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231 Notes

by: Issy Notetaker
Issy Notetaker
GPA 3.96
Fundamental nursing skills
Marsann Shafer, Jane Edwards, Kathryn Humphrey

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231 Notes from book, lecture, and clinical
Fundamental nursing skills
Marsann Shafer, Jane Edwards, Kathryn Humphrey
Class Notes
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This 29 page Class Notes was uploaded by Issy Notetaker on Saturday September 5, 2015. The Class Notes belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 110 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.

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Date Created: 09/05/15
Fundamentals Book Notes Chapter 26 Objectives Clinical Lecture 0 Documentation O 0000 0 Written or printed material used as recording device for proof of pt actionactivities Vital that proper documentation is made in medical records Vital that Accurate Comprehensive and Flexible Detailed Ensures continuing care saves time minimizes risk of errors Quality of care depends on correct documentation All care providers need the same information Information is transferred verbally electronically and in a written manner 0 Con dentiality O O 0 Keep information con dential don39t discuss with those not involved w Pt Pt have right to own medical record Written permission of release is needed HIPAA is the privacy legislation Health Insurance Portability and Accountability Act Provides pt w more control over health information Not allowed to look in chart that you aren39t working on Part of student nurse professional practice Only have information for safe effective care Don t have pt identi ers room DOB MR Disclosure forms are minimum legally and ethically responsible to follow HC providers must notify pt of privacy policy Medical records can be used for data collection research or continuing educa on Only can information that can be used is that that has been given permission Communicate pt health information Chart is con dential permanent legal document Document time of care along w continuing accout Nurses only review what is needed for safe pt care Never print records for personal needs never leave a computer logged on and alone have all screens pointed away of general population view don39t include pt identi ers Standards 0 O O O Govern information and documentation type an accountability Determine frequency Pt records are used as evidence in court All pt admitted must have these assessments Physical Psychosocial Environmental Selfcare Knowledge level Discharge needs Win Nursing process context From institution TJC NCQA HIPAA Federal and State Regulatory agencies Department ofJustice and the Center for Medicare and Medicaid Services TJC Makes US care better by giving accreditation and shutting down guidelines focus on communication and aIarms InterDis Communication 0 O O O O 0 Record is continuous account of status all members of team can access 70 of error are from bad communication Contain Identi cation the Demographics Informed consent Admission data and Nursing diagnosisproblems Record of treatment and evaluation Medical history diagnosis discipline progress notes Therapeutic orders Physical Assessment Diagnostic results Education Summary of procedures and discharge plan and summary Change of shift telephone handoff and incident reports are all methods of interdis communication Done via verbal written audiotaped Communicate interdis by conference Consultations one professional gives advice to another on pt care Referrals arrangement of services 0 Purpose of records 0 O Source of data from all members of team for Communication Legal documentation Education Financial Billing Research AuditingMonitoring Communication Needs and progress Therapies Plan of care Consultations Educann Discharge planning Most current and accurate Base on assessment ndings and pt information Legal documentation Defense for cIaim Indicate Individualized care 0 Goal directed care based on assessment 0 Describe exact event 0 Follow agency standards Chart right after care Mistakes Failing to record health and drug information nursing actions medication given and reactions discontinued medications Not legible or incomplete 0 Financial billing DRGs diagnostic related groups Establish reimbursement based on diagnosis Documentation clari es 0 Education Identify patterns in records and anticipate type of care needed 0 Research Gather statistical data on frequency complications recoveries and death For investigation of interventions or health problems Contributes to EBP o Auditingmonitoring Quality improvement programs Ongoing and objective data collection Informed standards to maintain excellent nursing care Determine if standards of care were met Identify needs for improvement Help to make changes to policies 0 Guidelines for Quality Documentation and Reporting 0 Needed for effective and ef cient individualized care 0 Five need characteristics Factual ONLY SUBJECTIVE Descriptive Hears smeIIs feeIs Avoid vague terms Observations of behaviors If subjective is noted put in Accurate Exact measurements Determine change in status Clear and Concise Institution has a standard list of abbreviations symbols and acronyms Incorrect spelling results in errors Transcribe