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Bowel Elimination Identify factors that influence bowel elimination.A. Development DevelopmentNewborns and Infantsmeconium - the first fecal material passed by the newborn, normally up to 24 hours after birth; it is black, tarry, odorless, and stickytransitional stoolsfollow meconium for about a week - greenish-yellow, contains mucus, looseinfantspass stool frequently, after each feedingintestine is immature = stool is soft, liquid and frequentbacterial flora increase as intestines maturesolid foods = stool becomes less frequent and firmerbreast-fed - light yellow to golden fecesformula-fed - dark yellow or tan stool, more formedToddlerscontrol of defecationstarts at 1.5-2 years of agedesire to control daytime BM starts when child becomes aware of:discomfort caused by a soiled diapersensation that indicates the need for a BMtypically attained by 2.5 y/o after toilet trainingSchool-Age Children and Adolescentshave BM habits similar to adultspatterns vary in frequency, quantity, and consistencymay delay defecation because of an activity such as playOlder Adultsconstipationsignificant health problem in older adults due to:reduced activity levelsinadequate amount of fluid and fiber intakemuscle weaknessmay be relieved by increasing fiber intake to 20-35 grams per daypreventive measures for constipation:adequate roughage in the dietadequate exercise6-8 glasses of fluidcup of hot water/tea at a regular time in the morningresponding to gastrocolic reflex (i.e. 30 minutes after meals)gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after breakfastshould be warned that consistent laxative use may cause constipationmay also interfere with body’s electrolyte balancemay decrease absorption of certain vitaminscauses of constipationlifestyle habitsserious malignant disordersCLINICAL MANIFESTATIONS: COLORECTAL CANCERRISK FACTORSNonmodifiableAgeRaceFamily historyModifiableCigarette smokingPoor diet (e.g., low in fiber and high in fat)Lack of physical activityRegular consumption of alcoholSYMPTOMSA change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few daysA feeling of needing to have a BM that is not relieved by doing soRectal belleding or blood in the stool (often, though, stool will look normal)Cramping or steady abdominal painWeakness and fatigueUnexpected weight lossDietsufficient bulk (cellulose, fiber)necessary for adequate fecal volumeinadequate fiber contributes to risk of developingobesitytype 2 diabetescoronary artery diseasecolon cancerinsoluble fiberpromotes movement of material through digestive system and increases stool bulkex: whole wheat flour, wheat bran, nuts, many vegetablessoluble fiberforms a gel when mixed with waterlowers blood cholesterol and glucose levelsex: oats, peas, beans, apples, citrus fruits, carrots, barley, psylliumdrink plenty of waterlow-residue foodsmove more slowlyneed to increase fluid intake with such foods to increase rate of movementex: rice, eggs, lean meatscertain foods are difficult or impossible for some people to digestresults in digestive upsetsmay cause passage of watery stoolsirregular eatingimpairs regular defecationfoods that may influence bowel eliminationspicy foods - diarrhea and flatusexcessive sugar - diarrheagas-producing foods - cabbage, onions, cauliflower, bananas, appleslaxative-producing foods - bran, prunes, figs, chocolate, alcoholconstipation-producing foods - cheese, pasta, eggs, lean meatRECOMMENDED DAILY INTAKE OF FIBERMen50 and younger38 grams51 and older30 gramsWomen50 and younger25 grams51 and older21 gramsFluidbody continues to reabsorb fluid from chyme even when fluid intake is inadequate or output is excessivereduced fluid intake slows passage and further increases fluid reabsorptionhealthy fecal elimination requires intake of 2,000-3,000 mLif chyme moves abnormally quickly, less fluid is absorbed - feces are soft or wateryActivitystimulates peristalsis - facilitates movement of chyme along colonweak abdominal and pelvic muscles are ineffective in assisting defecationresults from lack of exercise, immobility, or impaired neurologic functioningconfined to bed = constipationPsychological Factorsanxiety/anger - increased peristaltic activity causing nausea or diarrheadepression - slowed intestinal motility causing constipationDefecation Habitsearly bowel training may establish habit of defecating at a regular timewhen normal defecation reflexes are inhibited or ignored, reflexes tend to be progressively weakenedwhen habitually ignored, urge to defecate is ultimately lostreasons adults/patients ignore reflexespressures of time or workembarrassment about using a bedpanlack of privacydefecation too uncomfortableMedicationsdrug side effects may interfere with normal eliminationdiarrheaconstipationmorphine, codeine (decrease GI activity through CNS effect)iron tablets - astringent effect, act more locally on bowel mucosasome medications directly affect eliminationlaxatives - medications that stimulate bowel activity and assist fecal eliminationstool softeners facilitate defecationcertain medications suppress peristaltic activity - treats diarrheaaffect appearance of fecesGI bleeding (e.g. aspirin products) - red or blackiron salts - blackantibiotics - gray-greenantacids - whitish or white specksPepto-Bismol - black stoolsDiagnostic Proceduressome procedures (colonoscopy or sigmoidoscopy)require NPOcleansing enemanormal defecation will not occur until eating resumesAnesthesia and Surgerygeneral anesthesianormal colonic movements cease or slow by blocking parasympathetic stimulationregional/spinal anesthesia less likely to experience this problemsurgerydirect intestinal handling - causes temporary cessation of intestinal movement or ileum (lasts 24-48 hours)listen for bowel sounds - intestinal motility, important nursing assessmentPathologic Conditionsspinal cord injuiries/head injuries - may decrease sensory stimulation for defecationimpaired mobilitymay limit ability to respond to urgemay cause constipationmay cause client to experience fecal incontinence due to poorly functioning anal sphinctersPaindiscomfort when defecating - may cause client to suppress urge to defecate; may cause constipationnarcotic analgesics for pain - may cause constipation2.Review the common bowel diversions.ostomy - an opening for the gastrointestinal, urinary, or respiratory tract onto the skinAlternate feeding routegastrostomy - an opening through the abdominal wall into the stomachjejunostomy - a type of ostomy that opens through the abdominal wall into the jejunumBowel ostomies - to divert and drain fecal materialIleostomy - a type of ostomy that opens into the ileum (small bowel)colostomy - a type of ostomy that opens into the colon (large bowelClassificationby permanent or temporary statusby anatomic locationby construction of the stomastoma - the opening created in the abdominal wall by the osmotic; generally red in color and moistmay bleed when touchedhas no nerve endingsPermanenceTemporary ostomies - allows distal diseased portion to healtraumatic injuriesinflammatory conditionsPermanent ostomies - provide a means of elimination when the rectum or anus is nonfunctionalbirth defectsdisease such as cancer of the bowelAnatomic Locationlocation influences the character and management of fecal drainagethe farther along, the more formed the stool, the more control over frequency