Study Guide - Foundations Exam 2 PDF

Nutrition: Identify nutrition and fluid intake and output requirements across the lifespan. o Nutrients provide energy for cellular metabolism, tissue maintenance and repair; organ function, growth and development; and physical activity. Describe nutrition and flu...

Nutrition: Identify nutrition and fluid intake and output requirements across the lifespan. o Nutrients provide energy for cellular metabolism, tissue maintenance and repair; organ function, growth and development; and physical activity. Describe nutrition and fluid balance. o Energy is needed to maintain life sustaining activities, age body mass gender, fever, starvation, menstruation, illness, injury infection, activity level, and thyroid function affect energy requirements. KCALs of the food we eat meet energy requirements, if what we intake meets our energy requirements our weight will not change, if our intake exceeds our energy requirements we gain weight. Carbohydrates, proteins, fats, water, vitamins, and minerals help meet our energy needs. Explain types of therapeutic diets. o NPO- abbreviation meaning nothing by mouth o Regular diet- A healthy, varied diet with food from all food groups o Soft diet- Diet containing foods that are soft, easy to digest, low in fiber, and easy to swallow without difficulty o Pureed diet- Diet of foods that do not require chewing o Full liquid diet- diet of liquids, foods that are considered liquids, and foods that turn into liquids at room temperature o Clear liquid diet- Diet consists of only liquids that are clear and offers little daily calories and nutrients. o Heart-healthy diet- promotes cardiovascular health through controlling portion, eating a varied diet, and watching sodium intake o Renal diet- diet for individuals with kidney disease that limits intake of sodium, potassium, and phosphorus Explain the relationship of prescribed diet to nutritional/fluid balance. o The diet is appropriate for the client. The nurse ensures that the client receives the correct diet based on the provider’s order and promotes adequate nutritional intake. o Diets ▪ NPO-nothing by mouth Restricts the client from eating or drinking anything until diet is advanced o Due to inability to safely eat and drink o A scheduled surgery o An upcoming diagnostic test requires fasting of empty stomach  Regular diet- consists of healthy foods coming from all the food groups such as fruits, vegetables, grains, protein, and dairy sources. Soft diet- contains foods that are soft, easy to digest, low in fiber and can be swallowed without difficulty. o For patients recovering from surgeries on areas of the body such as jaw, mouth, or abdomen. Pureed diet- consists of foods that are soft and smooth and do not need to be chewed. o Nutrients needed are protein, carbohydrates, fats, vitamins, and minerals Full liquid diet- diet that contains only fluids, foods that are liquids, and foods that are liquid at room temperature, such as ice cream o No solid foods o For clients who are postoperative from abdominal surgery, dysphagia or undergoing certain procedures Clear liquid diet- contains only clear liquids, such as broth, gelatin, and water. Tea, fruit juice (w/o pulp) and sports drinks. o Easy to digest and keeps the body hydrated. o Avoid red coloring for colon procedures and tonsillectomies to avoid any confusion with possible bleeding. o Clear liquid diet is good for clients with nausea, vomiting, and diarrhea Heart-healthy diet-focuses on controlling portioned, consuming more fruits and vegetables, increasing whole grains, limiting unhealthy fats, eating low-fat protein sources, and decreasing sodium intake. o Diet is essential for clients with cardiovascular disease o Promote weight loss o Includes fiber to promote heart health and blood pressure Renal Diet- offers guidance to clients who have kidney disease in controlling the intake of these minerals. o Avoiding table salts o Kidney disease patients ▪ Limit intake of potassium ▪ High postassium lead to heart dysrhythmias increase myocardial infarction Identify equipment for measuring nutrition and fluid intake and output. o Intake equipment measurement  ▪ Cups ▪ Glass ▪ Soup bowl ▪ Package ▪ Lid w/containers o Output equipment measurement ▪ Emesis basin ▪ Graduated cylinder ▪ Urinal ▪ Wound drainage device ▪ Urinary catheter bag ▪ Wall drainage suction container Calculate nutritional/fluid intake and output. o Add up all input numbers, then add up all output numbers. o Then, subtract the input from the output. If the number is positive, then it is a positive I & O. If the number is negative, the pt has negative I & O. Explain the process of monitoring client nutritional intake and output. o The measurement of intake and output (I & O) during the shift and within a 24-hour period provides important information about a patient’s fluid and electrolyte balance. The health-care provider may order the measurement of intake and output for the patient, or the nurse may independently place the patient on intake and output. Explain documentation requirements for nutrition and fluid intake and output. o Nurses record a patient’s intake in mL. o Household measurements such as the teaspoon, tablespoon, glass, cup, and ounce, need to be converted to mL. o The nurse monitors the patient’s intake throughout the shift by writing down the patient’s liquid intake on a clinical worksheet. o At the end of the shift, the nurse adds the intake and records the total in the patient’s Intake and output Record. o Output is recorded in mL, and is identified under specific categories, such as urine, gastric, drainage, emesis, wound drainage, and others, o For urine output, the amount measured at each voiding is entered in the I &O worksheet and the total is entered in the I & O at the end of the shift. o The same is true ech time the patient vomits. Gastric and drainage containers are usually emptied and measured at the end of the shift. o When recording the output on the electronic medical record, the nurse selects the category (urine, emesis, gastric drainage, etc.) from a list provided and enters the total output for each category. If using a printed Intake and Output form, the nurse writes in the category if it is not identified on the form.  