Module 1- Basic Care and Comfort 26.pptx

NUR2356LL MDC 1​

Basic Care and ComfortModule 1

Modular Learning Outcomes

MDC1

By the end of this module, you will be able to:

• List basic care and comfort needs across physiological domains.
• Describe non-pharmacologic strategies used to promote basic care and comfort.
• Explain how physiological, psychological, and cultural factors influence the provision of comfort care.

Michelle A Weas

Topics

Vital signs

Stress

Rest, pain, comfort

Nutrition, feedings

Incontinence

Urge

Functional

Diarrhea

Unconscious

Bowel elimination

Constipation

Michelle A Weas

This week’s Reading

Hinkle Chapter 4 pp. 85-91: Adult Health and Physical, Nutritional, and Cultural Assessment  Hinkle Chapter 9: Pain Management  Hinkle Chapter 41 pp. 1286-1293: Management of Patients with Intestinal and Rectal Disorders  Hinkle Chapter 49 pp. 1611-1616: Management of Patients with Urinary Disorders

What is Multi-Dimensional Care?

Caring for the “Whole Patient” Compassionate care that includes the patients’ beliefs, values, preferences, and needs. Include patient’s support system (ex. Family, hired care giver, etc. Centered to provide the outmost quality care

Michelle A Weas

Attributes of Patient Centered Care

Physical comfort.

Coordination and integration of care.

Information, communication, and education.

Respect for patient and family’s values, preferences, and expressed needs.

Access to care.

Involvement of family and friends.

Transition and continuity.

Emotional support and alleviation of fear and anxiety.

Cultural and Spiritual self-awareness

Michelle A Weas

Happiness...consists of giving and in serving others.

Henry Drummond

Maslow’s Hierarchy of Needs

Maslow believed that physiological and psychological needs motivate our actions

• https://youtu.be/O-4ithG_07Q

Michelle A Weas

What are the Basic Physiological Needs?

• Air
• Food
• Water
• Temperature regulation
• Elimination
• Rest
• Sex
• Physical Activity
• Blood flow (perfusion) is necessary to meet other basic needs

Michelle A Weas

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Role of the Nurse

Collaborative effort

Health history

Physical assessment

Nursing process guides care

Electronic medical record (EMR)

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Considerations—Effective Communication

• Establish rapport
• Make eye contact
• Listen
• Be aware of nonverbal communication
• Consider patient’s educational/cultural background
• Language proficiency
• Avoid technical terms/medical jargon
• Summarize at end of visit

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Considerations—Ethical

Explain what the holistic, comprehensive health history and physical examination include How the information will be obtained How it will be used Private setting The Health Insurance Portability and Accountability Act (HIPAA) 1996 EHR

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Components of the Health History

Biographical data

Chief complaint

Past health history

Present health concern/illness

Family history

Review of systems

Patient profile

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Patient Profile

Past life events related to health

• Disability
• Self-concept
• Sexuality
• Risk for abuse
• Stress and coping

Current medications

Education, occupation

Financial resources

Environment: physical, spiritual, interpersonal

Lifestyle patterns

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Components of the Physical Examination

•Posture•Body movements•Speech patterns

General observations

•Blood pressure, pulse, respirations, temperature, and pain

Vital signs and pain

Focused assessment of body systems

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Focused Assessment

Abdomen

• Skin
• Head, neck
• Thorax, lungs
• Breasts
• Cardiovascular system

Rectum

Genitalia

Neurologic system

Musculoskeletal system

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Basic Physical Assessment Techniques

Inspection: observation of each relevant body system

Palpation: assessment of structures of the body with light and deep palpation

Percussion: use of sound to examine different body organs; a skill that requires much practice

Auscultation: listening to sounds produced within different body structures created by movement of air or fluid

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Light and Deep Palpation

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Auscultation of Heart

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Question #1

Which environment is most conducive for a nurse to perform a physical assessment on a patient? •The physical examination is performed before the health history to decrease anxiety•The room is dimly lit to respect the patient’s privacy•The examination is scheduled for a 2-hour time frame so the patient is not rushed and the nurse can complete a comprehensive assessment•The examination room is well lit and warm to provide maximum comfort

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Answer to Question #1

D. The examination room is well lit and warm to provide maximum comfort Rationale: The best environment to perform an assessment is one that will provide the most comfort to the patient. The physical examination is usually performed after the health history is obtained. It is carried out in a well-lighted, warm area. The patient’s physical and psychological comfort are considered at all times. A comprehensive physical assessment is not always performed.

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Vital Signs!

Temperature

Oral Rectal Axillary Tympanic Temporal

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Body Temperature

• BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE BODY
• IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT PRODUCED AND THE AMOUNT OF HEAT LOST
• HEAT IS PRODUCED BY :

THE CONTRACTION OF MUSCLES DURING EXERCISE THE BREAKDOWN OF FOOD DURING DIGESTION THE ENVIRONMENTAL TEMPERATURE

• HEAT IS LOST THROUGH : URINE, RESPIRATIONS, FECES, and PERSPIRATION

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Vital Signs: Temperature

Temperature:

Influences

Types of Assessing Temperature

•Temporal (non-invasive)•Oral•Tympanic•Axillary•Rectal (Most invasive)

•Time of date variation (Lower in AM, highest in PM)•Exercise•Menstrual cycle•Fluids (Cold or hot)•Age

•Normal 96.4 -99.5 degrees Fahrenheit•Hypothermia: temperature below the normal range •Hyperthermia: temperature above the normal range

Vital Signs: Temperature Routes

The pulse is:the beat of the heart. It is felt at an artery as a wave of blood passes through the artery. A pulse is felt every time the heart beats.