of dischargelength of time ostomy is in place also causes stool to become more formedremaining functioning portions tend to compensate by increasing water absorption ileostomy - empties from distal end of small intestineproduced liquid fecal drainageconstant drainage, cannot be regulatedcontains skin-damaging digestive enzymesappliance must be worn continuouslyodor is minimal compared to colostomiescecostomy - empties from the cecumascending colostomy - empties from ascending colonsimilar to an ileostomydrainage is liquid, cannot be regulated, digestive enzymes presentodor is a problemtransverse colostomy - empties from transverse colonmalodorous, mushy drainageusually no controldescending colostomy - empties from descending colonincreasingly solid drainagesigmoidostomy - empties from the sigmoid colonnormal/formed consistencyfrequency of discharge can be regulatedmay not need to wear an appliance at all timesodors can usually be controlledSurgical Construction of the Stomaend or terminal colostomy - a type of colostomy that has a singe stoma created when one end of bowel is brought out through an opening onto the anterior abdominal wall; the stoma is permanentloop colostomy - a type of colostomy where a loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge, or a piece of rubber tubing; the stoma has two ends: an active proximal end, and an inactive distal endusually for emergenciesstoma is bulky and more difficult to managedivided colostomy - consists of two edges of bowel brought out onto the abdomen but separated from each other; the proximal end is the colostomy and the distal end is the mucous fistulaused where spillage of feces into distal end needs to be avoideddouble-barreled colostomy - resembles a double-barreled shotgun; the proximal and distal loops of bowel are sutured together for about 10 cm (4 in) and both ends are brought up onto the abdominal wall3.Identify common causes and effects of the following bowel elimination problems.a.constipationconstipationsignificant health problem in older adults due to:reduced activity levelsinadequate amount of fluid and fiber intakemuscle weaknessmay be relieved by increasing fiber intake to 20-35 grams per daypreventive measures for constipation:adequate roughage in the dietadequate exercise6-8 glasses of fluidcup of hot water/tea at a regular time in the morningresponding to gastrocolic reflex (i.e. 30 minutes after meals)gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after breakfastshould be warned that consistent laxative use may cause constipationmay also interfere with body’s electrolyte balancemay decrease absorption of certain vitaminscauses of constipationlifestyle habitsserious malignant disordersb.diarrheadiarrhea - the passage of liquid feces and an increased frequency of defecationopposite of constipationresults from rapid movement of fecal contents through the large intestineSymptomsstool is relatively unformed and excessively liquidfinds it difficult or impossible to control the urge to defecateoften accompanied by spasmodic cramps and increased bowel soundspersistent diarrhea irritates anal region and buttocksprolonged diarrhea results in fatigue, weakness, malaise, and emaciationCausesirritants in the intestinal tract - protective flushing; can create serious fluid and electrolyte losses (especially in infants, small children, and older adults)Clostridium difficile-associated diseaseproduces mucoid and foul-smelling diarrheahighest risk: immunosuppressed persons, clients on chemotherapy, those who have recently used antimicrobial agents (fluoroquinolones)greatest risk: elderlyinfection control: hand hygiene with soap and water, contact precautions, cleaning of surfaces with bleachCAUSEPHYSIOLOGICAL EFFECTPsychological stress (e.g. anxiety)Increased intestinal motility and mucous secretionMedicationsInflammation and infection of mucosa due to overgrowth of pathogenic intestinal microorganismsAntibioticsIrritation of intestinal mucosaIronIrritation of intestinal mucosaCatharticsIncomplete digestion of food or fluidAllergy to food, fluid, drugsIncreased intestinal motility and mucous secretionIntolerance of food or fluidReduced absorption of fluidsDiseases of the colon (e.g., malabsorption syndrome, Crohn’s disease)Inflammation of the mucosa often leading to ulcer formationincreased risk for skin breakdownskin around anal region should be kept clean and dry; use zinc oxideuse a fecal collectorAlso: spicy foods, excessive sugar, and anxiety/anger (^peristaltic activity) all can cause diarrheac. fecal impactionfecal impaction - a mass or collection of hardened feces in the folds of the rectum; results from prolonged retention and accumulation of fecal materialsevere impaction - accumulation well up into sigmoid colon and beyondSymptomswill experience passage of liquid fecal seepage and no normal stoolfrequent but nonproductive desire to defecate and rectal painresults in a generalized feeling of illnessanorexia, distention of abdomen, nausea and vomiting may occurmay be assessed by digital examination of the rectumCausespoor defecation habitsconstipationadministration of medications such as anticholinergics and antihistaminesbarium used in radiologic examinations of upper and lower GITreatmentoil retention enema followed by a cleansing enema 2-4 hrs later, daily cleansing enemas, suppositories/stool softenersdigital removald.bowel incontinencebowel incontinence (fecal incontinence) - the loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter may occur at specific times or irregularlytwo types:partial - inability to control flatus or to prevent minor soilingmajor - inability to control feces of normal consistencyassociated with impaired functioning of anal sphincter or nerve supply (in neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle)prevalence increases with ageemotionally distressing and may lead to social isolationTreatmentrepair of sphincterbowel diversion/colostomye. flatulencePrimary sourcesaction of bacteria on the chyme in the large intestineswallowed airgas that diffuses between the bloodstream and the intestinemost swallowed gases are expelled by eructation/belchinggas may accumulate in the stomach - gastric distentiongases formed in the large intestine - absorbed into circulationflatulence - the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines (intestinal distention)Causesfood (cabbage, onions)abdominal surgerynarcoticsReliefif gas is propelled by increased colon activity before it is absorbed, it is expelled through the anususe of a rectal tube to remove the gas4.Develop 2 nursing diagnoses, interventions and outcomes for clients with elimination problems.Dysfunctional gastrointestinal motilityBowel incontinenceConstipationDiarrheaRisk for electrolyte imbalanceImpaired skin IntegrityDisturbed body imageDeficient knowledge, ostomy managementNutritionDiscuss therapeutic diets and the rationale for the diet.Clear liquid diet – Includes minimum residue fluids that can be seen through. Examples are juices without pulp, broth, and Jell-O. Is often used as the first step to restarting oral feeding after surgery or an abdominal procedure. Can also be used for fluid and electrolyte replacement in people with severe diarrhea. Should not be used for an extended period as it does not provide enough calories and nutrients. Full liquid diet – Includes fluids that are creamy. Some examples