Carefully Date each entry and sign w RN after Complete 0 Appropriate and Essential Information Thorough communication is needed Describe care given and changes Use flow sheets or graphic records More reIevantmore detailed C C C u n and support w objective Current Timely military time Delays unsafe care 0 Document at time of Vital signs Pain assessment Administration of meds and treatment Prep for tests and surgery Change is status and noti ed persons Admission transfer discharge or death Treatment for sudden change Response OOOOOOOO Organized Logical order Concise clear to the point 0 Make list bf entering into system RERED what was written 0 Methods of Documentation 0 Paper and Electronic Paper Separate for each visit 0 Information is easily lost for visit to visit Electronic Health Record EHR accessed and added to whenever the pt seeks care in any setting 0 Provides information at any time and any place 0 Includes al information from each visit tests and diagnosis Easier to access 0 Clinical data for quality issue linking of interventions and outcomes and make EB decisions Improves care 0 Includes guiding critiquing and basic support tools 0 Allow comparison from ongoing data and baseline maintains ongoing record for education easier to access Electronic Medical Record EMR Is part of the EHR but is speci c to time and place 0 Narrative Traditional storylike format Disadvantages Repe ous Time consuming Sort through lots of information o ProblemOriented Medical Record Emphasizes pt problems and organizes them by problemdiagnosis Team members all contribute to a list Coordinates a common care plan Sections 0 Database Contains all assessment data for that pt 0 Used for identifying problems an planning of care 0 Stays w pt through visit 0 Problem List 0 Identify all problems and make a list 0 In chronological order in front of record new one will be added 0 Care Plan 0 Documents plan in many formats 0 Diagnosis expected outcomes and intervention 0 Progress Notes 0 SOAPIE Subjective Objective Assessment Plan Intervention Evaluation Collect information draw conclusions and develop pIn of care Medical records origin 0 PIE Problem Intervention Evaluation Problem oriented nursing origin Narrative doesn39t include assessment information Continuing problems are documented dain 0 Focus Charting DAR Data Action Response Address concerns Integrates all nursing process emphasizes concerns put into all clinical settings 0 Source Records Chart as new section for each discipline DetaiIs that are speci c are in each section 0 Charting by Exception CBE Documents deviations form norms Reduces time and emphasizes problems Rede ned norms are in documentation forms Notes only written when not in norm Assessments are standardized Easy to track changes 0 Case Management Plan and Critical Pathways Case Management model of care delivery and is interdisciplinary Critical Pathways include problems key interventions and expected outcomes 0 Each member use the same for monitoring of progress 0 No nurses notes row sheets or nursing care plans 0 Not met goaIs unexpected outcomes and interventions are caII variances 0 Activities in critical pathway is so met 0 Positive is when completed more quickly 0 Negative is when slower or not completed at all 0 Identify and change care to meet needs Common Record Keeping forms Usually derived from institutional standards of practices or guidelines 0 Admission nursing history forms Complete nursing history Relevant nursing diagnosis or problems Identi es baseline data 0 Flow Sheet and Graphic Data Quick and easy entering of assessment data Current information all members can access Critical and acute care use these commonly 0 Pt Care summary or Kardex Electronic Summary automatically updates as new info is added Kardex is portable le that eliminates needs to continuously refer to chart 0 Standardized Care Plans Ef cient and improve continuing care Preestablished guidelines for pt w similar problems that modi ed to t individual Add goals and outcomes and dates based on pt Useful for quality of care audits Don39t replace judgement and decision making must be updated regularly 0 Discharge Summary Save costs ensure reimbursement Discharge prep is important to be timely and effective Leave with needed resources Begins at admission allowing for longer planning times Involve pt and fam Include meds diet resources followups emergency contact 0 Acuity Records NOT part of medical record Determine hours of care and needed staff Pt level is determined by computer based on type and amount of interventions in 24 hr 1totay dependent and 5independent Home Care Documentation 0 Information is from fam Different from other documentation Speci c guidelines for reimbursement Provide all HC workers and information Quality control and Justi cation for reimbursement Document ALL services Pt assessment referral and intake forms interprofessional plan medications reports to others OOOOO 0 Long Term HC Documentation 0 Careful documentation is needed for right reimbursement 0 Use RAIMDS Standardized protocols for assessment and planning 0 Supports interdisciplinary approach 0 Communication is key 0 Reporting Timely accurate relevant o Handoff Any time care is transferred from one to another Provide better continuity and individualized care