PULSE

How the Heart Works

https://www.youtube.com/watch?v=TMdKp2zHgog

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Vital Signs: Peripheral Pulses

Peripheral Pulses:

•Normal 60-100 beats per minute•Pulse points (carotid, radial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries)•Bradycardia beats below 60/min•Tachycardia beats higher than 100/min

Influences

•exercise•age•gender•anxiety•Pain

Documentation

•Rhythm – even tempo •Strength (0-4+, absent, weak or thready, normal, strong, bounding)•Regular rhythm: 30 seconds x 2- or 15-seconds x 4•Irregular rhythm (regular/irregular); full minute; apical.•Amplitude is what is measured•Rate, rhythm (regular or irregular), and quality (strong, weak or bounding)

Pulse Sites

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Apical Pulse or Pulse of Maximal Impulse

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Vital Signs: Respiration & Pulse-Oximetry

Respiration Rate (RR):

Pulse-Oximetry:

•Normal 94-100%• Noninvasive •Estimate arterial oxygen saturation in blood•LED probe reflects off oxygenated/ deoxygenated Hgb for estimation of O2 percentage/pulse

•Normal 12-20 breaths per minute•Rhythm - even, regular•Depth – deep, moderate, shallow•Effort – labored vs. non-labored, use of accessory muscles, nasal flaring or body positioning?•Count 30 seconds X 2 or full minute (abnormal or infant)•Influences – exercise, anxiety

Survival depends on O 2 -CO 2 exchange in the body.

• Respiration is the mechanism the body uses to exchange gases between the atmosphere and the blood and the cells

Gas Exchange

• Definition: Oxygen transportation to the cell & carbon dioxide removal from the cell
• Ventilation = Inspiration
• Diffusion = Expiration
• Scope: Gas exchange can be normal or decreased.
• Normal = adequate perfusion and removal
• Decreased = inadequate gas exchange (minimal to severe.)

Gas Exchange

Risk Factors:

Requires proper function in different systems•Central nerve function•Musculoskeletal contraction•Intact Chest thorax•Diaphragm Function

Example of High-Risk Diseases

COPD CHFAsthma PneumoniaCancer/Abscess Cervical Spinal Cord InjurySmoking

Physiologic Consequences:

IschemiaNecrosis or InfarctionCarbonic Acid- Increase in acid can cause respiratory acidosis

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Gas Exchange Assessment & Interventions

Assessment:

Interventions for Maintenance

Interventions to Prevent & Promote

Proper hand washing to avoid respiratory illness.Smoking Cessation (prevents COPD and emphysema)Teach about exposure to TB or FLUVaccinations (prevents flu, pneumonia, etc.)Turn, Cough and use deep breath techniques.

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Complete health historyFocused or Problem based assessment (Assess RR, O2 sats, breathing patterns, effort, capillary refill, thoracic expansion and lung sounds)Collect specimens (ABGs, sputum culture, CBC)Ensure chest x-rays, chest computerized tomography (CT) and pulmonary ventilation and perfusion (V/Q) scan are performed.Pulmonary Function TestBronchoscopy

Determine the underlying causeRequires Immediate Attention (emergent)Administer oxygenMonitor pulse oximetry.Medications will be needed (antihistamine, decongestants, glucocorticoids, bronchodilators, mucolytics, & antimicrobials)Reposition patient in Semi-FowlersTeach about deep breathing (use an incentive spirometer)Coughing exerciseDeep Breathing Techniques

Signs/Symptoms of Hypoxia & Cyanosis

• Look for skin and mucosal tissue color changes.
• Determine Pulse-Oximetry.
• Identify oxygen method (Nasal cannula, room air, mask, etc.)
• Determine the cause
• Notify the provider as this is an emergency, especially cyanosis.
• Encourage breathing techniques (Pursed-Lip, Cough, Deep Breath, Reposition)

Gas Exchange Devices

• Nasal Cannula: Increases Airflow (28% O2). Mixture of air & Oxygen
• Venturi-Mask: Delivers up-to 60% of O2 controlled by the interchangeable adapter.
• Non-rebreather: Delivers up-to 100% & doesn’t allow the CO2 be rebreathed.
• C-Pap (Continuous Positive Airway Pressure), Bi-Pap (bilevel positive airway pressure):  CPAP therapy is considered the "gold standard" for treating obstructive sleep apnea (OSA). Bi-Pap are great to treat CHF and conditions with elevated CO2 levels.
• Ventilator: A machine that supports breathing.
• Get oxygen into the lungs.
• Remove carbon dioxide from the body. (Carbon dioxide is a waste gas that can be toxic.)
• Help people breathe easier.
• Breathe for people who have lost all ability to breathe on their own.

Perfusion

Definition: Adequate arterial blood flow to the peripheral tissue.•Peripheral perfusion = peripheral tissue•Central perfusion = Major organs

Scope: Ability of the heart to supply blood•Ischemia = Impaired Perfusion•Infarction = Tissue Death

Perfusion: Risk Factors & Physiologic Consequences

Risk Factors:

Physiologic Consequences: Mostly occur in the lower extremities

Modifiable = Can be changed. Ex. diet, activity, smoking or social habitsNon-modifiable = Cannot be changed. Ex. Age, genetics, race, gender

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Peripheral changes: Causes skin color changes (pale, cyanotic), diminish or absent pulses, wounds, and cell death (gangrene)Central changes: Could result in life-threatening consequences (Myocardial infarction –heart attack, shock- major organs failure, and stroke)

Perfusion Assessment & Interventions

Assessment:

Perform a complete patient and family historyIdentify signs and symptoms of central perfusion (dyspnea, syncope/dizziness, chest pain), decreased cardiac output (hypotension, tachycardia, diaphoresis, anxiety, decrease cognitive functions, dysrhythmias) and decrease peripheral perfusion ( decrease hair distribution, pallor, coolness, cyanosis)Document findings

Interventions to Prevent & Promote

Encourage changes to modifiable high risk (smoking cessation, nutritional balance).Provide education about the high-risk and importance of performing annual checks.

Interventions for Maintenance

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Educate about the importance of taking medications as prescribed and compliance.Procedural interventions could be needed (cardiac caths, bypass, etc.)

