NR 224 Exam 2 Key Concepts

Chapter 40 Hygiene
 What is the function of the skin and the implications for skin care? The skin serves several
functions, including protection, secretion, excretion, body temperature regulation, and
cutaneous sensation

 Weakening of the epidermis occurs by scraping or stripping its surface (e.g., use of dry
razors, tape removal, improper turning or positioning techniques).
 Excessive dryness causes cracks and breaks in skin and mucosa that allow bacteria to
enter. Emollients soften skin and prevent moisture loss, soaking skin improves moisture
retention, and hydrating mucosa prevents dryness.
 Constant exposure of skin to moisture causes maceration or softening, interrupting dermal
integrity and promoting ulcer formation and bacterial growth.
 Keep bed linen and clothing dry.
 Misuse of soap, detergents, cosmetics, deodorant, and depilatories causes chemical
irritation. Alkaline soaps neutralize the protective acid condition of skin. Cleaning skin
removes excess oil, sweat, dead skin cells, and dirt, which promote bacterial growth.
 Factors that interfere with heat loss alter temperature control.
 Wet bed linen or gowns increase heat loss.
 Excess blankets or bed coverings conserve heat and interfere with heat loss through
radiation and conduction. Coverings promote heat conservation.
 Perspiration and oil sometimes harbor microorganisms.
 Bathing removes excess body secretions, but excessive bathing causes dry skin.
 Minimize friction to avoid loss of stratum corneum, which increases risk for pressure
injuries.

 What does personal hygiene affect? Personal hygiene influences patients’ comfort, safety, and
well-being.
 What does personal hygiene include? Hygiene includes cleaning and grooming activities that
maintain personal body cleanliness and appearance.
 Discuss nursing considerations when providing: assess each patient’s ability to perform self–
hygiene care according to individual needs and preferences. Always ensure privacy, convey
respect, and foster a patient’s independence, safety, and comfort.

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 o Cultural influences-Culture influences hygiene practices, and hygiene care may become
a potential source of conflict and stress in the caregiving environment

 Maintain privacy, especially for women from cultures that value female modesty, and
provide gender-congruent caregivers as requested.
 Collaborate with community leaders when providing health education for a diverse
community.
 Allow family members to participate in care if desired by adapting the schedule of
hygiene activities.
 Recognize that some cultures prohibit or restrict touching. Incorporate awareness
that people from different cultural backgrounds have differing preferences regarding
personal space. In some cases touch is considered magical and healing; others view
it as evil or anxiety producing.
 Recognize cultural hair practices, and do not cut or shave hair without prior
discussion with patient or family.
 Be aware that toileting practices vary by culture.
 Recognize that different cultures have preferences about hot and cold water and
their effects on healing or disease.

o For the older adult

 frequently or is exposed to an environment with low humidity, it becomes dry and flaky. With
aging the rate of epidermal cell replacement slows, and the skin thins and loses resiliency.
Moisture leaves the skin, increasing the risk for bruising and other types of injury. As the
production of lubricating substances from skin glands decreases, the skin becomes dry and
itching.These changes warrant caution when bathing, turning, and repositioning older adults.
Too-frequent bathing and bathing with hot water or harsh soap cause the skin to become
excessively dry.
 Older adults do not always have the strength, flexibility, visual acuity, or manual dexterity to
care for their feet and nails. Foot problems may be overlooked and impact a patient’s comfort,
mobility, and quality of life.
 Common problems of the feet affecting older adults include corns, calluses, bunions,
hammertoes, maceration between toes, and fungal infections.
 As a person ages, numerous factors result in poor oral health, including age-related changes
of the mouth, changes resulting from chronic disease such as diabetes, physical disabilities
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 involving hand grasp or strength affecting the ability to perform oral care, lack of attention to
oral care, and prescribed medications that have oral side effects. Gums lose vascularity and
tissue elasticity, which may cause dentures to fit poorly.
 With aging, as scalp hair becomes thinner and drier, shampooing is usually performed less.
 Hygiene of sensory structures must be provided in a way to prevent injury to sensitive tissues
such as the cornea of the eye and the internal ear canal.

o For a patient with special needs

 Safety is a priority for a patient with a sensory deficit. Be careful because they can not feel hot
or cold
 Patients who become tired or short of breath frequently need to have complete hygiene care
provided.
 Include periods of rest during care to allow patients who are tired the opportunity to participate
in their care.

 What nursing assessments need to be completed when providing hygiene to a patient?

Cultural and/or Religious Practices • Do you have preferences for how you bathe, shampoo
your hair, brush your teeth, or care for your feet? • How comfortable are you with someone
helping you with your bathing? • In what way can I best help you with your bath, hair care?
Tolerance of Hygiene Activities • Tell me about any symptoms, such as shortness of breath,
pain, or fatigue, that you have during bathing. • What can I do to minimize these symptoms? •
Which aspects of bathing, toothbrushing, or foot care cause discomfort or fatigue? Assistance
with Hygiene • Do you use any aids to help you with your bath such as grab bars in your tub or
shower? • Do you prefer someone of the same gender to help in your hygiene care? • Which
parts of the bath, toothbrushing, and foot care can you do for yourself? With which parts of
hygiene care do you need help?