of food allowed are ice cream, pudding, thinned hot cereal, custard, strained cream soups, and juices with pulp. Used as the second step to restarting oral feeding once clear liquids are tolerated. Used for people who cannot tolerate a mechanical soft diet. Should not be used for extended periods. No Concentrated Sweets (NCS) diet – Is considered a liberalized diet for diabetics when their weight and blood sugar levels are under control. It includes regular foods without the addition of sugar. Calories are not counted as in ADA calorie controlled diets. Diabetic or calorie controlled diet (ADA) – These diets control calories, carbohydrates, protein, and fat intake in balanced amounts to meet nutritional needs, control blood sugar levels, and control weight. Portion control is used at mealtimes as outlined in the ADA “Exchange List for Meal Planning.” Most commonly used calorie levels are: 1,200, 1,500, 1,800 and 2,000. No Added Salt (NAS) diet –Is a regular diet with no salt packet on the tray. Food is seasoned as regular food. Low Sodium (LS) diet – May also be called a 2 gram Sodium Diet. Limits salt and salty foods such as bacon, sausage, cured meats, canned soups, salty seasonings, pickled foods, salted crackers, etc. Is used for people who may be “holding water” (edema) or who have high blood pressure, heart disease, liver disease, or first stages of kidney disease. Low fat/low cholesterol diet – Is used to reduce fat levels and/or treat medical conditions that interfere with how the body uses fat such as diseases of the liver, gallbladder, or pancreas. Limits fat to 50 grams or no more than 30% calories derived from fat. Is low in total fat and saturated fats and contains approximately 250-300 mg cholesterol. High fiber diet – Is prescribed in the prevention or treatment of a number of gastrointestinal, cardiovascular, and metabolic diseases. Increased fiber should come from a variety of sources including fruits, legumes, vegetables, whole breads, and cereals. Renal diet – Is for renal/kidney people. The diet plan is individualized depending on if the person is on dialysis. The diet restricts sodium, potassium, fluid, and protein specified levels. Lab work is followed closely. Mechanically altered or soft diet – Is used when there are problems with chewing and swallowing. Changes the consistency of the regular diet to a softer texture. Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables. Is for people with poor dental conditions, missing teeth, no teeth, or a condition known as dysphasia. Pureed diet – Changes the regular diet by pureeing it to a smooth liquid consistency. Indicated for those with wired jaws extremely poor dentition in which chewing is inadequate. Often thinned down so it can pass through a straw. Is for people with chewing or swallowing difficulties or with the condition of dysphasia. Foods should be pureed separately. Avoid nuts, seeds, raw vegetables, and raw fruits. Is nutritionally adequate when offering all food groups. Food allergy modification – Food allergies are due to an abnormal immune response to an otherwise harmless food. Foods implicated with allergies are strictly eliminated from the diet. Appropriate substitutions are made to ensure the meal is adequate. The most common food allergens are milk, egg, soy, wheat, peanuts, tree nuts, fish, and shellfish. A gluten free diet would include the elimination of wheat, rye, and barley. Replaced with potato, corn, and rice products. Food intolerance modification – The most common food intolerance is intolerance to lactose (milk sugar) because of a decreased amount of an enzyme in the body. Other common types of food intolerance include adverse reactions to certain products added to food to enhance taste, color, or protect against bacterial growth. ? Common symptoms involving food intolerances are vomiting, diarrhea, abdominal pain, and headaches. Tube feedings – Tube feedings are used for people who cannot take adequate food or fluids by mouth. All or parts of nutritional needs are met through tube feedings. Some people may receive food by mouth if they can swallow safely and are working to be weaned off the tube feeding. 2.Enteral feeding:ReasonsInterventions Complications NasoentericNaso or oral gastric NGT or OGTGastrostomy PEGJejunostomy PEJHOB >30, maintain for at least half hour afterwardsCheck placement confirmed by x-ray, or aspirate fluids if pH <4, tube is probably in stomachresidual q4h and prior to medication administrationFlush with 30 mL of H20 q4hkeep securely tapedif indicated, food coloring to help indicate aspirationstop continual feeding temporarily when turning or moving clientaspiration, hyperglycemia, abdominal distention, diarrhea, and fecal impaction^report to primary care provider. Often, a change in formula or rate of admin can correct problems.3.Define dysphagia and list causes.Dysphagia = difficulty swallowing. Clients at risk for dysphagia: older adults, those who have experienced stroke, clients with cancer who have had radiation therapy to the head and neck, and others with cranial nerve dysfunction4. Complete the table for dysphagia:Causesstroke, radiation therapy to the head or neck, cranial nerve dysfunctionWarning Signspain while swallowing (odynophagia), unable to swallow, sensation of food getting stuck, drooling, being hoarse, regurgitation, frequent heartburn, unexpected weight loss, doughing or gagging when swallowing, having to cut food into smaller pieces Complicationsmalnutrition, weight loss and dehydration. respiratory problems (aspiration.. pneumonia or upper respiratory infections)5.Identify risk factors for aspiration.Risk factors for aspiration:Reduced LOCIncreased intragastric pressureTube feedingsSituations hindering elevation of upper bodyTracheostomy or endotracheal tubeMedication administerationWired jawsIncreased gastric residualIncomplete lower esophageal sphincterImpaired swallowingTrauma/surgery of face, oral, neckDepressed cough or gag reflexesDecreased GI motilityDelayed gastric emptying6.List nursing interventions to decrease aspiration.Decrease aspiration:Monitor resp rate, depth and effot.Auscultate lung sounds frequently and before/after feedingsCheck gag reflex before oral feedingsWhen feeding, watch for signs of impaired swallowing or aspiration – coughing, choking, spitting food, excessive droolingHave suction machine available for high-risk clients in case of aspirationKeep HOB elevated for at least half an hour afterwardNot presence of n&v or diarrheaListen to BS qhNote any onset of abdominal distention or increased rigidity of abdomenIf tracheostomy, refer to speech pathologist for swallowing studiesIf n&v, position on sideFeed slowly7.Discuss risk factors related to poor nutrition intake.Old ageIllness, physical or psychologicalMultiple medicationsChronic alcohol intakeLow incomeSocial isolationPhysical disabilityInvoluntary weight loss or gainPoor dietUrinary Elimination1.Identify factors that influence urinary elimination.Developmental FactorsInfants: 250-500mL, 20x a day, sp.gr: 1.008. colorless and odorless. School-age children (5-10yr): kidneys double in size -> urination 6-8x a day. Enuresis: involuntary urination when control should be established.Nocturnal enuresis: bed-wetting Older Adultsprerenal failure: hypertensionIntrarenal failure = hypertension, diabetes, toxinsPost renal failure = outflow obstructiondiminished