Change of shift and transfer reports 0 Follow order basic identi cation information reason for admission and testtherapies changes Ensures safety Up to date information Facetoface writing or verbally phone audiotape Quick and ef cient Important to note changes in priority conditions Include Condition required care treatments meds services and change that have occurred or are anticipated EXACT information emotional support need concise priorities 0 Telephone Reports only when signi cant changes have occurred 0 Needs to be clear accurate and concise Use SBAR Document who to and when the call was made who made the call what information was given an received and veri cation that it was read back and later signed by provider 0 State name and relationship to pt date time content c When order is given of telephone or verbally Usually occur at night or during emergencies only used when needed Frequent cause of errors Receiver writes complete order down reads it back an receives conformation for orderer Provider later veri es via signing Know state board and agency policy speak slowly and clearly on both ends ask to spell out medication question drug dosage or changes 0 Incident or Occurrence Occurs when something goes not according to routine Falls needle sticks med errors ect Helps to identify trends providing justi cation for changes Important for improvements Contact HCP when these happen Don39t note in medical record but document an objective description of incident Follow agency policy and le w risk management Health Informatics O O 0 Use of computer an information science in biomedical sciences Focus on pt and care process enhance quality and ef cacy of care Use of EMR and ERH Nursing Informatics 0 Record interpret and reporting of data for its application and use in critical thinking Recognize patterns that develop an evidence base to research and apply knowledge to for correct interventions Data is more ef ciently used to quality of care research and providing education when information technology is used Information Tech IT management and processing of information Advances that help to group and support information Clinical CIS and Administrative information systems NIS Nursing information system Order entry Iab radiology and pharmacy systems that coordinate care Documents process of nursing process activities and give resources for managing care Product of Nursing informatics Nursing computer and information science for communication information and knowledge that supports decision making Ef cient and Effective care Supports nursing function an gives exibility Improves access to information and decision making tooIs Helps w error reduction AIIow quick sharing of information gathered and plans made Designs 0 Nursing Process organizes win formats admin post op care plan discharge 0 Helps to direct nurse through assessment categories and once data is entered it offers intervention and diagnosis 0 Must make individualized care 0 Protocol or Critical Pathway design interdis format o All providers document care given 0 Allows selection of protocols o Identi es variances of anticipated outcomes Clinical Decision support systems CDSSs Support decision making 0 Based on rules and if then link information produce aIters Current and EB information 0 Improve care O Advantages Increased time w pt Access to information Quality documentation Reduced errors and costs Increased job satisfaction Better compliance Development of clinical database Privacy Con dentiality and Security 0 Top priority 0 Fire walls and antivirus spyware Automatic sign off 0 Place computers and servers in restricted areas or using privacy lters 0 Access and log ins w passwords Don39t share 0 Random times for changes in passwords Handling and Disposal of Information Safeguard information that is printed sherd when no longerneeded Printing and Faxing is primary source for unauthorized release Clinical Information Systems Monitoring system Order Entry and labs radiology and pharm systems Automatically record and save measurements Computerized provider order entry have built in reminders and alerts for correct test diagnosis and medications Eliminates transcribing and illegible writing 0 Common Malpractice 0 00000 Chapter 44 Don t document correct time Don39t record verbal order sign verbal order Pre charting Wrong information is documented Don t give report or giving an incomplete Narrative form 0 Nutrition 0 O O 0 Essential and basic component of health Food is needed for bodily activities and functions of cells and systems Food Security access to safe suf cient and nutritious foods for maintenance of lifestyle and available consistently and household has the means to obtain this food Holds meaning ceremonies social religious Nightingale stressed the role in science Nutrition therapy and counseling is now part of nursing to manage or treat diseases 0 Optimal nutrition is to be available to all 0 Be aware of requirements and needs for others 0 Scienti c Knowledge Base 0 Nutrients Biochemical Units BMR energy to maintain lifesustaining activities In uenced by age body mass gender fever starvation menstruation illness injury infection activity thyroid function REE resting energy expenditure or resting metabolic rate Amount energy consumed in 2 hr period to maintain