Define enteral feedings. o A method of providing nutrients to clients who cannot consume foods orally but whose GI tract is functioning. o Dietary intake via a medical device such as a feeding tube Identify equipment used for enteral feedings. o Nasogastric or nasointestinal ▪ For short-term therapy ▪ Inserted via the nose o Gastrostomy or jejunostomy ▪ Therapy duration longer than 6 weeks ▪ Inserted surgically o Percutaneous endoscopic or gastrostomy or jejunostomy ▪ Therapy duration longer than 6 weeks ▪ Inserted endoscopically Explain the procedure for initiating enteral feedings. o Check page 325- Preprocedure Explain the procedure for inserting a nasogastric tube. o Check page 326-Intraprocedure Define parenteral therapy. o Nutritional intake through the veins, given when a client’s GI system does not function o IV fluid is administered into a large vein through a venous access device. o The provider can individualize the nutrition provided for a client by monitoring their serum laboratory results o The lab measurements let the provider know how the client is responding to the parenteral nutrition and allow for evaluation of the fluid balance, catheter site, and clients ability to move to tube feedings or normal (by mouth) feeding. Describe equipment requirements for parenteral therapy. o Partial parenteral nutrition- supplies a client with only part of their nutritional requirements, allowing for supplemental oral intake o Total parenteral nutriton- gives the client their total daily nutritional requirements ▪ w/o functioning GI tract, total parenteral nutrition may be the only option ▪ Complication of total parenteral nutrition is abnormalities in glucose, including high blood glucose ▪ Frequent blood glucose checks should be completed per the provider’s prescription ▪ Insulin dose can be adjusted if client has high blood glucose ▪ Subcutaneous insulin is a treatment option to prevent high blood glucose. Describe the types, purposes, operations of various GI tubes. o Gastrostomy tube- a tube that delivers nutrition directly into the stomach.  ▪ Inserted through the abdomen and is indicated for clients who are unable to consume enough nutrition on their own ▪ Performed by a surgeon that takes about 30 to 45mins ▪ Xrays are done before procedure to view digestive tract ▪ Client required to remain NPO for at least 8 hours before procedure. Percutaneous endoscopic gastrostomy (PEG) Most Common Laparoscopic technique-procedure where small incisions are made on the abdomen and a tiny. telescope is used to place a g-tube Open Surgery Technique-technique used to place a G-tube when laparoscopic is not an option; open surgery allowing the surgeon to complete other procedures if indicated. Urinary Elimination: Discuss body functions related to the production of urine and feces Urinary Tract functions Convert and remove excess waste and fluids from the body in urine Regulates levels of electrolytes and the production of red blood cells Produces hormones that are important for blood pressure regulation Helps to keep bones strong o Urinary System (travel) ▪ Kidneys –convert waste products and excess fluid into urine to be removed from the body ▪ Bladder-urine moves from the kidneys to the bladder through the ureters ▪ Urethra-once the bladder is full then the urine goes to the urethra which is known urination Production of urine o Is how much liquid and food a client consumes o Breathing, sweat producing exercise, and medication influence the amount of urine produced. o Age can affect urine production, urine decreases with age o Dehydration and kidney dysfunction affects urine production Production of Feces o Food starts by entering the mouth Explore expected and unexpected findings related to elimination. Expected/Unexpected findings (ATI chapter 44) Urinary Elimination Complications UTI (Urinary tract infections) - Risk factors: o Female clients due to close location of urethral meatus and anus o Indwelling urinary catheters - Manifestations: o Urgency, frequency, fever, burning or painful urination, flank pain or suprapubic discomfort, cloudy, foul-smelling, blood-tinged urine o Older adult clients: might experience confusion, incontinence, falls, fatigue, anorexia CAUTI (catheter-associated urinary tract infection): Occurs while an indwelling catheter is in place or up to 48 hours after discontinuing. - Manifestations: urinary frequency, urgency, nocturia, flank pain, hematuria, cloudy, foul smelling urine, and fever. - In older adults, new onset of increased confusion, recent falls new onset incontinence, anorexia, fever, tachycardia, hypotension. Urinary Incontinence: urinary incontinence is a significant contributing factor to skin breakdown and falls, especially in older adults. - Risk factors o Female anatomy o History of multiple pregnancies and vaginal births, aging, chronic urinary retention, urinary bladder spasm, renal disease, chronic bladder infection (cystitis) o Neurologic disorders: Parkinson’s disease, cerebrovascular accident, spinal cord injury, multiple sclerosis o Medication therapy: Diuretics, opioids, anticholinergics, calcium channel blockers, sedative/hypnotics, adrenergic antagonists o Obesity o Confusion, dementia, immobility, depression o Physiological changes of aging o Decreased estrogen levels and decreased pelvic-muscle tone o Immobility, chronic degenerative diseases, dementia, diabetes mellitus, cerebrovascular accident o Urinary incontinence increasing the risk for falls, fractures, pressure injuries, and depression - Expected findings o Enuresis (bed-wetting) o Bladder spasms  o Urinary retention o Frequency, urgency, nocturia Therapeutic Procedures you can do for incontinence - Bladder-retraining program o Urinary bladder retraining increases the bladder’s ability to hold urine and clients’ ability to suppress urination. - Nursing Actions o Use timed voiding to increase intervals between urination. o Assist clients to perform relaxation techniques. o Offer incontinence undergarments while clients are retraining. o Provide positive reinforcement as clients remain continent. - Client Education o Urinate at scheduled intervals. o Gradually increase urination intervals after no incontinence episodes for 3 days, working toward the optimal 4-hr intervals. o Hold urine until the scheduled toileting time. o Keep track of urination times. o Perform pelvic floor (Kegel) exercises. o Use distraction methods to inhibit the urge to urinate. - Eliminate or decrease caffeine drinks. o Take diuretics in the morning. - Urinary habit training o Urinary habit training helps clients who have limited cognitive ability to establish a predictable pattern of bladder emptying. - Client Education o Urinate at scheduled intervals. o Urination patterns determine the toileting schedule. o Follow a toileting schedule according to the pattern with which they have no incontinence. - Intermittent urinary catheterization o Intermittent urinary catheterization is periodic catheterization to empty the bladder. It reduces the risk of infection from indwelling catheterization, which is a temporary intervention for clients at risk for skin breakdown, or when other options have failed. - Nursing Actions o Adjust the frequency of catheterization to keep output at 400 mL or less. o Explain the procedure. - Client Education: Follow a toileting schedule according to the pattern with which they have no incontinence.  