excretory function factors that impair renal function:arteriosclerosissurgerymore susceptible to toxicity from medications due to decreased excretionUrinary frequency factors:men: enlarged prostate glanddouble void technique: empty bladder, after feeling done, try to void againwomen: weakness of muscle supporting bladderdecreased bladder capacity and ability to completely emptyretention of residual volume also predisposes to UTI. Psychosocial Factorsstress triggers ADH secretion no time to pee, anxiety = no urination = higher risk of UTISociocultural factorsdifferent traditions of urinating Fluid and Food Intake (1.5-3L of fluid)alcohol and caffeine increase urine production (ETOH inhibits ADH)Beets and carotene can change urine color. MedicationsUrinary Retention (Box 1 pg 749)Anticholinergic medications, such as Atropine, Robinul, and Pro-Banthine. Antidepressant and antipsychotic agents, such as tricyclic antidepressants and MAO inhibitors. aminotryptaline (blueish tinge) Antihistamine: Pseudoephedrine (Actifed and Sudafed)Antihypertensives: hydralazine (Apresoline) and methyldopate (Aldomet)Antiparkinsonism: levadopa, trihexyphenidyl (artane), and benzotropine mesylate (Cogentin)Beta-adrenergic blockers, such as propranolol (Inderal)Opiods: hydrocodone (Vicodin) Anesthetics Peridium decreases urinary tract (turns urine orange)Muscle Tonegood muscle tone important to maintain stretch and contractility of bladder. Pathologic ConditionsDiseases of nephronsAbnormal amounts of protein or RBC’s in urine.Heart and circulatory disorders. Kidney stonesenlarged prostateSurgical and Diagnostic Procedures 2.Identify common causes and effects of the following urinary elimination problems.a. frequencyPolyuriaincrease fluid intakeDiuretics, lots of ETOHPresence of thirst, dehydration, and weight loss. History of diabetes or kidney disease. some stages of renal failureOliguria, anuria (<500mL in 24 hr)Decreased fluid intakedehydrationhypotension, shock, or heart failurehistory of kidney disease or renal failure or decrease perfusion to kidneys (high BUN, creatinine, edema, hypertension) b.nocturiaFrequency of nocturia (2 or 3 times a night)pregnancyincreased fluid intakeUTIc.urgencyUrgency - sudden desire to urinate immediately stressUTIenlarged prostated. dysuriaDysuria - pain or difficultyUTIhematuria, pyuria (pus in urine)e. incontinenceIncontinence - involuntary urination of adultsbladder inflammation or CVAdifficult access to toilet (impaired mobility)leakage when coughing, laughing, sneezing cognitive impairmentSCIf. urinary retentionRetention distended bladder on palpation and percussion discomfort, restlessness, frequency, small urine volumerecent anesthesia/ surgeryperineal swellingmedicationslack of privacy or other factors inhibiting micturition g.neurogenic bladderNeurogenic Bladderimpaired neurologic function (SCI) does not perceive fullness therefore unable to control urinary sphinctersself-catheterization (q4h) 3.Describe appropriate care for a patient with a Foley catheter.Indications for FoleyAcute urinary retention or bladder outlet obstructionNeed for accurate output in critically ill clientsPeri-operative use for selected surgical proceduresTo assist in healing of open sacral or perineal wounds in incontinent clientsClient requires prolonged immobilization To improve comfort for end of life care Foley CareCare:Urinary catheters is indicatedHand hygieneMust be continuously connected to the drainage bagNO breach in systemRoutine daily meatal hygiene & after BMUrinary catheter bag should be emptied regularly into a clean containerSecurement deviceNo dependent loops4.List nursing interventions that may prevent a urinary tract infection.Prevent infectionsDrink 8 glasses of water a dayPractice frequent voidingAvoid harsh cleansing products.Avoid tight-fitting pantsWear cotton rather than nylon (enhances ventilation)Wipe from front to backtake showers rather than baths (bacteria in bath water) Acidifying urineFoods such as:eggs, cheese, meat, whole grains, cranberries, plums, and tomatoes increase the acidity of urine. acidifying the urine of clients reduce risk of UTI and calculus formation. 5.Describe interventions to manage urinary incontinence. Client educationContinence (bladder) trainingclient resists urge or sensation to urinate and only void according to a timetable to gradually stabilize the bladder and diminish urgency. also provides larger voided volumes and longer intervals between voiding. Habit trainingscheduled toileting, have client void at regular intervalsno delay voiding of urge occursused in children with urinary dysfunctionPrompted voidingprompting or reminding client when to void.Pelvic Muscle ExercisesMaintaining Skin Integrity Maintain elimination habitsmedications usually interfere with normal voiding habitsassist client to maintain habits (assisting with toilet PRN) Fluid intake (2-3L/day) promote increased fluid intake -> increased urine production -> more stimulation of micturition reflex. keep bladder flushed out and decreases risk of sediment or other obstructions1500 mL of measurable fluid is adequate for most adultsmay be c/i for clients with kidney or heart failure. 6.Review the common urinary diversions.Continent (indicated by bladder cancer) Kock Pouch new bladder out of ileumNipple valve which permits external catheter to drainNeobladder Intact urethra**A small part of the small intestine is made into a reservoir or pouch, which is connected to the urethra. Closely matches normal urinationIncontinentSuprapubic catheter urethral trauma, short-term 2-3 weeksUreterostomyDetaches one or both ureters from the bladder, and brings them to the surface of the abdomen with the formation of a stoma to divert the flow of urine away from the bladder when the bladder is not functioning or has been removed. Birth defects, malfunction of bladder, SCI, bladder cancerNephrostomy Flow of urine is diverted directly from the kidneys to the abdominal wall. Usually temporary but may be permanent for cancer pts.Vesicostomyurethra no longer functioning, bladder attached directly to skinIleal conduit aka bricker’s loop the ureters are detached from the bladder and joined to a short length of the small intestine (ileum)The ureters drain freely. One end of the ileum piece is sealed off and the other end is brought to the surgace of the abdomen to form the stoma. An ostomy bag is worn over the stoma to collect urine. 