Respirations

• Place arm across the chest in a relaxed position. Observe one complete respiratory cycle. Look at second hand of watch, Begin count.
• If respirations are “normal” count for 30 seconds and multiply times 2 .
• If abnormal count for 1 minute.

Michelle A Weas

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Respirations

Rate: (normal = 12 -20) involves one complete inspiration and expiration

Depth: observation of the excursion or movement of the chest wall

Rhythm: regularity of respirations

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Respiratory Terms

• PNEA = breathing
• DYSPNEA (dys = difficult)
• EUPNEA (eu = normal)
• APNEA ( a = without)
• BRADYPNEA (brady = slow)
• TACHYPNEA (tachy = rapid, fast)
• ORTHOPNEA (ortho = straight)
• HYPOVENTILATION ( hypo = decreased)
• HYPERVENTILATION (hyper = increased)
• CHEYNE-STOKES (apnea & dyspnea)

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Blood Pressure

• https://www.youtube.com/watch?v=Ab9OZsDECZw
• https://www.youtube.com/watch?v=bHXvhOQ0hYc

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Blood Pressure

• THE MEASUREMENT OF THE AMOUNT OF FORCE THE BLOOD EXERTS AGAINST THE ARTERY WALLS.
• SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS CONTRACTING.
• DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS RELAXING BETWEEN BEATS.
• BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE ON THE BOTTOM.
• BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)

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Vital Signs: B/P

B/P:

Factors that affect B/P

Causes B/P Changes

B/P Cuff Sizing

•Width 40% Circumference•Bladder circle 80% of arm

•Normal values: 120/80•Systolic: Maximum pressure on the arteries.•Ventricles contract•Normal range: 90-120•Diastolic: Minimum pressure on the arteries. •Ventricles relaxes•Normal range: 60-80

•Age•Gender•Race•Diurnal variations•Emotions•Pain•Weight•Personal Habits•Wrong B/P Cuff•Too Large = False Hypotension•Too Small = False Hypertension

•Cardiac Output•Vascular Resistance (diameter, length, viscosity)•Volume•Elasticity of arterial walls•Dehydration = Hypotension•Ex. Diarrhea, elevated temperature.•Intervention: Vitals Signs initially will show increased HR and BP, I&O, Daily Weight, watch for signs

Rest and Sleep

• Why is rest and sleep necessary for bodily functions?
• What interventions can we use to promote rest and sleep to our patients? Educate clients the importance of getting a good night sleep.

• Insomnia – Client has trouble sleeping at night.
• Narcolepsy – excessively uncontrollable daytime sleepiness. Educate clients to not drive or use heavy machinery.
• Things that negatively affect sleep are a large meal right before bedtime, a stressful job and frequent travel & unfamiliar environment. What else could affect sleep?

Michelle A Weas

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Comfort

No Comfort

Nursing Role

Consequences

Definition of Comfort

Scope of Comfort

A primary role of the nurse is to promote basic care and comfort. HOW?

Comfort is a state of physical well-being, pleasure, and absence of pain or stress.

This definition implies that comfort has physical and emotional dimensions.

Michelle A Weas

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Reduce concentration and productivityIncreases obesityIncreases the risk for heart disease, Diabetes, stroke, depression and social interaction

Comfort Assessment & Interventions

• Assessment
• Assess level of comfort
• Assess pain level
• Identify emotional status
• Determine the underlying cause
• Interventions to Prevent & Promote
• Maintain a proper pain level
• Address any emotional stress before it escalate
• Ensure the patient is well-rested by creating a restful environment (clean linen, dark quiet room, etc.)
• Promote relaxation techniques (back rubs, guided imagery, etc.)
• Avoid caffeine, smoking and alcohol at bedtime.
• Provide a snack before bedtime
• Interventions for Maintenance
• Identify comfort level
• Implement treatment based on the need
• Involve the interdisciplinary team (Social worker, case manager, counselor, etc.)

Pain Concept

• Defined as “unpleasant sensory, emotional experience with actual or potential tissue damage”
• Personal and subjective experience
• Patient is the most reliable indicator of pain and essential component of pain assessment
• Most common reason for seeking health care

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Pain

• Pain means to ache, hurt, or be sore.
• Pain is a warning from the body.
• Pain is personal.

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Care of Patients with Pain

Requires a collaborative approach

Must be evidence-based and comprehensive

Refer to Chart 9-8

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Nursing Process Framework for Pain Management

Identify goals for pain management Establish nurse–patient relationship, teaching Provide physical care Manage anxiety related to pain Evaluate pain management strategies

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Types and Categories of Pain

• Acute pain involves tissue damage as a result of surgery, trauma, burn, or venipuncture, and is expected to have a relatively short duration and resolve with normal healing.

• Chronic or persistent pain is subcategorized as being of cancer or noncancer origin and can persist throughout the course of a person’s life. Examples of noncancer chronic pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.

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Nociceptive PainNociception includes four specific processes: transduction, transmission, perception, and modulation (Ellison, 2017).

Modulation

Perception

Transduction

Transmission

https://www.youtube.com/watch?v=28MNAaiEyP4

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Neuropathic (pathophysiologic) pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the peripheral or central nervous system (CNS) or both (IASP, 2017).

Neuropathic (pathophysiologic) pain

Pain Types

• Cutaneous pain: Arises from burning your skin like on a hot iron or from touching a hot pan on the stove.
• Visceral pain: Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections.
• Deep Somatic pain: Musculoskeletal Pain. Originates from the ligaments, tendons, nerves, blood vessels and bones. Examples would be fractures or sprains.
• Radiating pain: Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head.
• Referred pain: Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw.
• Phantom pain: Pain that is perceived from an area that has been surgically or traumatically removed. Example: pain from an amputated limb.
• Neuropathic pain: Results from an injury of one or more nerves.
• Acute pain: Short duration, rapid onset, and associated with some kind of injury.
• Chronic pain: Last 6 months or longer and interferes with activities of daily living.