Skin Care • Which type of bath do you prefer? • How often and when do you usually bathe? •
What kind of soap and lotion do you use? • Have you noticed any skin changes or irritation? •
Do you have any known allergies or reactions to soaps, cosmetics, or skin care products?
Mouth Care • Do you have any mouth pain or toothaches? Have you noticed any sores in your
mouth? Do your gums bleed during brushing or flossing? • Do you wear dentures or a partial
plate?

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 Foot and Nail Care • How do you usually care for your feet and nails? Do you soak your feet? •
Do you file or trim your own fingernails and toenails?

Hair and Scalp Care • Have you recently experienced itching of the scalp or noticed flaking or
dandruff? • Have you noticed any changes in the texture or thickness of your hair?

 What are nursing considerations for common skin problems such as dry skin etc.?

 Bathe less frequently. Rinse body of all soap because residue left on skin can cause
irritation and breakdown.
 Add moisture to air with use of humidifier.
 Increase fluid intake when skin is dry.
 Use moisturizing cream to aid healing. (Cream forms protective barrier and helps
maintain fluid within skin.)
 Use creams to clean skin that is dry or allergic to soaps and detergents.

 What are the different types of bath?

 Complete bed bath: Bath administered to totally dependent patient in bed (see Skill 40.1).
 Partial bed bath: Bed bath that consists of bathing only body parts that would cause
discomfort if left unbathed such as the hands, face, axillae, and perineal area. Partial
bath may also include washing back and providing back rub. Provide a partial bath to
dependent patients in need of partial hygiene or self-sufficient bedridden patients who are
unable to reach all body parts.
 Sponge bath at the sink: Involves bathing from a bath basin or sink with patient sitting in a
chair. Patient is able to perform part of the bath independently. Assistance is needed for
hard-to-reach areas.
 Tub bath: Involves immersion in a tub of water that allows more thorough washing and
rinsing than a bed bath. Commonly used in long-term care. A patient may require the
nurse’s help. Some institutions have tubs equipped with lifting devices that facilitate
positioning dependent patients in the tub.
 Shower: Patient sits or stands under a continuous stream of water. The shower provides
more thorough cleaning than a bed bath but can cause fatigue.
 Bag bath/travel bath: Contains several soft, nonwoven cotton cloths that are
premoistened in a solution of no-rinse surfactant cleanser and emollient. The bag

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 bath offers an alternative because of the ease of use, reduced time bathing, and patient
comfort.
 Chlorhexidine gluconate (CHG) bath: Antimicrobial agent used to reduce incidence
of hospital-acquired infections on skin, invasive lines, and catheters

 Describe nursing care for the following devices: eyeglasses, contact lenses, artificial eyes,
dentures, and hearing aids. assess their knowledge and methods used for care, and have
them describe the typical approach used in routine care.
o Dentures- They must be removed at night to rest the gums and prevent bacterial
buildup. To prevent warping, keep dentures covered in water when they are not worn
and always store them in an enclosed, labeled cup with the cup placed on the patient’s
bedside stand.
o Be careful when cleaning glasses and protect them from breakage or other damage
when they are not worn. Put them in a case in a drawer of the bedside table when not in
use. Cool water sufficiently cleans glass lenses
o all contact lenses must be removed periodically to prevent ocular infection and corneal
ulcers or abrasions from infectious agents Keep lenses moist or wet when not worn.

Use fresh solution daily when storing and disinfecting lenses.

Thoroughly wash and rinse lens storage case on a daily basis. Clean periodically
with soap or liquid detergent, rinse thoroughly with warm water, and air dry

 Hearing Aids-

 Ear Whistling sound indicates incorrect earmold insertion, improper fit of aid, or buildup of
earwax or fluid.
• Adjust volume to comfortable level for talking at distance of 1 yard.
• Do not wear aid under heat lamps or hair dryer or in very wet, cold weather.
• Batteries last 1 week with daily wearing of 10 to 12 hours.
• Remove or disconnect battery when not in use.
• Replace earmolds every 2 or 3 years.
• Routinely check battery compartment: Is it clean? Are batteries inserted properly? Is
compartment shut all the way?

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 • Make sure that dials on hearing aid are clean and easy to rotate, creating no static
during adjusting.
• Keep aid clean. See manufacturer instructions. Aids are usually cleaned with a soft
cloth.
• Avoid use of hairspray and perfume while wearing hearing aids; residue from spray
causes aid to become oily and greasy.
• Do not submerge in water.
• Routinely check cord or tubing (depending on type of aid) for cracking, fraying, and poor
connections.

 How do you maintain hygiene in the patient’s room environment (Ex. room equipment, beds,
bed making, linens)? It needs to be safe and large enough to allow the patient and visitors to
move about freely. Removal of barriers around the bed and along walkways reduces risk of
falls. Control room temperature, ventilation, noise, and odors. Keeping the room neat and
orderly also contributes to the patient’s sense of well-being.

Bed Linen- frequent inspection to be sure that linen is clean, dry, and free of wrinkles. When
patients are diaphoretic, have draining wounds, or are incontinent, check more frequently for
wet or soiled linen.

Usually you make a bed in the morning after patients bathe or while they bathe

Place soiled linen in special linen bags before placing in a hamper. To avoid air currents that
spread microorganisms, never shake the linen. To avoid transmitting infection, do not place
soiled linen on the floor. If clean linen touches the floor or any unclean surface, immediately
place it in the dirty-linen container.

