtube.com/watch?v=lKtfwiwHjLI Listen for Korotkoff sounds If arm is unavailable for measurement, use a large enough cuff around the thigh and auscultate over the popliteal artery in the back of the knee Orthostatic/postural hypotension: occurs when a drop of 25 points systolic occurs from lying to sitting, or sitting to standing ○ Especially present in those who are older or taking certain medications Common Errors When Taking Blood Pressure Error or Artifact Consequence Cuff too wide Falsely low reading Cuff too small/narrow Falsely high reading Cuff too loose Falsely elevated reading Cuff over a joint Less likely to compress reading Hole in cuff Pressure leaks too fast to reliably record Cardiac arrhythmias Erratic readings Heavy respiration Can be mistaken for flow with doppler Motion Interferes with obtaining a doppler signal and oscillometer devices Oxygen Saturation What is Oxygen Saturation? Oxygen saturation: measures the oxygen circulating around the body. It measures this by creating a percentage of the hemoglobin on red blood cells (oxygen carrying molecules on our cells) which are saturated with oxygen. Usually seen as SpO2 How is Oxygen Saturation Measured? Measured with a pulse oximeter Noninvasive; measures amount of light transmitted by deoxygenated vs oxygenated hemoglobin B. Body Mechanics & Positioning Proper Body Mechanics Proper Body Mechanics Body Mechanics: use of the safest and most efficient methods of moving and lifting ○ Means applying mechanical principles of movement to the human body ○ Some ways of moving and carrying objects are more effective than others Principles underlying proper body mechanics involve three major factors: center of gravity, base of support, and line of gravity Major Factors Underlying Body Mechanics 1: Center of Gravity Located in the pelvic area (lower part of the body between the abdomen and thighs) Means that about half the body weight is distributed above this area and the other half below it (horizontally) and half the body weight is to each side (when thinking vertically) When lifting an object, bend at the knees and hips, keep the back straight  ○ Center of gravity remains over the feet, helping to maintain balance 2: Base of Support Base of support: provided by feet, the wider the feet, the more stable the object being moved Feet being too far apart = instability Feet are spread sidewise when lifting, gives side-to-side stability One foot placed slightly in front of the other for back-to-front stability Knees are flexed slightly to absorb jolts. The feet are moved to turn the object being moved 3: Line of Gravity The line of gravity: draw an imaginary vertical (up and down) line through the top of the head, the center of gravity, and the base of support. ○ For highest efficiency, draw line straight from the top of the head to the base of support, with equal weight on each side When lifting, walking, or performing any body activity, proper body alignment is essential to maintain balance When a person’s body is in correct alignment, all the muscles work together for the safest and most efficient movement , without muscle strain Positioning the Client Encouraging clients to move in bed, get out of bed or walk serves several purposes Immobility = multiple disorders such as pressure ulcers, blood clots, constipation, muscle weakness and atrophy, pneumonia, joint deformities, and mental disorders Moving and Positioning Clients Make sure to explain to the client why their position is being changed and how it will be done. Also explain how they can help if it is possible Important client positions: ○ Supine: dorsal recumbent — lying on the back ○ Prone: lying on the abdomen ○ Sims’ semi-prone: lying on the side (usually the left—with the upper knee flexed)  ○ ○ Fowler’s: lying on the back with the head elevated ○ Dorsal lithotomy: lying on the back, with the feet in stirrups ○ ○ Lateral: lying on the side Positioning the Client for Comfort Maintain functional client body alignment Maintain client safety Reassure the client, to promote comfort and cooperation Obtain assistance to move heavy or immobile clients Follow the provider’s orders A specific order is needed for a client to be out of bed Make sure the client is comfortable and has the nurse signal cord available after positioning Joint Mobility and Range of Motion Range of Motion (ROM): every body joint has a specific but limited opening and closing motion Regular exercises prevent joint deformities that are caused by prolonged muscle contractures ○ Contracture: the continuous contraction (shortening of the length) of the muscles that move the bones of the joint Passive ROM If a client is unable to move, the nurse helps by performing passive range of motion (PROM) exercises  In PROM, the nurse or therapist moves the clients joints and assists in assuming various positions Do not force joint movement during PROM exercises Active ROM Active range of motion (AROM): when the client is doing individual self-directed exercises, although supervision may