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Pain Assessment: Collection of Data

Quality and Safety Nursing Alert Although accepting and responding to the report of pain may result in administering analgesic agents to an occasional patient who does not have pain, doing so helps to ensure that everyone who does have pain receives appropriate care. Health care professionals do not have the right to deprive any patient of appropriate assessment and treatment simply because they believe a patient is not being truthful. Pain is an extremely personal experience manifested uniquely by each person. It is important to carefully assess and reassess pain when administering analgesic medications.

• Subjective Data:
• Patient description of symptoms is the most reliable information.
• Individuals react to pain differently ---“Do not assume”

• Location of pain and whether it radiates or is referred to other areas of the body • Intensity of pain using one of several valid and reliable pain assessment tools • Quality of pain (such as burning, stabbing, and sharp in patient’s own words) • Onset and duration of pain • Aggravating or precipitating factors that cause pain • Effects of pain on quality of life and daily function • Psychosocial effects of pain (such as anxiety, fear, and depression)

Pain Assessment: Rating

• Step 1. Show the pain rating scale to the patient and family and explain its primary purpose.
• Step 2. Explain the parts of the pain rating scale. If the patient does not like it or understand it, switch to another scale (e.g., vertical presentation, VDS, or FACES).
• Step 3. Discuss pain as a broad concept that is not restricted to a severe and intolerable sensation.
• Step 4. Verify that the patient understands the broad concept of pain. Ask the patient to mention two examples of pain that he or she has experienced. If the patient is already in pain that requires treatment, use the present situation as the example.
• Step 5. Ask the patient to practice using the pain rating scale with the present pain or select one of the examples mentioned.
• Step 6. Set goals for comfort and function/recovery/quality of life. Ask patients which pain rating would be acceptable or satisfactory, considering the activities required for recovery or for maintaining a satisfactory quality of life.

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Pain Management

Effective and safe analgesia

Optimal relief

Comfort function goal

Responsibility of all members of the health care team

Pharmacologic: multimodal

Routes and dosing

Patient-controlled analgesia (PCA)

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Nonpharmacologic Methods

Natural products

• Herbs, botanicals, vitamins, probiotics

Mind and body practices

• Acupuncture, chiropractic manipulation, massage therapy, yoga, tai chi

Refer to Table 9-5

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Alternative therapies:

Alternative therapies are used instead of medical treatment. Examples:

• Maintaining appointment with the massage therapist instead of following up with recommended treatments for chronic pain.
• Refusing antibiotics using only “cupping” for pneumonia
• Utilizing lavender instead of using Ativan for anxiety

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Complimentary medicine

Any of a range of medical therapies that fall beyond the scope of scientific medicine but may be use alongside it in the treatment of disease and ill health. Examples: The use of diet and exercise in conjunction with the recommended cholesterol-lowering medication The use of needles in specific healing points throughout the body (acupuncture) are used in conjunction with the recommended cholesterol-lowering medication.

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Herbal Product

Aloe promotes wound healing

Echinacea enhances immunity

Ginseng increases physical endurance

Nonpharmacological Nursing Interventions

Exercise

Non-pharmacological interventions for an ankle sprain is RICE : Rest, ice, compress & elevate

Meditation

Relaxation techniques

Cutaneous stimulation

•Warm and cold therapies•Reposition•Rubs

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Physiologic Basis for Pain Relief Pharmacologic Interventions

• Opioid analgesics act on the CNS to inhibit activity of ascending nociceptive pathways
• NSAIDs decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)
• Local anesthetics block nerve conduction when applied to nerve fibers

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Pharmacological Nursing Interventions

NSAIDS

Opioids

PCAIMTransdermalEpidural

When administering oral pain medication be sure to reevaluate the client’s pain withing 30 to 60 minutes to evaluate the effectiveness.

Analgesic Agents

• Nonopioid
• Acetaminophen
• NSAIDs: ibuprofen, naproxen, celecoxib
• Opioid
• Mu agonist: Morphine, hydromorphone, fentanyl, oxycodone
• Agonist–antagonist: buprenorphine, nalbuphine, butorphanol

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Narcotics

• https://ed.ted.com/lessons/what-causes-opioid-addiction-and-why-is-it-so-tough-to-combat-mike-davis

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Adverse Effects of Analgesic Agents

Sedation

Nausea, vomiting

Respiratory depression

Pruritis

Constipation

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Adjunctive Analgesics

Local anesthetics

•Lidocaine patch 5%

Anticonvulsants

•Gabapentin, pregabalin

Antidepressants

•TCAs: desipramine, nortriptyline•SNRIs: duloxetine, venlafaxine

Ketamine

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Opioid Physical Dependence and Tolerance

Physical dependence:

Normal response with opioid use of 2 weeks or more

Manifested by withdrawal symptoms

Tolerance:

Decrease in one or more of the effects

Normal response with regular use of opioid

Increased usage needed to effect pain relief

Refer to Chart 9-5

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Substance Use Disorder

Impaired control over use

Continued use despite harm

Impaired use of a substance, even while experiencing major problems

Craving for the substance

Use of opioid for nontherapeutic reasons; independent of pain relief

Influenced by genetic, psychosocial, and environmental factors

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Gerontologic Considerations

• Sensitive to agents that produce sedation and CNS effects
• Initiate with low dose and titrate slowly
• Increased risk for NSAID-induced GI toxicity
• Acetaminophen preferred for mild pain
• Opioid dose should be reduced 25% to 50%

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Answer to Question #1

True Rationale: At a minimum, pain should be reassessed with each new report of pain, and before, and after the administration of analgesic agents. General rules include, if the medication is parenteral administration reassess between 15 and 30 minutes, if oral administration reassess between 1 and 2 hours.

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Question #2

Is the following statement true or false?

Using a placebo to treat pain is acceptable in patients with a history of opioid use disorder.