Procedures for treatment of stress urinary incontinence - Anterior vaginal repair, retropubic suspension, pubovaginal sling, insertion of an artificial sphincter Suprapubic catheter - Surgeons insert suprapubic catheters into the abdomen above the pubic bone and in the bladder and suture the catheter in place. The care for the catheter tubing and drainage bag is the same as for an indwelling catheter. - Catheters (suprapubic or urinary) remain until clients have a post-void residual of less than 50 mL. Traction (with tape) helps prevent movement of the bladder. Nursing Actions - Monitor output and for any manifestations of infection (color of urine, sediment, level of output). - Keep the catheter patent at all times. - Determine clients’ ability to detect the urge to urinate. Client Education - Perform skin care around the insertion site. - Perform care and emptying of the catheter bag. - Client Education QEBP - Drink 2 to 3 L of fluid daily. - Try to hold urine to stay on schedule with bladder retraining. - Drink cranberry juice to decrease the risk of infection. - Take prescribed medications to resolve incontinence. - Perform intermittent catheterization if necessary. - Express any feelings about incontinence. - Avoid colas, coffee, tea, alcohol, and chocolate as these can irritate the bladder. Discuss conditions that alter a client’s elimination patterns. Factors affecting urinary elimination: - Poor abdominal and pelvic muscle tone - Acute and chronic disorders - Age o Children achieve full bladder control by 4 to 5 years of age. o The prostate can enlarge in older adult males. An enlarged prostate can obstruct the bladder outlet and cause urinary retention and urgency, which can lead to incontinence and urinary tract infections (UTIs).  o Childbirth and gravity weaken the pelvic floor, putting clients at risk for prolapse of the bladder, leading to stress incontinence, which clients can help manage with pelvic floor (Kegel) exercises. o Clients who are post-menopausal can have decreased perineal tone due to reduced estrogen levels, which can cause urgency, stress incontinence, and UTIs. - Older adult clinets o Fewer nephrons o Loss of muscle tone of the bladder leading to frequency o Inefficient emptying of the bladder can result in residual urine and increasing the risk for UTIs o Increase in nocturia due to a decrease in bladder capacity o Presence of chronic illnesses o Factors that interfere with mobility and dexterity - Pregnancy o A growing fetus compromises bladder space and compresses the bladder. o There is a 30% to 50% increase in circulatory volume, which increases renal workload and output. o The hormone relaxin causes relaxation of the sphincter. - Diet o An increase in sodium leads to decreased urination. o Caffeine and alcohol intake lead to increased urination. - Immobility o Incontinence can occur from impaired mobility due to difficulty transferring to the bathroom. - Psychosocial Factors o Emotional stress and anxiety o Having to use public toilets o Lack of privacy during hospital stays o Not having enough time to urinate (predetermined bathroom breaks in elementary schools) - Pain o Suppression of the urge to urinate when there is pain in the urinary tract o Obstruction in the ureter leading to renal colic o Arthritis or painful joints causing immobility and leading to delayed urination - Surgical Procedures o Alterations in glomerular filtration rate from anesthesia and opioid analgesics, resulting in decreased urine output o Lower abdominal surgery creating obstructive edema and inflammation - Medications o Diuretics preventing reabsorption of water  o Antihistamines and anticholinergics causing urinary retention o Chemotherapy creating a toxic environment for the kidneys - Medications that change urine color o Phenazopyridine: orange, red o Amitriptyline: green-blue o Levodopa: dark o Riboflavin: bright yellow Examine the use of diversions to manage altered elimination. Urinary Diversions are: - Urinary diversions are created to reroute urine and are temporary or permanent. Surgeons create urinary diversions for clients who have bladder cancer or injury. QPCC - Urinary diversions have many similarities to bowel diversions. Clients who have urinary diversions often share similar body image concerns as those who have bowel diversions. - Diversions are either continent (with controlled elimination of urine from the body) or incontinent (with urine draining continuously without control). - Continent diversions have a reservoir in the abdomen that allows clients to control the elimination of urine. Types of Factors that Affect Urinary Eliminations - Ureterostomy (ileal conduct): An incontinent urinary diversion in which the surgeon attaches one or both ureters via a stoma to the surface of the abdominal wall - Nephrostomy: An incontinent urinary diversion in which the surgeon attaches a tube from the renal pelvis via a stoma to the surface of the abdominal wall - Kock pouch (continent ileal bladder conduit): A continent urinary diversion in which the surgeon forms a reservoir from the ileum. The pouch is emptied by clean straight catheterization every 2 to 3 hr initially, and every 5 to 6 hr once the pouch expands to capacity. - Neobladder: A new bladder created by the surgeon using the ileum that attaches to the ureters and urethra. It allows the client to maintain continence; the client learns to void by straining the abdominal muscles. Identify diagnostic tests related to elimination and the nurse’s role in obtaining specimens. Diagnostic Tests - Bedside sonography with a bladder scanner: Noninvasive portable ultrasound scanner for measuring bladder volume and residual volume after urination  - Kidneys, ureters, bladder: X-ray to determine size, shape, and position of these structures - Intravenous pyelogram: Injection of contrast media (iodine) for viewing of ducts, renal pelvis, ureters, bladder, and urethra - Contrast media (iodine) may not always be contraindicated in clients who have a shellfish allergy. Further assessment may be needed. - Renal scan: View of renal blood flow and anatomy of the kidneys without contrast - Renal ultrasound: View of gross renal structures and structural abnormalities using high-frequency sound waves - Cystoscopy: Use of a lighted instrument to visualize, treat, and obtain specimens from the bladder and urethra - Urodynamic testing: Test for bladder muscle function by filling the bladder with CO2 or 0.9% sodium chloride and comparing pressure readings with reported sensations Considerations Promoting healthy urinary elimination - Equipment o Urinal for males o Toilet, bedpan, or commode o Fracture pan: For clients who must remain supine and clients in body or leg casts o Regular pan: For clients who can sit up - Procedure Nursing Actions o Have clients sit when possible. o Provide for privacy needs with adequate time for urinating. I&O - Equipment o Hard plastic urometer on an indwelling catheter drainage bag o Graduated cylinders, urinal, or toilet receptacle - Procedure Nursing Actions o Measure output from a bedpan, commode, or collection