be necessary to ensure that the client moves all joints and muscles to the fullest extent possible Isometric (muscle-setting) exercises: exercise that the client performs by tightening and releasing certain muscle groups Assisting the Mobile and Partially Mobile Client Some clients are allowed out of bed for the entire day; others are up for certain lengths of time each day as their conditions permit Follow these basic principles when assisting clients out of bed: ○ Check the provider’s order to determine the client’s prescribed level of activity ○ Assist the client to put on a bathrobe and slippers. Provide a bedpan if necessary, offer a blanket to avoid chilling ○ Tell the client to inform you if he or she is becoming tired, faint or weak ○ Offer pain relief medicine around 30 mins before the client is to get up to increase comfort and time they are able to be up ○ Make sure the client’s nurse call signal is within reach, if you leave the client while he or she is sitting up ○ Start with short periods of being out of bed and increase as the client is able Evaluating Falls Risk Clients who have difficulty moving or walking or who have had a recent fall are vulnerable All clients in a healthcare facility must be continuously evaluated for the risk of falling. This is done on admission to the facility and throughout the client’s stay Use of the Transfer Belt Transfer belt: allows the nurse to provide support to the weak or unsteady person ○ Secures around the clients waist, explain to the client that the belt provides safety and protection for both the client and nurse  ○ Is it important to use a transfer belt whenever assisting an unsteady, weak, faint or partially paralyzed person to walk Client in Danger of Falling If a client feels faint, try to assist the person into a sitting position Even if a client is falling, the nurse must avoid letting the client grab him or herself around the neck All healthcare professionals are responsible for preventing the clients from falling Dangling Dangling: refers to allowing the client to sit on the edge of the bed, with the legs down and the feet supported on a footstool on the floor ○ Helps the client who has been in bed prepare to sit in a chair and eventually, to walk It is important for the nurse to be aware of the client’s limitations Helping the Mobile Client out of Bed Assistance from bed is required for clients who are weak from long periods of bedrest or who are unsteady due to illness Helping the Client Walk Clients are usually encouraged to be walking ASAP after surgery or serious illness, helps to prevent the serious complications of immobility One nurse can assist Have the client wear non-slip shoes Use a transfer belt for safety Position yourself to the side and slightly bend the client If the client is more unsteady on the feet: ○ Two assistants are required, often one is a family member ○ Hold the client’s arms and support the lower arms and hands If the client needs firm support: ○ Two assistants are required ○ The assistants grasp each other’s arms behind the client’s back  ○ The client is asked to put his or her arms around the shoulders of the assistants Using Mobility Devices Wheelchair: often used to move clients who cannot walk or who should be spared fatigue as much as possible Cane: a slender, hand-held, curved stick/device meant to provide support while walking. The three basic types of canes: ○ Standard straight-legged cane ○ Tripod cane (3 feet) ○ Quad cane (4 feet) Cane Walker Supports balance and helps A four-legged tubular the client to walk. Provides device with hand grips. additional support when one Provides sturdy support side of a person’s body is for clients who are unable weak or if the client has pain or too unstable to walk in one hip or knee with a cane. Crutches Walking aids made of wood or metal in the form of a shaft. They reach the ground to the client’s axillae or forearm. The Client Lift Client lift: a mechanical device that elevates and transfers immobile clients to and from the bed, stretcher, wheelchair, tub or toilet ○ It assists the nurse lift a client who otherwise be too difficult to move or who would be harmed if lifted in the conventional manner Moving the Client who is Partially Paralyzed: Paraplegia Paraplegia: paralyzed from the waist down ○ Person has limited or no ability to move the legs, but is usually able to build up adequate arm strength ○ A transfer board may be used ○ If the client cannot move their upper body skillfully, two nurses will be needed Moving the Client who is Partially Paralyzed: Hemiplegia Hemiplegia: paralyzed on one side of the body, usually the result of a stroke ○ To help this client move into a chair, help the client move to the side of the bed ○ The client is assisted to swing around so the feet are on the floor. Then the client is assisted to stand on the stronger leg, with the nurse supporting the client on the weaker side ○ The client is pivoted around in front of the chair and holds the arm of the chair with the stronger