 What are delegation considerations when providing hygiene to your patient?

 The skills of combing, shampooing, and shaving can be delegated to assistive

personnel (AP).
 The skill of oral hygiene (including tooth brushing, flossing, and rinsing) can be
delegated to assistive personnel (AP
 The skill of denture care can be delegated to assistive personnel (AP).
 The skill of making an occupied bed can be delegated to assistive personnel (AP)
 The skill of making an unoccupied bed can be delegated to assistive person.
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  the skill of bathing and perineal care can be delegated to AP.
 Assessment of the patient’s skin, pain level, and ROM cannot be delegated to
assistive personnel (AP)
 The skill of nail and foot care of patients without diabetes mellitus or peripheral vascular
disease can be delegated to assistive personnel (AP)
 The skill of providing oral hygiene to an unconscious or debilitated patient can be
delegated to assistive personnel (AP).
 The nurse is responsible for assessing a patient’s gag reflex

Chap 48: Skin Integrity

 What is a pressure ulcer?

Pressure injury, pressure ulcer, decubitus ulcer, and bedsore are terms used to describe
impaired skin integrity related to unrelieved, prolonged pressure. pressure injury is localized
damage to the skin and underlying soft tissue, usually over a bony prominence or related to a
medical device or other device.

 Who is susceptible to skin breakdown and the development of pressure ulcers?

Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence, and/or poor nutrition is at risk for pressure injury development.
• Older adults, those who have experienced trauma
• Those with spinal-cord injuries (SCI)
• Those who have sustained a fractured hip
• Those in long-term homes or community care, the acutely ill, or those in a hospice setting
• Individuals with diabetes
• Patients in critical care settings
 Review locations where pressure injuries are likely to occur.

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  Know the stages of pressure ulcer (including unstageable).

Stage 1 Pressure Injury: Nonblanchable erythema of intact skin. Intact skin with a localized area of
nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of
blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
Color changes do not include purple or maroon discoloration; these may indicate deep tissue
pressure injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of
skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as
an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible.
Granulation tissue, slough, and eschar are not present.

Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose
(fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often

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present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical
location; areas of significant adiposity can develop in deep wounds.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss
with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the
ulcer, Slough and/or eschar may be visible.

Deep-Tissue Pressure Injury: Persistent no blanchable deep red, maroon, or purple

discoloration. Intact or nonintact skin with localized area of persistent no blanchable deep red,
maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled
blister.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin
and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed
because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4
pressure injury will be revealed.

 Define Braden Scale. The Braden Scale is the most widely used risk-assessment tool for
pressure injuries and is in the WOCN guidelines (2016) as being a valid tool to use for

pressure injury risk assessment. Sensory perception, moisture, activity, mobility, nutrition,
and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher
risk for pressure injury development .
o What are the six categories?
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction/shear.
o What score would a client have who is at highest risk for pressure ulcer formation?

mild risk, 15-18

moderate risk, 13-14

high risk, 10-12

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 very high risk, less than 9.

o What score would a client have who is at lowest risk for pressure ulcer formation?

Not at risk, greater than 18

 Identify 4 types of drainage. What does each indicate?

 Serous: Clear, watery plasma (fluid in blisters)

 Purulent: Thick, yellow, green, tan or brown. Result of infection it is thick and contains white
blood cells, tissue debris, and bacteria. It may have a foul odor.
 Serosanguineous: Pale, pink, watery; mixture of clear and red fluid. Contains both serum and
blood.
 Sanguineous: Bright red; indicates active bleeding. Brighter drainage indicates active
bleeding; darker drainage indicates older bleeding/drainage.

 Describe normal wound closure. Discuss the different types of healing process.

 Primary intention- The skin edges are approximated, or closed, and the risk of infection is
low. Healing occurs quickly, with minimal scar formation, as long as infection and
secondary breakdown are prevented
 secondary intention- The wound is left open until it becomes filled by scar tissue. It takes
longer for a wound to heal by secondary intention; thus the chance of infection is greater. If
scarring from secondary intention is severe, loss of tissue function is often permanent
 tertiary intention - Spontaneous opening of a previously closed wound, Closure of wounds
occurs when they are free of infection and edema, Extensive drainage and tissue debris,longer
healing time

 Inflammatory stage- tissue and mast cells secrete histamine, resulting in vasodilation of
surrounding capillaries and movement/migration of serum and white blood cells into the
damaged tissues. This results in localized redness, edema, warmth, and throbbing. The
inflammatory response is beneficial, and there is no value in attempting to cool the area or
reduce the swelling unless the swelling occurs within a closed compartment
 proliferative stage- With the appearance of new blood vessels as reconstruction progresses,
the proliferative phase begins and lasts from 3 to 24 days. The main activities during this
phase are the filling of a wound with granulation tissue, wound contraction, and

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 wound resurfacing by epithelialization. Collagen mixes with the granulation tissue to form a
matrix that supports the re-epithelialization. Collagen provides strength and structural integrity
to a wound. During this period a wound contracts to reduce the area that requires healing.
 maturation or remodeling stage- Maturation, the final stage of healing, sometimes takes
place for more than a year, depending on the depth and extent of the wound. The collagen
scar continues to reorganize and gain strength for several months. However, a healed wound
usually does not have the tensile strength of the tissue it replaces. Collagen fibers undergo
remodeling or reorganization before assuming their normal appearance.