bag into a graduated container. o Use a receptacle to measure urine clients void into the toilet. o Use markings on the side of the urinal to measure urine. ****Less than 30 mL/hr for more than 2 hr should be reported to the provider because inadequate urinary output is a manifestation of urinary retention, hypovolemia, or impaired kidney function. Specimen collection  - Equipment o Specimen container ▪ Non-sterile for urinalysis ▪ Sterile for clean-catch midstream and specimens from a catheter o Soap or cleansing solution and towel o Gloves (for contact with any body fluids) o Specimen label o Urine collection container (catheter, urinal, receptacle in toilet, commode) Urinalysis: random non-sterile specimen - Nursing Actions o Explain the procedure. o Label the container with clients’ identifying information and follow the facility’s policy for transporting the specimen to the laboratory. Clean-catch midstream for culture and sensitivity (C&S) - Nursing Actions o Teach client the technique for obtaining the specimen. o After thorough cleansing of the urethral meatus, clients catch the urine sample midstream. Catheter urine specimen for C&S - Nursing Actions o Obtain a sterile specimen from a straight or indwelling catheter using surgical asepsis (sterile technique). Timed urine specimens - Nursing Actions o Collect for 24 hr or other duration. o Discard the first voiding. o Collect all other urine. Refrigerate, label, and transport the specimen. Discuss nursing interventions that can facilitate or maintain a client’s elimination patterns Straight or indwelling catheter insertion - Equipment o Usual size and type of catheter ▪ 8 to 10 Fr for children ▪ 10 to 12 Fr for females  ▪ 12 to 14 Fr for males ▪ Use silicon or Teflon products for clients who have latex allergies. o Catheterization kit with a sterile drainage bag for indwelling catheter insertion o Soap and water o Collection container for straight catheterization - Procedure Nursing Actions o Explain the procedure and provide for privacy. o Use sterile technique for inserting an indwelling catheter or for straight catheterization. Closed intermittent irrigation - Performed to maintain patency or remove a blockage of an indwelling urinary catheter. Use sterile technique to perform closed intermittent irrigation. Routine catheter care - Equipment o Soap and water o Washcloth o Gloves - Procedure Nursing Actions o Use soap and water at the insertion site. o Cleanse the catheter at least three times a day and after defecation. o Monitor the patency of the catheter. ▪ For reports of fullness in the bladder area, check for kinks in the tubing, and check for sediment in the tubing. ▪ Make sure the collection bag is at a level below the bladder to avoid reflux. Condom catheter application - Equipment o Gloves o Condom catheter o Elastic tape o Leg or standard collection bag - Procedure Nursing Actions o Explain the procedure. o Use the correct technique for application of a condom catheter. Bowel Elimination: ATI ebook Chapter 43  Discuss body functions related to the production of urine and feces - Many factors can alter bowel function. Interventions (surgery, immobility, medications, therapeutic diets) can affect bowel elimination. Various disease processes necessitate the creation of bowel diversions to allow fecal elimination to continue. - Stool specimens are collected both for screening and for diagnostic tests (detection of occult blood, bacteria, or parasites). - Alterations in bowel pattern include infrequent stools (constipation) or an increased number of loose, liquid stools (diarrhea). Explore expected and unexpected findings related to elimination. Factors Affecting Bowel Elimination - Age o Infants ▪ Breast milk stools: watery and yellow brown ▪ Formula stools: pasty and brown o Toddlers ▪ Bowel control at 2 to 3 years old o Adolescents ▪ Increased secretion of gastric acids ▪ Accelerated growth of the large intestine o Older Adults ▪ Decreased peristalsis, relaxation of sphincters - Diet o Fiber requirement: 25 to 38 g/day ▪ Difficulty digesting foods (lactose intolerance) can cause watery stools. ▪ Certain foods can increase gas (cabbage, cauliflower, apples), have a laxative effect (figs, chocolate), or increase the risk for constipation (pasta, cheese, eggs). - Fluid Intake o Fluid requirement: 2.7 L/day for females and 3.7 L/day for males from fluid and food sources - Physical Activity o Stimulates intestinal activity and increases skeletal muscle tone needed for defecation - Psychosocial Factors o Emotional distress increases peristalsis and exacerbates chronic conditions (colitis, Crohn’s disease, ulcers, irritable bowel syndrome)  o Depression can lead to decreased peristaltic activity and constipation - Personal Habits o Reluctance to use public toilets, false perception of the need for “one-a-day” bowel movements, lack of privacy when hospitalized - Positioning o Normal: Squatting o Immobility: Can result in difficulty contracting gluteal muscles and defecating - Pain o Normal defecation is painless; discomfort due to conditions (hemorrhoids, fissures, perianal surgery) can lead to suppression of the urge to defecate o Opioid use contributes to constipation - Pregnancy o Growing fetus compromising intestinal space o Slower peristalsis o Straining increasing the risk of hemorrhoids - Surgery and Anesthesia o Temporary slowing of intestinal activity (rationale for auscultating bowel sounds before advancing diet) - Medications o Laxatives: Soften stool o Cathartics: Promote peristalsis o Laxative overuse: Chronic use of laxatives causes a weakening of the bowel’s expected response to distention from feces, resulting in the development of chronic constipation - Incontinence o Fecal incontinence is the inability to control defecation, often caused by diarrhea. ▪ Determine causes (medications, infections, or impaction). ▪ Provide perineal care after each stool and apply a moisture barrier. ▪ Provider can prescribe fecal incontinence pouch or other bowel management system to collect stool to prevent it from coming into contact with the skin. - Flatulence Flatulence results from distention of the bowel from gas accumulation (can cause cramping or a feeling of fullness). o Check for abdominal distention and the ability to pass gas through the anus. o Encourage ambulation to promote the passage of flatus. - Hemorrhoids Hemorrhoids are engorged, dilated blood vessels in the rectal wall from difficult defecation, pregnancy, liver disease, and heart failure. o Hemorrhoids can be itchy, painful, and bloody after defecation.  