HEMODIALYSIS AND PERITONEAL DIALYSIS

● Definition
Removal of unwanted and excessive substances from blood by means of
semipermeable membrane.
● Functions of dialysis
◯ Rids the body of excess fluid and electrolytes
◯ Achieves acid-base balance
◯ Eliminates waste products
◯ Dialysis can sustain life for clients who have both acute and chronic renal failure.
◯ Dialysis does not replace the hormonal functions of the kidneys.

● Principles of dialysis)
Restores internal homeostasis by osmosis, diffusion, and ultrafiltration
● Types
Two types of dialysis are hemodialysis and peritoneal dialysis.
1. Hemodialysis
2. Peritoneal dialysis

Hemodialysis
Definition
● Hemodialysis shunts the client’s blood from the body through a dialyzer and back
into circulation. Vascular access is needed for hemodialysis.

● Indications
◯ Diagnosis
■ Renal insufficiency
■ Acute kidney injury
■ Chronic kidney disease
■ Drug overdose
■ Persistent hyperkalemia (refractory)
■ Acidosis (refractory)
 ■ Hypervolemia unresponsive to diuretics (refractory)
■ Elevated urea
■ Pericarditis
■ Encephalopathy
■ Edema (pulmonary)
◯ Client Manifestations
■ Related to fluid volume changes, electrolyte and pH imbalances, and nitrogenous
wastes.
■ Hemodialysis is based on symptoms, not glomerular filtration rate (GRF).
■ Client symptoms include fluid overload, neurological changes, bleeding, or signs of
uremia.

● Contraindications
■ Cardiac diseases
■ Septicaemia
■ Anemia

● How to Write Dialysis Orders (MUST BE INDIVIDUALIZED)

• Filter Type (e.g. F80)
• Length (e.g. 4h 3 times/wk or 2h daily)
• Q Blood Flow (Max 500 cc/min)
• Ultrafiltration (e.g. 2L or to target dry weight)
• Na+ 140 (can be adjusted by starting at 155 and "ramping" down to minimize cramping)
• K+ (based on serum [K+J) Serum K+ Dialysate 4-6 1.5 3.5-4 2.5 < 3.5 3.5
• Ca2+ 1.25 • HC03- 40
• Heparin (none, tight [500 U!h] or lull [1000 U/h])
• IV fluid to support BP (e.g. N/S)
Peritoneal Dialysis vs. Hemodialysis
Peritoneal Dialysis Hemodialysis
Rate Slow Fast

Location Home Hospital (usually)

Ultrafiltration Osmotic pressure via dextrose Hydrostatic pressure

dialysate
Solute Concentration gradient and
Removal Concentration gradient and convection
convection
Membrane Semi-permeable artificial membrane
Peritoneum
Method line from vessel to artificial kidney
Indwelling catheter in peritoneal
Complications cavity Vascular access (clots, collapse)

Infection at catheter site Bacteremia

Bacterial peritonitis Bleeding due to heparin

Metabolic effects of glucose Hemodynamic stress of

Difficult to achieve adequate
clearance in patients with large
body mass
extracorporeal circuit Disequilibrium
syndrome (headache, cerebral
edema, hypotension, nausea, muscle
cramps related to solute/water flux
over short time)

Preferred Young, high functioning, residual Bed-bound, co-morbidities, no renal

When renal function function
Success depends on presence of Residual renal function not as
residual renal function important

● Procedure
 Duration- 4-6 hours
 Frequency- 3 times / week
 Drugs used during procedure - Heparin
 Drugs withheld during procedure – Digoxin, Antihypertensive
 Needle size- 15 gauze
 Access for hemodialysis
1. Subclavian vein and femoral vein catheterization
Max for 6 weeks in emergency condition till the maturation of fistula.