 Name the 4 wound complications discussed.

Dehiscence: A partial or total rupture (separation) of a sutured wound, usually with separation
of underlying skin layers. When an incision fails to heal properly, the layers of skin and tissue
separate.
Evisceration: A dehiscence that involves the protrusion of visceral organs through a wound
opening.
Hemorrhage: bleeding from a wound site, is normal during and immediately after initial
trauma. However, hemostasis occurs within several minutes unless large blood vessels are
involved, or a patient has poor clotting function. Hemorrhage occurring after hemostasis
indicates a dislodged surgical suture, a clot, infection, or erosion of a blood vessel by a foreign
object.
Infection: Wound infection is present when the microorganisms invade the wound tissues.
o Define any associated risk factors.

Dehiscence: patient who is at risk for poor wound healing (e.g., poor nutritional status, infection, or
underlying diseases such as diabetes mellitus or peripheral vascular disease) is at risk for
dehiscence. Obese patients have a higher risk of wound dehiscence because of the constant strain
placed on their wounds and the poor healing qualities of fat tissue. After a sudden strain such as
coughing, vomiting, or sitting up in bed.
Infection: contaminated or traumatic wounds
Hemorrhage: patient has poor clotting function
o What are indications of wound infection? The local clinical signs of wound infection can
include erythema; increased amount of wound drainage; change in appearance of the
wound drainage (thick, color change, presence of odor); and peri wound warmth, pain,
or edema.
 Consider potential nursing diagnosis.

 Impaired Skin Integrity

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  Risk for Impaired Skin Integrity
 Risk for Infection
 Acute or Chronic Pain
 Impaired Mobility
 Impaired Peripheral Tissue Perfusion

 What factors influence pressure ulcer formation and wound healing?

 Impaired sensory perception
 Impaired mobility
 Alteration in LOC
 Shear
 Friction
 Moisture (Increases chance of skin break ups)
 Nutrition
 tissue perfusion
 infection
 age
 psychological impact of wounds
To maintain a healthy wound environment, you need to address the following objectives:
prevent and manage infection, clean the wound, remove nonviable tissue, maintain the wound
in a moist environment, eliminate dead space, control odor, eliminate or minimize pain, and
protect the wound and periwound skin. To maintain a healthy wound environment, you need
to address the following objectives: prevent and manage infection, clean the wound, remove
nonviable tissue, maintain the wound in a moist environment, eliminate dead space, control
odor, eliminate or minimize pain, and protect the wound and periwound skin
 What nutrients can aid with pressure ulcer prevention?

o CaloriesFuel for cell energy “Protein protection”

o ProteinFibroplasia, angiogenesis, collagen formation and wound remodeling, immune

function
o Vitamin C (ascorbic acid)Collagen synthesis, capillary wall integrity, fibroblast function,
immunological function, antioxidant.
o Vitamin AEpithelialization, wound closure, inflammatory response, angiogenesis, collagen
formation. Can reverse steroid effects on skin and delayed healing.
o ZincCollagen formation, protein synthesis, cell membrane and host defense
o FluidEssential fluid environment for all cell function

 Discuss interventions to assist with pressure ulcer prevention.

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Nursing interventions for patients who are immobile or have other risk factors for pressure injuries
focus on prevention.
Decreased sensory perceptionProvide pressure-redistribution surface.
Medical deviceProtect pressure points from medical devices such as oxygen tubing, feeding
tubes, and casts.
MoistureFollowing each incontinent episode, clean area with no-rinse perineal cleaner and protect
skin with moisture-barrier ointment. Keep skin dry and free of maceration.
Friction and shearReposition patient using drawsheet or a transfer board surface.Provide trapeze
to facilitate movement in bed.Position patient at a 30-degree lateral turn and limit head elevation to 30
degrees (see Fig. 48.15).
Decreased activity/mobilityEstablish and post individualized turning schedule.Turn patient off at-
risk areas often.
Poor nutrition Provide adequate nutritional and fluid intake; help with intake as necessary.
Consult dietitian for nutritional assessment and recommended nutrients
 How does a nurse collect a wound culture?
Needle Aspiration Procedure (Anaerobic Organisms) use a sterile 10-mL disposable syringe

with a 22-gauge needle, pulling 0.5 mL of air into the syringe. Insert the needle through intact
skin next to the wound; withdraw plunger and apply suction to the 10-mL mark. the syringe is
capped and sent to the lab.
Quantitative Swab Procedure (Aerobic Organisms) Use a sterile swab from a culturette tube.
Identify a 1-cm area of the wound that is free from necrotic tissue. Rotate the swab while applying
pressure sufficient to express fluid from the wound tissue label, and transport to the laboratory.

 Why may a client have a drain? Drains provide a means for fluid or blood that accumulates
within a wound bed to drain out of the body. placed by the interventional radiologist to drain an
area found after or before surgery.
 What should the nurse asses if the client has a drain? Assess the number and type of drains,
drain placement, character of drainage, and condition of collecting equipment. Observe the
security of the drain and its location with respect to the wound. Next note the character of
drainage. If there is a collecting device, measure the drainage volume.
 When may a client need an abdominal binder? A simple gauze dressing is often not enough to
immobilize or provide support to a wound and a larger dressing or bandage is required.
Binders are bandages that are made of large pieces of material, usually elastic or cotton, to fit

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 a specific body part. supports large abdominal incisions that are vulnerable to tension or
stress as a patient moves or coughs
 Why may a client need heat or cold therapy? What are safety considerations for each therapy?