all internal activities Requirements met y kcal intake Exceed needsweight gain Nutrients elements for normal function of processes 0 Nutrient Dense more nutrients per kcal high is fruits and vegies low is sugar Carbohydrate CHO Main energy source glucose 1gram4kcal Monosaccharides Glucose Fructose Disaccharides Sucrose Lactose Maltose Mono and Di are simple carbs Poly Glycogen complex water insoube o nsoube ber is nondigestable o Soluble dissolve in water and are digestible Proteins 1 gram4kcal Essential for synthesis of tissue clotting stability transport 0 Amino Acid AA is simplest form HOCN 0 Essential need to come from diet 0 Nonessential can be synthesized from the body 0 Complex protein is combination of protein with a non protein lipoprotein Compete or high quality protein has all AA in it Incomplete are missing 1 AA and need to be eaten in complementary pair Nitrogen Balance inputoutput o baance is needed growth pregnancy maintenance of lean mm mass and organs and heaHng o baance results in destruction of tissues Fats Most calories dense 1g 9 kcal 2030 of diet Water Composed of triglycerides and fatty acids 0 Fatty acids are saturated all single bonds or unsaturated 1 double or triple bonds can be mono or poly 0 Fatty acids are essential or nonessential 6070 of total body weight higher in lean people Mm Mass contains more water than any other tissue 0 Infants have highest and older have the least 0 Can39t survive for more than a few days 0 III person has increased needs for uid intake and decreased ability to excrete Vitamins Organic small amounts 0 Essential Catalysts in reactions Neutralize free radicals Needed amounts depend on intake and highest inn fresh foods 0 Types 0 Fatsoluble ADEK Stored in fat Through intake 0 WaterSoluble C and B complex Aren39t stored and needed daily Minerals 0 Inorganic Catalysts Macro 100mg daily 0 Balance pH MicroTrace lt100mg daily 0 Anatomy and Physiology Digestion mechanical breakdown into simplest form Enzymes are catalysts to speed up reactions that break food down Each method is interdependent on the others mechanical chemical hormonal Begins in mouth down esophagus into fundus body antrum pyloric sphincter duodenum major digestion occur in small intestine Absorption Small intestine is primary site w use of villi Carbs proteins minerals watersoluble vitamins are absorbed by small intestine moved to liver sent out portal vein Fatty Acids are absorbed into lymphatic system 0 Dietary Guidelines 0 Nursing Knowledge Base Food is incorporated into traditions and rituals Requirements depend on developmental stage body comp activity pregnancy and lactation disease presence Factors In uencing Nutrition 0 O 0 8590 of water is absorbed in small intestine Electrolytes and minerals re absorbed in colon Remaining is eliminated in feces Metabolism and Storage Metabolism all biochemical reactions win cells 0 Anabolic building building mm 0 O Catabolic Breakingoccurs in N balance or starvation Converts nutrients to energy 0 Some require nutrients are stored in tissue 0 O O Mainlly adipose but protein is stored as mm mass Fatty acids are stored as ketone for energy when there is no glucose Glycogen for fastingis stored in liver Metabolism is 3 processes 0 O O Elimination Catabolism of glycogen into glucose C02 and water Glycogenolysis Anabolism of Glucose into glycogen glycogenesis Catabolism of AA and glycerol into glucose gluconeogenesis Chyme become feces in large intestine DRIs Dietary Reference Intake acceptable range amounts for gender and age 0 Four components 0 O O EAR Estimated Average Requirement maintain body function in 50 of pop RDA recommended daily allowance needs of 98 of the pop AI Adequate Intake Suggested intake UL upper level Highest level posing no risks Food Guidelines 0 Recommended food amount intake for 5 food groups for American over 2 0 Consider cultural preferences Choosemyplate is a good resource Daily values are made of RDI and DRV Don t replace DRI Based on of diet of 2000 kcal per day Environmental Factors Sedentary lifestyle work schedules poor meal choices 0 Lack of access to health food stores availability to fast foods lack of places to exercise and play Developmental Needs 0 Infant through School Age 0 Rapid growth and need for more protein vitamin minerals and energy occurs in infancy able to absorb simple carbs proteins and small amount of fats Breastfeeding should be only source of food for rst 6 months ten add complementary foods in 6 12 months w breastfeeding Bene ts for mother and baby Formula About same nutrient amounts as breastmilk Babies should NOT be given straight cow39s milk until after the rst year Introduction to Solid Food IronForti ed cereals are rst food Foods w higher incidence of allergies should be added later Should be added one at a time w a week in between each Introduce before feeding milk Toddler has slowed growth rate and need less kcal and more protein Strong food preferences Should have 3 meals w 3 healthy snacks Should drink whole milk until age 2 Preschoolers are similar to toddlers but consume more more nutrient dense School age 612 grow at slow and steady rate Limit high calorie foods and maintain good activity 0 Childhood obesity is on the rise Need for the promotion of a healthy lifestyle Adolescence O O 0 Energy needs