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Answer to Question #2

False Rationale: Pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that there are no individuals for whom and no condition for which placebos are the recommended treatment.

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Question #3

Is the following statement true or false? Nonpharmacologic pain therapies can be a replacement for pharmacologic therapies used for severe pain.

ADD A FOOTER

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Answer to Question #3

False Rationale: Nonpharmacologic therapies are usually effective alone for mild to some moderate-intensity pain. They should not be a replacement or alternative but a complement to pharmacologic therapies as part of a multimodal approach for more severe pain.

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Let’s talk Nutrition

Nutrition is important to maintain health and to prevent disease and premature death.

Understanding the physiology of digestion, importance of healthy eating patterns, and the nutritional value of food allows nurses to promote the nutritional intake of their clients.

Digestion and Nutrition

Nutrition

Risk Factors:

•Familial predisposition or genetic risk•High stress level•Depression and social isolation, especially among older adults•Consuming fad diets that do not provide adequate nutrients•Obesity•Substance use•Lack of money to purchase food•Impaired food intake caused by dysphagia, poor appetite, or poor oral health•Thyroid disorders•Chronic diseases such as chronic obstructive pulmonary disease (COPD) and cancer•Gastrointestinal (GI) distress such as excessive diarrhea or vomiting•Anorexia or bulimia nervosa

Physiologic Consequences: Decreased nutritional levels can have negative impact in the overall health.

•Delay wound healing: Due to decrease protein•Osteoporosis: Decrease vitamin D and calcium•Anemia- due to iron deficiency•Vascular consequences: Decrease protein level can cause osmotic pull to keep fluid in the vascular space, causing edema•Aspiration Risk (Elderly, Stroke, dementia, Alzheimer, Parkinson)

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Nutrition Assessment & Interventions

Assessment

•Conduct a complete patient and family history for risk factors•Ask about current or recent GI symptoms such as nausea, vomiting, constipation, and diarrhea. •Obtain the patient's height and weight and calculate body mass index (BMI). •Assess the patient's skin, hair, and nails. •Serum laboratory testing depends on which nutrients are inadequate.

Interventions to Prevent & Promote

•Healthy lifestyle that includes regular exercise and adequate nutrients•Promote optimal nutrition•BMI between 19 and 24.9. •Educate about avoiding high-calorie, high-fat foods with no nutritive value. •Collaborate with the interprofessional team to implement the appropriate interventions.

Interventions for Maintenance

•Collaborative interventions to improve nutrition depend on the cause of decreased nutrition. •Include high-protein oral supplements, enteral supplements (either oral or by feeding tube), or parenteral nutrition. •Collaborate with the registered dietitian for specific instructions regarding enteral feedings; consult with the pharmacist to administer parenteral therapy. •Drug therapy •Weight the patient at least once a week or as prescribed, using the same scale at the same time of day and preferably before breakfast.•Patients experiencing obesity may be prescribed drug therapy to help them lose weight or bariatric surgical

Nutrition

• A regular diet is one that consists of healthy foods coming from all of the food groups.
• A soft diet contains foods that are soft and easy to digest as well as swallow.
• A pureed diet consists of foods that do not need to be chewed.
• A full liquid diet is a diet that only contains fluids, foods that are liquids, and foods that are liquids at room temperature.
• A clear liquid diet only contains clear liquids such as broth, gelatin, and water.

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Types of Nutrition

Mouth/Oral•Through the oral cavity•Regular, cardiac, blend, clear liquid, full liquid, cardiac, diabetic, renal, etc.

Enteral•NGT, NJT, PEG, G-Tube, •Specific formulas depending on the patient’s need

Parenteral•IV through a Central Line•Partial or Complete

The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health.

Obesity is a major concern for children, adolescents, and adults in the United States and globally.

There are no BIG BONED people!!

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Obesity and being overweight are leading risk factors for global deaths; most of the world’s population lives in countries where overweight and obesity kill more people than underweight. In addition, coronary artery disease, diabetes, musculoskeletal disorders, and certain cancers can be attributable to obesity.

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Lifespan Considerations

Adolescents

• Critical growth, obesity rising concern
• Females—iron, folate, calcium

Older adults

• Mini Nutritional Assessment (MNA)
• Refer to Chart 4-5

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AdolescentsAdolescence is a time of critical growth and when lifelong eating and exercise habits are established.

• Adolescents gain 40% of their adult weight and 15% of their adult height during this developmental stage of life (Lassi, Moin, & Bhutta, 2017).

• Adolescent girls should consume approximately 1400 to 2400 calories daily; whereas adolescent boys require between 1600 to 3200 calories each day to support their greater growth needs in terms of both overall size and muscle mass. Athletes of either gender may need to consume up to 5000 calories daily to support their metabolic demands.

• Adolescents of both genders are at risk for behavioral eating disorders, such as anorexia, bulimia, and binge-eating disorders, although girls are at greater risk (Lassi et al., 2017).

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Older Adults

• Older adults are particularly at high risk for poor nutrition due to factors that may include social isolation, frailty, cognitive impairment, polypharmacy (i.e., use of multiple prescription and OTC medications), reduced functional status, and financial instability (Astrup & O’Connor, 2018).

• Polypharmacy also may place older adults at risk nutritionally. The number of adverse reactions increases proportionately with the number of medications taken.

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Nutritional Assessment

• The sequence of the assessment may vary; however, evaluation of a patient’s nutritional status includes the use of one or more of the following methods: measurement of body mass index (BMI) and waist circumference, biochemical assessment, clinical examination findings, and dietary data. Measurement of BMI and waist circumference is recommended to determine whether a patient has obesity (CDC, 2019a).