2. Ext AV shunt
Access is created by surgical insertion of two silicon cannulas, 1 into large artery
and other 1 into large vein
Blood taken for dialysis through artery and goes back into vein
Both cannulas are connected by v shaped rubber tube during dialysis.
a. Radial artery and cephalic vein
b. Brachial artery and basalic vein
3. Int Av fistula
Access of choice
End to end anastomosis in non-dominant hand
End of vein anastomosis with side of an artery
Maturation time- 1-2 weeks

4. Int AV graft
Graft used for connection b/w artery and veinCow carotid artery
Polytetrafluroethylene tube
Maturation time- 1-2 weeks
  Dialyzer-
A plastic chamber
2 compartments
Act as a kidney
Surface area= 1.5-2.0 meter square
Semipermeable membrane made up of 8-10000 cellulose fibers
Blood flow rate = 250-500 ml/ min
Dialysate flow rate -500-800 ml / min (Both in opposite direction)

 Dialysate
Temperature =35-37 c
Solution is a mixture of H2o, hco3-, ca+2, k+, cl- na+ etc

● Preprocedure Nursing Actions

■ Check for an informed consent.
■ Use the temporary hemodialysis dual- or triple-lumen catheter, or subcutaneous device
until a long-term device is inserted and available for access.
■ Assess patency of a long-term device – arteriovenous (AV) fistula, or arteriovenous graft
(presence of bruit, palpable thrill, distal pulses, and circulation).
■ Avoid taking blood pressure, administering injections, performing venipunctures or
inserting IV lines on an arm with an access site.
Elevate the extremity following surgical development of AV fistula to reduce swelling.
■ Assess vital signs, laboratory values (BUN, serum creatinine, electrolytes etc.) and weight.
■ Discuss with the provider medications that need to be withheld until after dialysis.
Dialyzable medications and medications that lower blood pressure are withheld.
◯ Client Education
■ Advise the client that hemodialysis is usually done three times per week, for 4- to 6-hr
sessions. Two needles are inserted, one into an artery and the other into a vein.

● Intraprocedure Nursing Actions

■ Monitor for complications during dialysis.

☐ Dialysis circuit clotting, air bubbles in blood tubing,

Temperature of the dialysate (37.8° C [100° F]),

☐ Hypotension, cramping, vomiting, bleeding at the access site, contamination

of equipment.
■ Monitor vital signs and coagulation studies during dialysis.
Monitor for bleeding, such as oozing from insertion site.

☐ Administer anticoagulants as prescribed.

☐ Heparin is used to prevent clotting of the blood with foreign surfaces.

■ Have protamine sulfate ready to reverse heparin if needed.
■ Offer activities, such as books, magazines, music, cards, or television, to occupy the client.

◯ Client Education
■ Advise the client to notify the nurse of headache, nausea, or dizziness during dialysis.
Advise the client not to eat during dialysis.

● Postprocedure Nursing Actions

■ Monitor vital signs and laboratory values (BUN, serum creatinine, electrolytes, Hct).
Decreases in blood pressure and laboratory values are expected following dialysis.
■ Compare the client’s preprocedure weight with the postprocedure weight as a way to
estimate the amount of fluid removed (1 liter of fluid is equal to 1 kg or 2.2 lb).
■ Assess for the following:

☐ Complications (hypotension, clotting of vascular access, headache, muscle

cramps, bleeding)

☐ Indications of bleeding, and/or infection at the access site

 ☐ Signs of disequilibrium syndrome

☐ Signs of hypovolemia (hypotension, dizziness, tachycardia)

■ Avoid invasive procedures for 4 to 6 hr after dialysis due to the risk of bleeding related to
an anticoagulant.

◯ Client Education
■ Teach the client to perform the following:

☐ Alert the nurse of early signs of disequilibrium syndrome, such as nausea and headache.

☐ Check the access site at intervals following dialysis. Apply light pressure if bleeding.

☐ Check the graft for patency by checking for thrill or bruit.

☐ Monitor the access site for signs of an infection such as fever, redness, drainage or
swelling.

☐ Contact the provider if bleeding from the insertion site lasts longer than 30 min following
dialysis, for absence of thrill/bruit, or signs of infection.

☐ Take medications and supplements as prescribed to replace folate loss.

☐ Eat well-balanced meals to include foods high in folate (beans, green vegetables), and
take supplements. Protein is lost with each exchange during dialysis and also requires the
client to increase protein intake.

☐ Avoid lifting heavy objects with access-site arm.

☐ Avoid carrying objects that compress or constrict the extremity.

☐ Avoid sleeping on top of the extremity with the access device.

☐ Perform hand exercises that promote fistula maturation.

● Complications
◯ Clotting/infection of access site
■ Anticoagulants are often given to prevent blood clots from forming.
Monitor for hemorrhage at the insertion site.
■ Infections of the access site are likely introduced during cannulation.