Cold therapy is designed to treat the localized inflammatory response of an injured body part that
presents as edema, hemorrhage, muscle spasm, or pain. Improvement to joint mobility
following cold therapy is related to reducing pain and swelling, inhibiting muscle spasm, and
reducing muscle tension. Before applying heat or cold therapies, assess a patient’s physical
condition for signs of potential intolerance to heat and cold. Cold is contraindicated if the
site of injury is already edematous. It further retards circulation to the area and prevents
absorption of the interstitial fluid. If a patient has impaired circulation. contraindicated in
the presence of neuropathy.

Warm applications are contraindicated when a patient has an acute, localized inflammation
such as appendicitis because the heat could cause the appendix to rupture. If a patient has
cardiovascular problems, it is unwise to apply heat to large parts of the body because the
resulting massive vasodilation disrupts blood supply to vital organs. Excessive heat causes a
burning sensation.

Chap 41: Oxygenation

 Describe the importance of oxygenation. Oxygen is a basic human need. The cardiac and
respiratory systems work together to supply the body with oxygen necessary for carrying out
the respiratory and metabolic processes needed to sustain life.
 Discuss techniques used during respiratory assessment.

Inspection perform a head-to-toe observation of the patient for skin and mucous membrane color,
general appearance, level of consciousness, adequacy of systemic circulation, breathing patterns,
and chest wall movement. Clubbed nails often occur in patients with chronic oxygen
deficiency, such as cystic fibrosis and congenital heart defects. Also note the shape of the chest
wall. Conditions such as advancing age and chronic obstructive pulmonary disease (COPD)
cause the chest to assume a rounded “barrel” shape. Observe chest wall movement for
retraction and use of accessory muscles. Elevation of a patient’s clavicles at rest reveals
increased work of breathing. Also observe the patient’s breathing pattern.

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 Palpation- area of tenderness; and helps to identify tactile fremitus, thrills, heaves, and the cardiac

point of maximal impulse. Palpate the pulses in the neck and extremities to assess arterial blood
flow.

Percussion detects the presence of abnormal fluid or air in the lungs. It also determines
diaphragmatic excursion, Adventitious breath sounds” is another term for abnormal breath
sounds. They include wheezing, crackles, and rhonchi. Wheezing is a continuous, high-pitched
musical sound caused by high-velocity movement of air through a narrowed airway. It is
associated with asthma, acute bronchitis, or pneumonia. It occurs during inspiration, expiration, or
both.

Auscultation helps identify normal and abnormal heart and lung sounds.

o What is the normal respiratory rate for an adult? At rest the normal adult respiratory rate
is 12 to 20 breaths/min
o Define the following terms:
 Bradypnea- Rate of breathing is regular but abnormally slow (less than 12
breaths/min).
 Tachypnea- Rate of breathing is regular but abnormally rapid (greater than 20
breaths/min).
 Eupnea- is normal, good, unlabored breathing, sometimes known as quiet
breathing or resting respiratory rate
 Apnea- Respirations cease for several seconds. Persistent cessation results in
respiratory arrest.
 Define hypoxia. Hypoxia is inadequate tissue oxygenation at the cellular level. It results from a
deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening
condition. Causes of hypoxia include
(1) a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood
(2) a diminished concentration of inspired oxygen, which occurs at high altitudes
(3) the inability of the tissues to extract oxygen from the blood, as with cyanide poisoning
(4) decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia
(5) poor tissue perfusion with oxygenated blood, as with shock
(6) impaired ventilation, as with multiple rib fractures or chest trauma
o What are the early signs and symptoms of hypoxia?

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 apprehension, restlessness (often an early sign), inability to concentrate, decreased
level of consciousness, dizziness, and behavioral changes. Unable to lie flat and
appears both fatigued and agitated. Increased pulse rate and increased rate and
depth of respiration, blood pressure is elevated.
o What are the late signs and symptoms of hypoxia?

Cyanosis, blue discoloration of the skin and mucous membranes caused by the
presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Central
cyanosis, observed in the tongue, soft palate, and conjunctiva of the eye where blood
flow is high, indicates hypoxemia. Peripheral cyanosis, seen in the extremities, nail
beds, and earlobes, is often a result of vasoconstriction and stagnant blood flow

 Interventions- Oxygen is used to relieve or prevent hypoxia, which can lead to hypoxemia
o Describe the patient that may need a nasal cannula. to deliver supplemental oxygen or
increased airflow for flow rate 1-6 L/min: 24%-44% Effective for low concentrations
o Discuss techniques used during tracheostomy care.
 Use surgical asepsis for all other types of suctioning.
 Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. Can monitor
SaO2 continually during the procedure.
 use no larger than a 16 French suction catheter when suctioning an 8 mm endotracheal tube
or tracheostomy tube. Hyper-oxygenate the client.
 Use suction pressure no higher than 120 to 150 mm Hg.
 Limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and the
vagal response.
 Repeat suctioning if needed. Limit total suctioning time to 5 min
o What are the indications for chest tube placement? - to remove air, fluids, or blood;
to prevent air or fluid from reentering the pleural space; or to reestablish normal

intrapleural and intrapulmonic pressures after trauma or surgery. chest tubes are
common after chest surgery and chest trauma and are used for treatment of
pneumothorax or hemothorax to promote lung re-expansion.
 Describe the nursing role during the procedure:
 Keep a chest tube drainage system closed and below the chest

 Chest tube should be secured to the chest wall.