arm Moving the Immoble Client Is difficult, usually requires at least 2 people ○ A transfer board or lifting sheet may be used ○ The use of a client lift or device such as the HoverMatt is often recommended if there is any question If a transfer board or client lift is unavailable, it is possible to transfer client using only a lifting sheet ○ The lifting sheet is placed under the client and the client is lifted instead of being slide across a transfer board  C. Personal Hygiene Mouth Care Offer the client the opportunity to brush his or her teeth before and after each meal and in the evening When caring for the client’s mouth, observe the condition of the gums, tongue, mucous membranes and teeth If brushing the teeth is impossible, encourage client to the mouth with water or mouthwash after eating It's important to floss ○ Flossing removes debris that could cause tooth decay and bad breath odor A client with dentures needs the same mouth care as a client without dentures Special Mouth Care: The Dependant Client Oral cleansing can remove secretions and prevent choking. In such cases, mouth care is performed frequently Oral hygiene is ordered every hour because of extreme dryness for unresponsive and mouth-breathing clients Routine Eye Care Tears: produced by the lacrimal glands, which are situated at the top and outer portion of each eye ○ Tears help protect the eyes from bacteria, viruses and other foreign matter, and lubricate the eyes ○ Infections may be caused by the accumulation of dried secretions on eyelids and eyelashes ○ Eyecare should be done to remove secretions by applying a cotton ball or gauze square moistened with sterile water or normal saline to the eyelids ○ Some clients also will need supplemental moisture in the form of eye drops, as ordered Routine Ear Care A client's external ears are washed routinely during the bed bath. If excessive cerumen (ear wax) is present, a special procedure may be necessary to remove it to prevent hearing difficulty.  ○ This is done by specially trained professionals. Care for a Hearing Aid Clients who have a hearing impairment may use a hearing aid Hearing aid: a battery-operated, sound-amplifying device that consists of an earpiece that fits into the ear canal and a power source ○ May be very small and may fit entirely into the outer ear ○ The size of the device depends in part of the type of hearing loss that exists Clean the earpiece regularly with saline or the prescribed solution (to prevent cerumen buildup). Do not clean with alcohol. Check and replace batteries regularly. Teach the client to have spare batteries on had at all times Turn off the aid when the client is not using it to preserve the life of the battery Avoid exposing the aid to heat and moisture Turn the volume down completely before inserting the aid into the client;s ear Evaluate client complaints about the hearing aid or repeated removal or refusal to use the aid Care for Hands and Feet A client’s general condition and health habits affect the condition of his or her fingernails and toenails Improper diet, illness, infection or fever → brittle, broken, or discolored nails Caring for fingernails: ○ Emotional tension may cause nail/cuticle biting ○ Conditions such as torn cuticles cause infection ○ If a client’s nails are torn of jagged, clip them with a sterile nail clipper and make them smooth ○ Soap and water loosen dirt and temporarily soften cuticles. Cuticle oil/lotion applied to the nails and cuticles softens them as well Toenails need the same care as fingernails A foot soak is of particular importance to the client who has edema, tenderness, or some form of foot infection Shaving  Clients unable to shave everyday may feel or look untidy If the client can shave without assistance: ○ Prepare equipment ○ Provide a mirror ○ Make sure the room is well lighted ○ Allow as much privacy as possible If the client cannot shave without assistance ○ It is up to the nurse to provide needed assistance ○ Be sure to allow the client to do as much as possible for themself Each client uses his or her individual shaver head Clean the head and razor after each use Detach and mark the shaver head with the client’s name and keep in a safe place for the next use Hair Care Part of daily care, regardless of location Helps keep the hair in good condition and makes the person feel better, encourage clients to do as much of their own hair care as possible This provides exercise and diversion, helps a client achieve his or her desired hair style and add to the client’s self-esteem Daily hair care varies with the type of hair Skin Care Skin: the body’s primary defense against disease and infection, it is the body’s largest organ. For this defense system to be effective, it must remain unbroken and not irritated The skin also helps regulate body heat; a break in the skin could upset that balance When giving nursing care, observe for any signs of skin irritation or lack of skin integrity (breaks in the skin) Inflammation: it is important to to check under