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Components of Nutritional Assessment

• Body mass index (BMI)
• Waist circumference
• Biochemical measurements
• Clinical findings
• Dietary data

Presentation title

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Body Mass Index

BMI is ratio based on body weight and height (Table 4-1)

Compared to standards but trends are more useful than isolated measurements

BMI less than 18.5 = increased risk of problems associated with poor nutrition

BMI of 30 or more = considered obese

Must take ethnicity into account

BMI between 25 and 29.9 = considered overweight

Presentation title

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Body Mass Index, Ideal Weight, and Waist Circumference

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Waist Circumference

Excess abdominal fat

•Males—greater than 40 inches•Females—greater than 35 inches

High waist circumferences put patients at risk for diabetes, dyslipidemia, hypertension, heart attack, and stroke

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The Mini Nutritional Assessment is a commonly used, well-validated tool developed specifically for this purpose (Chart 4:5

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Components of Nutritional Assessment

• Biochemical Assessment
• Tests of serum and urine are done to determine whether the values are within an acceptable range. Some of these tests, while reflecting recent intake of the elements detected, can also identify a long-term deficiency (below-normal levels) even when there are no clinical symptoms of deficiency.

• Clinical Examination
• The state of nutrition is often reflected in a person’s appearance. Although the most obvious physical sign of good nutrition is a normal body weight with respect to height, body frame, and age, other tissues can serve as indicators of general nutritional status and adequate intake of specific nutrients; these include the hair, skin, teeth, gums, mucous membranes, mouth and tongue, skeletal muscles, abdomen, lower extremities, and thyroid gland (Table 4-2).

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Biochemical Assessment

Serum prealbumin and albumin

Serum transferrin and retinol-binding protein

Complete blood count

Electrolytes

Urine tests

Presentation title

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Clinical Examination

Indicators of nutritional status

• General appearance (height/weight)
• Skin, hair, nails
• Mouth—includes teeth, tongue, gums
• Mucous membranes
• Neck—includes thyroid
• Musculoskeletal
• Abdomen
• Refer to Table 4-2

Presentation title

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Dietary Data

Food record

24-hour food recall

Conducting dietary interview

Religious, cultural considerations

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Evaluation of Data

Collaborative approach Compare food intake with dietary guidelines (refer to Fig. 4-5) Fat intake and cholesterol levels

ADD A FOOTER

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Hospitalization Physical problems or limitations Limited fixed incomes Cultural influence Medications

Factors That Influence Nutrition

Question #2

The nurse is caring for a patient whose BMI is 32. Based on this assessment finding, what should the nurse do first?

1. Refer the patient to a dietitian so that a meal plan can be created
2. Ask the primary care provider if a cholesterol-lowering medication might help
3. Assess the patient’s dietary intake, using a 24-hour food recall
4. Reassess the patient’s BMI in 6 months

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Answer to Question #2

C. Assess the patient’s dietary intake, using a 24-hour food recall Rationale: The patient’s BMI level classifies the patient as obese. Further assessment is needed, and a food recall is an appropriate assessment. Referral to a dietitian is an intervention and may be indicated at some point but not first. The nurse does not have enough information to determine the patient’s need for cholesterol-lowering medication, and the BMI is high enough that further assessment and intervention are needed now and not in 6 months.

Presentation title

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Cultural, Ethnic, and Religious Considerations

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Cultural Assessment

A systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices.

Self-assessment of one’s own cultural bias

Cultural assessment tool (refer to Chart 4-7)

Cultural preferences

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Question #3

The nurse is caring for a patient that has a language barrier. Which is the most appropriate way for the nurse to communicate with this patient?

Speak loudly so the patient can hear the words clearly

Do not have them repeat instructions because it may be too difficult

Use a short, simple sentence structure, and speak in an active voice

Talk to the patient and the person who accompanies them so that maybe one of them will understand what is being said

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Answer to Question #3

D. Use a short, simple sentence structure, and speak in an active voice Rationale: Nurses should use a short, simple sentence structure and speak in an active voice—questions and instructions should be phrased so they are easily understandable. The nurse should always speak to the patient directly and should ask the patient to repeat the instructions.

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Urinary Disorders

The micturition (voiding or urination) process involves several highly coordinated neurologic responses that mediate bladder function.

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Urinary Incontinence

Urinary Incontinence

Caregiver or toilet unavailable

Age-related changes in the urinary tract

Class III obesity (also called extreme or severe obesity)

Cognitive disturbances—dementia, Parkinson’s disease

Immobility

•High-impact exercise

Diabetes •Genitourinary surgery

Medications—diuretic, sedative, hypnotic, and opioid agents

Incompetent urethra due to trauma or sphincter relaxation

Menopause

Stroke

Pelvic muscle weakness

Pregnancy—vaginal delivery, episiotomy

Presentation title

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Urinary Incontinence

Functional incontinence

Stress incontinence

Iatrogenic incontinence

Overflow incontinence

Urge incontinence

Transient Incontinence

Mixed incontinence

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Strategies for Promoting Urinary Continence

•Avoid bladder irritants, such as caffeine, alcohol, and artificial sweeteners such as aspartame (NutraSweet). •Avoid taking diuretic agents after 4 PM. •Increase awareness of the amount and timing of all fluid intake. •Perform all pelvic floor muscle exercises as prescribed, every day. •Stop smoking (smokers usually cough frequently, which increases incontinence). •Take steps to avoid constipation: Drink adequate fluids, eat a well-balanced diet high in fiber, exercise regularly, and take stool softeners if recommended. •Void regularly, five to eight times a day (about every 2 to 3 hours): •First thing in the morning •Before each meal •Before retiring to bed •Once during the night if necessary

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Patient Education for Urinary Incontinence

• Urinary incontinence is not inevitable and is treatable
• Management takes time (provide encouragement and support)
• Education verbally and in writing
• Develop and use a voiding log or diary
• Behavioral interventions
• Medication education related to pharmacologic therapy
• Strategies for promoting continence

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Question

Is the following statement true or false?

Urinary incontinence is a normal consequence of aging.

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Answer

False Rationale: Urinary incontinence is not a normal consequence of aging. However, age-related changes in the urinary tract do predispose the older person to incontinence. Nurses must listen to patients and provide teaching on strategies to help manage urinary incontinence in older adults.

