NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LEC)

WEEK 13: PROMOTING OXYGENATION

3RD SEMESTER | S.Y 2021 – 2022 TRANSCRIBED BY: NICOLE ROMERO
LECTURER: PATRICK RANALO

THE RESPIRATORY SYSTEM  Each lung extends from its top portion (apex),
 The exchange of oxygen and carbon dioxide in the which is just above the clavicle, to its bottom
body is essential for life. portion (base), which rests on the diaphragm.
o takes place in the lungs and at the cellular level.  Composed of tiny, thin-walled air sacks (alveoli)
 mechanisms of respiration integration of factors
involving the nervous system, chemoreceptors in
the cardiovascular system, as well as the respiratory
system.
 Knowledge of the anatomy and physiology that
influences breathing is the basis for understanding
how to best care for patients with oxygenation
problems.

STRUCTURES OF THE RESPIRATORY SYSTEM

1. AIRWAYS.
 UPPER AIRWAYS (located above the larynx;
include nasal passages, oral cavity, and pharynx)
 LOWER AIRWAYS (located below the larynx;
include trachea, bronchi, and bronchioles).
 Humidify the air: Moist mucous membranes add
water to the inhaled air
 Warm the air: Heat is transferred from the blood
circulating in the capillary beds of the airways to the
inhaled air.
 Filter the air: Sticky mucus traps debris, and tiny
hair-like projections from the walls of the airway
(cilia) move debris up and out of the airway
surrounded by an extensive network of
capillaries. ALVEOLI - involved with gas
exchange.
FUNCTIONS OF THE RESPIRATORY SYSTEM
A. VENTILATION.
 Movement of air into and out of the lungs
through the process of breathing.
 Involves inhalation and exhalation.
1. INHALATION: Expansion of the chest cavity and
lungs resulting from contraction of the diaphragm
that pulls the chest cavity downward and
contraction of the intercostal muscles that pulls the
ribs outward;
 lung expansion causes negative pressure that
draws air into the respiratory system.

2. LUNGS.
 Soft, spongy, cone-shaped organs.
 Right lung has three lobes, and left lung has
two lobes.

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2. EXHALATION: Chest cavity and lungs return to their
original size and position when the diaphragm and
intercostal muscles relax;
 this is a passive response that requires no
effort.
B. RESPIRATION.
 Exchange of gases that provides oxygenation of
blood and body tissues and elimination of
carbon dioxide from the lungs.
 Occurs at two levels, known as external and
internal respiration
1. EXTERNAL RESPIRATION.
 Involves alveolar-capillary gas exchange.
1. Oxygen diffuses from the alveoli, through the
alveolar capillaries, and into the blood.
2. Carbon dioxide diffuses out of the blood,
through the alveolar capillaries, and into the
alveoli.
 Rate of diffusion depends on the thickness of the
membranes and extent of lung tissue.
2. INTERNAL RESPIRATION.
 Involves capillary-tissue gas exchange.
1. OXYGEN diffuses from the blood, through the
peripheral capillaries, and into tissue cells; oxygen is
used for cellular metabolism.
2. CARBON DIOXIDE, which is a waste product of
cellular metabolism, diffuses from tissue cells,
through the peripheral capillaries, and is
transported via the blood to the lungs for
exhalation.
 The effectiveness of internal respiration depends on
adequate peripheral circulation and external
respiration.
CHEMICAL CONTROL OF BREATHING
 CARBON DIOXIDE – major chemical regulator of
breathing
 CHEMORECEPTORS (in medulla oblongata) –
respond to changes in blood pH
o If blood CO2 levels decrease, such as during
more rapid breathing, blood pH will increase
(become more basic)
o homeostatic mechanism is that the medullary
chemoreceptors signal a decreased breathing
rate, which retains CO2 in the blood.
o More CO2 in the blood causes H+ levels to
increase, which causes blood pH to decrease to
normal levels.
 CHEMORECEPTORS (in carotid and aortic bodies) –
respond to changes in blood O2.
o send action potentials to the respiratory center
and produce an increase in the rate and depth
of breathing
× which increases O2 diffusion from the
alveoli into the blood.
FACTORS THAT INFLUENCE RESPIRATORY
FUNCTIONING
Developmental Level
Infants (particularly premature infants).
 Airways are narrow, small, and immature.
 Central nervous system is immature, leading to
impaired breathing patterns and periods of apnea.
 Small structures and immature immune systems
increase the risk of respiratory infections.
Toddlers and preschoolers.
 Tonsils and adenoids are large, increasing the risk of
tonsillitis.
 Putting small objects in the mouth may lead to
mechanical obstruction of the airway.
 Exposure to children in preschool and transmission
of infection via toys increases the risk of upper
respiratory infections.
 Viral infections, croup, and pneumonia are
associated with this age group.
School-aged children.
 Although the lungs are developed, they are still
vulnerable to infections and exercise-induced
asthma
 Exposure to children in school and after-school
activities increases the risk of acquiring a respiratory
infection.
Adolescents.
 Lungs develop adult characteristics.
 Vulnerability to peer pressure lead this age group to
engage in habits that can impair the lungs, such as
smoking and inhaling drugs or toxins.
Young and middle-aged adults.
 Prior habits that impair the lungs may continue into
adulthood.
 Issues such as anesthesia, infections, and diseases
may stress the respiratory system, which is
becoming less efficient.
Older adults.
 Reduced lung compliance, increased airway
resistance, and decreased lung elasticity impair
ventilation.
 Drier mucus, fewer cilia, a less effective cough, air
trapping in the alveoli, and declining immunity
increase the risk of respiratory tract infections.
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Environmental Factors
1. Air quality
 Air pollution, such as cigarette smoke, automobile
emissions, mold spores, and radon, can precipitate
disease in vulnerable people
 e.g., infants, toddlers, older adults, people with
heart or lung disease
2. Pulmonary allergens:
 Allergens, such as dust, animal dander, cockroach
particles, environmental grasses, and foods such as
peanuts and gluten
 can precipitate respiratory hypersensitivity
responses and allergies.
3. Altitude:
 Low oxygen levels place strain on the
cardiopulmonary system
 lead to increased ventilation, production of red
blood cells and hemoglobin, and vascularity of lungs
and body tissues.
LIFESTYLE FACTORS
Smoking tobacco and inhaling secondhand smoke.
 Tobacco smoke contains tars, toxins, and nicotine;
tars and toxins are known to precipitate cancer and
nicotine constricts bronchioles.
 Smoke also causes mucous membrane
inflammation, increases respiratory secretions,
breaks down elastin, and decreases the numbers
and efficiency of cilia
Improper nutrition:
 Inappropriate balance of proteins, carbohydrates,
and fats may reduce the immune system, impair
cellular functioning, impede tissue repair, and cause
obesity.
Lack of exercise:
 Sedentary lifestyle results in a depressed metabolic
rate and an inability of the cardiopulmonary system
to respond when any situation causes an increased
metabolic rate;
 regular exercise increases the heart and respiratory
rates, which helps condition the body so that the
body can better adapt to physical or emotional
stressors.
Obesity.
 A body mass index more than 30 increases the risk
of respiratory infections because excess abdominal
adipose tissue limits chest expansion and gas
exchange in the alveoli.
 Sleep apnea occurs due to increased neck girth and
fat deposits in the upper airway.
Occupational hazards
 Toxic agents include chemical fumes from cleaning
products, carbon monoxide from automobile or
machine combustion, particles from construction
debris, such as asbestos, and coal dust from coal
mines.
 Toxic agents can cause chronic inflammation of the
mucous membranes of the respiratory system and
lung cancer.
Substance use or abuse.
a. Alcohol and medications that depress the
respiratory center in the medulla (e.g., opioids,
sedatives, anxiolytics, and hypnotics) can cause
hypoventilation, aspiration, apnea, and death.
b. Stimulants, such as amphetamines and cocaine,
hallucinogens, and marijuana, also adversely affect
lung tissue, increase the risk of aspiration, and
depress respirations
PREGNANCY
 Body metabolism increases by 15 percent and
oxygen consumption increases by 15 to 25 percent.
 The enlarging uterus rises into the abdominal cavity,
limiting enlargement of the chest cavity and
downward movement of the diaphragm.
 Maternal respiratory rate increases and the mother
may experience shortness of breath with activity.
ALTERATIONS IN RESPIRATORY FUNCTION
Respiratory function can be altered by conditions that
affect:
1. patency (open airway)
2. movement of air into or out of the lungs
3. diffusion of oxygen and carbon dioxide between the
alveoli and the pulmonary capillaries
4. transport of oxygen and carbon dioxide via the
blood to and from the tissue cells
CONDITIONS AFFECTING THE AIRWAY
A completely or partially obstructed airway:
 Upper airway obstruction - that is, in the nose,
pharynx, or larynx—can occur when a foreign object
such as food is present, when the tongue falls back
into the oropharynx when a person is unconscious,
or when secretions collect in the passageways.
 Lower airway obstruction - involves partial or
complete occlusion of the passageways in the
bronchi and lungs most often due to increased
accumulation of mucus or inflammatory exudate.
o Stridor, a harsh, high-pitched sound, may be
heard during inspiration.
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CONDITIONS AFFECTING MOVEMENT OF AIR
The term breathing patterns refers to the rate, volume,
rhythm, and relative ease or effort of respiration.
 Eupnea - Normal respiration, is quiet, rhythmic, and
effortless.
 Tachypnea - rapid respirations, is seen with fevers,
metabolic acidosis, pain, and hypoxemia.
 Bradypnea - is an abnormally slow respiratory rate,
which may be seen in clients who have taken drugs
such as morphine or sedatives, who have metabolic
alkalosis, or who have increased intracranial
pressure (e.g., from brain injuries).
 Apnea - is the absence of any breathing.
 Hypercarbia or Hypercapnia - increased levels of
carbon dioxide
 Hypoxemia - low levels of oxygen
Hypoventilation - inadequate alveolar ventilation, may
be caused by either slow or shallow breathing, or both.
 occur because of diseases of the respiratory
muscles, drugs, or anesthesia.
 lead to increased levels of carbon dioxide or low
levels of oxygen
Hyperventilation is the increased movement of air into
and out of the lungs.
 rate and depth of respirations increase and more
CO2 is eliminated than is produced.
Kussmaul’s breathing
 type of hyperventilation that accompanies
metabolic acidosis
 by which the body attempts to compensate for
increased metabolic acids by blowing off acid in the
form of CO2.
 also occur in response to stress or anxiety
Other abnormal breathing patterns may create
breathing irregularities. Irregular rhythms include:
 Cheyne-Stokes respirations: marked rhythmic
waxing and waning of respirations from very deep
to very shallow with short periods of apnea
o commonly caused by chronic diseases,
increased intracranial pressure, or drug
overdose
 Biot’s (cluster) respirations: shallow breaths
interrupted by apnea;
o may be seen in clients with CNS disorders.
CONDITIONS AFFECTING DIFFUSION
 Orthopnea - is the inability to breathe easily unless
sitting upright or standing.
 Dyspnea - Difficulty breathing or the feeling of
being short of breath (SOB)
o may occur with varying levels of exertion or at
rest.
o (objective) signs: flaring of the nostrils, labored-
appearing breathing, increased heart rate,
cyanosis, and diaphoresis.
o most of which stem from cardiac or respiratory
disorders.
o treatment is aimed at removing the underlying
cause
× thorough history of the onset, duration, and
precipitating and relieving factors
 Impaired diffusion may affect levels of gases in the
blood, particularly oxygen, which does not diffuse
as readily as carbon dioxide.
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 Hypoxemia, or reduced oxygen levels in the blood
o caused by conditions that impair diffusion at the
alveolar-capillary level such as pulmonary
edema or atelectasis (collapsed alveoli) or by
low hemoglobin levels.
 cardiovascular system compensates for hypoxemia
by increasing the heart rate and cardiac output, to
attempt to transport adequate oxygen to the
tissues.
o If unable to compensate or hypoxemia is
severe, tissue hypoxia (insufficient oxygen
anywhere in the body) results, potentially
causing cellular injury or death.
 Cyanosis (bluish discoloration of the skin, nail beds,
and mucous membranes due to reduced
hemoglobin-oxygen saturation) may be present
with hypoxemia or hypoxia.
 Adequate oxygenation is essential for cerebral
functioning.
o cerebral cortex can tolerate hypoxia for only 3
to 5 minutes before permanent damage
occurs.
 The face of the acutely hypoxic person usually
appears anxious, tired, and drawn
 usually assumes a sitting position, often leaning
forward slightly to permit greater expansion of the
thoracic cavity
SIGNS OF INCREASED RESPIRATORY EFFORT.
 Use of accessory muscles of respiration: Use of
intercostal, abdominal, and trapezius muscles to
help expand the chest cavity.
 Retractions: Intercostal, supraclavicular, and
subcostal tissues recede during inspiration as a
result of excessive negative pressure required to
increase the depth of respirations.
 Nasal flaring: Widening of the nares during
inhalation to reduce resistance to airflow; more
common in infants and young children.
 Grunting immediately before exhalation: Closed
glottis at the height of inspiration keeps alveoli
open to enhance gas exchange; grunt occurs when
air is expelled through the larynx.
 Pursed-lip breathing: Exhalation through the mouth
with lips positioned to create a small opening to
prolong exhalation; keeps alveoli open longer for
gas exchange and more efficiently expels trapped
air
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SPUTUM
Sputum is produced when lungs are damaged or
diseased and can give nurses important information
about the patient and his or her illness.
 Identify whether coughing is not bringing up
sputum (nonproductive cough) or bringing up
sputum (productive cough)