need to meet metabolic demands Protein requirement increases Nutritional de ciencies are common due to fad diets and lack of healthy food intake Skipping meals and fast food are contributing to this and obesity Forti ed and fruits and vegetables food are better for snacking along with increasing activity levels Anorexia and bulimia are common occurrences O O O O O O Carbs simple and complex are main source of energy along with an increased need for protein but NOT fat Hydration is really important too Parents strongly in uence what the child eats by keeping healthy food at home and setting an example Pregnancy win four years of beginning period poses risks Malnutrition at the time of conception increases risks and Middle Adults Reduction in needs after puberty Pregnancy Poor nutrition low BW and decrease in survival chance More emphasis on quality rather than quantity Protein and calcium intake needs to increase Folic acid is also at increased need Lactation Need 500 more kcal daily More protein is needed than during pregnancy but same need for calcium as during pregnancy Older Adults Decreased need for energy lower metabolic rate Vitamin and mineral needs remain unchanged Changes related to age include taste smell appetites These can affect foods eaten and amounts eaten Pain dentures or teeth can affect eating Higher risk for drug interactions Thirst sensation is decreased increasing risk for dehydration Some avoid meats bc hard to chew need soups for protein Need high calcium amounts Those homebound have increased risks food insecur y 0 Alternative Food Patterns Special diets based on ethnicity culture and religions aren39t wrong Vegetarian Diet Consumption of plant food Ovolactovegetarian No meat but eggs and milk are okay Lactovegetarian No egg but milk 0 Nursing Process 0 Assessment Vegans only plant food Children on vegetarian diet are at risk for protein and vitamin de ciencies Thoroughly assess for malnutrition or at risk pt Those that are malnourished are at higher risks for complications Through Pt Eyes Asses nutrition Gather data about in uences on nutrition Ask about preferences values regarding nutrition and expectations Understand pt beliefs and values about food and assess traditions rituals culture and needs 0 Determine from foo purchase prep and intake Screening quick method to identify malnutrition or risk for Gather data on condition stability assessment and if disease process accelerates Use objective measures and subjective measures combined Tools 0 Subjective Global Assessment obtains history wt and physical assessment s simple and cheap 0 Mini Nutritional Assessment developed for older adults 18 items divided into assessment and screening 11 or less in screening complete assessment Total score of lt17 means malnutrition o Malnutrition Screening Tool useful in many settings 0 Assess when conditions interfere with digestion or absorption for risk Congenital abnormalities and surgical revisions of GI tract IV infusion feeding Chronic disease increased metabolic requirements infant or older adults Anthropometry Measurement system of body size and make up Measure ht and wt same time same scale same clothing Compare Ideal Body weight is what person should weigh Other measurements include 0 Height to wrist circumference MAC TSF MAMC 0 Changes over time are more valuable than one measurement BMI Lab Biochemical Tests 0 Need more than one to diagnose malnutrition Many factors can alter test 0 Common test 0 Plasma proteins different proteins are better for determining different diseases 0 Nitrogen balance Diet and Health History 0 Focus on common intakes of foods and liquids lnclude preferences allergies Activity level and illness for energy intake 0 Health status age culture religion SES preferences psychological factors drugsalcohol use supplements Use questionnaires Collaborate w RD to meet nutritional needs Physical Examination 0 Most important aspect Nutrition affects all systems Recheck all relevant areas 0 Clinical signs of nutritional status should be observed Dysphagia Dif culty swallowing Caused by 0 Myogenic o Neurogenic o Obstructive o Other disorders 0 Cause other complications 0 Aspiration o Pneumonia o Dehydration 0 Weight loss 0 Look out for signs of gagging change in voice and delayed swallowing and silent aspiration Leads to decreased nutrition intake 0 Screening increases likelihood of nding dysphagia 0 Medical record review observation of eating 0 Requires interdis communication 0 Swallow Study might be done w video ouroscopy done by speech pathologist 0 Diagnosis Cluster all data for actual or at risk Determine diagnosis and related factors 0 Planning Need for long term changes Multidis planning is needed Refer to RD for help Goals and Outcomes Physiological therapeutic individualized Education and counseling are important 0 Understand why diet is helping them Know in uencing factors pain shortness of breath sadness Know pt feelings about wt and diet Require pt and multidis team input Setting Priorities Pt and fam must collaborate w nurse Managing pain is usually at the top Teamwork and Collaboration Treatment continues after hospital stay Discharge should include nutritional interventions for when returning home Communicate goals and interventions to whole team 0 Implementation Chosen