o Use moist wipes for cleansing the perianal area and apply ointments or creams as prescribed. o Use a sitz bath or ice pack to promote relief from hemorrhoid discomfort. - Ostomies o Some bowel disorders prevent the expected elimination of stool from the body. Bowel diversions through ostomies are temporary or permanent openings (stomas) surgically created in the abdominal wall to allow fecal matter to pass. o Ostomies are created in either the large intestine or the small intestine. Colostomies end in the colon, and ileostomies end in the ileum. ▪ End stomas are a result of colorectal cancer or some types of bowel disease. ▪ Loop colostomies help resolve a medical emergency and are temporary. In a loop colostomy, a loop of bowel is supported on the abdomen with a proximal stoma draining stool and a distal stoma draining mucus. It is usually constructed in the transverse colon. ▪ Double-barrel colostomies consist of two abdominal stomas: one proximal and one distal. The proximal stoma drains stool and the distal stoma leads to inactive intestine. After the injured area of the intestine heals, the colostomy is often reversed by reattaching the two ends. Discuss conditions that alter a client’s elimination patterns. Complications of Constipation - Fecal impaction: Stool becomes wedged in the rectum and can involve diarrhea fluid leaking around the impacted stool. o Administer enemas and suppositories or stool softeners as prescribed to promote relief of fecal impaction. If necessary, manually remove fecal impactions that do not respond to other interventions. o Use a gloved, lubricated finger for digital removal of stool. o Loosen the stool around the edges and then remove it in small pieces, allowing the client to rest as necessary. o When evacuating the rectum, be careful to avoid stimulating the vagus nerve. o Stop the procedure if the heart rate drops significantly or the heart rhythm changes. QS - Hemorrhoids and rectal fissures Bradycardia, hypotension, syncope o Associated with the Valsalva maneuver (occurs with straining/bearing down). o Instruct clients not to strain to have bowel movements. o Encourage measures to treat and prevent constipation. QS  Complications of Diarrhea - Dehydration - Fluid and electrolyte disturbances: Metabolic acidosis from excessive loss of bicarbonate o Monitor for manifestations of dehydration (weak, rapid pulse; hypotension; poor skin turgor; elevated body temperature). ▪ Hypernatremia: Muscle weakness, lethargy, swollen red tongue ▪ Hypokalemia: Leg cramps, muscle weakness, nausea, vomiting, cardiac dysrhythmias. o Monitor for manifestations of electrolyte imbalance. o Replace fluid and electrolytes as prescribed. ** Skin breakdown around the anal area: Provide treatment for skin breakdown as prescribed. Examine the use of diversions to manage altered elimination. Identify diagnostic tests related to elimination and the nurse’s role in obtaining specimens. Diagnostic Procedures ** Stool samples should come from fresh stools. Avoid contaminating with water or urine. - Fecal occult blood (guaiac) test: Obtain a fecal sample using medical asepsis while wearing gloves. Collect stool specimens for serial guaiac testing three times from three different defecations. Some foods (red meat, citrus fruit, raw vegetables) and medications can cause false positive results. Bleeding can be an indication of cancer. QEBP - Specimens for stool cultures: Obtain using medical asepsis while wearing gloves. Label the specimen, and promptly send it to the laboratory. Specimen Collection - Equipment o Specimen container o Soap/cleansing solution or wipe o Clean gloves o Specimen label o Fecal occult blood test cards o Wooden applicator or tongue depressor o Developer solution o Stool collection container (bedside commode, bedpan, receptacle in toilet) - Procedure  o Fecal occult blood testing (guaiac test) o Explain the procedure to the client. o Ask the client to collect a specimen in the toilet receptacle, bedpan, or bedside commode. o Don gloves. o With a wooden applicator, place small amounts of stool on the windows of the test card or as directed. o Follow the facility’s procedures for handling. ▪ Apply a label to the cards and send them to the laboratory for processing. ▪ Alternatively, place a couple of drops of developer on the opposite side of the card. A blue color indicates the stool is positive for blood. o Remove the gloves and perform hand hygiene. - Stool for culture, parasites, and ova o Explain the procedure to the client. o Ask the client to collect the specimen in the toilet receptacle, bedside commode, or bedpan. o Don gloves. o Use a wooden tongue depressor to transfer the stool to a specimen container. o Label the container with the client’s identifying information. o Remove the gloves. o Perform hand hygiene. o Transport the specimen to the laboratory. Colonoscopy - Use of a lighted instrument by the provider to visualize and collect tissue samples for biopsy or remove polyps from the colon or lower small bowel. Sigmoidoscopy - Use of a lighted instrument by the provider to visualize and collect tissue for biopsy or remove polyps from the sigmoid colon and rectum. Client Preparation - Protocols vary with the provider and the facility, but generally include clear liquids only and a bowel cleanser. - Clients receive moderate (conscious) sedation and cannot drive home afterwards. Patient-Centered Care Nursing Care - Closely monitor fluid status and elimination pattern. - Record food and fluid intake and output. For diarrhea, measure the volume of the stools.  - Observe and document the character of bowel movements. Carefully check for blood or pus. - Promote regular bowel elimination through several measures. QEBP o Adequate fiber in the diet Adequate fluid intake Adequate activity: Walking 15 to 20 min/day if mobile and exercises in bed or chair (pelvic tilt, single leg lifts, lower trunk rotation) Constipation - Increase fiber and water consumption (unless contraindicated) before more invasive interventions. - Give bulk-forming products before stool softeners, stimulants, or suppositories. - Enemas are a last resort for stimulating defecation. - Encourage regular exercise. Diarrhea - Help determine and treat the cause. - Administer medications to slow peristalsis. - Provide perineal care after each stool and apply a moisture barrier. - After diarrhea stops, suggest eating yogurt to help re-establish an intestinal balance of beneficial bacteria. - Encourage fluid intake to replace fluid loss. - Instruct client to avoid bowel irritants, such as caffeinated beverages and alcohol. Discuss nursing interventions that can facilitate or maintain a client’s elimination patterns. Bowel Elimination - Equipment o Bedpans ▪ Fracture pans for supine clients and clients in body casts or leg casts ▪ Regular pan for seated clients o Bedside commode o Toilet - Procedure o Encourage the client to set aside time to defecate. Sometimes, after a meal works best.  o If not contraindicated or restricted, encourage the client to drink plenty of fluids and to consume a diet high in fiber to prevent constipation. o Wear gloves when addressing toileting needs. o Provide privacy. o Assist the client to a sitting position whether using a regular bedpan, commode, or