the breasts or any other skin folds for any signs of inflammation, and be particularly observant if the client complains of itching Frequent and effective skin care is essential to keep the skin intact and remove dirt, excess oil and harmful bacteria Skin Infections Pediculosis: the term for infestation by lice, tiny oval, gray insects that suck blood from the person they infest Causes intense itching Both nits and adult lice can be destroyed by a routine treatment, often with special shampoo or a shower with specially medicated soap Scabies: a common contagious condition caused by the itch mite. Usually occurs in warm protected areas of the body, such as skin folds. The skin lesions cause intense itching (pruritus) and are easily spread from person to person Treatment is similar to that of pediculosis D. Elimination Introduction Urine: the body’s liquid waste product. Passing urine from the body is called urination, micturition or voiding. Feces: also called a bowel movement (BM) or stool, is the body’s solid waste product Defecation: refers to the excretion of feces Urine and feces are the waste products of the urinary and digestive systems Urine Urine Elimination Urine: formed by the kidneys, is composed of: ○ Excess water from the body ○ Some carbon dioxide ○ Small amount of solid wastes ○ Abnormal substances being filtered out form the blood The total adult urine output varies, according to the person;s fluid intake and kidney efficiency Adult average → approximately 500-2,400 mL every 24 hrs Edema: an excess body fluid that collects in the tissues and often causes puffiness; a deficiency in body fluids leads to dehydration  The urge to void (urinate) is triggered when approximately 250 mL of urine has collected in the bladder Adult bladder can hold approximately 400-500 mL when it is moderately full Fluid output = fluid intake (usually) Encourage clients to drink adequate amounts of fluids. To maintain normal fluid balance, each adult needs 6-8 glasses of liquid daily Characteristics of Urine Urine is observed for colour, clarity, odor and volume Colour: ○ Freshly voided urine is light yellow or amber ○ The degree of colour varies with the body’s level or hydrations ○ Overhydration = dilute urine, nearly colourless ○ Dehydration = concentrated urine, dark amber or orange-brown Clarity: ○ Freshly voided urine is clear or transparent ○ If it appears cloudy, it contains abnormal substances (bacteria, blood, mucous shreds, or pus) or it has been standing for a period of time in a collection container Odor: ○ Freshly voided urine has characteristic odor, sometimes called aromatic ○ Dilute urine has fewer odors than concentrated urine Volume: ○ Typically ranges from 250 mL - 400 mL Specific Gravity ○ Normal urine has a specific gravity, when compared with water, of 1.010 to 1.025 Acidity: ○ Most body fluids are slightly alkaline ○ The more acidic a solution is, the greater the hydrogen ion concentration, and the lower the pH Abnormal Components: ○ Abnormal components (eg. microorganisms) in urine suggest dysfunction or disease somewhere in the body Urinary Tract Problems Urinary tract infections (UTI): are common, often occur when microorganisms contaminate the usually sterile urinary tract through the urethral opening ○ More common in women than men, since the female urethra is shorter Urethritis technically means inflammation of the urethra Cystitis: inflammation of the bladder Nephritis and pyelonephritis: refer to inflammation of the kidneys Urinary calculi: stones, may occur in the kidney, renal calculi, or bladder, cystic calculi. Calculi are formed from substances excreted by the body, such as calcium Renal colic: when a stone becomes lodged in a ureter, results in the person experiencing severe, penetrating pain in the lower back Bowel Elimination Changes in bowel elimination may occur because of gastrointestinal illness or illness in another body system The bowel responds to even the slightest changes in a person's usual eating or exercise habits Bowel elimination can change quickly when a client is ill or immobilized Characteristics of Feces Feces: stool, bowel movement. The solid waste products of digestion, consists of the end products of the metabolism and digestion of foods Colour ○ Normally, feces are yellowish-brown (due to presence of bile Consistency ○ Normal stools are soft and formed. ○ Hard, dry stools result when the rectum has not been emptied as needed and excess liquid has been absorbed, called constipation ○ Diarrhea: the expulsion of loose, watery, unformed stools Shape ○ Generally the same shape as the bowel’s interior - round, oval, cylindrical Odor  ○ A characteristic odor Density: ○ The weight concentration of waste products in relation to water ○ Normally, stools are heavy enough to sink in water Abnormal components ○ The presence of pus or mucus in the stool indicates an inflammation or infection somewhere in the digestive system Fecal impaction: ○ The term fecal impaction denotes stool that is so hard and dry or putty-like