on ability to eat and digest overall health and long term needs Health Promotion Education about healthy diets and nutrition Incorporate knowledge into lifestyle Early identi cation of problems or risks is key Educate about community resources Consider income and preferences when planning meals Plan meals week in advance Support those who want to lose weight and can39t seem to Give information about groups Educate about food safety Acute Care Testing and pre disrupt eating Continuously assess status Create interventions that promote intake NPO patients on IV uid for 7 days are at increased risk Advancing Diets 0 Special diets for those w decreased immune system 0 Clear Clear when at room temp and Full Liquid creamers and plups Pureed Mechanical soft low residue high ber low sodium low cholesterol diabetic Promoting Appetite 0 Keep environment clean provide oral hygiene 0 Offer small frequent meals 0 Encourage socialization while eating also educate Assisting w oral Feeding 0000 0 Remember Safety Independence Dignity Assess aspiration risk 30 min rest before an seat upright at 90 degrees Feed slowly and in small sizes if coughchoke remove food immediately Ask simple questions right temp What food would you like Enteral Tube Feeding 0 00000 Into GI tract Used if unable to swallow Safe and economical nutrition Receive formula Can be given by nurse or fam Continuous Intermittent short periods of feeding and not feeding Bolus Only put in what is ordered and runs about 30 minutes Open Must clean bag every 8 hours must replace bag every 24 hours Closed must be changed every 24 hours Must be veri ed by x ray before rst feeding Aspirate and listen w 30 mL or air and then pull up residual measure pH and amount and then return flush feed flush Fourtypes Polymeric milk based 12kcalmL Modular single macronutrient and added to other foods to meet needs 384 kcalmL Elemental predigested nutrients for partially dysfunctional GI tract 13 kcalmL Specialty meet certain needs in certain illnesses 12 kcalmL Started at slow rates and gradually increased Fill syringe only 12 full at a time Reduces sepsis decreases mortality maintains structure and function of intestines Keep head of bed elevated to reduce risk of aspiration minimum 30 but preferred 45 degrees must stay in this position for 30 minutes after feeding Measure residual volumes every 46 hours Must ush w 30mL water before and after feeding unless PO say otherwise Enteral Access Tubes When able to digest but not ingest Inserted through nose surgically or endoscopically o If less than 4 weeks total nose path may be used Sometimes placement is needed in the intestine Adult tube 812 Fr and 3644 inches Ensured placement is done w xray Parenteral Nutrition 0 O 0000 Nutrition is intravenous AA dextrose electrolytes vitamins and trace elements Must be carefully monitored Can be given in the home When unable to digest or absorb PN is needed Intravenous fat emulsions can be added for kcal but are added through peripheral line White or opaque in color Initiating Parenteral Nutrition lnsert catheter and con rm w x ray Cover w sterile dressing No more than 12 of estimated needs in st 2448 hours Gradually increased 0 Preventing Complications O O O O O 0 Monitor pt w CVC for 55 of pulmonary distress Turn onto L lateral decubitus position and perform Valsalva maneuver to prevent air emboli Flush lines to prevent occlusion Change tubing every 24 hr to prevent sepsis during dressing changes be sterile Give Vitamin K Monitor blood glucose Don39t stop infusion if too much and don39t increase rate if falling behind Restorative and Continuing Care 0 Medical Nutrition Therapy 0 0 Use of nutrition to treat illness injury or condition Needed for metabolizing nutrients correct de ciencies and eliminate food causing harm GI Diseases Peptic Ulcers are controlled w regular meals and meds Avoid acidic foods 0 Teach well balanced and healthy diet and to avoid large meals In ammatory Bowel Elemental diets or PN Malabsorption Gluten free diet Diverticulitis Moderate or low residue diet until infection leaves 0 After high ber diet is recommended 0 Diabetes Mellitus Type 1 dietary restrictions and insulin Type 2 exercise and diet 0 Cardiovascular Disease Diet therapy Lean meats and veges Balancing intake w output maintaining healthy weight 0 Cancer Meet increase metabolic demand Malnutrition is common Small frequent meals are encouraged o HIVAIDS Body wasting and wt loss are common Malnutrition and inadequate intake are the common causes Small Frequent nutrient dense foods are the best 0 Evaluation Through pt Eyes Expectation that nurse will recognize failing treatment and x it Pt outcomes 0 Not always rapid results 0 Ask how Pt feels about changes made Revise pans when outcomes are not met Chapter 46 Elimination o Alterations from the norm are early 55 of problems 0 Regular is essential o Depends on balance of patterns and habit 0 Be supportive Scienti c Knowledge Base 0 Hollow tubes lined w a mucous membrane 0 Absorb nutrientsprepare nutrients for absorption provide temp storage 0 Electrolyte balancekey function of GI system 0 Receives secretions from gallbladder and pancreas o Mouth Digestion begins here and ends in small intestine Mechanical and chemical breakdown o Esophagus Upper sphincter Peristalsis CardiacLower