☐ Immunosuppressive disorders increase the risk for infection.

☐ Advanced age is a risk factor for dialysis-induced hypotension and access site
complications related to chronic illnesses and/or fragile veins.
■ Nursing Actions
 ☐ Use surgical aseptic technique during cannulation.

☐ Avoid compression of access site, and venipuncture or blood pressure measurements

on extremity with access site.

☐ Administer anticoagulants as prescribed.

☐ Assess graft site for palpable thrill or audible bruit indicating vascular flow.

☐ Assess the access site for redness, swelling, or drainage. Monitor for fever.
◯ Disequilibrium syndrome
■ Disequilibrium syndrome is caused by too rapid a decrease of BUN and circulating fluid
volume. It may result in cerebral edema and increased intracranial pressure.

☐ Early recognition of disequilibrium syndrome is essential.

Signs include headache, nausea, vomiting, change in level of consciousness, seizures, and
agitation.

☐ Advanced age is a risk factor for dialysis disequilibrium and hypotension due to rapid
changes in fluid and electrolyte status.
■ Nursing Actions

☐ Use a slow dialysis exchange rate, especially for older adult clients and those being
treated with hemodialysis for the first time.

☐ Administer anticonvulsants/barbiturates if needed.

◯ Hypotension
■ Rapid fluid depletion during dialysis may cause hypotension.
Other causes include antihypertensives and splanchnic vasodilation due to food ingestion
during dialysis.
■ Nursing Actions

☐ Carefully replace fluid volume with transfusion of intravenous fluids or colloid as

prescribed.
Slow the dialysis exchange rate.

☐ Lower the head of the client’s bed.

☐ For severe hypotension that is unresponsive to fluid replacement, discontinue the

dialysis.
◯ Anemia
■ Blood loss and removal of folate during dialysis may contribute to an existing anemia that
often occurs with chronic kidney disease (caused by decreased RBC production due to
decreased erythropoietin secretion).
■ Nursing Actions

☐ Administer prescribed medication therapy (erythropoietin) to stimulate the production

of red blood cells.

☐ Monitor Hgb and RBC level.

☐ Monitor for hypotension and tachycardia.

☐ Transfuse blood products if prescribed.

◯ Infectious Diseases
■ Blood transfusions and frequent blood access due to hemodialysis pose a risk for
transmission of blood-borne diseases such as HIV and hepatitis B and C.
■ Nursing Actions

☐ Maintain sterility of equipment.

☐ Use standard precautions.

☐ Administer medications as prescribed.

◯ Cushing triad
Peritoneal dialysis
● Peritoneal dialysis involves instillation of hypertonic dialysate solution into the peritoneal
cavity. Allow the hypertonic dialysate solution to dwell in the peritoneal cavity as ordered
by the provider. Drain the dialysate solution that includes the waste products.
The peritoneum serves as the filtration membrane.

● Indications
◯ Peritoneal dialysis is the treatment of choice for the older adult.
◯ Peritoneal dialysis is indicated for clients requiring dialysis who
■ Are unable to tolerate anticoagulation.
■ Have difficulty with vascular access.
■ Have chronic infections or are unstable.
Contraindications
■ Not intact peritoneal membrane,
■ Peritoneal membrane with adhesions from infection or multiple surgeries.
■ Peritonitis
■ Bowel / bladder perforation
■ Intestinal diseases
■ Recent abdominal surgery
■ After renal transplantations

Procedure
A) Types of catheter
1. Tenkhoff ( mostly used)
2. Swan neck
3. Coiled catheter
B) Fixation of catheter
Using two Dacron kuffs
1. With rectus abdominis muscle
2. With skin

C) Access point
b/w visceral and parietal peritoneum, 2-3 cm below umbilicus
 D) Surface area= 1.7-2.0 meter square
E) Inflow of solution
10-20 mins
1 to 3 liters (average 2 liters)
F) Dwell time of solution
20-30 mins to 4-6 hours

Types
1. CAPD
4 times a day for all 7 days of week
4-6 hours dwell time
No use of peritoneal cycle machine

2. APD
A. NPD
Daily basis, at night time, 8-12 hours
B. IPD
3 times/ week, for 10-12 hours
C. CCPD
Continuous cycle
3 times at night, 1 time at day time

● Preprocedure Nursing Actions

■ Assess dry weight (obtained when dialysate is drained), serum electrolytes, creatinine,
BUN, and blood glucose.
■ Determine the client’s ability to perform self-peritoneal dialysis and follow sterile
technique.