Dr. Aniekwe pg. 16

  Watch for fluctuation (tailing) of the fluid level to ensure that the chest tube and
system are working.
o Discuss the process for feeding a patient wearing an oxygen mask. obtain a provider
order for a nasal cannula at 5L/min
o Discuss important topics to teach the patient using oxygen therapy.
oxygen safety, regulation of the amount of oxygen, and how to use the prescribed home
oxygen-delivery system.
a. make sure that the prongs on the nasal cannula are properly positioned in the nares
b. apply a water soluble gel to the nares as needed
d. be sure to assess the patency of both nares
e. assess the patient for any changes in RR and pattern

Chapter 46: Urinary Elimination

 Discuss the assessment process for urinary function.
 Kidneys- Kidneys become tender, resulting in flank pain. You assess for tenderness by gently percussing the
costovertebral angle (the angle formed by the spine and twelfth rib). Auscultation with the bell of the
stethoscope is sometimes performed to detect the presence of a renal artery brui
 Bladder- observe a swelling or convex curvature of the lower abdomen. On gentle palpation of the lower
abdomen, a full bladder may be felt as a smooth and rounded mass. When a full bladder is palpated, patients
report a sensation of urinary urge tenderness or even pain.
 External genitalia and urethral meatus- Look for drainage and lesions, and ask the patient whether there is
discomfort. If there is drainage, note the color and consistency and any odor. The vaginal tissue of a
postmenopausal woman may be drier and less pink than that of younger women
 Perineal skin- assessment of skin exposed to moisture, especially urine, needs to occur at least daily (and
more often if incontinence is ongoing) to pick up early signs of skin damage related to the moisture.
Observe for erythema in areas exposed to moisture, skin erosion, and patient complaints of a burning,
itching pain.
 Describe normal urinary elimination.
Urination, micturition, and voiding are all terms that describe the process of bladder emptying. Micturition is a
complex interaction among the bladder, urinary sphincter, and central nervous system.
As the bladder fills and stretches, bladder contractions are inhibited by sympathetic stimulation from the
thoracic micturition center. When the bladder fills to approximately 400 to 600 mL, most people experience a
strong sensation of urgency. When in the appropriate place to void, the central nervous system sends a
message to the micturition centers, stopping sympathetic stimulation and starting parasympathetic stimulation
from the sacral micturition center. The urinary sphincter relaxes, and the bladder contracts
 Describe the characteristics of normal urine.
 Color- Normal urine ranges in color from a pale straw to amber, depending on its concentration. Urine is
usually more concentrated in the morning or with fluid volume deficits. in the urine (hematuria) is never a
normal finding.

Dr. Aniekwe pg. 17

 Clarity- Normal urine appears transparent at the time of voiding. Urine that stands several minutes in a
container becomes cloudy. In patients with renal disease, freshly voided urine appears cloudy because of
protein concentration.
 Odor- Urine has a characteristic ammonia odor. The more concentrated the urine, the stronger the odor
 Discuss the components of a urine analysis and provide normal values.

Normal: 1200-1500 ml
Color: pale yellow, straw, amber, or transparent
Odor: Faint aromatic
Consistency: Clear liquid
pH: 4.6 to 8
Specific gravity: 1.010 to 1.025
Constituants: urea, uric acid, creatinine, hippuric acid, indican, urine pigments, undetermined nitrogen
Abnormal: Under 1200 ml
Color: Dark amber, Cloudy, dark orange, Red or dark brown
Odor: Offensive
Consistency: Mucous plugs, viscid, thick
pH: Under 4.5
Specific gravity: Over 1.025
Constituants: blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, and bile

 Define the following urinary elimination terms:

o Urgency- Involuntary passage of urine often associated with strong sense of urgency
related to an overactive bladder caused by neurological problems, bladder
inflammation, or bladder outlet obstruction.
o Dysuria- Painful Uriantion
o Frequency-voiding more than 8 times during waking hours and/or at decreased
intervals, such as less than every 2 hours.
o Hesitancy- Delay in start of urinary stream when voiding
o Polyuria- Excessive Urine
o Nocturia-Urination during the night
o Hematuria – blood in the urine
o Oliguria- decrease urine 400-500ml day in relation to fluid intake
o Anuria. Absence of urine

 Discuss examples of urinary elimination issues.

Dr. Aniekwe pg. 18

1. Congenital birth defects (children born early may not have a fully developed bladder),
2. Developmental level (age of child)
3. Intake of food and fluids (diuretics like coffee)
4. Psychosocial factors (fear, anxiety, mental illness)
5. Muscle tone (low or high)
6. Pathologic conditions (MS, BPH, DM, SCI)
7. Medications (ex. Furosemide), other diuretics
8. Surgical and medical procedures (for which empty bladder is required)
 Describe the process for assessing a patient with urinary retention.