7. Develop 2 nursing diagnoses, interventions and outcomes for clients with urinary problems.Disturbed body image : shame r/t incontinence Urinary incontinence PainRisk for infectionToileting self care deficitImpaired urinary eliminationQSEN - Ensuring Healthcare Quality and Safety What does it mean to give quality care? Quality care is STEEEP: safe, timely, effective, efficient, equitable, patient-centeredDefine a high reliability organization.High Reliability organization:Organizations that continually look at themselves and ask are we giving the best care possible? Do we provide an environment for safe care?State at least 2 indicators of the quality of nursing care within an institution.All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informaticsThe six competencies:SafeTimelyEffectiveEfficientEquitablePatient-centered A local hospital is being evaluated on whether it gives quality care. Which of the following would the evaluating agency find in a successful evaluation? (select all that apply)Care is provided in a timely mannerThe hospital regularly reviews policies for their effectivenessThe cost of care is lower than other hospitals in the areaPhysicians review all policies for medical usefulnessCare is given without regard for ability to payPatients are actively involved in decisions about their own carePatient-Centered CareList at least 3 techniques to provide patient-centered care.Open visiting hoursFamily Zones – comfortable places for family to visit. Lots in PEDs.Views of nature – views, plants, painting of something natural Noise reductionDecrease environment stressors“we are guests in their lives”Describe the benefits of quality and safety in providing patient-centered care.The nurse asks the diabetic patient when she would like her AM care, before or after breakfast. This is an example of providing:Safe carePatient-centered care XEvidence-based practiceCare using teamworkTeamwork and CollaborationComplete the following chart:How is it practiced?How does it help teamwork?BenefitsOpen Communicationassertive communication… honest, direct, and appropriate while being open to ideas and respescting the rights of othersValues perspectives, expertise and unique contributions of all team membersPrevents errors.. minimizes miscommunication with colleaguesMutual RespectSkilled communicators focus on finding solutions and achieving desirable outcomesSeek to protect and advance collaborative relationships among colleaguesInvite and hear all relevant perspectivesCall upon goodwill and mutual respect to build consensus and arrive at common understandingDemonstrate congruence between words and actions, holding others accountable for doing the sameValues perspectives, expertise and unique contributions of all team membersTeamwork, benefits the patient, the team, and the organization.Shared Decision-MakingEmotional intelligence… ability to form work relationships with colleagues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of othersValues perspectives, expertise and unique contributions of all team membersBenefits the patient, the team, and the organization.With emotional intellifence, the nurse is viewed as mature, approachable, and easygoingDefine the elements of SBAR.SBAR:Situation – What is going on with the patient?Background – What is the clinical background or context?Assessment – What do I think the problem is?Recommendation – What would I recommend?List the activities of the rapid response team and define how these enhance quality and safety in health care.Rapid Response Team:When a pt demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or deathCritical care nurse, respiratory therapist, and physician (critical care or hospitalist) backupProactively evaluate high-risk ward patientsEducate and act as liaison to warm staffWhat is the purpose of using the SBAR format?It makes report and shift changes go faster It ensures the unit is compliant with Magnet requirementsIt ensures complete and organized communication between shiftsIt maintains Safe, Better, Appropriate and Reliable care.Evidence-Based Practice List the steps (in order) of the EBP proces.Collect the most relevant and best evidenceCritically appraise the evidenceIntegrate the evidence with one’s own clinical expertise, patient preferences and values in making a practice decision or changeEvaluate the results of the practice decision or changeList elements that can be used as evidence in EBP.Established research methodsSystematic research, randomized clinical trials, descriptive studies, qualitative research, Experts in the health care fieldstaff educators, CNSs, NPs, the medical staff, pharmacistsAnything that helps you answer the questionDescribe how a nurse would critique evidence to determine its usefulness to a particular clinical setting.It is not just enough to find the articles you want, but you need to ask yourself whether or not they hold any merit.Ask yourself whether or not the article deals with you questionInterpret the evidenceApply what you have learned in your patient careObserve how evidence is used to make policy and procedure changes to improve patient careEvaluate the decisionDefine the 4 elements of a PICO question.PICO FormatPatient population of interestIntervention of interestComparisonOutcomeDefine bundles and describe how they improve quality and safety in health care.Bundles: groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. Central line bundleVAP bundleCatheter-associated UTI bundleSurgical site infectionQuality ImprovementDefine never events and give examples.Never eventsObjects left in after surgery, air embolism, blood incompatibility, pressure ulcers, fallsDescribe strategies a health care organization uses in quality improvement.Nursing sensitive measureAffected by the supply of nursing staff, the skill level of the nursing staff, and the education/certification of nursing staffCentral line infections, falls, IV infiltrationsTest of change (PDSA)Plan, Do, Study, ActWhat is the significance of reporting and investigating never events?To guarantee they never happen againTo figure out who is responsible so they can be disciplinedTo identify human factors that contributed to the eventTo write them up in research for other hospitals to learn fromWhich of the following are elements of Joint Commission Patient Safety goals? (Select all that apply)Hand hygieneTime outs before surgeryUse of unit dose syringesCost containmentThe use of 3 patient identifiers - need only 2SafetyDefine the concept of human factors and its role in patient safety.Human factors: humans make mistakes. What can we do to avoid them. List measures to increase safety in medication administration.Safety in Medication Administration:Two patient identifiersPatient armbands – pt, allergies.Look-alike and sound-alike drugsMedication reconciliationGood faith effortInvolve the patientDecrease tolerance of riskDefine national patient safety indicators; and describe the 6 safety goals.Identify patients correctly2 patient identifiersNever room numberSpecial attention when giving bloodImprove staff communicationCritical test resultsUse medications safelyUnit dose and prefilled syringes when possibleMedication reconcilliationPrevent infectionHand hygieneMDRO risk assessmentCatheter guidelinesIdentify patient safety risksPrevent mistakes in surgeryTime outsVerify correct patient, correct procedure, correct siteHealthcare InformaticsList the elements of EHRs and how they contribute to quality and safety.EHRsRespond to alertsUse for communicationDecision support toolsUp-to-the-minute informationDescribe concerns about the use of EHRs in health care.EMR concerns (eye contact, decreased critical thinking, system offline, patient privacy)Describe how consumers use informatics and the benefits and challenges for nurses.Consumer useIncreased medical knowledge by consumer increases the need for assessment of resourcesSocial media for patient careHome monitoringDiabetes Discuss the classifications and risk factors for developing diabetes.388620186360ClassificationType One (10%)Inherited with environmental triggerAutoimmune - beta cell destructionBorn with or develop during early childhoodType Two (90%)Genetic & lifestyleInsulin resistance – the pancrease will respond by producing more insulin and then the beta cells get exhaustedInsulin deficiencyGestational