sphincter prevents re ux o Stomach Storage Mixing Emptying HCI is produced and secreted 0 Small Intestine Segmentation creates peristalsis Peristalsis Mixes chime and digestive movements Digestion and Absorption Goes from liquid like to paste like when reaching large coon Three sections Duodenum Jejunum carb and protein absorption eum Water Fats Bile salts certain Vitamins and Iron absorption 0 Duo and Jej do most absorbing 0 Large Intestine Lower GI tract Larger diameter Cecum Colon Ascending Transverse Descending Sigmoid Absorption Water Sodium Chloride Secretion bicarbonate for a chloride Elimination Rectum bacteria convert fecal matter into nal form 0 Empty unti jet before de cation Primary organ of elimination for bowel Chyme enters by ieoceca valve 34 major movements a day with largest and hour after mealtime o Anus Sensory nerves for control Contraction and relaxation of sphincter allow for release 0 Defecation Sensory Awareness Voluntary sphincter control Adequate rectal capacity and compliance Begins in L coon pushing feces to rectum Distension occurs relaxing internal sphincter External relaxes abdominal mm contract increasing pressure and oushing stoo out Vasava Maneuver is sometimes used Nursing Knowledge Base 0 Factors In uencing Bowel Elimination Age 0 Infant Small capacity quick passage lack of mm control 0 23 neuromm control 0 Older adults have decrease in absorption an peristalsis emptying slows 0 Dif culty controlling sphincters also occurs Diet 0 Regular intakeRegular pattern 0 More fibermore ushing of fats and wastes Bulk foods pass more quickly bc stretch re ex Gas forming foods increase peristalsis Food intoleranceallergy Fluid Intake Intake changes character 0 Reduced intake slows movement Physical Activity Promotes peristalsis Psychological Factors Prolonged Emotional Stress impairs function Digestive process is sped up Personal Habits Using own toilet rather than another 0 Work schedule preventing use of facility 0 Being in hospital and having to use bed pan Position during Defecation Squatting is best 0 In bed immobilized makes it more dif cult Pain Suppress need when in pain Pregnancy Fetus exerts pressure on rectum and it impairs function Constipation occurs Straining can lead to permanent hemorrhoids Surgery and Anesthesia Cause cessation of peristalsis lasting 2448 hours paralytic ileus Medications Some promote or slow Laxatives and cathartics Diagnostic Test Require bowel quotprepquot to ensure emptying Can39t eatdrink a certain time before 0 Changes occur right after having normal diet again 0 Common Bowl Elimination Problems Constipation symptom Signi cant hazard Reopens wounds and causes pressure Improper diet lack of exercise and medication Impaction From constipation that is not relieved Wedged fecal matter in rectum Can extend into sigmoid colon Can result in intestinal obstruction Diarrhea Increase in number passage of liquid unformed feces From inadequate digestion absorption and secretion Expensive and dangerous 0 Contamination 0 Skin ulceration 0 Severe dehydration electrolyte imbalance Older and infants are at high risk If taking antibiotics or EN feeding risk is increased C diff mild to severe 0 Hand hygiene is best protection InconUnence Inability to control passage Harms body image Causes skin breakdown if not controlled Flatulence Gas that is trapped causing distension Pain and cramping can occur Hemorrhoids Dilated engorged veins Internal or external Cause pain 0 Bowel Diversions When normal passage is affected arti cial openings are created Ileostomy or Colostomy Ostomies Temp or permanent Location determines stool consistency Ileostomy bypasses all of large intestineliquid stool Medical problem determines placement Loop Colostomy 0 Medical emergency 0 In transverse colon 0 Supporting device is inserted under and transverse is opened an sutured to abdomen 0 Supporting device is remove in 710 days End Colostomy 0 Some at proximal end w distal removed or sewn closed Double Barrel 0 Divides intestine and sews both ends to abdomen Alternative Procedures lleoanal Pouch Anastomosis o Removes colon o Creates pouch from small intestine and connects it to anus Kock Continent lleostomy 0 Change small intestine into spherical reservoir 0 Continent stme nipple valve draining into catheter MacedoMalone Antegrade Continence Enema 0 Isolates ap of colon and places in foley catheter o Enemas are given daily 0 PsychologicalConsiderations Body image changes Anxiety on how to manage Emotional support is needed Doesn39t interfere w activities and is concealed Aging affects ability to maintain Nursing Process 0 Assessment Bowel patterns and abnormalities Through Pt Eyes Want knowledge on promotion and maintenance or normal patterns Culture and preferences should be kept in min Nursing History Review of all bowel patterns and habits 0 Note what they describe as normal or abnormal Determine normal pattern Frequency and time Description subjective of characteristics determines pt normal color shape consistency Routines to promote normal elimination Use of arti cial aids Presence and status of diversions Ostomy Changes in appetite History of diet exercise paindiscomfort social Fluid intake Surgery or illnesses affecting GI tract Medication history Emotional state Mobility and dexterity Physical