☐ Level of alertness

☐ Past experience with dialysis

☐ Understanding of procedure
◯ Client Education
■ The client should be instructed about the procedure. The client may feel fullness when
the dialysate is dwelling. There may be discomfort initially with dialysate infusion.
■ Continuous ambulatory peritoneal dialysis (CAPD) is usually done 7 days a week for 4 to 8
hr. Clients may continue normal activities during CAPD.
■ Continuous-cycle peritoneal dialysis (CCPD) is a 24-hr dialysis. The exchange occurs at
night while the client is sleeping. The final exchange is left in to dwell during the day.
■ Automated peritoneal dialysis (APD) is a 30-min exchange repeated over 8 to 10 hr while
the client is sleeping.

● Intraprocedure
◯ Nursing Actions
■ Monitor the client’s vital signs frequently during initial dialysis of clients in a hospital
setting.
■ Monitor the client’s serum glucose level (dialysate contains glucose, a hypertonic
solution).
■ Record the amount of inflow compared to outflow of dialysate.
■ Monitor the color (clear, light yellow is expected) and amount (expected to equal or
exceed amount of dialysate inflow) of outflow.
■ Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return; drainage
at access site) and for complications (respiratory distress, abdominal pain, insufficient
outflow, discolored outflow).
■ Check the access site dressing for wetness (risk of dialysate leakage) and exit site
infections.
■ Warm the dialysate prior to instilling. Avoid the use of microwaves, which cause uneven
heating.
■ Follow prescribed times for infusion, dwell, and outflow.
■ Maintain surgical asepsis of the catheter insertion site and when accessing the catheter.
■ Keep the outflow bag lower than the client’s abdomen (drain by gravity, prevent reflux).
■ Reposition the client if inflow or outflow is inadequate.
■ Carefully milk peritoneal dialysis catheter if fibrin clot has formed.
■ Provide emotional support to the client and family.
● Postprocedure Nursing Actions
■ Monitor weight, serum electrolytes, creatinine, BUN, and blood glucose.
◯ Client Education
■ Teach the client home care of the access site.

☐ Instruct the client and family how to perform peritoneal dialysis exchanges at home.
Provide support for home peritoneal dialysis with home visits.
☐ Seek additional information from the National Kidney Foundation for local support
groups.

☐ Instruct the client to follow instructions carefully and to take all medications as directed.
☐ Instruct the client to take prescribed essential minerals and vitamins with supplements
of phosphorus, calcium, sodium, potassium.

☐ Older adult clients may be unable to care for a peritoneal access site due to cognitive or
physical deficits.

☐ Body image changes from bloating may be a concern for clients.

● Complications
◯ Peritonitis
■ Peritoneal dialysis can allow micro-organisms into the peritoneum and cause peritonitis.
■ Nursing Actions

☐ Maintain surgical asepsis during the procedure.

☐ Monitor for infection, such as fever, purulent drainage, redness or swelling, and cloudy
or discolored drained dialysate.
■ Client Education

☐ Educate the client to use strict sterile technique during exchanges.

☐ Instruct the client to notify the provider about any sign of infection.

◯ Infection at the access site

■ Infection at the access site may be related to leakage of dialysate. Access site infections
may cause peritonitis.

☐ Advanced age is a risk factor for access site complications related to chronic illnesses
and/or fragile veins.
■ Nursing Actions

☐ Maintain surgical asepsis of access site.

☐ Assess site for wetness from a leaking catheter.

☐ Monitor for infection, such as fever, purulent drainage, redness, or swelling.

■ Client Education

☐ Educate the client to use strict sterile technique during exchanges. ☐ Instruct the client
to notify the provider with any sign of infection.

☐ Advise the client to assess the site for leaks, and prevent tugging or twisting of tubing.
◯ Protein Loss
■ Peritoneal dialysis may remove needed protein from the blood as well as excess fluid,
wastes, and electrolytes.
■ Nursing Actions

☐ Increase dietary intake of protein.

☐ Monitor serum albumin level.