DiabetesOccurs in 2%–5% of?pregnanciesInadequate insulin secretion & responsivenesMany will not have diabetes after pregnancy, some will develop type 2 diabetes 2.List the complications of diabetes and appropriate preventative plications from DM:Hypoglycemia Blood glucose level < 60 mg/dL (normal BGluc 70-110)Diet therapy: glucose/carbohydrate replacementDrug therapy: glucagon, 50% dextrose Prevention strategies for:Insulin excessDeficient food intakeExerciseAlcoholHyperglycemia Blood glucose level > 200 mg/dLCauses microvascular changes leading to vascular disease and neuropathiesResults from Insulin deficiencyHyperglycemiaPolyuriaPolydipsia Polyphagia Development of ketone bodiesDehydrationHemoconcentrationHypovolemiaHyperviscosityHypoperfusionHypoxiaTreatment/prevention: oral and/or insulin therapyTherapeutic diet – low glycemic foods etcDiabetic ketoacidosis (DKA)Serum glucose >300 mg/dlCommon in type 1, rare in type 2Results from inadequate insulinAcidosis results from ketone production of fat breakdown for energy demandsSymptomsPolyuria, polydipsia Hyperventilation, Kussmual respirationsDehydrationFruity odor of ketones, fatigueGI symptomsInterventions include ICU admissionMonitor for manifestationsAssessment of airway, LOC, hydration status, blood glucose levelManagement of fluid & electrolytesDrug therapy goal: to lower serum glucose by 75 - 150 mg/dL/hrManage of acidosisClient education & preventionNPOHyperosmolar hyperglycemic syndrome (HHS)Severe hyperglycemia with little or no ketonesCauses profound dehydration & shockGlucose levels are in excess of 600 mg/dLOlder adults with type 2 DM who are still producing some insulinSymptomsconfusion , coma, febrile, polydipsia, nausea, weight lossInterventionsMonitoringFluid therapy: rehydrate & restore normal blood glucose levels within 36 to 72 hrIV insulin therapy often needed to reduce blood glucose levelsNPOFoot ulcersInterventions and foot care practicesCleanse & inspect feet dailyWear properly fitting shoesAvoid walking barefootTrim toenails regularlyReport non-healing breaks in the skinPeriodontal disease3. Discuss teaching topics and priorities for a patient newly diagnosed with diabetes mellitus type 2.Goals of treatmentProvide the individual with adequate tools to achieve glycemic controlPrevent, delay or arrest the microvascular(neuro-, renal-, retinalopathy) & macrovascular complications of DMMinimize hypoglycemia Optimize BMI Diet considerations for Type 2 diabetic:Hypocaloric diet = weight loss & better glycemic controlModification of eating habitsAdjust CHO to glucose levelsRestrict ETOH intake4.List the medication classifications used in the treatment of the client with diabetes:Oral Drug Therapy: probably too much information. None of this was discussed in lecDrug ClassificationGeneric/Trade NamesNursing Considerations Adverse EffectsSulfonylurea agents - antidiabeticTolbutamide (Modenol, Novobutamide, Orinase)Glimepiride (Amaryl) Directly stimulates beta cells to produce insulin. Adjunct to diet and exerciseNo common adverse effects.. Dizziness, headache, possible leukopenia Meglitinide analogs- antidiabeticNateglinide (Starlix) Repaglinide (Prandin, Gluconorm)St. the release of insulin. Use alone or with metformin for nonIDDMNo common.. flu like symptoms, hypoglycemia, URIAlpha-glucosidase inhibitorsAcarbose (Precose)Delays absorption of sugars from intestinal tract. Adjunct to diet and exerciseDiarrhea, flatulence, andominal distentionBiguanidesMetformin (Fortamet, Glucophage, Glumetza, Riomet)Increase binding of insulin and potentiate insulin action. Adjunct to diet and exercise.N&v, abdominal pain, bitter or metallic tastem diarrhea, bloatedness, anorexiaThiazolidinedione agentsPiolitazone hydrochloride (Actos)Decreases hepatic glucose output and increases glucose uptake in skel muscle and fat. Adjunct to dietUpper respiratory tract infectionDipeptidyl peptidase inhibitorsExenatide (Byetta, Bydureon)Mimicks incretin, enhances insulin secretion. Slows gastric empyting. With d/exNo common. Jittery, n&v, gi upset , hypoglycemia5. List signs and symptoms of hypo- and hyperglycemia.Hypoglycemia:WarmWeakness or fatigueConfusion or difficulty thinkingShaky, nervous, anxiousSeizures, loss of consciousnessSweaty, hungry, tinglingHyperglycemia:Always tiredCrave extra liquids (polydipsia)DehydrationHemoconcentrationHypovolemiaHyperviscosityHypoperfusionHypoxiaFrequent urination (polyuria)Numbness and tingling of feetAlways hungry (polyphagia)Unexplained weight lossBlurred visionSexual dysfunction6. Discuss the appropriate therapeutic diet for a patient with diabetes. Diet Considerations:Type 1 Consistency in timing & amount of caloriesAdjust insulin for departures from meal planFrequent, smaller meals rather than quantityType 2 Hypocaloric diet = weight loss & better glycemic controlModification of eating habitsAdjust CHO to glucose levelsRestrict ETOH intakeMedical nutritional therapy:ADA 50-60% CHO 45-60 grams per meal15-20% PRO20-30% FATDiscourage refined & simple sugarsEncourage complex CHOs & fiberAlcohol consumptionGlycemic indexConsumption of high-glycemic index foods results in higher & more rapid increases in glucose levels than the consumption of low-glycemic index foodsHigh BMIs linked to obesity, heart disease & DMConsumption of low-glycemic index foods results in lower & sustained increases in blood glucose & lower insulin demands on beta-cells People who eat low glycemic index foods tend to have lower body fat 7. Discuss the different types of insulin and appropriate times to administer.Drug ClassificationGeneric/Trade NamesNursing Considerations Adverse EffectsRapid-actingLispro (Humalog)Aspart (Novolog)Glulisine (Apidra)Onset: <15 minutesPeak: 1-2 hoursDuration: 3-6 hourshypoglycemiaShort-actingRegular (Novolin R, Humulin R)Onset: 30-60 minutesPeak: 2-4 hoursDuration: Up to 24 hr^Intermediate-actingNPH (Novolin N, Humulin N, ReliOn)Onset: 2-4 hoursPeak: 4-8 hoursDuration: 10-18 hrs^Long-actingGlargine (Lantus)Detemir (Levemir)Onset: 1-2 hoursPeak: Usually noneDuration: Up to 24 hr^CombinationsNovolin 70/30, Humulin 70/30Humalog 75/25, Novolog 70/30, Humalog 50/50Onset: 30-60 minutesPeak: 2-10 hrsDuration: 10-18 hrsOnset: 10-30 minutesPeak: 1-6 hrsDuration: 10-24 hrs^SkinIdentify risk factors for skin impairment:Risk FactorAssessment DataNursing InterventionGeneticscolor, allergies, acne, excemaMonitor skin care practices Agewrinkles - skin is drier, less sebum. Skin is thinner, decreased subQ tissue and collagen. old age – increased healing time due to decreased circulationmonitor continence status, immobility-related risk factors, help position, assess nutritional status, teaching about skin and wound assessment, signs of infection, how to use topical meds, how to turn/reposition every 2 hoursIllnessArterial illnesses (deceases o2 to tissues).. peripheral artery disease >> thin, shiny skin with no hair. Assess nutrtional status, fluids, circulationPoor nutritionmuscle atrophy, decreased subQ tissue, decreased skin integrityAssess nutrition statusCirculationneed good circulation for o2/nutrients/etc and goo venous return to remove wasteCompression socks, ankle exercisesPressureBed or wheelchair bound = higher chance of skin breakdownRepostion/turn every 2 hoursMedicationsphotosensitive medications = reation >burning, stinging, blisters. RetinA, birth controlLong term corticosteroid usage = skin is