toilet. o For clients using a fracture pan, raise the head of the bed to 30°. o If the client cannot lift their hips, roll the client onto one side, position the bedpan over the buttocks, and roll the client back onto the bedpan. o Encourage the client to decrease stress when sitting or rising by using an elevated toilet seat or a footstool. o Never leave a client lying flat on a regular bedpan. o After the client defecates, provide skin care to the perianal area. Cleansing Enema ** The height of the bag above the rectum determines the depth of cleansing. - Equipment o Gloves o Lubricant o Absorbent, waterproof pads o Bedpan, beside commode, or toilet o IV pole o Enema bag with tubing or prepackaged enema o Solutions and additives: vary with the type of enema o Tap water or hypotonic solution o Stimulates evacuation o Use with caution due to potential water toxicity Soapsuds - Pure castile soap in tap water or normal saline - Acts as an irritant to promote bowel peristalsis - Used cautiously in older adults and clients who are pregnant due to an increased risk of electrolyte imbalance and intestinal mucosa damage Normal saline - Safest due to equal osmotic pressure - Volume stimulates peristalsis Low-volume hypertonic - Used by clients who cannot tolerate high-volume enemas  - Commercially prepared - Not used on infants or clients who are dehydrated Oil retention: Lubricates the rectum and colon for easier passage of stool Medicated enema: Contains medications (antibiotics or anthelmintics) to retain for a period of time (1 to 3 hr) - Procedure o Perform hand hygiene. o Prepare and warm the enema solution (ensure enema solution is at a warm temperature. A cold solution can result in cramping and a hot solution can result in mucosal injury). o Pour the solution into the enema bag, allowing it to fill the tubing, and then close the clamp. o Provide privacy. o Provide quick access to a commode or bedpan. o Place absorbent pads under the client to protect the bed linens. o Position the client on the left side with the right leg flexed forward. o Put on gloves. o Lubricate the rectal tube or nozzle. o Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). For a child, insert the tube 5 to 7.5 cm (2 to 3 in). o With the bag level with the client’s hip, open the clamp. o Raise the bag 30 to 45 cm (12 to 18 in) above the anus, depending on the level of cleansing desired. o Slow the flow of solution by lowering the container if the client reports cramping, or if fluid leaks around the tube at the anus. o If using a prepackaged solution, insert the lubricated tip into the rectum, and squeeze the container to instill all of the solution. o Ask the client to retain the solution for the prescribed amount of time, or until the client is no longer able to retain it. o Discard the enema bag and tubing. o Assist the client to the appropriate position to defecate. o Remove the gloves. o Perform hand hygiene. o For clients who have little or no sphincter control, administer the enema on a bedpan. o Document the results and the client’s tolerance of the procedure. Ostomy Care - Equipment  o Pouch system (skin barrier and pouch) o Pouch closure clamp o Barrier pastes (optional) o Gloves o Washcloths o Towel o Warm water o Scissors o Pen - Procedure o If a wound ostomy continence nurse is not available, educate the client about stoma care. o Perform hand hygiene. o Put on gloves. o Remove the pouch from the stoma. o Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. o Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. o Apply paste if necessary. o Measure and mark the desired size for the skin barrier. o Cut the opening 0.15 to 0.3 cm (1⁄18 to 1⁄8 in) larger, allowing only the stoma to appear through the opening. o If necessary, apply barrier pastes to creases. o Apply the skin barrier and pouch. o Fold the bottom of the pouch and place the closure clamp on the pouch. o Dispose of the used pouch. Remove the gloves and perform hand hygiene. Fluid/ Electrolyte (ATI Chapter 57 & 58) Background on Fluid/Electrolyte balance: ▫ Body fluids are distributed between intracellular fluid (ICF) and extracellular fluid (ECF) compartments. ICF lies within body cells and constitutes two-thirds of the total body fluids in adults. ECF is comprised of intravascular (plasma), interstitial (fluid that surrounds the cells), lymph, and transcellular fluids (cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids). ▫ Fluid can move between compartments (through selectively permeable membranes) by a variety of methods (diffusion, active transport, filtration, osmosis) to maintain homeostasis.  Fluid imbalances that the nurse should be familiar with are fluid volume deficit and fluid volume excess. Dehydration ▫ Dehydration is a lack of fluid in the body, from insufficient intake or excessive loss. o Actual dehydration is a lack of fluid in the body; relative dehydration involves a shift of water from the plasma (blood) to the interstitial space. o Hypovolemia, or isotonic dehydration, is a lack of both water and electrolytes, causing a decrease in circulating blood volume. This is also called fluid volume deficit. ▫ Compensatory mechanisms include sympathetic nervous system responses of increased thirst, antidiuretic hormone (ADH) release, and aldosterone release. ▫ Rapid or severe dehydration can induce seizures. ▫ FVD can lead to hypovolemic shock. ▫ Older adults have an increased risk for dehydration due to multiple physiological factors including a decrease in total body mass, which includes total body water content and a decrease in the ability to detect thirst. Describe the role of the kidneys, lungs, and endocrine glands in regulating the body's fluid composition and volume. The kidneys, lungs, and endocrine glands play a crucial role in maintaining homeostasis, particularly in regulating the body's fluid composition and volume. Kidneys The kidneys are primarily responsible for regulating fluid balance by filtering blood and excreting waste products in the urine. They adjust the volume and concentration of body fluids through processes such as glomerular filtration, tubular reabsorption, and tubular secretion. The kidneys maintain electrolyte balance by selectively reabsorbing essential ions like sodium, potassium, calcium, and bicarbonate, and eliminating excess ions and wastes. They also play a significant role in blood pressure regulation by controlling the volume of extracellular fluid. The kidneys produce hormones such as renin, which activates the renin-angiotensin-aldosterone system (RAAS), leading to the retention of sodium and water, and erythropoietin, which stimulates red blood cell production. Lungs The lungs contribute to fluid and pH balance by regulating the elimination of carbon dioxide (CO₂). When CO₂ levels in the blood increase, the lungs remove the excess through exhalation. This process of gas exchange is crucial because CO₂ combines with water to form carbonic acid, which dissociates into hydrogen and bicarbonate ions. By controlling the rate and depth of respiration, the lungs can influence the acid-base balance of the blood. Hyperventilation, for example, expels CO₂ and reduces acidity, while hypoventilation retains CO₂, increasing acidity.  