that it cannot be expelled by the client, even after administration of laxatives and/or enemas Symptoms include: severe abdominal discomfort, a hard abdomen, and a feeling of pressure Patterns of Bowel Elimination Defecation: usually occurs at regular intervals when the mass of feces moves into the colon through the muscular action of the intestinal wall, called peristalsis Patterns of elimination are unique to each individual Remember that not everyone has a bowel movement everyday. If the person is symptom-free, bowel movements occurring less often are not a cause for concern Flatus: Flatus/flatulence: intestinal gas The normal intestine creates gas as part of the digestive process. Most flatus if reabsorbed through the vasculature of the intestinal wall; some of it is expelled with defecation Some people are susceptible to developing and retaining gas in uncomfortable amounts Flatus may accumulate and cause considerable discomfort and embarrassment Abdominal Signs and Symptoms The first step is to listen for bowel sounds in each quadrant of the abdomen The action of peristalsis, which causes the products of digestion to move through the intestines, creates distinctive sounds that can be heard with a stethoscope Diminished or absent sounds indicate that the bowel is functioning improperly  After auscultating for bowel sounds, palpate the client's abdomen. Normally the abdomen is soft and pliable If it is hard, swollen, or tender, the client may have flatus, fecal impaction, or an intestinal obstruction Assisting with Toileting Elimination is a function included in the activities of daily living when describing a client’s independence level Helping the client with elimination is a basic nursing responsibility The client who is weak, confused, sedated or extremely tired may require help in getting to and from the bathroom Male clients confined to bed → use a bedpan for defecation and a urinal for voiding Female clients → use only the bedpan for both defecation and urination Assisting with Urinary Elimination Urinary catheter: a latex or vinyl tube that is inserted to remove urine ○ Approx. 24 inches long and is inserted into the bladder through the urethra using sterile technique Straight catheter: is inserted, urine is drained, and the catheter is removed and discarded Retention catheter: is inserted, anchored in place, and continuously drains urine from the bladder ○ Sometimes called an indwelling catheter; it is placed when a client is unable to void naturally or has had certain types of surgery Assisting with Bowel Elimination When monitoring bowel function, identify the client who has not had a recent bowel movement and who may require nursing intervention. In many situations, client bowel movements are documented and monitored Suppository: a bullet-shaped, soft wax-like mass that is inserted into a body opening for the purpose of administering a medication or to lubricate the area ○ The suppository melts after administration, thus releasing the medicating or other substances. Sometimes it is given to stimulate a bowel movement Enema: the introduction of a solution into the rectum and colon to stimulate peristalsis, thereby causing elimination of stool Types of Enemas Cleansing enema: the instillation of enough fluid or of a specially formulated solution into the colon to help soften the feces, stimulate peristalsis, and provide lubrication in preparation for evacuation Commercially Prepared Disposable Enema (fleet enema): this enema contains a small amount of hypertonic solution, usually saline, with 120 mL being the most common size. As a hypertonic solution, it pulls water from the colon tissue into the intestinal lumen by osmosis. Carminative enema: given to stimulate peristalsis so that flatus (gas) is expelled from the intestine, along with stool Anthelmintic drugs: help destroy intestinal parasites Emollient enema: consists of small amounts of olive or cottonseed oil given to protect or soothe the mucous membrane of the colon. This enema is to be retained. Oil retention enema: contains a small amount of oil and is given in very small amounts because it must be retained to be effective Medicated enema: inserts a drug into the rectum; sometimes, it is the only way to give a drug to a client, possibly because the client is vomiting, unconscious, or has had mouth or throat surgery The Harris Flush: prescribed to relieve intestinal gas and distention, which causes pain. It is given with the bag-and-tubing equipment ○ The goal of this process is to stimulate the expelling of flatus, thereby relieving abdominal distention and “gas pains” Manual Removal of Impacted Feces Manual disimpaction or digital evacuation: manual or digital removal of the feces is ordered when a fecal impaction does not respond to an enema, or if a client has paralysis Stop this procedure immediately if a client complains of paint, faintness, or nausea, or if you note any untoward effect, such as bleeding Bowel Retraining Bowel retraining may be necessary if the client