thinner (especially on forearem) and has purple echymosisTeach how to use and possible side effects/interactions, increased risk for skin impairment2.Describe the pressure ulcer staging system.Stage I: Intact skin with non-blanchable redness. Darkly pigmented skin may not have visible blanchingStage II: Partial thickness loss of dermis; shallow open ulcer, red pink wound bed, without slough. May present as intact or open/ruptured bullaStage III: Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present. May include undermining & tunnelingStage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. May include undermining & tunneling3.Differentiate primary, secondary and tertiary wound healing.Healing by first intention - primary wound healingWound closed by approximation of margins or wound created & closed in the ORFirst choice for clean, fresh well-vascularized wounds Indications: onset <24h, clean, viable tissue, approximation of skin edges is achievableTreated with: irrigation, débribement, margins approximated using simple methodsScar depends on: initial injury, amount of contamination, accuracy of closureFastest healing & most cosmetically pleasingHealing by second intention - secondary wound healingWound is left open & closed by epithelialization & myofibroblastsWound heals without surgical interventionIndicated in infected or contaminated woundPresence of granulation tissueComplications: wound contracture & hypertrophic scarringHealing by third intention - tertiary wound healingFor managing wounds that: bacterial count contraindicates primary closure subsequent repair of a wound initially left open or not previously treated a crush component with tissue plete the following. Wound Exudate TypeWhat is it?Color?ConsistencySerous(ex, fluid in blister or burn)Serum or plasmaclear or strawwateryPurulentPus. Filled with leuokocytes, dead tissue, bacteria (alive or dead)green or yellowThicker than serousSerosanguineous(seen in surgical incisions)serum and sanguineous(RBCs)tends to be light redmoderately thinSanguineous(seen in open wounds)RBCsdark redmoderately thick, may have clotsPurosanguineous(seen in new wound that is infected)Pus and bloodreddish?thick5.Describe the difference between an arterial and a venous woundArterial (Insufficiency ulcers)Venous (stasis ulcers) MAINLYWound Characteristicsremember..good arterial blood flow!Pale base color when elevatedShiny, taut skinPunched out appearanceMinimal exudateCool skin temperaturePain with rest & exercisePedal pulses diminished or absentLateralBAD arterial blood flowRuddy color baseShallow woundIrregular marginsModerate to heavy exudateWarm skin temperature Minimal to severe painPedal pulses present Medial Nursing careLikely to have emboli, VET incompetent venous valves (varicose veins)6.Describe ways the nurse can enhance wound healing.Order special mattresses, reposition and turn clients regularly, moist wound healing, nutrition and fluids, prevent infection, positioningUntreated WoundsControl bleeding by applying direct pressure elevating the extremity Prevent infection byCleaning or flushingCovering the wound with a clean dressingIf severe, assess for shockTreated WoundsAssess the wound, record drainage, measure the size, integrity of skin surrounding area, clinical signs of infection7.Identify assessment data pertinenet to skin integrity, pressure sores and wounds.Location – related to a bony prominenceType of wound – stage of ulcerSize – in centimeters (length, width and depth in order). Insert sterile swab at the deepest part of the wound then measure it against a measuring guide, undermining, tunnelingWound bed – color and location of necrosis (dead tissue) or eschar. Healthy is pink. Exudate – type, note color, amountOdor – can indicate infection.Wound margins – condition and integrity of surrounding skin. Approximated? Erythemic?Pain – most of the time there is no sensation. Don’t normally medicate for wound careCause8.Write at least 2 nursing diagnoses, expected outcomes and interventions associated with impaired skin integrity.Risk for impaired skin integrity r/t urinary and fecal incontinence or r/t decreased mobility or r/t decreased nutrional intake.Impaired skin integrity r/t impaired mobility, decreased nutrtional intake AEB stage II pressure ulcerImbalanced nutrition (less/more than body requirements) r/t increased intake, decreased absorption AEB weight loss or weight gainRisk for infection r/t a break in the skinPain, Acute or chronic r/t to the wound AEB pt complaintImpaired physical mobility r/t increased BMI, decreased muscle tone AEB decreased movement in bedIneffective tissue perfusion r/t decresed Hgb hct AEB cool extremities Sleep1.Briefly discuss mechanisms that regulate sleep. Sleep regulationBiological process. 24 hours cycle. Indoginous. (built in)Internal clock.. hypothalamus. SCN. Reticular activating system to shut us off and turn us on3-6 months old babies able to regulate sleep betterCircadian. Around the dayNREM – 80% of sleep1- very light sleep. Couple of minutes. Might wake self back up at this time2- light sleep. 10-15 minutes. HR, RR, BP all start decreasing3- deep sleep4- deep sleep (difference ? is the amount of delta waves) Paradoxcycal sleep (looks like awake on EEG)Beta = highest frequency, awake. Theta = drowsy. Delta = asleep.REMEvery 90 minutes. Lasts up to 30 minutes. More dreams. 4-5 sleep cycles a night. Most need this amount to wake up refreshed. Each cycle consists of NREM and REM. Even though we are asleep. We can still respond to meaningful stimuli (wake for child crying, fire alarm.. but will sleep through sprinklers, garbage truck)2.Explain the functions of sleep and the effect it has on health and well-being.Functions of sleep:Not completely understoodRestores normal levels of activity and normal balance among parts of the nervous systemNecessary for protein synthesis, which allows repair processes to occueLack of sleep = become emotionally irritable, have poor concentration, and experience difficulty making decisionsGlial cells shrink while we are asleep.. they think that the CSF and lymph fluid can wash the brain out. 3.Identify factors that affect sleep and related nursing assessments and interventions.Illness – pain, COPD- difficulty lying down (become short of breath), women decreased estrogen making them more restless, BPH and CHF have nocturiaEnvironment – too noisy or quiet, temperature (most people like it cooler), dark or too dark, comfortable: pillows, blankets. Lifestyle – shift work, irregular routines, travel a lot through different time zonesEmotional stress – norep stimulates CNS which makes it harder to go to sleep (stressing out before sleep over daily life)Stimulants and alcohol – caffeine and nicotine should be avoided 2-3 hours before bed. As well as ritalin, cocaine, meth. Diet – high BMI have a more difficult time falling asleep and staying asleep. Smoking – stimulant. Smokers are light sleepersMotivation – staying up all night for studying.. body eventually falls asleepMedications – beta blockers have insomnia and bad dreams.. in the day time more sleep. Narcotics – decrease REM sleep and make more drowsy in the day. Insomnia is the number one sleep problem Difficulty falling or staying asleep. More than 1 week is chronic. r/t stress and it is intermittent. Risk factors.. age stress and higher in females esp in menopause. Investigate their sleep patterns, environment, sleep positively Activity and Exercise1.Define the role of the nurse in activity and exercise.Assessing: history, physical examination of body alignment, gait, appearance, and movement of joints, capabilities and limitations for movement, muscle mass, and strength, activity tolerance, problems related to immobility, and physical fitness. 