Endocrine Glands The endocrine glands release hormones that influence fluid balance and composition. Notable among these hormones are: - Antidiuretic hormone (ADH), also called vasopressin, is released by the posterior pituitary gland in response to increased plasma osmolality or decreased blood volume. ADH prompts the kidneys to reabsorb more water, thus concentrating the urine and diluting the blood plasma. - Aldosterone, secreted by the adrenal cortex, enhances sodium reabsorption and potassium excretion by the kidneys, promoting water retention and increasing blood volume and pressure. - Natriuretic peptides, such as atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), are secreted by the heart when it detects increased blood volume and pressure. These peptides counteract the effects of the RAAS by promoting sodium and water excretion to decrease blood volume and pressure. Together, these organs and hormones fine-tune the body's fluid composition and volume, ensuring that cells function optimally in a stable internal environment. Identify the effects of aging on fluid and electrolyte regulation. Describe the cause, clinical manifestations, management, and nursing interventions for the following imbalances: Calcium deficit (hypocalcemia) Clinical Manifestation Definition: Hypocalcemia is a total blood calcium level less than 9 mg/dL. Increased calcium output o Chronic diarrhea o Laxative misuse o Steatorrhea as with pancreatitis (binding of calcium to undigested fat) Inadequate calcium intake or absorption o Malabsorption syndromes (Crohn’s disease) o Vitamin D deficiency (alcohol use disorder, chronic kidney disease) Calcium shift from ECF into bone or to an inactive form o Rapid infusion of citrated blood transfusion o Post-thyroidectomy, o Hypoparathyroidism  o Hypoalbuminemia o Alkalosis o Pancreatitis o Hyperphosphatemia Nursing Interventions/Management o Administer oral or IV calcium supplements and vitamin D supplements. o Initiate seizure and fall precautions. o Keep emergency equipment on standby. o Encourage foods high in calcium, including dairy products and dark green vegetables. Calcium excess (hypercalcemia) Manifestation o Hypercalcemia is a total blood calcium level greater than 10.5 mg/dL. Hypercalcemia is not as common as hypocalcemia. Causes include thiazide diuretic or long-term glucocorticoid use, Paget’s disease, hyperthyroidism and hyperparathyroidism, and bone cancer. Clinical Manifestation of hypercalcemia Neuromuscular o Decreased reflexes o Bone pain Cardiovascular o Dysrhythmias (shortened QT and ST intervals) o Increased risk for blood clot GI: Anorexia, nausea, vomiting, constipation Central nervous system o Weakness, lethargy o Confusion, decreased level of consciousness o Personality change GU: Hypercalciuria Nursing Interventions/Management o Treatment includes restricting calcium and increasing fluid intake. o Monitor the client for pathological fractures.  magnesium deficit (hypomagnesemia) Definition: Hypomagnesemia is a blood magnesium level less than 1.3 mEq/L. Manifestations o Increased magnesium output o GI losses (diarrhea, nasogastric suction) o Thiazide or loop diuretics o Often associated with hypocalcemia Shift Into Inactive Form: Rapid infusion of citrated blood Inadequate magnesium intake or absorption o Malnutrition o Alcohol use disorder o Laxative misuse Expected findings o Neuromuscular: Increased nerve impulse transmission (hyperactive DTRs, paresthesia, muscle tetany), positive Chvostek’s and Trousseau’s signs, tetany, seizures, insomnia o GI: Hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus o Cardiovascular: Dysrhythmias, tachycardia, hypertension, ECG waveform changes or PVCs Nursing Interventions/Management o Discontinue magnesium-losing medications. o Magnesium replacement can be required orally (if the client is experiencing mild manifestations) or IV (if manifestations are severe). Oral magnesium can cause diarrhea and increase magnesium depletion. o Encourage foods high in magnesium, including whole grains and dark green vegetables. Hypermagnesemia Definition: Hypermagnesemia is a blood magnesium level greater than 2.1 mEq/L. Causes include kidney or adrenal impairment and increased intake of medications containing magnesium (laxatives, antacids). Manifestations Neuromuscular o Diminished DTRs o Muscle paralysis o Shallow respirations, decreased respiratory rate Cardiovascular o Bradycardia, hypotension o Cardiac arrest o Dysrhythmias, ECG changes (prolonged PR interval) Central nervous system: Lethargy Diagnostic Procedures o ECG: Prolonged PR interval, widened QRS Nursing Interventions/Management o Perform frequent focused assessments (vital signs, level of consciousness, reflexes). Notify the provider of changes or absent reflexes. o Administer loop diuretics and magnesium free IV fluids if kidney function is adequate. o Administer calcium gluconate for severe cardiac changes. Plan effective care of patients with the following imbalances: fluid volume deficit (FVD- Hypovolemia) Nursing Interventions o Monitor respiratory rate, effort, and oxygen saturation (SaO2). o Check urinalysis, CBC, and electrolytes. o Administer supplemental oxygen as prescribed. o Measure the client’s weight daily at same time of day using the same scale. o Observe for nausea and vomiting. o Assess postural blood pressure and pulse. (Check for hypotension and orthostatic hypotension.) o Check neurologic status to determine level of consciousness. o Assess heart rhythm. o Initiate and maintain IV access. o Provide oral and IV rehydration therapy as prescribed. o Monitor I&O. Encourage fluids as tolerated. Alert the provider to a urine output less than 30 mL/hr. o Monitor level of consciousness and ensure client safety. o Observe level of gait stability. o Encourage the client to use the call light and ask for assistance. o Encourage the client to change positions slowly (rolling from side to side or standing up).  