CHARACTERISTICS OF SPUTUM.
 Amount: From slight to copious.
 When produced: From once to continuous; in the
am; when lying down; after behaviors such as
smoking. Rhonchi (sonorous wheeze)
 Mucus accumulated in large bronchi.
 Loud, coarse, low-pitched sound heard during
inspiration and/or expiration

Wheeze (sibilant wheeze)

 Air moving through narrowed airways.
 High-pitched, musical sound that may be heard
throughout inspiration and expiration; more
prominent during expiration.
 Color.
 May be audible without a stethoscope
o Clear/white: Associated with viral infections.
o Yellow/green: Associated with bacterial
infection.
o Black: Associated with inhalation of smoke,
soot, or coal dust.
o Red/rust colored: Associated with the presence
of blood (hemoptysis), tuberculosis, and
pneumococcal pneumonia.
o Pink/frothy: Associated with pulmonary edema
 Odor: Foul smelling, associated with bacterial
infections such as pneumonia and abscesses of the
lung.

DISTINGUISHING ABNORMAL BREATH SOUNDS

Crackles (rales)
 Air bubbling through moisture in the alveoli.
 Not cleared by coughing.
Classified as:
1. Fine: Soft, high-pitched crackling sound heard at
height of inspiration
2. Medium: Lower-pitched, popping sound heard
during the middle of inspiration.
3. Coarse: Loud, bubbling sound heard throughout
inspiration.
Pleural Friction Rub
 Inflamed pleural surfaces rubbing together.
 Low-pitched, grating sound during inspiration
and/or expiration; more prominent at height of
inspiration.
 Heard at lateral, anterior, base of lung
Stridor
 High-pitched crowing sound; more prominent
during inspiration.

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 Heard over larynx and trachea.
 May be audible without a stethoscope.
 Tracheal or laryngeal spasm
 Partial airway obstruction
TUBERCULIN SKIN TESTING
Tuberculin Skin Testing - Identifies past or present
exposure to tubercle bacilli but does not diagnose that
the patient has tuberculosis (TB)
 patients with positive purified protein derivative
(PPD) results require a chest x-ray and sputum
culture for a definitive diagnosis.
 PPD of the tubercle bacillus is inserted via an
intradermal injection.
NANDA INTERNATIONAL (HERDMAN & KAMITSURU,
2014)
Includes the following diagnostic labels for clients with
oxygenation problems:
 Ineffective Airway Clearance: inability to clear
secretions or obstructions from the respiratory tract
to maintain a clear airway.
 Ineffective Breathing Pattern: inspiration and/or
expiration that does not provide adequate
ventilation.
 Impaired Gas Exchange: excess or deficit in
oxygenation and/or carbon dioxide elimination at
the alveolar-capillary membrane.
 Activity Intolerance: insufficient physiological or
psychological energy to endure or complete
required or desired daily activities
THE PRECEDING NURSING
Diagnoses may also be the etiology of several other
nursing diagnoses, such as these:
 Anxiety related to ineffective airway clearance and
feeling of suffocation
 Fatigue related to ineffective breathing pattern
 Fear related to chronic disabling respiratory illness
 Insomnia related to orthopnea and required O2
therapy
 Social Isolation related to activity intolerance and
inability to travel to usual social activities.
PLANNING
The overall outcomes/goals for a client with
oxygenation problems are to:
 Maintain a patent airway.
 Improve comfort and ease of breathing.
 Maintain or improve pulmonary ventilation and
oxygenation.
 Improve the ability to participate in physical
activities.
 Prevent risks associated with oxygenation problems
such as skin and tissue breakdown, syncope, acid–
base imbalances, and feelings of hopelessness and
social isolation
NURSING CARE FOR PATIENTS WITH RESPIRATORY
PROBLEMS
Vaccinations.
 Annual flu vaccines are recommended for all people
6 months and older.
 Patients with chronic illnesses (heart, lung, kidney,
or immunocompromised), infants, older adults, and
pregnant women can get very sick; thus they should
be immunized.
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Mobilization of Pulmonary Secretions.
 The ability of a patient to mobilize pulmonary
secretions makes the difference between a short-
term illness and a long recovery involving
complications.
 Nursing interventions promoting removal of
pulmonary secretions assist in achieving and
maintaining a clear airway and help to promote
lung expansion and gas exchange.
Hydration.
 Maintenance of adequate systemic hydration keeps
mucociliary clearance normal.
 Excessive coughing to clear thick, tenacious
secretions is fatiguing and energy depleting.
 best way to maintain thin secretions is to provide a
fluid intake of 1500 to 2500 mL/day unless
contraindicated by cardiac or renal status.
Humidification - is the process of adding water to gas.
 Temperature is the most important factor affecting
the amount of water vapor a gas can hold.
 Relative humidity is the percentage of water in the
gas.
 Air or oxygen with a high relative humidity keeps
the airways moist and loosens and mobilizes
pulmonary secretions.
 Humidification is necessary for patients receiving
oxygen therapy at greater than 4 L/min (check
agency protocol).
o It might be necessary to add humidification at
lower oxygen concentrations if the environment
is dry and arid.
Nebulization - adds moisture or medications to inspired
air by mixing particles of varying sizes with the air.
 Aerosolization suspends the maximum number of
water drops or particles of the desired size in
inspired air.
 moisture added through nebulization improves
clearance of pulmonary secretions.
 used for administration of bronchodilators and
mucolytic agents
Chest physiotherapy (CPT) is a group of therapies for
mobilizing pulmonary secretions.
Chest physiotherapy may be implemented by a
respiratory therapist.
a. Postural drainage: Place the patient sequentially in
a variety of positions so that it permits gravity to
drain secretions from all lobes of the lungs.
b. Percussion: Strike the chest wall using cupped
hands to generate sounds and slight negative
pressure that loosen secretions
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c. Vibration: Apply vibrations to the chest wall with POSITIONS FOR POSTURAL DRAINAGE
the hands or a vibrator to loosen secretions;

PROMOTE LUNG EXPANSION

 Have the patient assume a position that allows the
diaphragm to contract without pressure from
abdominal organs and permits thoracic excursion
 such as semi-Fowler, high-fowler, or orthopneic
(tripod) position.

 Encourage an intake of air in which the abdomen

expands on deep inhalation and abdominal muscles
tighten on exhalation (diaphragmatic [abdominal]
breathing) to increase the amount of air entering
and exiting the lungs.
 Encourage the patient to exhale through the mouth
with the lips positioned to create a small opening
(pursed-lip breathing) to prolong exhalation.
 Doing so keeps alveoli open longer for gas exchange
and more efficiently expels trapped air.
 This is a beneficial breathing technique for patients
with obstructive airway diseases, such as
emphysema, asthma, and chronic bronchitis.
 Encourage use of an incentive spirometer 10 times
every hour to help prevent atelectasis and reexpand
collapsed alveoli;
 device promotes deep breaths by providing a visual
goal to progressively increase the volume of breaths

NURSING CARE FOR PATIENTS WITH RESPIRATORY

PROBLEMS
Suctioning Techniques.

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 Suctioning - is necessary when patients are unable  Assess for dryness of the nasal mucosa.
to clear respiratory secretions from the airways by  Humidify oxygen if the flow rate is >3 L/minute.
coughing or other less invasive procedures.
1. Oropharyngeal or nasopharyngeal suctioning - is
used when the patient is able to cough effectively
but unable to clear secretions by expectorating.
2. Orotracheal or nasotracheal suctioning - is
necessary when a patient with pulmonary
secretions is unable to manage secretions by
coughing and does not have an artificial airway
present

 Flood the reservoir with oxygen before attaching

the mask to the patient.
 Ensure that the reservoir does not collapse during
inhalation; a higher flow rate is required if this
occurs.

OXYGEN DELIVERY SYSTEMS

Oxygen therapy - is widely available and used in a
variety of settings to relieve or prevent tissue hypoxia.
 Goal: is to prevent or relieve hypoxia by delivering
oxygen at concentrations greater than ambient air
(21%).
 Oxygen is a medical gas and should be used in
accordance with federal, state, and local
regulations.
 Flood the reservoir with oxygen before attaching
the mask to the patient.
 Ensure that the reservoir remains half full during
inhalation; if not, a higher flow rate is required.

 Place the mask securely over the nose and mouth

with the elastic straps above the ears.
 Ensure the flow rate is ≥5 L/minute to prevent
carbon dioxide accumulation in the mask.
 Switch to a nasal cannula when eating.

 Delivers oxygen to the nose and mouth via a clear,

flexible mask with a valve and tubing attached
between the mask and the oxygen tubing.
 Interchangeable color-coded valves permit a
specific mix of room air and oxygen to deliver a
 Place the nasal prongs curved downward into the precise percentage of oxygen.
nares with the elastic straps wrapped around the
ears and the slider under the chin.

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 Exhaled air is discharged through ports on the side
of the mask to keep carbon dioxide buildup to a
minimum.
 Liter flow: Depends on valve being used.
 FIO2: 24% to 60%, depending on color-coded valve
used.
 Leukotriene receptor antagonists - Inhibit
leukotriene synthesis or activity; Minimize
inflammation and edema.
o Example: montelukast

 Inhaled and nasal route steroids - Decrease

 Most patients do not feel claustrophobic.
 High levels of humidity can be used.
 Monitor pulse oximetry routinely because the
percentage of oxygen delivered is not precise.
inflammatory response and edema
o Example: Budesonide, fluticasone
 Mucolytics are medicines taken orally that may
loosen sputum, making it easier to cough it up.
o Example: Acetylcysteine

TYPES OF ARTIFICIAL AIRWAYS

Artificial airway - is for a patient with a decreased level
of consciousness or airway obstruction
 aids in removal of tracheobronchial secretions.
 places a patient at high risk for infection and airway
injury.
 Oropharyngeal - Hard plastic tube that extends  Expectorants - Increase volume and decrease
from the front of the teeth to the pharynx viscosity of respiratory secretions in trachea and
 Nasopharyngeal - Flexible tube that extends from bronchi.
the nares to the pharynx. o Example: guaifenesin (Robitussin)
 Antitussives - Suppress cough reflex.
o Example: dextromethorphan (DM)

Tracheostomy
 Insertion of a tube into the trachea through an
incision in the neck.
Endotracheal
 Insertion of tube into the trachea through the
mouth or nose (intubation).