Urinary retention is the inability to partially or completely empty the bladder. Acute or rapid-onset
urinary retention stretches the bladder, causing feelings of pressure, discomfort/pain,
tenderness over the symphysis pubis, restlessness, and sometimes diaphoresis. Patients may
have no urine output over several hours and in some cases experience frequency, urgency, small-
volume voiding, or incontinence of small volumes of urine. Postvoid residual (PVR) is the amount of
urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization.

 Discuss teaching needed for patient with a urinary tract infection (UTI).

 List and define the types of urinary incontinence.

 functional incontinence-urine loss caused by inability to reach the toilet because of

environmental barriers, physical limitations, loss of memory or disorientation
 reflex incontinence-emptying of the bladder without the sensation of the need to void (spinal
cord injury)
 stress incontinence-involuntary loss of urine related to an increase in intra-abdominal
pressure. Occurs during coughing, sneezing, laughing, or other physical activities. Childbirth,
menopause, obesity or straining from chronic constipation can also result in urine loss.
Leakage does not usually occur when person is in supine position.
 total incontinence-continuous and unpredictable loss of urine resulting from surgery, trauma,
or physical malformation. Urine cannot be controlled due to anatomic abnormality.
 mixed incontinence-urine loss with features of two or more types of incontinence
 urge incontinence-involuntary loss of urine that occurs soon after feeling an urgent need to
void. Experience a loss of urine before getting to the toilet and and inability to suppress the
need to urinate.
 overflow incontinence-involuntary loss of urine associated with distention and overflow of the
bladder. Signal to empty the bladder may be under-active or absent, the bladder fills and
dribbling occurs. Due to secondary effect of some drugs, fecal impaction of neurological
conditions.

 Teaching needed for a patient with a urinary tract infection (UTI).

Dr. Aniekwe pg. 19

 Some key interventions include promoting adequate fluid intake, promoting perineal hygiene, and
having patients void at regular intervals. Encourage women to wipe front to back after voiding and
defecation and teach them to avoid perfumed perineal washes and sprays, bubble baths, and tight
clothing. If a patient has a problem with urine leakage, hygiene should be especially stressed.

 Types of exercises a patient can do to improve urinary incontinence.

patient with stress incontinence often has a long-term goal that depends on weeks of pelvic floor
muscle exercise to improve urinary control Kegel exercises.

 Discuss patient teaching and health promotion on urinary elimination.

 Maintain adequate hydration.
 Keep good voiding habits.
 Keep the bowels regular. A rectum full of stool may irritate the bladder, causing urgency and
frequency.
 Prevent urinary tract infections
 Stop smoking to reduce your risk for bladder cancer and reduce the risk of developing a
cough, which can contribute to stress urinary incontinence.
 Report to your health care provider any changes in bladder habits, frequency, urgency, pain
when voiding, or blood in the urine
 Discuss the methods used to prevent a UTI in a patient with an indwelling urinary catheter.
 Regular perineal hygiene, especially after a bowel movement
 Catheter care every 8 hours as the minimal standard of care.
 Empty drainage bags when they are half full.
 check to make sure that there are no kinks or obvious occlusion of the drainage tubing or
catheter.
 maintain a closed urinary drainage system.
 prevention of urine backflow from the tubing and bag into the bladder.
 Secure indwelling catheters to prevent movement and pulling on the catheter.
 Obtain urine samples using the sampling port. Cleanse the port with disinfectant. Use a
sterile syringe/cannula
 Discuss the steps involved in the collection of a clean-void urine sample in an adult patient.
1. spread labia w/ thumb and forefinger of nondominant hand;
2. clean area from front to back 3x (start w/ left side, then right, then center);
3. if policy says to, rinse w/ sterile water & dry w/ dry cotton ball or gauze;
4. have pt start stream while still holding labia apart, after pt starts urine stream collect urine;
Dr. Aniekwe pg. 20
 5. remove container before flow stops and before releasing, have pt finish voiding in bedpan/
toilet
NOTE: if menstruating, record on file

Chapter 45: Nutrition

Discuss the assessment process for determining the nutritional needs of the adult patient.

 Identify the signs and symptoms associated with altered nutrition.

 gathered data from patient regarding nutritional practices and beliefs.
 determine patient rational energy needs
 obtain patients dietary history
 assist effects illness is having an ability to prepare meals at home
 Discuss the importance of the “Choose My Plate” program.-ChooseMyPlate provides a basic
guide for making food choices for a healthy lifestyle. It includes guidelines for balancing
calories; decreasing portion size; increasing healthy foods; increasing water consumption; and
decreasing fats, sodium, and sugars
 Different types of stool found in the Ascending Colon, Descending Colon, Transverse Colon
 Ascending - loose like water
 Transverse - semi formed, absorbed some water.
 Descending - formed
 What is Body Mass Index (BMI)? Body mass index (BMI) measures weight corrected for
height and serves as an alternative to traditional height-weight relationships. Calculate BMI by
dividing a patient’s weight in kilograms by height in meters squared
 List and describe therapeutic diets prescribed to improve health conditions such as cardiac
disease and renal disease.
Low protein-Kidney or renal disease in renal failure the body has difficulty metabolizing the end
product of protein
Low sodium diet- For cardiac disease such as congenital heart failure peripheral vascular
disease hypertension renal failure excessive fluid called edema in extremities
 Discuss the three ways to confirm placement of a nasogastric or oral gastric tube.
 After insertion of an enteral tube, it is initially necessary to verify tube placement by x-ray
film examination.
 use an irrigation syringe to aspire gastric contents.
 test the pH of 1124secretions withdrawn from the feeding tube to confirm tube location

Dr. Aniekwe pg. 21

  Enteral feedings:Enteral nutrition (EN) provides nutrients into the GI tract. It is the preferred
method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally
yet has a functioning GI tract.
o Discuss the routes for enteral feedings. enteral feedings receive formula via
nasogastric, jejunal, or gastric tubes.
o Discuss the nurse’s assessment prior to administering enteral feedings.
 Assess bowel sounds and perform abdominal exam.
 Obtain pulse oximetry reading.
 assess the condition of the patient’s nares and throat for inflammation.
o What is the best position during administration?

be sitting or lying with head of bed at 30° to 45° while on enteral feeds at all times.