■ Client Education

☐ Instruct the client to follow recommended renal diet with an increase in dietary protein.
◯ Hyperglycemia and Hyperlipidemia

■ Hyperglycemia can result due to the hyperosmolarity of the dialysate. ☐ Glucose may be
absorbed from the dialysate into the blood.

☐ Hyperlipidemia may also occur from long-term therapy and lead to hypertension.
■ Nursing Actions

☐ Monitor serum glucose.

☐ Administer insulin for glycemic control.

☐ Administer antilipemic medication for triglyceride control.

■ Client Education

☐ Instruct the client to check serum glucose.

☐ Instruct the client to follow a recommended diet.

☐ Instruct the client to take prescribed antihypertensive medication for elevated blood
pressure.
◯ Poor dialysate inflow or outflow
■ The tubing may become obstructed or twisted, causing a decrease in flow.
■ Constipation is a common cause of poor inflow or outflow.
■ Nursing Actions

☐ Reposition the client if inflow or outflow is inadequate.

☐ Milk tubing to break up fibrin clot.

☐ Check tubing for kinks or closed clamps.

☐ Tell the client to avoid constipation by using stool softeners and consuming a diet high
in fiber.
■ Client Education
☐ Advise the client to check the tubing for kinks, and teach the client how to remove a
fibrin clot.

☐ Remind the client to monitor the inflow and outflow, and to change position or lower or
raise the dialysate bag as needed to improve flow.

☐ Advise the client to prevent constipation with diet and stool softeners if needed.