MEDICATION THAT AFFECT THE RESPIRATORY SYSTEM

 Sympathomimetics (beta-adrenergic agonists) -
Stimulate beta receptors to dilate bronchioles
o Example: albuterol, salbutamol

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 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LEC)
WEEK 14: URINARY ELIMINATION
3RD SEMESTER | S.Y 2021 – 2022
LECTURER: PATRICK RANALO
URINARY SYSTEM
URINARY SYSTEM - major excretory system of the body.
 Some organs in other systems also eliminate
wastes, but they are not able to compensate in case
of kidney failure.
 consists of TWO KIDNEYS - primary excretory
organs.
 filter a large volume of blood.
FUNCTIONS
Excretion - filter waste products from the blood.
 Fluid and waste are captured by an extensive
network
 Large molecules, remain in the blood, whereas
smaller molecules and ions enter the filtered fluid.
Regulation of blood volume + pressure.
 depending on the hydration level, kidney produce
either a large volume of dilute urine or a small
volume of concentrated urine
Regulation of the concentration of solutes in the blood
 help regulate the concentration of the major ions,
such as Na+, Cl−, K+, Ca2+, HCO3 −, and HPO4 2−.
Regulation of extracellular fluid pH.
 secrete variable amounts of H+ to help regulate the
extracellular fluid pH
TRANSCRIBED BY: NICOLE ROMERO
Regulation of RBC synthesis.
 secrete a hormone, erythropoietin
Regulation of vit. D synthesis.
 play an important role in controlling blood levels of
Ca2+
STRUCTURES AND FUNCTIONS OF THE URINARY
SYSTEM
Kidneys
 Filter metabolic waste, excess ions, bacterial toxins,
water-soluble drugs, drug metabolites, and water
from the blood and excrete them as urine.
 Form urine by filtration, reabsorption, and
secretion.
 Regulate blood volume, blood pressure (BP), fluid
and electrolyte balance, and acid-base balance
 Secrete renin that causes the conversion of
angiotensinogen to angiotensin I, which is
subsequently converted to angiotensin II, which
stimulates the nephrons to promote sodium and
water retention.
 Secrete erythropoietin, which acts on the bone
marrow to produce red blood cells.
 Converts part of calcidiol, a vitamin D metabolite, to
calcitriol, the biologically active form of vitamin D,
which travels in the blood to control the
concentration of calcium and phosphate and
promote growth and remodeling of bone.
 Produce a volume of filtrate in 1 minute (glomerular
filtration rate [GFR]).
Ureters
 Transport urine produced by the kidneys to the
bladder.
 Funnel shaped at the renal pelvis.
 Are 10 to 12 inches (25 to 30 cm) in length.
 Enter the bladder at the posterior corners of the
bladder floor
Bladder
 Receives urine from the ureters.
 Stores urine (600 to 1,000 mL) until it is eliminated.
 Urge to eliminate is stimulated by 200 to 250 mL of
urine.
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Urethra
 Transports urine from the bladder and semen from
the prostate gland in males to outside the body.
 Is 1.5 to 2 inches long in a female and 8 inches in a
male.
 Opens at the urinary meatus.
URINATION
Micturition, voiding, and urination - all refer to the
process of emptying the urinary bladder.
 Urine collects in the bladder until pressure
stimulates special sensory nerve endings in the
bladder wall called stretch receptors.
 This occurs when the adult bladder contains
between 250 and 450 mL of urine.
 In children, a considerably smaller volume, 50 to
200 mL, stimulates these nerves.
FACTORS AFFECTING URINARY FUNCTION
Developmental
1. Infants.
 produce 8 to 10 wet diapers daily.
 Develop voluntary control at 18 to 24 months of
age.
2. Children:
 May experience involuntary passage of urine when
awake (enuresis) or when sleeping (nocturnal
enuresis).
3. Older adults
 Experience a decline in urinary system function.
 Are less able to filter waste and maintain acid-base
and fluid and electrolyte balance.
 Experience a loss of bladder tone, contributing to
urgency, frequency, and incomplete emptying of
the bladder
Psychosociocultural
 Lack of privacy or an unfamiliar environment may
lead to an inability to void in public (bashful
bladder).
 Loss of dignity related to toileting activities in a
health-care environment, especially if the patient is
catheterized, can cause emotional distress.
 Cultural influences may cause a person to insist on a
caregiver of the same gender to provide toileting
assistance
Nutrition and Hydration
 As fluid intake increases, a corresponding increase
in urine output occurs; as fluid intake decreases, a
corresponding decrease in urine output occurs.
 Some substances increase urine production (e.g.,
coffee, tea, cola, alcohol, and chocolate) by
inhibiting the release of antidiuretic hormone.
 Sodium intake produces water retention, causing
decreased urine production
Activity and Position
 Heavy exercise can precipitate dehydration via
sweating, causing the kidneys to retain water,
reducing urine output.
 Gravity assists in the flow of urine and the ability to
empty the bladder completely; typically, the sitting
position is best for women and the standing
position is best for men.
 The bladder may not empty completely when on a
bed pan or when using a urinal while lying flat; the
side-lying position may facilitate urination for men
Medications and Anesthetic Agents
 Many classifications of drugs can damage kidney
cells (nephrotoxic) or cause urinary retention, such
as antispasmodics, antihistamines, tricyclic
antidepressants, anticholinergics, antihypertensives,
antiparkinsonism drugs, and chemotherapeutic
agents for cancer.
 Diuretics cause an increase in urine production; if
urine output is excessive in relation to fluid intake,
dehydration occurs; urine output decreases when a
patient is dehydrated.
 Some drugs change the color of urine; for example,
phenazopyridine (Pyridium) causes the urine to
appear reddish orange
 Anesthetic agents generally decrease BP and GFR,
causing a decrease in urine production; spinal
anesthesia reduces the perception of the need to
void, leading to bladder distention
Medical Problems
 Problems can interfere with the production of
urine; for example, cardiovascular and metabolic
disorders that reduce blood flow through the
kidneys (e.g., hypertension, heart failure, shock, and
diabetes mellitus).
 Problems can impair the nervous system that
innervates the urinary system; for example, brain
attack (stroke) or spinal cord injury.
 Problems can interfere with the flow of urine; for
example, calculi and enlargement of the prostate
gland.
 Problems can cause inflammation of the structures
of the urinary system; for example, urinary tract
infection (UTI).
 Impaired cognition (e.g., delirium, dementia) or a
mental health/psychiatric problem may alter a
person’s perception of the need to void
NMR ♡
Surgical and Diagnostic Procedures
 Rectal, vaginal, and pubic surgery and childbirth can
result in trauma to and edema of local tissues,
causing pressure on the structures of the urinary
system and loss of pelvic floor muscle control.
 Some surgical procedures (e.g., hysterectomy,
transurethral resection of the prostate) require
insertion of a temporary indwelling urinary catheter
postoperatively.
 Insertion of a fiberoptic instrument (cystoscope)
through the urethra to examine the bladder
(cystoscopy) can cause urethral swelling,
obstructing urinary excretion.
Communication or Mobility Problems
 An inability to communicate the need to void can
result in what appears to others to be an episode of
incontinence when in fact the patient cannot
indicate personal needs to others.
 An inability to engage in toileting activities, such as
undressing, can result in episodes of urination
before reaching a toilet.
 An inability to be mobile, such as with patients who
are bed- or chair-bound, may prevent a patient
from obtaining assistance in time to make it to the
bathroom.
ALTERED URINE PRODUCTION
POLYURIA
 (or diuresis) refers to the production of abnormally
large amounts of urine by the kidneys, often several
liters more than the client’s usual daily output.
 Polyuria can follow excessive fluid intake, a
condition known as polydipsia, or may be
associated with diseases such as diabetes mellitus,
diabetes insipidus, and chronic nephritis.
 Polyuria can cause excessive fluid loss, leading to
intense thirst, dehydration, and weight loss.
Oliguria and Anuria
- Are used to describe decreased urinary output.
 Oliguria - is low urine output, usually less than 500
mL a day or 30 mL an hour for an adult.
o may occur because of abnormal fluid losses or a
lack of fluid intake
o often indicates impaired blood flow to the
kidneys
 Anuria - refers to a lack of urine production
o should be promptly reported to the primary care
provide
Frequency and Nocturia
 Urinary frequency is voiding at frequent intervals,
that is, more than four to six times per day.
oAn increased intake of fluid causes some
increase in the frequency of voiding.
o Conditions such as UTI, stress, and pregnancy
can cause frequent voiding of small quantities
(50 to 100 mL) of urine.
 Nocturia is voiding two or more times at night.
o it is usually expressed in terms of the number of
times the person gets out of bed to void, for
example, “nocturia × 4.”
Urgency is the sudden, strong desire to void.
 There may or may not be a great deal of urine in the
bladder, but the person feels a need to void
immediately.
 accompanies psychological stress and irritation of
the trigone and urethra.
 It is also common in people who have poor external
sphincter control and unstable bladder
contractions.
 It is not a normal finding.
Dysuria - means voiding that is either painful or difficult
 It can accompany a stricture (decrease in caliber) of
the urethra, urinary infections, and injury to the
bladder and urethra.
 Often clients will say they have to push to void or
that burning accompanies or follows voiding.
 burning may be described as severe, like a hot
poker, or like a sunburn.
urinary hesitancy (a delay and difficulty in initiating
voiding) is associated with dysuria.
Enuresis
- is involuntary urination in children beyond the age
when voluntary bladder control is normally
acquired, usually 4 or 5 years of age.
1. Nocturnal enuresis - often is irregular in occurrence
and affects boys more often than girls.
2. Diurnal (daytime) - enuresis may be persistent and
pathologic in origin. It affects women and girls more
frequently
 Urinary incontinence (UI), or involuntary leakage of
urine or loss of bladder control
o is a health symptom, not a disease.
o It is only normal in infants.
 STRESS URINARY INCONTINENCE occurs because of
weak pelvic floor muscles and/or urethral
hypermobility
o causing urine leakage with such activities as
laughing, coughing, sneezing, or any body
movement that puts pressure on the bladder.
NMR ♡
 URGE URINARY INCONTINENCE - described as an
urgent need to void and the inability to stop
micturition (passage of urine).
o urine leakage can range from a few drops to
soaking of undergarment
 MIXED URINARY INCONTINENCE both stress UI and
urgency UI are present.
 OVERFLOW INCONTINENCE is “continuous
involuntary leakage or dribbling of urine that occurs
with incomplete bladder emptying” (Scemons,
2013, p. 55).
o seen in men with an enlarged prostate and
clients with a neurologic disorder
Urinary Retention - When emptying of the bladder is
impaired, urine accumulates and the bladder becomes
overdistended
1. Acute urinary retention is the most common
complication in the first 2 to 4 hours
postoperatively.
2. Chronic urinary retention can include paraplegia,
quadriplegia, multiple sclerosis, and urethral or
perineal trauma.
MEASURING URINARY OUTPUT
 kidneys produce urine at a rate of approximately 60
mL/h or about 1,500 mL/day.
 Urine output is affected by many factors, including
fluid intake, body fluid losses through other routes
such as perspiration and breathing or diarrhea, and
the cardiovascular and renal status of the
individual.
 Urine outputs below 30 mL/h may indicate low
blood volume or kidney malfunction and must be
reported.
To MEASURE FLUID OUTPUT the nurse follows these
steps
 Wear clean gloves to prevent contact with
microorganisms or blood in urine.
 Ask the client to void in a clean urinal, bedpan,
commode, or toilet collection device (“hat”)
 Instruct the client to keep urine separate from feces
and to avoid putting toilet paper in the urine
collection container.
 Pour the voided urine into a calibrated container.
 Hold the container at eye level, read the amount in
the container. Containers usually have a measuring
scale on the inside.
 Record the amount on the fluid intake and output
sheet, which may be at the bedside or in the
bathroom.
 Rinse the urine collection and measuring containers
with cool water and store appropriately
 Remove gloves and perform hand hygiene.
 Calculate and document the total output at the end
of each shift and at the end of 24 h on the client’s
chart
When measuring urine form a client who has a
URINARY CATHETER, the nurse follows these steps:
 Apply clean gloves.
 Take the calibrated container to the bedside.
 Place the container under the urine collection bag
so that the spout of the bag is above the container
but not touching it.
o The calibrated container is not sterile, but the
inside of the collection bag is sterile
 Open the spout and permit the urine to flow into
the container.
 Close the spout, then proceed as described in the
previous list
MEASURING RESIDUAL URINE
Postvoid residual (PVR) - urine remaining in the bladder
following voiding
 is normally 50 to 100 mL.
 a bladder outlet obstruction (e.g., enlargement of
the prostate gland) or loss of bladder muscle tone
 Manifestations of urine retention may include:
o frequent voiding of small amounts (e.g., less
than 100 mL in an adult)
o urinary stasis, and UTI.
 To measure PVR, the nurse catheterizes or bladder
scans the client after voiding
 The amount of urine voided and the amount
obtained by catheterization or bladder scan are
measured and recorded
URINARY SYSTEM DIAGNOSTIC TEST AND RELATED
NURSING CARE
Urinalysis.
 Most commonly ordered laboratory test for overall
screening and aiding in the medical diagnosis of
disease.
 Macroscopic and microscopic analysis of urine for
normal and abnormal constituents (physical and
chemical)
Clean-catch (midstream) specimen.
 Provides a urine specimen with minimal
introduction of microorganisms from the perineal
area.
NMR ♡