Assessment Mouth 0 Ability to chew 0 Teeth tongue gums dentures 0 Look for sores Abdomen 0 Assess 0 Note bowel sounds o Gently palpate for tenderness 0 Look for masses and lumps Rectum O Lab Tests Inspect for lesions in ammation discoloration hemorrhoids Can detect tumor bleeding parasites and infection Fecal Specimens O Obtained accurately labeled properly and transported in time Use medical asepsis and wear gloves Hand hygiene is needed Teach to avoid coming into contact w water or urine Into clean dry bedpan or special container under toilet Performed w microscope Label and tightly seal Fecal Occult Blood test can be performed at home Measures blood amounts in stool Useful for noticing colon cancer Blue is positive Fecal Characteristics 0 O Reveals information about elimination alterations Pt is best source of this information Diagnostic Examinations Direct or Indirect Special training might be required 0 Crash Cart must be at the bedside Modern sedation might be needed 0 Diagnosis Determine risk associated w diagnosis and institute measures to promote normal function 0 Planning Use information from many sources Rely on professional standards Goals and Outcomes Incorporate pt routines and patterns as much as possible 0 Consider preexisting conditions 0 Have pt set regular habits ad routines Setting Priorities O 0 Pain is a the top Teamwork and Collaboration 0 Include family 0 Assistance is needed for bedpan use Multidis use lab tests Implementation Teach about proper diet and uid intake and factors affecting peristalsis Learn importance of regular movements exercise and measures for when elimination problems occur Health Promotion 0 Take time Urge will occur and establish time around that 1 hour after a meal 0 Help by offering bedpan or assisting to restroom Make sure interventions don39t interfere w routine P vacy Promotion of normal 0 Sitting position 0 Positioning on bedpan Sitting is uncomfortable Position is important for mm strain and comfort Sit 30 degree and lift hips by bending knees and slide pan under Or Lower into supine and roll on side Apply powder to buttocks and place pan rmly against and down into bed Place hand on fore hip and one on the pan ask pt to roll back onto pan and then raise bed and place pillow or rolled towel under lower back Bend knees P vacy 0 IMPORTANT 0 When pt nished respond immediately to call light to remove pan by asking to roll off or raise hips 0 Assist in wiping 0 Empty pan and spry clean 0 Document characteristics of feces 0 Ask often if it is needed Acute Care 0 Keep elimination needs in mind and intervene to help keep the norm 0 Medication 0 Some promote while others stopslow Cathartic and Laxatives O O O 0 Short term action Cathartics are stronger Many forms Excessive use leads to abnormal patterns and diarrhea and alterations in absorption occurs impairs normal re ex Antidiarrheal Agents 0 Most strong are opiates decrease mm tone Enemas o lnstillation of a solution in rectum and sigmoid O O Promotes defecation Solution breaks up fecal matter stretches wall and hit defecation re ex Cleansing Complete elimination Fleet 120 mL Becoming more common Deep breath squeeze and roll from bottom Tap Water Hypotonic exerting pressure Net movement of water is low and stimulates movement Normal Saline Safest Volume infused stimulates peristalsis Hype onm Pull uid out of wall and puts it into fecal matter promoting elimination Soap Suds Added to tap water creating irritation to stimulate peristalsis After high lay on left side 5001000mL water Soap goes in after water room temp and mix gently no bubbles Oil Retention Lubricate rectum Retain for several hour if possible Others Carminative For gas Medicated Enema Administration 0 0 First check PO Gather Supplies Commercially packaged disposable units Wear gloves Lube Toilet paper 0 Cover and lay on L side gravity 0 Explain 0 Insert and SLWOLY raise bag 1218 inches above If cramping slow ow If still clamp If still remove 0 At end slowly lower pull out wrap in toilet paper 0 Ask to hold as long as they can 0 Help onto toilet and tell not to ush Place slippers and commodebedpan close 0 Help back into bed and provide pericare 0 Don t give more than three 0 Digital Removal of Stool o If impaction use ngers 0 Last resort 0 PO is needed Continuing an Restorative Care 0 Care of Ostomies o Ef uent 0 Needs to use meticulous skin care lrrigating a Colostomy o Regulates emptying colon 0 Never use enema to irrigate colostomy 0 Fit in daily routines Pouching Ostomies o Protects kin contain feces odor free comfortable 0 Consider type size and location 0 Twopiece vs onepiece Skin barrier attached or separate Right t is necessary NutritionalConsideration 0 Low ber to start out and the gradually work up to high ber 0 Eat slowly o Chew completely Avoid gaseous foods Bowel Training 0 Helps to defecate normally 0 Daily routine 0 Maintenance of food and uid intake 0 High ber vs low for certain conditions 0 Promotion of Regular Exercise 0 Daily helps elimination Hemorrhoids 0 Soft painless bowels Skin Integrity 0 Protect w petrolatum zinc oxide and ointments 0 Evaluation Regular pain free elimination of soft stools Relieved problems Evaluate level of knowledge on eliminations ostomies and ski integrity


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