☐ Encourage the client to lie supine with head slightly elevated during CCPD and APD
treatment.
APPLICATION EXERCISES
1. A nurse is providing teaching to a client who has chronic kidney disease and is to start
hemodialysis. Which of the following information should the nurse include in the teaching?
A. Hemodialysis restores renal function.
B. Hemodialysis replaces hormonal function of the renal system.
C. Hemodialysis allows an unrestricted diet.
D. Hemodialysis returns a balance to serum electrolytes.
2. A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury and
has been hospitalized. Which of the following are appropriate nursing actions? (Select all
that apply.)
A. Review the client’s current medication history.
B. Assess the client’s arteriovenous fistula for a bruit.
C. Calculate the client’s total urine output during the shift.
D. Obtain the client’s weight.
E. Check the client’s serum electrolytes.
F. Use the client’s access site area for venipuncture.
3. A nurse is planning postprocedure care for a client who received hemodialysis. Which of
the following should the nurse include in the plan of care? (Select all that apply.)
A. Check BUN and serum creatinine.
B. Administer medications held prior to dialysis
C. Observe for signs of hypovolemia
D. Assess the access site for bleeding.
E. Evaluate blood pressure on side of AV access.
4. A nurse is caring for a client who is receiving hemodialysis and develops disequilibrium
syndrome. Which of the following is an appropriate action by the nurse?
A. Administer an opioid medication.
B. Monitor for hypertension.
C. Assess level of consciousness.
D. Increase the dialysis exchange rate.
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5. A nurse is planning care for a client who is having peritoneal dialysis. Which of the
following are appropriate nursing actions? (Select all that apply.)
A. Monitor serum glucose levels.
B. Report cloudy dialysate return.
C. Warm the dialysate in a microwave.
D. Assess for shortness of breath.
E. Check the access site dressing for wetness.
F. Maintain medical asepsis when accessing the catheter insertion site.
6. A nurse is reviewing possible complications that a client can experience when receiving
peritoneal dialysis. Which of the following complications and actions should the nurse
consider in the review? Use the ATI Active Learning Template: Diagnostic Procedure to
complete this item. Include the following:
A. Procedure Name: Write out the name, and define the diagnostic test.
B. Potential Complications: List three.
C. Nursing Actions: List two nursing actions for each of the three complications listed.
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APPLICATION EXERCISES KEy
1. A. INCORRECT: Hemodialysis does not restore kidney function, but it sustains the life of a
client who has kidney disease.
B. INCORRECT: Hemodialysis does not replace hormonal function of the renal system
because of tissue damage causing dysfunction of the renin-angiotensin-aldosterone system.
C. INCORRECT: Hemodialysis does not allow an unrestricted diet. It requires a diet high in
folate and protein, and low in sodium, potassium, and phosphorus.
D. CORRECT: Hemodialysis returns a balance to serum electrolytes by removing excess
sodium, potassium, fluids, and waste products; and restores acid-base balance.
NCLEX® Connection: Physiological Adaptations, Hemodynamics
2. A. CORRECT: Reviewing the client’s current medication history will determine what
medications to hold until after dialysis.
B. CORRECT: Assessing the client’s AV fistula for a bruit determines the patency of the
fistula for dialysis.
C. INCORRECT: The client’s total urine output over the shift may vary according to the
remaining kidney function and does not determine the need for dialysis.
D. CORRECT: Obtaining the client’s weight before dialysis is needed to compare with the
client’s weight after dialysis.
E. CORRECT: Checking the client’s serum electrolytes determines the need for dialysis.
F. INCORRECT: The client’s access site area should never be used for venipuncture because
it can cause loss of the vascular access.
NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems
3. A. CORRECT: The nurse should check the BUN and serum creatinine to determine the
presence and degree of uremia or waste products that remain following dialysis.
B. CORRECT: Medications that can be partially dialysed during the treatment should be
withheld. After the treatment, the nurse should administer the medications.
C. CORRECT: A client who is post-dialysis is at risk for hypovolemia due to a rapid decease
in fluid volume.
D. CORRECT: The nurse should assess the access site for bleeding because heparin is
administered during the procedure to prevent clotting of blood with the dialyzing surfaces.
E. INCORRECT: The blood pressure should never be taken on the extremity that has the AV
access site because it can cause collapse of the AV fistula or graft.
NCLEX® Connection: Physiological Adaptations, Hemodynamics
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4. A. INCORRECT: An altered level of consciousness is a clinical manifestation of
disequilibrium syndrome. The nurse should not administer an opioid medication. The
provider may prescribe medication to decrease seizure activity.
B. INCORRECT: The nurse should not monitor for hypertension but for hypotension due to
rapid change in fluids and electrolytes causing disequilibrium syndrome.
C. CORRECT: The nurse should assess the client’s level of consciousness. A change in urea
levels can cause increased intracranial pressure, and subsequently, the client’s level of
consciousness is decreased.
D. INCORRECT: The nurse should decrease the dialysis exchange rate to slow the rapid
changes in fluid and electrolyte status when a client develops disequilibrium syndrome.
NCLEX® Connection: Physiological Adaptations, unexpected Response to Therapies
5. A. CORRECT: The nurse should monitor serum glucose levels because the dialysate
solution contains glucose.
B. CORRECT: The nurse should monitor for cloudy dialysate return, which indicates an
infection. Clear, light yellow solution is expected during the outflow process.
C. INCORRECT: The nurse should avoid warming the dialysate in a microwave, which causes
uneven heating of the solution.
D. CORRECT: The nurse should assess for shortness of breath, which may indicate the
client’s inability to tolerate a large volume of dialysate.
E. CORRECT: The nurse should check the access site dressing for wetness and determine
whether the tubing is kinked, pulled, clamped, or twisted, which can increase the risk for
exit site infections.
F. INCORRECT: The nurse should maintain surgical, not medical, asepsis when accessing the
catheter insertion site to prevent infection caused from contamination.
NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems
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6. Using ATI Active Learning Template: Diagnostic Procedure
A. Procedure Name ● Peritoneal dialysis – to instill a hypertonic dialysate solution into the
peritoneal cavity, allow the solution to dwell for prescribed amount of time, and drain the
solution that includes the waste products.
B. Potential Complications ● Peritonitis ● Protein loss from protein wasting ●
Hyperglycemia ● Poor dialysate inflow or outflow
C. Nursing Actions ● Peritonitis ◯ Maintain surgical asepsis. ◯ Monitor color of outflow
solution, pain, fever. ● Protein loss ◯ Increase dietary intake of protein. ◯ Monitor
albumin level. ● Hyperglycemia ◯ Monitor serum glucose level. ◯ Administer insulin. ●
Poor dialysate inflow or outflow ◯ Reposition the client. ◯ Milk the tubing to break up
fibrin clots. ◯ Check the tubing for kinks or closed clamps. ◯ Encourage stool softeners
and high-fiber diet to prevent constipation.
NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems
RN Adult MedicAl SuRgicAl NuRSiNg 653