is unable to to have bowel movement naturally or is incontinent of stool ○ This procedure is often used for the client with paralysis Timing : the client is assisted with elimination at same time each day  Physical activity: the more exercise the client receives, the more likely it is that he or she will be able to achieve bowel control Fluid intake: a high oral fluid intake is recommended. The fluids should be varies, including water and fruit juices Diet: recommended is a diet to assist in maintaining a fairly solid fecal consistency without causing constipation or diarrhea. Fruits and vegetables and foods high in fiber are often helpful Flatus Some nursing measures to help relieve flatus influde: ○ Help the client to walk, if this is allowed ○ Help the client to dangle on the edge of the bed ○ Turn the client onto the left side ○ Avoid ice in water or other drinks ○ Avoid the use of drinking straws ○ Apply a warm compress to the abdomen Nausea and Vomiting Nausea: an unpleasant abdominal sensation; sometimes followed by vomiting Vomiting: also called emesis, is an involuntary action that expels stomach contents Symptoms of nausea leading to vomiting include weakness, frequent swallowing, produce preparation, dizziness, pallor (paleness), and shakiness, as well as an uncomfortable feeling in the stomach ○ Pulse and blood pressure may drop during vomiting E. Specimen Collection Intake and Output Records The amount of fluids a patient consumers and eliminates over a certain period is an indicator of their nutritional and fluid balance Over 24 hours a person’s normal fluid intake and urinary output will be approximately the same (balance) Records of the patients I&O help guide the providers decisions about increasing or decreasing fluids/foods.  To measure total food and fluid intake the order is given to record food and fluid intake or “I&O + calories count” Collecting Specimens and Samples Label specimen containers, including the lids’, with the client’s name and other data before collecting the specimen Always wash your hands before and after collecting the specimen Always observe Standard Precautions when collecting specimens ○ Wearing gloves is always necessary for specimen collection ○ The need for masking and wearing eye protection should be anticipated in some cases, such as sputum collection Collect the sample according to the individual facility’s policy and procedure Clean the area involved for sample collection Observe sterile technique for sample collection, even though the specimen is not always sterile Place all specimens in biohazard bags to protect staff and other clients Transport the specimen to the laboratory immediately Be sure the appropriate laboratory request forms accompany the specimen to the laboratory, or the computer order is appropriately entered Record the collection and forwarding of the sample to the laboratory on the client’s health record Check client record to determine if the results need to be brought to the attention of the primary healthcare provider immediately Measuring Fluid Intake Fluid intake: all fluids consumed through the gastrointestinal (GI) system (by mouth or tube feeding) and fluids taken as part of intravenous (IV) therapy or parenteral nutrition (TPN) Record all fluid the patient takes in – count ice as 50% water (eg. 100 mL of ice would count as 50 mL of fluid intake) Measuring Output Fluid output: all fluids excreted from body (wound drainage, emesis/vomiting, bleeding, diarrhea, nasogastric suction tube) returns When recording output other than urine, be sure to identify what the output was  Would drainage on dressings is measured by weighing the dressing after it is removed and comparing it with the dry weight of an identical Weights are done in milligrams and converted to milliliters Measuring Urine Specific Gravity Urine specific gravity: is an indicator of concentration of urine compared to pure water Measured during routine urinalysis Measure with a specialized instrument called a urinometer or hydrometer ○ Reading measured in decimal increments above (pure gravity) Normal range: 1.010 (dilute) - 1.025 (high concentration) Extremely concentrated urine (>1.025) may indicate dehydration/edema (fluid retention in tissues) Low specific gravity can indicate disorder (i.e. diabetes) or excessive use of diuretic medications Collecting Urine Specimens Be aware that the amount and content of a urine specimen varies with the time of day and with food and fluid intake Label specimen bottles before the client voids. Use a waterproof label Wake a client in the morning to obtain a routine specimen Single-Voided Urine Specimen ○ Often ordered ○ Tests are done to determine efficiency of kidneys or to examine urine for abnormalities Clean-Catch/Midstream Urine Specimen ○ Specimen obtained with minimal contamination from external sources without inserting a sterile catheter 24 Hour Urine Specimen ○ Accumulated urine quantity gives more detailed info because better shows the type and quantity of wastes being