 Discuss why a patient may need parenteral nutrition. What is the expected timeframe of the

therapy?Parenteral nutrition (PN) is a form of specialized nutritional support provided

intravenously.Parenteral nutrition (PN) is a form of specialized nutritional support provided

intravenously. Patients in highly stressed physiological states such as sepsis, head injury, or
burns
 Discuss types of parenteral feedings:
o PPN- peripheral parenteral nutrition (PPN) via peripheral intravenous access into large
central vein (PICC)- used in hospitalized pt who need therapy for LESS than 14 days
3change tubing every 24 hours
o TPN- Total PN (TPN), administered through a central line, is a 2-in-1 formula in which
administration of fat emulsions occurs separately from the protein and dextrose solution

Chapter 47: Bowel Elimination

 Describe the process for assessing a patient’s bowel elimination.
 Obtain diet and medication history
 identify signs and symptoms associated with altered elimination patterns
 determine impact of underlying illnesses activity patterns and diagnostics teston bowel
elimination patterns
 What factors that affect bowel elimination?

Age- Older adults may have decreased chewing ability. Partially chewed food is not digested as
easily. Peristalsis declines, and esophageal emptying slow

Dr. Aniekwe pg. 22

 Diet- Fiber in the diet provides the bulk in the fecal material.

Fluid intake- An inadequate fluid intake or disturbances resulting in fluid loss (such as vomiting)
affect the character of feces.

Physical activity- Physical activity promotes peristalsis, whereas immobilization depresses it.

Phycological Factors- Prolonged emotional stress impairs the function of almost all body systems,
digestive process is accelerated, and peristalsis is increased.

Personal Habbits- A busy work schedule sometimes prevents the individual from responding
appropriately to the urge to defecate, disrupting regular habits and causing possible alterations
such as constipation. Individuals need to recognize the best time for elimination.

Position during defecation- Squatting is the normal position during defecation.

Pain- patient often suppresses the urge to defecate to avoid pain

Pregnancy- A temporary obstruction created by the fetus impairs passage of feces. Slowing of
peristalsis during the third trimester often leads to constipation.

Surgery- anesthetic agents used during surgery cause temporary cessation of peristalsi

Medications- For example, opioid analgesics slow peristalsis and contractions, often resulting in
constipation; and antibiotics decrease intestinal bacterial flora, often resulting in diarrhea

 Discuss the best position in which to position a patient on a bedpan.

If a patient’s condition permits, raise the head of the bed to help him or her to a more normal
sitting position on a bedpan, enhancing the ability to defecate.

 Discuss the normal characteristics of stool.

 Color: brown/yellow in infants
 Odor- Malodorous; may be affected by certain food,
 Consistency- Soft, formed
 Frequency -Twice daily or 3 times a week
 Shape- Resembles diameter of rectum
 Constituents- Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal
mucosa, water.
 Determine why the patient may have change in stool color:
o Red stool- GI bleeding, hemorrhoids, ingestion of beets
Dr. Aniekwe pg. 23
 o Black stool- Iron ingestion or gastrointestinal (GI) bleeding
o Green stool

 Define Constipation- infrequent bowel movements (less than three per week) and hard, dry
stools that are difficult to pass
o What is the type of diet that is best for constipation and provide some examples?
 Define Diarrhea.
o What is the type of diet that is best for a patient with diarrhea and provide some
examples?
 Discuss the role of the nurse in caring for a patient with the following an ostomy
(colostomy/ileostomy).

The expected amount, color, and consistency of drainage from an ostomy

 Remove used pouch and skin barrier gently, and observe amount of effluent
 Note consistency of effluent, and record intake and output. Normal colostomy effluent is soft or
formed stool, whereas normal ileostomy effluent is liquid.

• The expected appearance of the stoma

 Observe existing skin barrier and pouch for leakage and length of time in place. Pouch should
be changed every 3 to 7 days, not daily

If an opaque pouch is being used, remove it to fully observe stoma.

 Special equipment needed to complete a particular patient’s pouching

• The changes in a patient’s stoma and surrounding skin integrity that should be reported

 Observe placement of stoma in relation to abdominal contours and presence of scars or

incisions.
 Abdominal contours, scars, or incisions affect type of system and adhesion to skin surface.
Reduces transmission of microorganisms.

 Describe the appearance of a healthy stoma.
 Assess the stoma color. It should be pink or red. You observe the skin at each pouch
change for signs of irritation or skin breakdown.
 An effective pouching system protects the skin, contains fecal material, remains odor free,
and is comfortable and inconspicuous.

Dr. Aniekwe pg. 24