2.Discuss the systemic effects of immobility.Musculoskeletal systemdisuse osteoporosiswithout exercise, bones demineralizeDisuse atrophyContractures: permanent shortening of the muscle Stiffness and pain in the joints ankylosed: permanently immobileexcess calcium deposited in joints. CV systemDiminished cardiac reservereduces ANS balance, reduces heart’s capacity to respond to any metabolic demands above basal levels.tachycardia with minimal exertion.Increase use of the Valsalva maneuverValsalva maneuver: holding breath and straining against a closed glottis. Orthostatic hypotensionVenous vasodilation and stasisImmobile person: skeletal muscles no longer assist in pumping blood back to heart against gravity.blood pools and causes vasodilation and engorgement. valve incompetenceDependent edema Thrombus formationRespiratory systemDecreased respiratory movementintercostal joints become fixed in an expiratory phase of respiration, further limiting the potential for maximal ventilation.produces shallow breathing and reduced vital capacity (additional inhalation passed maximum inhalation)Pooling of respiratory secretionsAtelectasisHypostatic pneumoniaGI systemconstipation due to decreased peristalsis + decreased abdominal and perineal muscles = impaction embarrassment of using a bedpan leads to postponement of defecation leads to weakened and suppressed defecation reflex some clients use Valsalva maneuver excessively which increases intra-abdominal and thoracic pressure and places stress on heart and circulatory system. Metabolic systemDecreased metabolic rateNegative nitrogen balancenegative balance between protein anabolism and catabolismmore catabolism of proteins than intakeAnorexiadecreased caloric intake due to decreased metabolic rate (less energy needed) Negative calcium balance greater amounts of calcium are extracted from bone than can be replaced GU systemUrinary stasisurine pools due to gravity Renal calculicalcium salts are no longer in balance and form stones. Urinary retention bladder distention and occasionally urinary incontinence Urinary infection static urineimproper perineal care/ indwelling catheterurinary reflex (backward flow) Integumentary systemReduced skin turgorSkin breakdownPsychoneurological Decline in mood-elevating substances such as endorphins Increased dependence on others may lower person’s self-esteemfrustration and exaggerated emotional reactions Decreased variety of stimuli time perception deterioratesproblem-solving and decision making deteriorate due to lack of intellectual stimulation. Anxiety 3.Describe the benefits of activityMusculoskeletal systemSize, shape, tone, and strength of muscles are maintained with exercise and increased with strenuous exercise.Strenuous exercise causes hypertrophy and increased efficiency of muscular contraction. Exercise increases:joint nourishmentjoint flexibilitystabilityROMBone density and strength is maintained through weight-bearing and high-impact movements. maintains balance between osteoblasts and osteoclasts. CV systemincreases strength of heart muscle contractionincreases blood supply to the heart and muscleslowering BPimproved O2 uptakeimproved HR variabilityimproved circulationreduces stressRespiratory systemBenefits: improves gas exchangeincreases toxin elimination through deeper breathingimproves O2 to brainenhances problem solving and emotional stabilityprevents pooling of secretionsdecreases breathing effort and risk for infectionSpecial considerations:LE exercise forms for treating COPD patientsyoga breathing and postures with asthma are helpfulGI systemImproves appetiteincreases GI tract tonefacilitates peristalsiscan help relieve constipation Metabolic/Endocrine systemincreases metabolic rateincreases use of triglycerides and fatty acidsresulting in lower serum triglycerides, A1C levels, and cholesterol.make cells more responsive to insulinGU systempromotes efficient blood flow = excretion of bodily wastes more effectively. prevents stasis of urine and therefore flushes out bacteria = less UTIImmune systemexercise allows for lymph fluid to be more efficiently pumped through the lymphatic system. moderate exercise enhances immunity, strenuous exercise may reduce immune function. Psychoneurological Systemexercise can elevate mode and relieve stress and anxiety. MoA:exercise increases levels of neurotransmitters exercise increases levels of endorphinsincreases level of O2 to brain inducing euphoriamuscular exertion releases stored stress associated with accumulated emotional demands. Relaxation response (RR): physiological state that can be elicited through deep relaxation breathing with emphasis on prolonged exhalation. Emphasis on exhalation recruits PNS “rest and digest” reflex. Progressive contraction and relaxation of muscles throughout body until feels relaxed. These can be done by anyone at anytime. Cognitive functionInduces cells in brain to strengthen and build neuronal connections. Enhances decision-making, problem-solving, planning, and paying attention. Brain Gym and cross-lateral movements helpful to enhance cognitive functions.Shown to help ADD< ADHD, learning disorders, and mood disorders. plete the following chart on the hazards of immobility: AssessmentProblemDesired outcomeInterventionsMetabolic*measure height and weight*palpate skinWeight loss due to muscle atrophy and loss of subQ fat. Generalized edema due to low blood protein levelsweight control, self-careNutritionCardiovascular*Auscultate the heart*Measure BP*Palpate and observe sacrum, legs and feet*Palpate peripheral pulses*Measure calf muscle circumferences*Observe calf muscle for redness, tenderness, and swellingIncreased HROrtho. HypotensionPeriph. EdemaWeak periph pulsesEdemaThombophlebitiscirculationprevent complications of immobilityMusculoskeletal*Measure arm and leg circumferences*Palpate and observe body joints*Take goniometric measurements of joint ROMDecreased muscle massStiffness or pain in jointsDecreased joint ROM, joint contracturesJoint movement, activity, mobilityROM exercises, ambulate, prevent complications of immobility Elimination*Measure fluid intake and output*Inspect urine*Palpate urinary bladder*Observe stool*Auscultate bowel soundsDehydrationCloudy, dark= ^SGravDistended bladder due to urinary retentionhard, dry small stooldecreased intestinal motility EliminationFoley, laxativeIntegumentary*Inspect skinBreak in skin integrityphysiological consequenceposition appropriately, move and turn clients in bedRespiratory*Observe chest movements*Auscultate chestAsymmetric chest movements, dyspneaDiminished breath sounds, crackles, weezes, and ^resp rateresp statusincentive spirometer,cough and deep breathing, position 30+Psychoneurological*Observe behaviors, affect, and cognition*Monitor development skills in childrenAnger, flat affect, crying, confusion, anxiety, cog function .. sleep or appetite disturbancesstress level, self-care,Coping strategies, stress relief, meds ................
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