exerted by the kidneys ○ Urine collected for 24 hours Fractional Urine Specimen 24 hour Fractional Urine Specimen ○ Used to determine amounts and characteristics of urine during very periods of the day  Often, fractional specimens are obtained for 6-hour periods of the day: ○ 12am-6am, 6am-12pm, 12pm-6pm, 6pm-12am ○ Need four specimen bottles, covers, and labels. Label all bottles before you begin. Indicate times. ○ Collect all urine from the first fraction of the day in bottle #2. Be sure to ask the client to void at the end of that period. Begin each collection with empty bladder Collect and end day on empty bladder Collecting Clean-Catch Midstream Urine Specimen Label the container before giving it to the client Instruct the client to cleanse the urethral area thoroughly Use prepackaged wipes Instruct the client to cleanse from front to back and to cleanse each side with a separate wipe or a separate area of the wipe, saving the last for the genital area itself Instruct both male and female clients to void a small amount into the toilet and to hold the rest of their urine Instruct the client to void into the sterile container, catching the midstream urine instruct the client to void the last of the stream into the toilet Take or send the specimen to the laboratory without delay ○ Rationale: delay could cause a false-positive result, particularly in the case of a urine culture Be sure to wear gloves when handling all specimens Store all specimens on ice or in fridge Collecting Specimen From an Indwelling Catheter Some clients have catheters (tubes) inserted into the urinary bladder that drain urine continuously Most likely, a catheterized specimen will be obtained only if the person is unconscious or has a retention catheter Contamination of any part of any catheter system can cause an infection because microorganisms can travel up the catheter into the bladder Take care not to allow the collecting bag to be elevated above the level of the bladder. This action could result in urine flowing back into the bladder, carrying microorganisms with it Obtaining a One-Time Catheterized Urine Specimen Circumstances may dictate that a urine specimen must be obtained through catherterization. A primary provider’s order is usually required. A catheterized urine specimen is usally not done unless there is a specific contraindicition for a midstream clean-cath specimen, another catheterized procedure is ot be done at the same time, or the catheterf is to be left in place after the specimen is obtained The one-time catheterized specimen procedure may be used for client in whom a clean-cath specimen cannot be obtained, such as the client who is unconscious, confused or otherwise unable to obtain the specimen May be ordered along with order to determine residual urine volume Residual urine: urine that remains in bladder after voiding ○ Client voids, nurse catheterizes immediately and amount of urine is documented ○ Significant amount indicates client may have bladder obstruction or deficient contractility in detruoser muscles (that push down) Computerized Dopper can also determine residual volume Stool Specimen Provides information about functioning of GI system and accessory organs Most common test: presence of occult (hidden) blood in stool → indicates bleeding in GI tract Test for ova and parasites: indicates presence of intestinal parasite or their eggs Hemoccult/hemtest brand methods: how stools are tested for occult blood ○ Nurse places a smear of stool on the testing card with a special narrow stick and add a drop of a reagent (testing solution) ○ After a timed interval, the smear is compared with a colour chart to determine the presence of blood. Always check the testing kit for any special instructions Sputum Specimen For patients with respiratory disorders Test is often used to determine the presence of the tubercle bacillus (tuberculosis) - often, such specimens are collected 3 days in a row Best time to obtain is soon after the patient awakens in the morning as sputum accumulates in the airways during the night, so it is more easily expelled by coughing the in the early morning  The first specimen of the morning is considered to be the most accurate Obtain the specimen before they eat, use mouthwash or brush teeth Consuming adequate amounts of fluid and breathing humidified air or aerosolized medications help to loosen and liquefy secretion making it easier for the client to cough it up If they have used aerosolized medications, document that Order to measure sputum: 2 ways ○ 1. If enough sputum is collected in a graduated specimen container, read the amount directly, or: ○ 2. Pour an equal amount of water into an identical container and measure the water In addition, do the following: ○ Weigh the specimen, if ordered. Do so on a balance scale ○ Take the specimen to the laboratory immediately after collection ○ Label the container appropriately and notify the laboratory personnel that this is a sputum specimen ○ Document sputum amount, color and consistency