ABNORMAL URINARY CONSTITUENTS
 Glycosuria (glucosuria) - High blood sugar levels in
urine due to inadequate insulin level
 Proteinuria (albuminuria) - protein in urine;
increased permeability of the glomerular filtration
membrane
 Hematuria – presence of blood in urine; result of
leakage of RBCs
 Pyuria - Presence of WBCs or pus in the urine
caused by inflammation of the urinary tract
URINARY SYSTEM DIAGNOSTIC TEST AND RELATED
NURSING CARE
Twenty-four-hour urine specimen.
 Measures kidneys’ excretion of substances, such as
protein, uric acid, creatinine, selected hormones,
urobilinogen, and other substances, that the body
does not excrete at an even rate throughout the
day.
Culture and sensitivity.
 Identifies the causative microorganism and the
most effective antibiotic to eradicate the
microorganism;
 takes 24 to 72 hours for organisms to multiply and
be identified.
NURSING DIAGNOSIS
 Impaired Urinary Elimination: dysfunction in urine
elimination
 Readiness for Enhanced Urinary Elimination: a
pattern of urinary functions for meeting eliminatory
needs, which can be strengthened.
Other nursing diagnoses related to urinary elimination
include the following:
 Functional Urinary Incontinence
 Overflow Urinary Incontinence
 Reflex Urinary Incontinence
 Stress Urinary Incontinence
 Urge Urinary Incontinence
 Risk for Urge Urinary Incontinence
 Urinary Retention
NURSING CARE TO ASSIST PATIENTS WITH URINARY
ELIMINATION
Promoting Fluid Intake
 Encourage the patient to drink 8 to 10 glasses of
fluid daily.
 Provide hourly goals for intake.
 Keep fluids in easy reach.
 Provide fluids that the patient prefers.
 Assist the patient with toileting as soon as the need
to void is indicated by the patient.
 Clients who are at risk for UTI or urinary calculi
(stones) should consume 2,000 to 3,000 mL of fluid
daily.
o Dilute urine and frequent urination reduce the
risk of UTI as well as stone formation.
Maintaining Normal Voiding
 Habits Prescribed medical therapies often interfere
with a client’s normal voiding habits.
 When a client’s urinary elimination pattern is
adequate, the nurse helps the client adhere to
normal voiding habits as much as possible
 Provide privacy during toileting
 Encourage the patient to void (e.g., when the urge
to void is felt; on awakening, after meals, and at
bedtime; every 2 hours).
 Encourage the patient to completely empty the
bladder when voiding to prevent urinary stasis.
 Assist with positioning.
o Female: Sitting.
o Male: Standing or side lying.
 Provide a commode at the bedside for patients who
are unable to ambulate to a bathroom
 Assist bedbound patients to use a bedpan.
Promote urination.
 Put the patient’s hands in warm water.
 Turn on a sink tap so that the patient can hear the
sound of running water.
 Pour warm water over the patient’s perineum.
 Place a warm moist wash cloth over the patient’s
perineum.
NMR ♡
 Apply manual pressure over the patient’s bladder
(Credé maneuver)
URINARY CATHETERIZATION
 Urinary catheterization is the introduction of a
catheter into the urinary bladder.
 performed only when absolutely necessary, because
the danger exists of introducing microorganisms
into the bladder.
 involves introducing a latex or plastic tube through
the urethra and into the bladder.
 provides a continuous flow of urine in patients
 unable to control micturition or those with
obstructions.
 provides a means of assessing urine output in
hemodynamically unstable patients.
CATHETERS
 Catheters are commonly made of rubber or plastics
although they may be made from latex, silicone, or
polyvinyl chloride (PVC).
 sized by the diameter of the lumen using the French
(Fr) scale: the larger the number, the larger the
lumen.
TYPES OF CATHETER
1. STRAIGHT CATHETER
 is a single-lumen tube with a small eye or opening
about 1.25 cm (0.5 in.) from the insertion tip
2. RETENTION, OR FOLEY CATHETER
 is a double-lumen catheter.
 outside end of this two-way retention catheter is
bifurcated; that is, it has two openings, one to drain
the urine, the other to inflate the balloon
 larger lumen drains urine from the bladder
 second smaller lumen is used to inflate the balloon
near
 size of the retention catheter balloon is indicated on
the catheter along with the diameter, for example,
“#16 Fr—5 mL balloon.”
 purpose of the catheter balloon is to secure the
catheter in the bladder.
 follow the manufacturer’s instructions for the
proper volume to use for balloon inflation
3. Coudé (ELBOWED) CATHETER
 which has a curved tip
 used for men who have a hypertrophied prostate
 its tip is somewhat stiffer than a regular catheter
 it can be better controlled during insertion, and
passage is often less traumatic.
4. THREE – WAY FOLEY CATHETER
 For clients who require continuous or intermittent
bladder irrigation
 has a third lumen through which sterile irrigating
fluid can flow into the bladder.
 fluid then exits the bladder through the drainage
lumen, along with the urine.
NMR ♡
CONDOM CATHETER
 also called urinary sheath or external catheter
 indicated for persons with urinary incontinence
 Use of a condom appliance is preferable to insertion
of a retention catheter because the risk of UTI is
minimal

PURPOSE:
 To collect urine and control urinary incontinence
 To permit the client physical activity while
controlling UI
 To prevent skin irritation as a result of UI URINARY TRACT INFECTIONS
Signs and Symptoms
 manifestations are very mild and may be unnoticed.
o pain is common in the lower abdomen.
o dysuria (painful urination)
o urgency (need to void immediately)
o frequency (short intervals between voiding)
o nocturia (need for urination during the sleep
period) occur as the inflamed bladder wall is
URINARY TRACT INFECTIONS irritated by urine.
 UTI: Inflammation and infection of the urinary tract  Systemic signs of infection may be present:
structures o Fever
 Urine generally provides an excellent medium for o Malaise
growth of microorganisms. o Nausea
 common causative organism is Escherichia coli o Leukocytosis
 urine often appears cloudy and has an unusual
ETIOLOGY odor.
 women are anatomically more vulnerable to  urinalysis indicates:
infection than men o bacteriuria (the presence of bacteria in the
 irritation may be caused by sexual activity, baths, urine)
and the use of some feminine hygiene products. o pyuria, and microscopic hematuria
 improper hygiene practices during defecation or
menstruation also increase risk.
 older men with prostatic hypertrophy and retention
of urine frequently develop infections
 elderly are at increased risk
 common predisposing factors for UTIs in both men
and women:
o incontinence with incomplete emptying of the
bladder
o retention of urine in the bladder
o any obstruction to urine flow

TYPES OF URINARY TRACT INFECTIONS

Infection typically ascends from the urethra to the
bladder and possibly to the ureters
 URETHRITIS: inflammation of the urethra
 CYSTITIS: inflammation of the bladder wall (most
common type)
 URETERITIS: inflammation of the ureter
 PYELONEPHRITIS: infection extends from the ureter
into the kidney, involving the renal pelvis and
medullary tissue

NMR ♡
UTIs are treated promptly with antibacterial drugs such Nursing Interventions
as: Nurses care for patients with urinary tract infection in
1. Trimethoprim-sulfamethoxazole (Bactrim, Cotrim) all settings.
2. Nitrofurantoin  Relieve pain. Antispasmodic agents may relieve
3. Cephalosporins bladder irritability and analgesics. Application of
4. Carbapenems heat help relieve pain and spasm.
5. Amoxicillin  Fluids. The nurse should encourage the patient to
 Cranberry juice may be recommended as a drink liberal amounts of fluids to promote renal
prophylactic measure. blood flow and to flush bacteria from the urinary
o tannin content appears to reduce the capability tract.
of E. coli to adhere to the bladder mucosa  Voiding. Encourage frequent voiding every 2 to 3
hours to empty the bladder completely because this
can significantly lower urine bacterial counts,
reduce urinary stasis, and prevent reinfection.
 Irritants. Avoid urinary irritants such as coffee, tea,
colas, and alcohol.

Care of the patient with UTI must continue until at

home because it has a high recurrence rate.
 Personal hygiene. The nurse should instruct the
female patient to wash the perineal area from front
to back and wear only cotton underwear.
 Fluid intake. Increase and fluid intake is the number
one intervention that could stop UTI from recurring.
 Therapy. Strictly adhere to the antibiotic regimen
prescribed by the physician.

Nursing Management
Nursing care of the patient with UTI focuses on treating
the underlying infection and preventing its recurrence.
 Assess changes in urinary pattern such as
frequency, urgency, or hesitancy.
 Assess the patient’s knowledge about antimicrobials
and preventive health care measures.
 Assess the characteristics of the patient’s urine such
as the color, concentration, odor, volume, and
cloudiness.

NMR ♡
 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LAB)
WEEK 15: INTRAVENOUS THERAPHY
3RD SEMESTER | S.Y 2021 – 2022 TRANSCRIBED BY: NICOLE ROMERO
LECTURER: PAVEL ANTIQUE

IV Statistics Preventions
 85% of all hospitalized patients have some type of  Choose vein appropriately
IV therapy o Location
 118 million IV catheters inserted yearly o Size
o Soft, spongy, resilient
IV CANNULAS o No pain or tenderness or redness with injection

INFILTRATION
 Leaking of nonvesicant fluid into tissues
surrounding the vein.
 Check IV site every two hours
 Complications
o Nerve compression requiring fasciotomy
(surgery to relieve swelling and pressure in a
compartment of the body.)

COMPLICATIONS

EXTRAVASATION
 Inadvertent administration of vesicant drug into
surrounding tissues
o Calcium
o Magnesium
o Phenergan
o Potassium chloride
o Antibiotics
PHLEBITIS o Chemotherapy drugs
 Inflammation of the vein wall—precursor to sepsis o Vasopressors (Dopamine, epinephrine)
 What causes phlebitis? o Dextrose > 10%
o IV left in too long o Lorazepam
o Cannula too large o Dilantin
o Vein in poor condition
o Acidic solution or high osmolality
o Infusion rate too fast

NMR ♡
INFECTION
 Cellulitis: An acute, spreading, bacterial infection
below the surface of the skin characterized by
redness (erythema), warmth, swelling, and pain.
Usually localized.
 Sepsis: clinical symptoms of systemic illness, such as
fever, chills, malaise, hypotension, and mental
status changes. Sepsis can be life threatening.
 > 200,000 infections per year
 More than 60,000 patients die annually from
bloodstream infections caused by intravenous
therapy
 Cost for one patient is $56,000
 Annual US total = $2.3 billion

Causes
 Poor insertion site
 Unsterile start
 IV left in too long—change q 96 hours!
 Hub contamination

Cellulitis

Prevention
 Hand washing
 Sterile technique
 Catheter size
 Insertion site
 Site inspection every two hours
 Encourage patient to report any discomfort

Other sites to avoid include:

 sclerosed or thrombosed veins
 areas of skin inflammation, disease, bruising, or
breakdown
 an arm affected by a radical mastectomy, edema,
blood clot, or infection
 an arm with an arteriovenous shunt or fistula.

NMR ♡
STARTING AN IV
 Talk with patient
 Gather equipment
 Set up fluid and tubing on pump
 Check patient order and ID band & allergies
 Wash your hands!!
 Select a vein
 Select a catheter size
 Withdraw stylet while putting pressure on vein
1. Apply tourniquet 5-6 inches above insertion site above injection site
2. Never leave tourniquet on longer than one minute
3. Then Remove tourniquet and prepare equipment

STARTING AN IV (CONT.)
 Open equipment and connect flush to J- loop
 Loosen caps of IV and J-loop but leave in place for
sterility. (They should just slide off when you pick up
the device).
 Cleanse skin with chlorhexidine gluconate solution
in back & forth motion X 30 seconds
 Allow to dry for 30 seconds
 Insert tubing or prn adaptor
 Immobilize vein
 Position needle 10-15 degree angle over site
 Insert cannula bevel up
 Watch for blood backflow
 Advance cannula
 Only try twice before calling another RN to help

 It may get messy sometimes, but with experience

this will be minimized

 Flush with saline to clear tubing and insure IV has

not infiltrated.
 Stabilize tubing with tape to prevent IV from pulling
out while applying the sterile dressing.