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Urinary Retention

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Urinary Retention

Inability of the bladder to empty completely

Adults 60 years and older may have 50 to 100 mL of residual urine remaining in the bladder after voiding

Residual urine: amount of urine left in the bladder after voiding

Postoperative spasms

Causes include:

Diabetes, prostatic enlargement, urethral pathology, trauma, pregnancy, neurologic disorder

Medications

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Question

Is the following statement true or false?

Voiding at least every 2 to 3 hours is a strategy to promote urinary continence.

ADD A FOOTER

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Answer

True Rationale: Voiding regularly, five to eight times a day (about every 2 to 3 hours) such as first thing in the morning, before each meal, before retiring to bed and once during the night if necessary, is a strategy to promote urinary continence.

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FECAL ELIMINATION

What is the Scoop on poop??

Constipation

Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass

Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise

Perceived constipation: a subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal

ADD A FOOTER

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Manifestations of Constipation

Fewer than three bowel movements per week Abdominal distention, pain, and bloating A sensation of incomplete evacuation Straining at stool Elimination of small-volume, hard, dry stools

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Assessment and Diagnostic Findings of Constipation

• Chronic constipation is usually idiopathic
• Further testing for severe, intractable constipation
• Thorough history and physical examination
• Barium enema, sigmoidoscopy, and stool testing
• Defecography and colonic transit studies
• MRI

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Complications of Constipation

Decreased cardiac output

Fecal impaction

Hemorrhoids

Fissures

Rectal prolapse

Megacolon

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Constipation

• There are four classes of constipation…
• Functional constipation
• Slow-transit constipation
• Defecatory disorder
• Opioid-induced constipation

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Patient Learning Needs for Constipation

• Refer to Chart 41-2
• Normal variations of bowel patterns
• Establishment of normal pattern
• Dietary fiber and fluid intake
• Responding to the urge to defecate
• Exercise and activity
• Laxative use

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Diarrhea

• Increased frequency of bowel movements (more than three per day) with altered consistency (i.e., increased liquidity) of stool
• Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors
• May be acute, persistent, or chronic
• Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

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Manifestations of Diarrhea

• Increased frequency and fluid content of stools
• Abdominal cramps
• Distention
• Borborygmus
• Anorexia and thirst
• Painful spasmodic contractions of the anus
• Tenesmus

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Diarrhea

• Acute and persistent diarrheas are classified as either noninflammatory (large-volume) or inflammatory (small-volume). Enteric pathogens that are noninvasive (e.g., S. aureus, Giardia) do not cause inflammation but secrete toxins that disrupt colonic fluid transport. They cause noninflammatory diarrhea, which is characterized by a large volume of loose, watery stools. Other pathogens that invade the intestinal mucosa and cause inflammatory changes typically result in smaller volumes of stool that is bloody (e.g., dysentery). Organisms implicated may include Shigella, Salmonella, and Yersinia species (Norris, 2019).

• Assessment and Diagnostic Findings
• Assessment and Diagnostic Findings
• Gerontologic Considerations
• Medical Management
• Nursing Management
• https://www.youtube.com/watch?v=uyP0YcxZKNo

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Assessment and Diagnostic Findings of Diarrhea

• CBC
• Serum chemistries
• Urinalysis
• Stool examination
• Endoscopy or barium enema

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Complications of Diarrhea

Fluid and electrolyte imbalances Dehydration Cardiac dysrhythmias Chronic diarrhea can result in skin care issues related to irritant dermatitis

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Patient Learning Needs for Diarrhea

Recognition of need for medical treatment

Rest

Diet and fluid intake

Avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods

Perianal skin care

Medications

May need to avoid milk, fat, whole grains, fresh fruit, and vegetables

Lactose intolerance

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Clostridioides difficile

• Clostridioides difficile (klos-TRID-e-oi-deez dif-uh-SEEL) is a bacterium that causes an infection of the colon, the longest part of the large intestine. Symptoms can range from diarrhea to life-threatening damage to the colon. The bacterium is often called C. difficile or C. diff.
• Illness from C. difficile often occurs after using antibiotic medicines. It mostly affects older adults in hospitals or in long-term care settings. People not in care settings or hospitals also can get C. difficile infection. Some strains of the bacterium that can cause serious infections are more likely to affect younger people.
• The bacterium used to be called Clostridium (klos-TRID-e-um) difficile.

Presentation title

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Fecal Incontinence

• Fecal incontinence has many causes and risk factors and may be a symptom of an underlying condition. In general, it results from conditions that interrupt or disrupt the structure or function of the anorectal unit.

Fecal incontinence

• inadvertent bowel leakage describes the recurrent involuntary passage of stool from the rectum for at least 3 months

• Medical management of fecal incontinence is directed at correcting the underlying cause.
• The nurse initiates a bowel training program that involves setting a schedule to establish bowel regularity. The goal is to help the patient achieve fecal continence.
• Fecal incontinence can disrupt perineal skin integrity. Maintaining skin integrity is a priority, especially in the debilitated or older adult patient.