fluid volume excess (hypervolemia) Nursing Interventions o Observe respiratory rate, symmetry, and effort. o Auscultate breath sounds in all lung fields. Lung sounds can be diminished with crackles. o Monitor for shortness of breath and dyspnea. o Check ABGs, SaO2, CBC, and chest x-ray results. o Position the client in semi-Fowler’s position. o Measure the client’s weight daily at same time of day using the same scale. o Monitor and document edema (pretibial, sacral, periorbital). o Monitor I&O. o Implement prescribed restrictions for fluid and sodium intake. o Provide fluids in small glass to promote the perception of a full glass of fluid. o Set 1- to 2-hr short-term goals for the fluid restriction to promote client control and understanding. QPCC o Administer supplemental oxygen as needed. Reduce IV flow rates. o Administer diuretics (osmotic, loop) as prescribed. o Monitor and document circulation to the extremities. o Reposition the client at least every 2 hr. o Support arms and legs to decrease dependent edema. For fluid overload we would o Restrict water intake as prescribed o This treatment is typically effective when fluid volume is normal to high. QEBP For severe hyponatremia, we would administer hypertonic oral and IV fluids as prescribed. Hypertonic IV fluids are solutions that has a greater concentration of particles as blood, such as 3% or 5% sodium chloride sodium deficit (hyponatremia) Nursing interventions o Monitor I&O and weigh the client daily at same time of day using the same scale. o Monitor vital signs and level of consciousness, report irregular findings. o Encourage the client to change positions slowly. o Follow any prescribed fluid restrictions. o Monitor respiratory status if muscle weakness is present. QS o Encourage foods and fluids high in sodium (cheese, milk, condiments). sodium excess (hypernatremia) Nursing Interventions  o Monitor level of consciousness (may see restlessness or disorientation)and ensure safety. o Provide oral hygiene and other comfort measures to decrease thirst. o Monitor I&O and alert the provider if urinary output is inadequate. o Maintain prescribed diet (low sodium, no added salt). o Encourage oral fluids as prescribed. o Monitor laboratory results (serum sodium). Fluid loss: Based on blood osmolarity o Administer hypotonic or isotonic (non-sodium) IV fluids. o Hypotonic IV fluids are solutions that has a lesser concentration (dilute) of particles as blood, including Dextrose 5% in water, Dextrose 10% in water, 0.225% sodium chloride, 0.45% sodium chloride, and Dextrose 5% in 0.45% sodium chloride. Excess sodium o Encourage water intake and discourage sodium intake. o Administer diuretics (loop diuretics) if impaired kidney excretion is the cause of hypernatremia. potassium deficit (hypokalemia)  Hypokalemia is a blood potassium level less than 3.5 mEq/L. o Hypokalemia is the result of an increased loss of potassium from the body, decreased intake and absorption of potassium, or movement of potassium into the cells. Manifestations o Hyperaldosteronism o Inadequate dietary intake (rare) o Prolonged administration of non-electrolyte-containing IV solutions (5% dextrose in water) o Receiving total parenteral nutrition o Metabolic alkalosis o Excessive GI losses: Vomiting, nasogastric suctioning, diarrhea, excessive laxative use o Renal losses: Excessive use of potassium-excreting diuretics (furosemide, corticosteroids) o Skin losses: Diaphoresis, wound losses Expected findings o Vital signs: Weak, irregular pulse, hypotension, orthostatic hypotension, respiratory distress o Neuromusculoskeletal: Ascending bilateral muscle weakness with respiratory collapse and paralysis, muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion o Electrocardiogram (ECG): Premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia, flattening, flattened, or inverted T waves, increased U waves, and ST depression o GI: Decreased motility, hypoactive bowel sounds, abdominal distention, constipation, ileus, nausea, vomiting, anorexia o Other clinical findings: Anxiety, which can progress to lethargy Nursing Implementation/Management o Treat the underlying cause. o Replace potassium. o Provide dietary education and encourage foods high in potassium (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach). o Provide oral potassium supplementation. o IV potassium administration might be required; it should always be diluted and administered slowly by intermittent infusion (5 to 10 mEq/hr). o Never IV bolus (high risk of cardiac arrest). o Monitor for and maintain an adequate urine output. o Monitor for shallow, ineffective respirations and diminished breath sounds.  o Monitor cardiac rhythm and intervene promptly as needed. o Monitor clients receiving digoxin. Hypokalemia increases the risk for digoxin toxicity. o Monitor level of consciousness and ensure safety. o Monitor bowel sounds and abdominal distention and intervene as needed. potassium excess (hyperkalemia) Hyperkalemia is a blood potassium level greater than 5.0 mEq/L. Manifestations o Hyperkalemia is the result of an increased intake of potassium, movement of potassium out of the cells, or inadequate renal excretion. o Hyperkalemia uncommon in clients who have adequate kidney function. o Hyperkalemia is potentially life-threatening due to the risk of cardiac dysrhythmias and cardiac arrest. o Increased total body potassium: IV potassium administration, salt substitutes, blood transfusion o ECF shift: Insufficient insulin, acidosis (diabetic ketoacidosis), tissue catabolism (sepsis, burns, trauma, surgery, fever, myocardial infarction) o Hypertonic states: Uncontrolled diabetes mellitus o Decreased excretion of potassium: Kidney failure, severe dehydration, potassium-sparing diuretics, ACE inhibitors, adrenal insufficiency o Age: Older adult clients at greater risk due to decreased kidney function and medical conditions resulting in the use of salt substitutes, angiotensin-converting enzyme inhibitors, and potassium-sparing diuretics Expected findings o Vital signs: Slow, irregular pulse; hypotension o Neuromusculoskeletal: Irritability, confusion, weakness with ascending flaccid paralysis, paresthesia, lack of reflexes o GI: Increased motility, diarrhea, abdominal cramps, hyperactive bowel sounds Diagnostic Procedures o ECG will show peaked T waves, widened PR and QRS. Dysrhythmias and asystole are possible. Nursing Interventions/Management o Implement continuous ECG monitoring to monitor cardiac rhythm, and intervene promptly as needed o Decrease potassium intake. o Stop infusion of IV potassium.  o Withhold oral potassium. o Provide a potassium-restricted diet. o Monitor serum potassium levels o If potassium levels are extremely high, dialysis might be required. Prepare the client for dialysis if prescribed. o Administer IV fluids with dextrose and regular insulin as prescribed to promote the movement of potassium from the ECF to the ICF. Follow agency protocol. Ensure patent IV access. o Administer sodium polystyrene sulfonate as prescribed. Medications o To increase potassium excretion o Administer loop diuretics (furosemide) if kidney function is adequate. Loop diuretics increase the excretion of potassium from the renal system. o Sodium polystyrene sulfonate is given orally or as an enema. Sodium polystyrene sulfonate increases the excretion of potassium from the gastrointestinal system. o Other medications can include calcium gluconate, albuterol, and patiromer. Identify a safe and effective procedure of venipuncture. Describe measures used for preventing complications of intravenous therapy