 Advance cannula while holding stylet stationary

Release tourniquet!!

NMR ♡
 CONTINUOUS INFUSION: SECURING THE NEEDLE
When starting a continuous infusion, you must secure
the right-angle, non-coring needle to the skin. If the
needle hub is flush with the skin, apply a transparent
semipermeable dressing over the entire site. If the
needle hub isn’t flush with the skin, place a folded
sterile dressing under the hub, as shown. Then apply
adhesive skin closures across it.

 Apply clear sterile dressing. Cover site and hub, not

tubing

Secure the needle and tubing, using the chevron-taping

technique with sterile tape.

http://www.youtube.com/watch?v=tfQbbCx6xFU&feat
 Date, time and initial site and tubing ure=related
 Document! http://www.youtube.com/watch?v=ZcCWTEsEqPg&feat
ure=related

Apply a transparent semi-permeable dressing over the

entire site.

NMR ♡
 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LAB)
WEEK 14: ENEMA AND CATHETERIZATION
3RD SEMESTER | S.Y 2021 – 2022 TRANSCRIBED BY: NICOLE ROMERO
LECTURER: PAVEL ANTIQUE

ENEMA
 A medical treatment commonly used to treat
constipation where liquid is introduced into the
colon to soften and liquefy stool
 Enemas may also be used before medical
examinations of the colon. Your doctor may order
an enema prior to an X-ray of the colon to detect
polyps so that they can get a clearer picture. This
procedure may also be done prior to a colonoscopy

TYPES OF ENEMA
According to the Purpose:
 Cleansing
 Carminative
Carminative.
 Retention
A small volume enema given to release flatus.
 Return - flow Enema
Traditionally the enema consisted of two ounces of
glycerin, one ounce of magnesium sulfate (epsom salts)
Cleansing.
and three ounces of water. The combination of
Cleansing enemas are water-based and meant to be
ingredients stimulated peristalsis resulting in a bowel
held in the rectum for a short time to flush your colon.
movement in which feces and flatus are expelled. The
Once injected, they’re retained for a few minutes until
advantage in times past of using the carminative enema
your body rids itself of the fluid, along with loose matter
was that the low volume made it comfortable for the
and impacted stool in your bowel.
patient to retain, and it took little time to administer.

Retention
A retention enema also stimulates the bowels, but
the solution that is used is intended to be “held” in
the body for 15 minutes or more.

Return-flow
A return-flow enema, or Harris flush, is used to
remove intestinal gas and stimulate peristalsis. A
large volume fluid is used but the fluid is instilled in
100-200 ml increments. Then, the fluid is drawn out
by lowering the container below the level of the
bowel. This brings the flatus out with the fluid.

Materials:
 Waterproof Pad
 IV Pole
 Enema Can/Bag
 Rectal Tube
 Water soluble lubricant
 Bedpan
 Towel
 Clean Gloves

NMR ♡
Rectal Tube Sizes:
 Adult: Fr. 22-30  Places the water proof pad under the client’s
 Children: Fr. 14-18 buttocks.
 Infant: Fr. 12  Positions the client in left Sim’s position.
 Prepares the irrigating can, tubing and solutions.
Hangs the enema can on the IV stand about 18-24
inches above the level of the patient’s rectum.
 Lubricates the rectal tube and allows a small
amount of solution to flow through the tubing into
the bedpan.
 Dons glove and lift the upper buttocks of the
patient
 Inserts the tube slowly and smoothly around 3-4
inches into the patient’s anus.
 Administer the solution slowly. If the patient
complains of fullness or pain, use the clamp to stop
the flow for 30 seconds, and then restart the flow at
Procedure
 Verify the doctor’s order of administering enema to a slower rate.
the client  Closes the clamp after all the solutions has been
administered or when the client cannot hold
 Prepares the needed materials and solutions.
 Performs handwashing before and after the anymore and wants to defecate.
procedure.  Removes the rectal tube and places it in a
 Identifies patient and explains the procedure. disposable towel.
 Encourages the patient to retain the enema
 Provides privacy to the client throughout the
solution.
procedure.
 Assist the patient to defecate.
 Assists the patient with the necessary cleansing.
 Makes the patient comfortable.
 After care of the unit and materials used.
 Document the procedure done. Record the kind and
amount of stool and solution used and the
character of the return flow

Urinary Catheterization
In urinary catheterization, a catheter (hollow tube) is
inserted into the bladder to drain or collect urine. There
are two main types of urinary catheterization:
indwelling catheterization and non-indwelling
catheterization.

Purposes of Urinary Catheterization

 Relieve urinary retention
 Obtain sterile urine specimen
 Measure residual urine

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 Empty the bladder before, during and after surgery  KY Jelly
 Allows accurate measurement of urine output  Syrine (10mL)
 Bladder irrigation (Cystoclysis)  Sterile Water
 Administration of medication  Forcep
 Sterile Cotton Balls
Types of Catheterization  Kidney Basin
 Indwelling Catheter  Sterile Drape
o A Foley catheter is a thin, sterile tube inserted  Tape to secure the catheter
into the bladder to drain urine. Because it can
be left in place in the bladder for a period of Types of Catheters
time, it is also called an indwelling catheter. It is  Single Lumen - used for onetime catheterization.
held in place with a balloon at the end, which is  Two - Lumen - also called an indwelling foley or
filled with sterile water to prevent the catheter retention catheter.
from being removed from the bladder. The  Triple - Lumen - used for bladder irrigation or
urine drains through the catheter tube into a Cystoclysis
bag, which is emptied when full.

 Non-indwelling Catheter
o A similar type of catheter will be inserted but
will not be left in place. this is used for a
onetime evacuation of urine. often referred to
as an intermittent catheter. Size of Catheters
 Male Fr. 16 -18
Materials  Female Fr. 12 – 14
 Catheter  Child Fr. 8 – 10
 Betadine  Infant Fr. 5 – 8
 Urine Bag

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  Picks up the catheter and places the drainage end of
the catheter in the urine receptacle using
uncontaminated hand.
 Lubricates the insertion end or tip of the catheter.
 Gently inserts the catheter in the direction of the
urethra until urine flows.

How catheter works

Procedure
Female Catheterization
 Assess the patient’s need for catheterization and
refer patient to the
 doctor. Male Catheterization
 Verify the doctor’s order for catheterization.  Assess the patient’s need for catheterization and
 Prepare the necessary materials. refer patient to thebdoctor.
 Perform hand washing.  Verify the doctor’s order for catheterization.
 Identifies the patient and explains the procedure.  Prepare the necessary materials.
 Positions the patient properly and ensures patient’s  Perform hand washing.
privacy.  Identifies the patient and explains the procedure.
 Applies aseptic technique during the entire  Positions the patient properly and ensures patient’s
procedure. privacy.
 Opens the catheterization kit aseptically.
 Add materials to the kit ensuring sterility the whole
time.
 Dons first glove and fills the syringe with distilled
water.
 Dons second glove and applies sterile drapes to the
patient.
 With the non-dominant hand, separates the labia
minora with the thumb and index finger. Never
removes fingers until catheter is inserted.
 With the dominant hand, uses sterile forcep to pick
up swabs. Cleans first from the meatus downward
and then on either side using a new swab for each
stroke.

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  Disposes soiled materials properly.
 Applies aseptic technique during the entire  Accurately records the procedure done
procedure.
 Opens the catheterization kit aseptically.
 Add materials to the kit ensuring sterility the whole
time.
 Dons first glove and fills the syringe with distilled
water.
 Dons second glove and applies sterile drapes to the
patient.
 Grabs the penis firmly behind the glans with the
non-dominant hand and

 With the dominant hand, uses sterile forcep to pick

up swabs. Cleans first from the meatus and then
wipe the tissue surrounding the meatus incircular
motion using a new swab for each stroke.
 Picks up the catheter and places the drainage end of
thecatheter in the urine receptacle using
uncontaminated hand.
 Lubricates the insertion end or tip of the catheter.
 Lifts the penis to a position at 90 degrees angle and
inserts the catheter until urine flows.
 Connects the catheter to the urine bag and ensures
that emptying base of the bag is closed.

 Inflates the balloon by injecting 5-10cc of distilled

water and checks the anchor.
 Tapes the catheter with non-allergenic tape at the
lower abdomen of the patient.
 Removes drapes and makes the patient
comfortable.

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 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LAB)
WEEK 13: RESPIRATORY FUNCTION AND NURSING CARE
3RD SEMESTER | S.Y 2021 – 2022 TRANSCRIBED BY: NICOLE ROMERO
LECTURER: PAVEL ANTIQUE

What is Oxygen? Inhalation and exhalation involves muscles:

 Oxygen, a clear, odorless gas that constitutes
approximately 21% of the air we breathe, is
necessary for proper functioning of all the living
cells. The absence of oxygen can lead to cellular,
tissue, and organism death.
 The respiratory system is most directly involved in
this process. Impaired function of the system can
significantly affect our ability to breathe, transport
gases, and participate in everyday activities.

SHARE KO LANG (SKL)

 A typical fart is composed of about 59 percent
nitrogen, 21 percent hydrogen, 9 percent carbon
dioxide, 7 percent methane and 4 percent oxygen.
 Only about one percent of a fart contains hydrogen
sulfide gas and mercaptans, which contain sulfur,
and the sulfur is what makes farts stink.

RESPIRATION

1. Rib muscles = the muscles between the ribs in the

chest.
2. Diaphragm muscle

Muscle movement – the diaphragm and rib muscles

UPPER RESPIRATORY TRACT
 The UPPER respiratory tract consists of the nose
and nares also referred to as the nostrils, the
pharynx, and the larynx;
 The LOWER respiratory tract consists of the
trachea, the bronchi, the lungs, and the alveoli.
are constantly contracting and relaxing (approximately
16 times per minute), thus causing the chest cavity to
increase and decrease.
CONTRACTION OF MUSCLES
During inhalation – the muscles contract:
Contraction of the diaphragm muscle – causes the
diaphragm to flatten, thus enlarging the chest cavity.

CILIA
Filter environmental air to free it of bacteria and other
harmful substances such as dust and air pollution.

The ACT OF BREATHING (2 Stages)

Inhalation – the intake of air into the lungs through
expansion of chest volume.
Exhalation – the expulsion of air from the lungs through
contraction of chest volume.

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During exhalation – the muscles relax:
The muscles are no longer contracting, they are relaxed.
The diaphragm curves and rises, the ribs descend – and
chest volume decreases.
ACT OF BREATHING
ASSESSING RESPIRATORY SYSTEM
1. Complaints of shortness of breath (dyspnea)
2. Bluish or cyanotic appearance of the nail beds, lips,
mucous membranes and skin
3. Restlessness, irritability, confusion, decreased level
of consciousness
4. Pain during inspiration and expiration
5. Labored or difficult breathing
6. Orthopnea
7. Use of accessory muscles
8. Abnormal breath sounds such as wheezes, rhonchi
or rales
9. Inability to breathe spontaneously
10. Thick, frothy, blood-tinged or copious sputum
production

PARADOXYCAL CHEST MOVEMENT

RESPIRATORY CONTROL CENTER

 Medulla oblongata
- primary respiratory system
- Rate and depth of respirations
 Pons
- Moderates the rhythm of inspiration and expiration
 Reflex Control
- Cough Reflex
FACTORS AFFECTING RESPIRATORY SYSTEM (HMEALS)  Peripheral Control (Carotid and Aortic bodies)
H - ealth status= diseases in the respiratory system can - Act to reduce oxygen level
affect respiratory function.
M - edications= anti-anxiety drugs and sedative TERMINOLOGIES
hypnotics can decrease the rate and depth of RESPIRATION
respirations. (ex. Diazepam (Valium), Flurazepam  is the act of breathing.
(Dalmane), Barbiturates (Phenobarbital)  supply the body with oxygen for metabolic activity
E - nvironment= altitude, heat, cold and air pollution and to remove carbon dioxide.
affect oxygenation
A - ge= increase in newborn, slows until adulthood and VENTILATION
decreases for elderly.  The movement of air in and out of the lungs
L - ifestyle= increase due to physical exercise/ activity;  Involves three forces:
occupations can predispose individual to lung diseases. - Compliance
Silicosis (sandstone blasters and potters), asbestosis - Surface Tension
(asbestos workers), anthracosis (coal miners), organic - Muscular Effort
dust disease (farmers/ agricultural workers)
S - tress= some hyperventilate when stressed, when
stress continues this increase the risk of cardiovascular
disease.