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Fecal Incontinence: Causes

• Anal sphincter weakness
• Traumatic (e.g., after surgical procedures involving the rectum) and nontraumatic (e.g., scleroderma)
• Neuropathies both peripheral (e.g., pudendal) and generalized (e.g., diabetes)
• Disorders of the pelvic floor (e.g., rectal prolapse)
• Inflammation (radiation proctitis, IBD)
• Central nervous system disorders (e.g., dementia, stroke, spinal cord injury, multiple sclerosis)
• Diarrhea; fecal impaction with overflow
• Behavioral disorders

Presentation title

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Manifestations of Fecal Incontinence

Minor soiling Occasional urgency Loss of control Complete incontinence

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Assessment and Diagnostic Findings of Fecal Incontinence

• History to determine etiology
• Rectal examination
• Endoscopic examinations
• Radiography studies
• Barium enema
• CT
• Anorectal manometry

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Patient Learning Needs for Fecal Incontinence

• Bowel training program
• Skin care
• Emotional support

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Irritable Bowel Syndrome

• Chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation, or both
• 15% of adults in the United States report symptoms of IBS; More common in women than men
• Triggers: chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods

Presentation title

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Clinical Manifestations of Irritable Bowel Syndrome

Alteration in bowel patterns Pain Bloating Abdominal distention

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Assessment and Diagnostic Findings of Irritable Bowel Syndrome

Stool studies

Proctoscopy

Barium enema

Contrast radiography studies

Colonoscopy

Manometry

Electromyography

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IBS

Patient Learning Needs for Irritable Bowel Syndrome

Medication management

Complimentary medicine

Dietary changes

Food diary

Adequate fluid intake

Avoid alcohol and smoking

Relaxation techniques

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Malabsorption

The inability of the digestive system to absorb one or more of the major vitamins, minerals, or nutrients

Conditions

Infectious disease

Luminal disorders

Mucosal (transport) disorders

Postoperative malabsorption

Disorders that cause malabsorption of specific nutrients

ADD A FOOTER

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Clinical Manifestations of Malabsorption

• Hallmark finding is diarrhea or frequent, loose, bulky, foul-smelling stools, high-fat content, and often grayish
• Symptoms similar to irritable bowel syndrome
• Manifested by weight loss and vitamin and mineral deficiency

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Assessment and Diagnostic Findings of Malabsorption

Fat analysis

Lactose tolerance tests

D-xylose absorption tests

Schilling tests

Hydrogen breath test

Endoscopy with biopsy

Ultrasound, CT, radiography

CBC, pancreatic function tests

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Patient Learning Needs for Malabsorption

Probiotics

Vitamin replacement

Dietary therapy

Risk of osteoporosis

Consider fluid and electrolyte imbalance

155

Question

Which is an example of a laxative osmotic agent?

1. Bisacodyl
2. Ducosate
3. Magnesium hydroxide
4. Polyethylene glycol and electrolytes

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Answer

D. Polyethylene glycol and electrolytes

Rationale: Polyethylene glycol and electrolytes is an osmotic agent. Bisacodyl is a stimulant laxative. Ducosate is an emollient stool softener. Magnesium hydroxide is a saline agent.

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Promote self-determination and Autonomy

• Allow the client to complete task and skills themselves if able
• Provide the needed tools for them to complete the skills and tasks.
• Educate clients to check their feet daily to reduce the risk of developing infections.
• Delegation: Right task, Right person, right circumstances, right direction/communication and the right supervision/evaluation

Presentation title

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Question 1

• The nurse is caring for an older adult client who smokes and does not exercise. Which finding requires immediate further nursing assessment?
• BMI of 35
• Temperature 99° F
• Cool, pale feet
• Respirations 20 breaths/min

Copyright © 2018 Elsevier Inc. All rights reserved.

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Question 2

• The nurse is caring for a client who has experienced numerous recent hospital admissions due to chronic obstructive pulmonary disease (COPD). Which client statement required nursing intervention?
• “I use an incentive spirometer often.”
• “I will avoid getting a flu shot.”
• “I quit smoking two months ago.”
• “I know it is important to use my home oxygen.”

Copyright © 2018 Elsevier Inc. All rights reserved.

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Question 3

Which action by the nurse might be a barrier to obtaining complete and reliable information from an interview with the client?

1. Nothing that the client’s body language indicates that he or she is fatigued
2. Maintaining eye contact with the client if it is not culturally inappropriate to do so
3. Carefully guiding the conversation so that important topics are discussed
4. Asking the client directly, “Why are you not taking your insulin?”

Presentation title

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Question 4

• A client tells the nurse, “I just don’t feel like being sexually intimate with my partner anymore.” What is the appropriate nursing response?
• “How often do you expect to have sex?”
• “Do you not find your partner attractive?”
• “Would you consider seeing a mental health professional?”
• “Have you experienced pain or difficulty with intercourse?”

Copyright © 2021, Elsevier Inc. All Rights Reserved.

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Question 5

• The nurse is caring for four clients. Which individual does the nurse identify at highest risk for a cognitive concern?
• 29-year-old with the common cold and an ankle fracture
• 40-year-old who just received a tetanus immunization after stepping on a rusty nail
• 59-year old with diabetes who is meeting with the registered dietician nutritionist (RDN)
• 71-year-old who drinks 6 beers daily and had surgery under general anesthesia this morning

Copyright © 2021, Elsevier Inc. All Rights Reserved.

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Ignatavicius, D., Workman, M. L. (2020). Medical-Surgical Nursing, 10th Edition. Elsevier. Nursing Nerds Tumbler: https://nursingnerds.tumblr.com/?og=1 Pictures: Google images, Unsplash.com, Pixabay.com Zerwekh, J., Claborn, J. C., Gaglione, T., Miller, C. & Garneau, A. (2009). Mosby memory Cards 2nd ed. St. Louis, MO: Elseiver Rebar, C., Ignatavicius, D., Workman, M. L. (2018). Medical-surgical nursing: Concepts for Interprofessional collaborative care, 9th ed. St. Loius, MO: Elsevier Pictures: Zerwekh, J., Claborn, J. C., Gaglione, T., Miller, C. & Garneau, A. (2009). Mosby memory Cards 2nd ed. St. Louis, MO: Elseiver Nursing Nerds Tumbler: https://nursingnerds.tumblr.com/?og=1 Wilkinson, J. M. (2019). Fundamentals of Nursing (Two Volume Set) (4th ed.). F. A. Davis Company. https://ambassadored.vitalsource.com/books/9781719642132 Hinkle, J. L., Cheever, K. H., & Overbaugh, K. (2021). Lippincott CoursePoint Enhanced for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 15th Edition. Vitalsource Bookshelf Online. https://coursepoint.vitalsource.com/reader/books/9781975186722

References