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  VOLUME
o HYPERVENTILATION
- deep, rapid respiration due to excessive amount of
air in lungs
o HYPOVENTILATION
- slow respiration and causes of retention of carbon
dioxide

 EFFORT
o DYSPNEA
- difficult and labored breathing.
o ORTHOPNEA
PULMONARY PERFUSION - ability to breath only in upright position or sitting
 Blood flow from the right side of the heart, through position
the pulmonary circulation, and into the left side of
the heart. NORMAL BREATH SOUNDS

DIFFUSION
 Gas movement from an area of greater to lesser
concentration through a semipermeable membrane

RESPIRATORY SYSTEM ASSESSMENT

 RATE

Eupnea
Adults:12-20/min
Infants: 44/min

ADVENTITIOUS SOUNDS
Tachypnea
Rapid, shallow breathing

Bradypnea
slow respiratory rate

 RHYTHM
Hyperypnea
Rapid, deep breathing
Hyperventilation
Kussmaul breathing
(metabolic acidosis)
What is the PURPOSE of O2 Therapy?
Ataxic breathing To relieve hypoxia and provide adequate tissue
Biot’s breathing oxygenation.
Irregularly irregular e.g.,
brain medullary injury Clinical Indications
Any client who is likely to have significant shunt from:
Cheyne-Stokes breathing  Fluid in the alveoli.
Regular rate, irregular depth 1. Pulmonary edema.
MAY be normal e.g., heart 2. Pneumonia.
failure 3. Near-drowning.
4. Chest trauma.

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 Collapsed alveoli (atelectasis)
Airway obstruction.
1. Any client who is unconscious.
2. Choking.
 Failure to take deep breaths.
1. Pain (rib fracture).
2. Paralysis of the respiratory muscles (spine injury).
Pulmonary manifestations due to:
Atelectasis.
Exudation of protein fluids into alveoli.
Damage to pulmonary capillaries.
Interstitial hemorrhage.
OXYGEN ADMINISTRATION
Oxygen is dispensed from cylinder or piped-in system.

A. Cardiac arrest.
B. Shock.
C. Shortness of breath.
D. Signs of respiratory insufficiency.
E. Breathing fewer than 10 times per minute.
F. Chest pain.
G. Stroke.
H. Anemia

 Depression of the respiratory center (head injury,

drug overdose).
1. Collapse of an entire lung

 Other gases in the alveoli.

1. Smoke inhalation.
2. Toxic inhalations. NASAL PRONGS/CANNULA
3. Carbon monoxide poisoning.  Comfortable and simple, and allows client to move
4. Respiratory arrest. about in bed.
 Delivers 25% to 40%oxygen at flow rates of 4 to 6
PRECAUTIONS L/min.
Clients with COPD should receive oxygen at low flow  Difficult to keep in position unless client is alert and
rates (usually 1 to 3 L/min), to prevent inhibition of cooperative.
hypoxic respiratory drive.

Excessive amounts of oxygen for prolonged periods of

time will cause retrolental fibroplasia and blindness in
infants who are premature.

Oxygen delivered without humidification will result in

drying and irritation of respiratory
 mucosa, decreased ciliary action, and thickening of
respiratory secretions.

Oxygen supports combustion, and fire is a potential

VENTURI MASK
hazard during its administration.
 Allows for accurate delivery of prescribed
 Ground electrical equipment.
concentration of oxygen.
 Prohibit smoking.
 Delivers 24% to 50% oxygen at flow rates of 4 to 8
 Institute measures to decrease static electricity.
L/min.
 Useful in long-term treatment of COPD.
High flow rates of oxygen delivered by ventilator or
cuffed tracheostomy and endotracheal tubes can
produce signs of oxygen toxicity in 24 to 48 hours:
Cough, sore throat, decreased vital capacity, and
substernal discomfort.

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SIMPLE 02 FACE MASK
 Poorly tolerated—used for short periods of time;
feeling of “suffocation.”
 Delivers 50% to 60% oxygen at flow rates of 8 to 12
L/min.
 Hot—may produce pressure sores around nose and
mouth.
NON-REBREATHER MASK
 Oxygen flow rate prevents collapse of bag during
inhalation.
 Delivers 90% to 95% oxygen at flow rates of 10 to
12 L/min.
 Ideal for severe hypoxia, but client may complain of
feelings of suffocation.
PARTIAL REBREATHER MASK
 The partial rebreather mask HAS A TWO-WAY
VALVE allows you to breathe a mix of pure oxygen
combined with your breath for a lower and variable
amount of oxygen.
 A partial rebreather mask typically delivers 50 to 70
percent oxygen. They're useful in situations when
people have extremely low levels of blood oxygen,
since they can quickly deliver oxygen to your blood.
TRACHEOSTOMY TUBE/ENDOTRACHEAL TUBE
 Provides humidification and enriched oxygen
mixtures to tracheostomy or endotracheal tube.
 Delivers up to 100% oxygen at flow rates at least
twice the minute ventilation
 Horizontal incision through the skin at the lower
part of the front of your neck. The surrounding
muscles are carefully pulled back and a small
portion of the thyroid gland is cut, exposing the
windpipe (trachea).
INTUBATION AND MECHANICAL VENTILATORS
INDICATIONS
1. Apnea.
2. Inadequate upper airway or inability to clear
secretions.
3. Worsening respiratory acidosis (PaCO2 greater than
50 mm Hg) and hypoventilation.
4. PaO2 less than 55 mm Hg.
5. Absent gag reflex.
6. Heavy sedation or paralysis.
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7. Imminent respiratory failure (respiratory rate less SUCTION CATHETERS
than 8 to 10 breaths/min or greater than 30 to 40
breaths/min).
8. Chest wall trauma.
9. Profound shock.
10. Controlled hyperventilation (e.g., increased ICP).

Types of positive-pressure ventilators

 Pressure cycled—gas flows into the client until a
predetermined airway pressure is reached.
 Time cycled—gas flows for a certain percentage of
time during ventilatory cycle.
 Volume cycled—most common ventilators used;
tidal volume is determined, and a fixed volume is
delivered with each breath.

VENTILATOR MODES
 Controlled—machine delivers a breath at a fixed
rate regardless of client’s effort or demands.
 Assist-controlled—machine senses a client’s
efforts to breathe and delivers a fixed tidal volume
with each effort.
 Intermittent mandatory ventilation (IMV)—
breaths are delivered by the machine, but the
client may also breathe spontaneously without The purpose of chest PT is to move fluid or mucus in the
machine assistance. lungs. It is done by clapping on the chest and by
 Pressure support—client breathes spontaneously positioning your child to help move mucus to the larger
and determines ventilator rate. airways where it can be coughed and/or suctioned out.
 Minute ventilation—determined by the
respiratory rate and the tidal volume. A respiratory
rate of 10 to 15 breaths/min is considered
appropriate.
 Positive end-expiratory pressure (PEEP)—
maintenance of positive airway pressure at the end
of expiration.

OROPHARYNGEL AND NASOPHARYNGEL SUCTIONING

Assess indications for suctioning:
 audible secretions during respiration
 adventitious breath sounds

Position
 Conscious: Semi- fowler’s
 Unconscious: Lateral

 Pressure of suction equipment to prevent trauma to

mucous membrane of airways.
 Appropriate size of sterile suction catheter

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NURSING CONSIDERATIONS:
1. Indicated to maintain a patent airway and to
remove saliva, pulmonary secretions, blood,
vomitus, or foreign material from the pharynx.
2. Suctioning of the nasopharynx or oropharynx may
be indicated if the pt. is able to raise secretions
from the airways but unable to clear from the
mouth, or suctioning of the tracheal when unable to
raise secretions from the airways.
3. Frequency varies with amount of secretions, but
should be done often enough to keep ventilation
effective and as effortless as possible.
4. Wear gloves, googles and mask, and gown if
necessary.
TRANSIENT TACHYPNEA OF THE NB
 Transient tachypnea of the newborn (TTN) is a
benign, self-limited condition that can present in
infants of any gestational age, shortly after birth.
 It is caused due to delay in clearance of fetal lung
fluid after birth which leads to ineffective gas
exchange, respiratory distress, and tachypnea
 NOT LIFE THREATENING but require constant
monitoring. It could last up to 36 hours but usually
patient improves within 12-24 hours.
 Tx: Tube feeling, IV Fluids, Antibiotics, OXYGEN
THERAPY.

1. Aspirating secretions through a catheter connected

to suction machine or wall suction outlet.
2. Assess for signs of respiratory distress.
3. Asses for client inability to cough up and
expectorate secretions, dyspnea, poor skin color,
bubbling or rattling breath sounds, decreased O2
saturation.
4. Monitor pt.’s color and heart rate, color, amount
and consistency of secretions.
5. Stop immediately, administer O2 and notify
physician if pt. is cyanotic, excessively slow or rapid
heart rate which can indicate hypoxemia or
suddenly bloody secretions which can indicate
damage to the mucosa

1. Can lead to trauma to airways, nosocomial

infection, cardiac dysrhythmia, hypoxia and even
death.
2. Decrease complications by:
o Hyperinflation
o Hyperoxygenation
o Hyperventilation
o Gently rotate catheter, withdraw while
suctioning, suction for 5-10 seconds
3. Can irritate the mucosa.
4. Removes oxygen from the respiratory tract possibly
causing hypoxemia (insufficient oxygen in blood)
5. Important to oxygenate the pt. before suctioning,
by applying supplemental O2 and taking deep
breaths.
6. When performed correctly, provides comfort by
relieving respiratory distress.
7. When performed incorrectly, can increase anxiety
and pain and cause respiratory arrest.
8. Uncomfortable procedure, can be painful.

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 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LAB)
WEEK 16: BLOOD TRANSFUSION
3RD SEMESTER | S.Y 2021 – 2022 TRANSCRIBED BY: NICOLE ROMERO
LECTURER: PAVEL ANTIQUE

BLOOD TRANSFUSION TREATMENT RH INCOMPATIBILITY

 It is a procedure in which a patient receives a blood
product through an intravenous line.
 It is the introduction of blood components into the
venous circulation.
 Process products of transferring blood-based from
one person into the circulatory system of another
Purposes
1. To replace blood lost during surgery or a serious
injury.
2. To restore oxygen-carrying capacity of the blood.
3. To provide plasma factors to prevent or treat
bleeding.
4. Done if patient’s body is not capable of making
blood properly because of an illness.
Rh Immune Globulin
 This treatment prevents your immune system from
making antibodies against your fetus's Rh-positive
red blood cells.
 The mother must have a shot of Rh immune
globulin around week 26-28 weeks of your
pregnancy.
 If your baby is found to be Rh-positive at birth, you
will receive an additional dose within 72 hours after
delivery

Typical Situations in which blood products are given

1. Major injuries after an accident or disaster
BLOOD TYPES
2. Surgery on an organ such as the liver and the heart
 The blood used in a transfusion must be compatible
3. Severe Anemia
with the patient's blood type.
4. Bleeding such as Haemophilia and
 Type O blood is called the universal donor
Thrombocytopenia.
 People with type AB blood are called universal
recipients
BLOOD TYPES
 People with Rh-positive blood can get Rh-positive
 Each person has one of the following blood types: A,
or Rh-negative blood. But people with Rh-negative
B, AB, or O.
blood should get only Rh-negative blood.
o can be given to anyone but can only receive O.
o AB can receive any type but can only be given to
AB.
o Also, every person's blood is either
o Rh-positive or Rh-negative

RH Incompatibility
 Rh incompatibility is a condition that occurs during
pregnancy if a woman has Rh-negative blood and
her baby has Rh-positive blood.
 "Rh-negative" and "Rh-positive" refer to whether
your blood has Rh factor. Rh factor is a protein on
BLOOD BANKS
red blood cells.
 Blood banks collect, test, and store blood.
 If you have Rh factor, you're Rh-positive.
 Autologous transfusion - If surgery is scheduled
 If you're Rh-negative and your baby is Rh-positive,
months in advance, patients may be able to donate
she may be at risk for Rh disease. It can cause
their own blood and have it stored.
serious problems for your baby, including death.
 Allogeneic transfusion/Homologous is when a donor
 Firstborn babies usually aren't affected by Rh
and a recipient are not the same person (in contrast
disease. But if it's not treated, Rh disease can cause
to autologous transfusion, where donor and
serious harm in later pregnancies.
recipient are the same person).

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PREPARATION TRANSFUSION REACTIONS
 Before a blood transfusion, a technician tests the
patient's blood to find out what blood type they REACTION:CAUSE CLINICAL SIGNS NURSING
INTERVENTIONS
have (that is, A, B, AB, or O and Rh positive or Rh Hemolytic Reaction: Chills, fever, 1. Discontinue the
negative). Incompatibility headache, backache, Transfusion
 Some patients may have allergic reactions even between client’s dyspnea, cyanosis, immediately. NOTE:
blood and donor’s chest pain, when the transfusion
when the blood given does work with their own blood. tachycardia, is discontinued, use
blood type hypotension new tubing for the
normal saline
infusion.
ADMINISTERING BLOOD 2. Notify primary care
 Blood transfusions take place in either a doctor's provider immediately.
3. Monitor vital signs.
office or a hospital. 4. Monitor fluid intake
 They can be done at the patient's home, but this is and output.
less common. 5. Send the remaining
blood, bag, filter,
 A needle is used to insert an intravenous (IV) line tubing, a sample of
into a blood vessel. Through this line, the blood is the client’s blood, and
a urine sample to the
transfused.
laboratory
 LARGE BORE NEEDLE gauge 16-17. Gauge 18 or 20 Febrile Reaction: Fever, chills, warm 1. Discontinue
for BT. sensitivity of the and flushed skin, the transfusion
client’s blood to white headache, anxiety, immediately.
 The procedure usually takes one to four hours. The blood cells, platelets, muscle pain 2. Give antipyretics as
time depends on how much blood is needed, which or plasma proteins ordered.
blood product is given, and whether the patient's 3. Notify the primary
care provider.
body can safely receive blood quickly or not. 4. Keep the vein open
 During the blood transfusion, a nurse carefully with a normal saline
watches the patient, especially for the first 15 infusion.
Allergic Reaction Flushing, itching, 1. Stop or slow the
minutes. (Mild) urticaria, bronchial transfusion,
 This is when bad reactions are most likely to occur. wheezing depending on agency
protocol.
 After a blood transfusion, vital signs are checked 2. Notify the primary
(such as temperature, blood pressure, respiration care provider.
rate, and heart rate). 3. Administer
antihistamines as
 Follow-up blood tests may be necessary to show Allergic Reaction Dyspnea, chest pain, 1. Stop the
how the body is reacting to the transfusion. (Severe) circulatory collapse, transfusion.
cardiac arrest 2. Keep the vein open
with a normal saline
BLOOD WARMER solution.
3. Notify the primary
care provider
immediately.
4. Monitor vital signs.
Administer CPR if
needed.
5. Administer
medications or
oxygen as ordered.
Circulatory Overload: Cough, dyspnea, 1. Place the client
blood administered crackles (rales), upright, with feet
faster than the distended neck veins, dependent.
circulation can tachycardia, 2. Stop or slow the
accommodate hypertension transfusion.
3. Notify the primary
care provider.
4. Administer
diuretics or oxygen as
ordered
Sepsis: contaminated High fever, chills, 1. Stop the
PRE-BT MEDS blood administered vomiting, diarrhea, transfusion.
Premedication with acetaminophen and hypotension 2. Keep the vein open
diphenhydramine is the most commonly used approach with a normal saline
solution infusion.
to reduce the incidence of FNHTR and allergic reactions 3. Notify the primary
to blood products.1st BT, no PRE-BT.2nd BT- PRE-BT care provider.
MEDS. 4. Administer IV
fluids, Antibiotics.

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 5. Obtain a blood
specimen from the
client for culture.
6. Send the remaining
blood and tubing to
the laboratory

WHAT IS THE MOST COMMON BLOOD TRANSFUSION

REACTION?
According to the CDC, a febrile non-hemolytic
transfusion reaction (FNHTR) is the most common
reaction. It involves an unexplained rise in temperature
during or 4 hours after the transfusion. The fever is part PRODUCTS DESCRIPTION
of the person's white blood cells response to the new C. Platelets ➢ Also known as thrombocytes
➢ Tiny cell structures necessary in
blood. Usual amount: 50ml blood clotting process.
➢ Replaces platelets in clients with
MANAGEMENT bleeding disorders, or platelet
deficiency
Fever usually resolves in 15-30 minutes without specific
➢ 1 unit = increases the average
treatment. If fever causes discomfort, oral adult client’s platelet count by
acetaminophen (325-500 mg) may be administered. about 5,000 platelets/microliter

BLOOD PRODUCTS
 Components of the blood which are collected from
a donor for use in blood transfusion.

PRODUCTS
A. Packed Red Blood Cells (PRBCs)
Usual amount: 250-300m
DESCRIPTION
➢ Most common type of blood
product for transfusion
➢ Used to increase the oxygen-
carrying capacity of blood
➢ 1 unit of PRBCs = raises
hematocrit by 2-3%
PRODUCTS DESCRIPTION
D. Whole Blood (200-300ML) ➢ Not commonly used except for
extreme cases of acute
hemorrhage.
➢ Replaces blood volume and all
blood products.
E. Autologous Red Blood ➢ Used for blood replacement
Cells following planned elective
surgery
➢ Must be donated 4-5 weeks
prior to surgery

PRODUCTS
B. Fresh Frozen Plasma (FFP)
Usual amount: 250-330ml
DESCRIPTION
➢ Plasma is the liquid component
of blood; it has proteins called
clotting factors
➢ Expands blood volume and
provides clotting factors
➢ Contains no RBCs
➢ 1 unit of FFP = increases level of
any clotting factor by 2-3%
PRODUCTS DESCRIPTION
F. Albumin and Plasma Protein ➢ Blood volume expander
Fraction ➢ Provides plasma protein
G. Clotting Factors and ➢ A portion of plasma containing
Cryoprecipitate certain specific clotting factors
➢ Used for clients with clotting
factor deficiencies
➢ Contains Fibrinogen

NMR ♡
BLOOD DONATION
BENEFITS:
1. Stimulates Blood Cell Production.
2. Blood Donation helps to reduce risk of heart attack
and cancer.
3. Donation of blood, burns calories & helps in weight
loss.
4. Blood donation helps to maintain healthy liver.
5. May look younger and glowing skin.

REQUIREMENTS:
1. You must be in good health at the time you donate.
2. You cannot donate if you have a cold, flu, sore
throat, cold sore, stomach bug or any other
infection.
3. If you have recently had a tattoo or body piercing
you cannot donate for 6 months from the date of
the procedure.
4. If previously treated with dengue, wait for 6 months
before donating.
5. Patient should have negative results to HIV,
HEPATITIS, or any blood borne diseases.

NMR ♡
 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LEC)
WEEK 17: GRIEF LOSS DEATH DYING
3RD SEMESTER | S.Y 2021 – 2022
LECTURER: PATRICK RANALO
GRIEF AND LOSS
 LOSS = something of value is gone
 GRIEF = total response to emotional experience
related to loss.
 BEREAVEMENT = subjective response to by loved
ones.
 MOURNING = behavioral response
 Loss is a universal experience that occurs
throughout the lifespan.
 Grief is a form of sorrow involving feelings,
thoughts and behaviors caused by bereavement.
 Responses to loss are strongly influenced by one’s
cultural background.
 The grief process involves a sequence of affective,
cognitive and psychological states as a person
responds to and finally accepts a loss.
STAGES OF GRIEVING
DENIAL
 “No not me”
 After the initial shock has worn off, the next stage is
usually one of classic denial, where they pretend
that the news has not been given.
 They effectively close their eyes to any evidence
and pretend that nothing has happened.
Interventions:
 Do not interfere unless it becomes destructive
 Do not support denial; conversations should include
reality
 Continue to teach and encourage self care activities.
ANGER
 “Why me?”
 This stage often occurs in an explosion of emotion,
where the bottled-up feelings of the previous stages
are expulsed in a huge outpouring of grief.
TRANSCRIBED BY: NICOLE ROMERO
 Whoever is in the way is likely to be blamed.
Interventions:
 Give space allowing them to rail and below. The
more the storm blows the sooner it will blow itself
out.
 Try not to respond in “kind”
 When anger is destructive, it must be addressed
directly. Remind the person of appropriate and
inappropriate behavior.
BARGAINING
 “Yes me, but…”
 The patient attempts to negotiate a postponement
with God and is generally kept a secret.
Interventions:
 Spend time with patients
 Discuss importance of valued objects and people
DEPRESSION
The inevitability of the news eventually (and not before
time) sinks in and the person reluctantly accepts that it
is going to happen.
Interventions:
 Be available
 Don’t attempt to cheer person up
 Find out any religious support
ACCEPTANCE
 Restful time, but not necessarily happy.
 Often begin putting their life in order, sorting out
wills and helping others to accept the inevitability
Interventions:
 Plan care to allow the person with whom patient is
comfortable to care for him or her
 It is important that you don’t withdraw
DEATH
 "cessation of heart- lung function, or of whole brain
function, or of higher brain function.
 "either irreversible cessation of circulatory and
respiratory functions or irreversible cessation of all
functions of the entire brain, including the brain
stem
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DEATH CONCEPT AMONG AGE
 1-5 immobility and inactivity; wishes and unrelated
action responsible for action.
 5-8 final but can be avoided.
 9-12 understands own mortality and fears death.
 12-18 fears and fantasizes avoidance.
 18- 45 increased attitude awareness.
 45-65 accepts mortality.
 Above 65 multiple meanings; encounters and fears.
FEARS OF DYING PERSON
FEAR OF LONELINESS
 Distancing by support people and caregivers can
occur
 Debilitation, pain, and incapacitation
 Hospital, a place that can be very lonely
 Fear of dying alone
FEAR OF SORROW
 Sadness
 Letting go of hopes, dreams, the future
 Awareness of own mortality
 Grief about future losses
 Anticipatory grief that involves mourning, coping
skills.
 Grief related to diagnosis that has a long term effect
on the body such as cancer
FEAR OF THE UNKNOWN
 Death is an unknown state
 What will happen after death?
 What will happen to loved ones, those left behind
LOSS OF SELF CONCEPT AND BODY INTEGRITY
 Mutilation via therapy and body image changes
 Loss of role or status
 Loss of standard of living
FEAR OF REGRESSION
 Ego is threatened
 Physical deterioration may occur
 Mental deterioration may occur
 Unable to care for self
 Become dependent on others for care
FEAR OF SUFFERING AND PAIN
 May be many different types of pain or suffering
such as physical, emotional, social, or spiritual in
nature
 Altered relationships with others
 Anxiety related to the disease and consequences of
the disease
TAKING CARE OF DYING PERSON
 The role of the nursing staff is fundamentally
supportive
 Accept the physical and mental state he is in
 Show him that they will not abandon him
 Responds to the persons needs in a physical,
psychological, social and intellectual level
PHYSICAL LEVEL
 Biological needs, reduction and control of pain
 Pain is a subjective experience
 Acute pain: usually temporary
 Chronic pain: interrupts normal everyday
functioning
 Medication is more effective in the context of a
holistic intervention
PSYCHOLOGICAL LEVEL
 The only way for the person to reconcile with these
feelings is to talk to someone who is willing to listen
 Support has to respond to the person’s need for
safety, autonomy and self-control
SOCIAL LEVEL
 Emotional and social withdrawal
 Need of emotional withdrawal co-exists with the
need of belonging to an accepting and supportive
social environment.
 When family/medical nursing staff keep their
distance in order to protect themselves, the person
experiences a “social death”, which is sometimes
more painful than the actual death
 Nursing staff must treat the dying person without
fear, encourage relatives to be close to him, act as a
liaison with the outside world
INTELLECTUAL LEVEL
 Need to evaluate his life as meaningful, important,
useful
 Nursing staff should stand by him without being
judgmental, let him decide where he wants to
spend his last days, and interact with him as a
person who LIVES
NURSING RESPONSIBILITIES
 Nurses need to take time to analyze their own
feelings about death before they can effectively
help others with terminal illness.
 Understand that you may experience grief
 Nurses have to be strong to control their feelings to
be able to tolerate pain, illness, and death, and to
keep their distance
 Provide relief from illness, fear and depression
 Help clients maintain sense of security
NMR ♡
 Help accept losses number of breaths per minute, or breathing that
 Provide physical comfort switches between rapid and slow
 Involuntary movements (called myoclonus),
ROLE OF THE CHAPLAIN changes in heart rate, and loss of reflexes in the legs
 Can be a member of the health care team and arms also mean that the end of life is near
 Assist with religious practices
 Perform rites PRONOUNCEMENT OF DEATH
 Provide prayer, support, and comfort  Absence of carotid pulses
 Assist with mobilizing other support systems that  Pupils are fixed and dilated
are important to the client  Absent heart sounds
 Support family members  Absent breath sounds

COMMUNICATING WITH CLIENT

 Right to know
 Time frame
 Nurse needs to assess whether or not the
patient/family have been told and what was told to
them
 THE PHYSICIAN WILL TELL THE CLIENT FIRST, NOT
THE NURSE.
 Clarifies what was said
 Listens to concerns
 Fosters communication between MD, client, and
family
 Allows patient to express loss
 Facilitate grief through nursing process
 Be available for patient
 Assist patient to identify needs/hopes for remainder
of life
 Connect patient with proper resources

ASSIST FAMILY
 Explain procedures and equipment
 Prepare them about the dying process
 Involve family and arrange for visitors
 Encourage communication
 Provide daily updates
 Resources
 Do not deliver bad news when only one family
member is present

PHYSICAL SIGNS OF DYING

 Confusion – about time, place, and identity of loved
ones; visions of people and places that are not
present
 A decreased need for food and drink, as well as loss
of appetite
 Drowsiness – an increased need for sleep and
unresponsiveness.
 Withdrawal and decreased socialization
 Skin becomes cool to the touch
 Loss of bowel or bladder control
 Rattling or gurgling sounds while breathing or
breathing that is irregular and shallow, decreased

NMR ♡
 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LEC)
WEEK 16: CONCEPTS AND PRINCIPLES OF PARTNERSHIP, COLLABORATION AND TEAMWORK
3RD SEMESTER | S.Y 2021 – 2022
LECTURER: PATRICK RANALO
TERMINOLOGIES
 COLLABORATIVE HEALTH CARE
- A comprehensive care provided to the clients
through the collaborative efforts and expertise of
each member of the health team
PARTNERSHIP
PARTNERSHIP
- A collaborative relationship between two or more
parties based on trust, equality, and mutual
understanding for the achievement of a specified
goal
“TWINNING”
- Coined by the Tropical Health Education Trust
(THET) -"the establishment of a formal link between
a specified department/ institution and a
corresponding department/institution, to facilitate
an accurate assessment of need and consequently
to ensure effective mutual collaboration at all
levels."
COLLABORATION
- As defined by ANA, (1992) refers to the collegial
working relationship with another health care
provider in the provision of patient care.
Figure 2. Members of the health care team individualize
care for the client based on the expertise of their own
discipline, Though there may be areas of overlapping,
these can be eased through collaboration and
teamwork. (Adapted from Kozier & Erb’s Fundamentals
of Nursing, 10th edition)
TRANSCRIBED BY: NICOLE ROMERO
TEAMWORK
- Is when two or more people are interacting
interdependently with a common purpose, working
toward measurable goals that benefit from
leadership that maintains stability while
encouraging honest discussion and problem solving.
Common Principles Related to Partnership,
Collaboration, Teamwork
 EFFECTIVE COMMUNICATION
o Involves commitment of both parties to meet
regularly, understand each other’s professional
roles and appreciating each other as individuals,
sensitivity to differences in their communication
styles yet being focused on a common ground:
the client’s needs
 CLEAR ROLES AND EXPECTATIONS
o Must be related to team member’s functions,
responsibilities, and accountabilities, thus
optimizing the team’s efficiency through
division of labor.
 MUTUAL RESPECT AND TRUST
o Mutual respect when two or more people show
or feel honor or esteem toward one another.
o Trust is confidence in the actions of another
person which must expressed verbally and non-
verbally.
o Can be attained through openness and honesty.
 SHARED GOALS
o There must be a clear purpose that are mutually
agreed upon by the group, which should reflect
patient and family priorities, and can be clearly
articulated, understood, and supported by all
team members.
 MEASURABLE PROCESSES AND OUTCOMES
o These include the protocols and procedures
necessary for orderly and systematic delivery of
care thus, providing a means for reliable and
timely feedback on successes and failures in
both the functioning of the team and
achievement of the team’s goals.
NMR ♡
 DECISION MAKING
o Involves shared responsibility of the team for
the outcome. An important aspect is for the
interdisciplinary team to focus on the client’s
priority needs and organizing interventions
accordingly.
o Participate as a member of a quality team in
implementing the appropriate quality
improvement process on identified
improvement opportunities.

KEY AREAS OF RESPONSIBILITY FOR BSN GRADUATES

(CHED Memo. No. 5, Series of 2008)

- Nurses also play the role of collaborators, them

being part of the health care team. Therefore, they
must develop this competency as they assume their
professional practice. The importance of the
concepts of collaboration and teamwork had been
given emphasis with their inclusion in the Key Areas
of Responsibility for BSN graduates (CHED Memo.
No. 5, Series of 2008) with the corresponding core
competencies that every nurse should demonstrate.

 COLLABORATION AND TEAMWORK CORE

COMPETENCY:
1.) Establishes collaborative relationship with
colleagues and other members of the health team.
2.) Collaborates plan of care with other members of
the health team

PROGRAM OUTCOMES FOR BSN GRADUATES

(CHED Memo. No. 15, Series of 2017)

 PROGRAM OUTCOMES
o Collaborate effectively with inter-, intra-, and
multi- disciplinary and multi-cultural teams

 PERFORMANCE INDICATORS
o Ensure intra- agency, inter-agency, multi-
disciplinary and sectoral collaboration in the
delivery of health care
o Implement strategies, approaches to
enhance/support the capability of client/care
providers to participate in decision making by
the inter professional team
o Maintain a harmonious and collegial
relationship among members of the health
team for effective, efficient, and safe client care
o Coordinate the tasks/ functions of other nursing
personnel (midwife, BHW and utility worker)
o Collaborate with GOs, NGOs, and other
socio civic agencies to improve health care
services, support environment protection
policies and strategies, and safety and security
mechanisms in the community

NMR ♡
 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LEC)
WEEK 17: FECAL ELIMINATION
3RD SEMESTER | S.Y 2021 – 2022 TRANSCRIBED BY: NICOLE ROMERO
LECTURER: PATRICK RANALO

FUNCTION OF GASTROINTESTINAL TRACT

 Digestion
o mechanical digestion of food particles
o breaks up food particles
 Motility
o movements of organs and food
o mechanical digestion of food particles
 Secretion
o secretion of digestive juices
o chemical digestion of food particles
 Absorption
o absorption of digestion products to blood or
lymphatic vessels
 Storage and Elimination
o non-digested food particles
 Protective function – mechanical, chemical,
immunological
o not only GIT organs but also the body as a
whole, against the potential harmful food
components

GASTROINTESTINAL TRACT – absorption

ASSOCIATED EVENTS

FACTORS AFFECTING BOWEL ELIMINATION

Developmental level.
 Toddlers: Develop intestinal control at about 2 to 3
years of age.

NMR ♡
 Pregnant women: Enlarged uterus imposes on
intestinal structures, resulting in decreased
peristalsis.
 Older adults: Experience decreased peristalsis
Emotional and cultural factors.
 Lack of privacy: Some cultures are open and others
prefer privacy when attending to bodily functions.
 Inadequate amount of time to defecate.
 Embarrassment: Fecal elimination is often
associated with sights and odors that may be
offensive to others and make the patient self-
conscious.
Nutrition.
 Lack of fiber and excessive milk: Results in a
decrease in peristalsis.
 Irregular eating patterns: Can interfere with
regularity of bowel movements or decrease
peristalsis.
 Caffeine and fiber promote peristalsis.
Fluid intake.
 Need 6 to 8 glasses of water daily.
 Decreased fluid intake causes constipation.
Activity.
 Activity increases muscle tone and stimulates
peristalsis.
 Inactivity contributes to decreased muscle tone and
constipation.
Medications.
 Antibiotics destroy normal intestinal flora.
 Antacids often slow peristalsis.
 Iron causes constipation.
 Analgesics, opioids, and anti-motility drugs slow
peristalsis.
 Laxatives and cathartics increase peristalsis.
Perioperative issues:
 Anesthesia and handling of the bowel during
surgery may slow motility and cause cessation of
peristalsis
Medical problems:
 Common problems include GI infections, food
allergies, cancer, and malabsorption syndromes
COMMON HUMAN RESPONSES RELATED TO THE GI
SYSTEM AND NURSING CARE
 Diarrhea, constipation, fecal incontinence, and
flatulence
 It is essential that the nurse understand the clinical
manifestations, precipitating factors, and nursing
care associated
DIARRHEA
Description.
 Intestinal hypermotility that precipitates passage of
fluid and unformed stool.
 Frequency of stool occurs three or more times a
day.
Clinical manifestations.
 Frequent loose stools.
 Abdominal cramps, pain, or urgency.
 Abdominal distention.
 Hyperactive bowel sounds or flatus.
 Anorexia, nausea, and vomiting.
 Blood in the stool (frank, occult).
ʭ Clinical manifestations of fluid volume deficit, such
as:
o weight loss; thready pulse; hypotension;
decreased tissue turgor; furrows of the tongue;
o flushed, dry skin and mucous membranes;
sunken eyeballs; decreased urine output; atonic
muscles; and mental confusion.
ʭ Electrolyte imbalances, such as hyponatremia and
hypokalemia.
ʭ Stool possibly positive for causative pathogen or
helminthic.
ʭ With Clostridium difficile, characteristic odor and
green-colored stool.
Precipitating factors.
 Viral, bacterial, or parasitic gastroenteritis.
 Spicy or greasy food.
 Raw seafood.
 Contaminated food and water.
 Excessive dietary fiber.
 Anxiety or other emotional disturbance.
 Drug side effects
 Health problems, such as lactose intolerance,
irritable bowel syndrome
NURSING CARE FOR PATIENTS WHO HAVE DIARRHEA
 Assess the patient.
o Stool frequency, amount, and characteristics,
such as consistency, color, and odor.
o Signs and symptoms of FVD and electrolyte
imbalances.
o Recent foreign travel and dietary intake.
 Obtain a stool specimen (e.g., culture and
sensitivity, ova and parasite).
NMR ♡
 Maintain the prescribed diet, such as NPO, clear
liquid, full liquid, bland, low fiber, or dairy- or
gluten-free.
 Increase oral fluid intake gradually because a large
amount can precipitate peristalsis.
 Administer prescribed medications, such as
antibiotics, antidiarrheals, antihelminthics, enteric
bacterial replacements, and electrolytes.
 Administer ordered IV fluids.
CONSTIPATION
DESCRIPTION.
 Constipation: Intestinal hypomotility that
precipitates two or less stools a week and hard, dry
feces.
 Obstipation: Intractable constipation.
 Fecal impaction: Hard, dry stool firmly wedged in
the rectal vault that cannot be passed.
Clinical manifestations.
 Hypoactive bowel sounds.
 Distended abdomen.
 Rectal pressure or back pain.
 Straining at stool.
 Anorexia.
 Blood-streaked stool.
 Possible fluid and electrolyte imbalances. (High Ca++
- Low Potassium)
 For fecal impaction
o fecal mass confirmed by digital examination.
Precipitating factors.
 Elimination habits.
 Laxative or enema abuse.
 Urge ignored because of inaccessible bathroom
 Inadequate fluid intake (less than 2 L/day).
 Inadequate intake of fiber (e.g., whole grains, fruits,
vegetables) in diet.
 Side effects of opioids, iron, or anesthesia.
 Developmental level.
o Child: Stool with holding behavior.
o Pregnant woman: Uterine compression of
intestine, decreasing peristalsis.
o Older adult: Decreased peristalsis.
 Inadequate physical activity.
 Presence of mechanical obstruction or anal lesion.
 Anxiety or other emotional disturbance.
NURSING CARE FOR PATIENTS WHO HAVE DIARRHEA.
 Assess stool for frequency, amount, color (e.g.,
greenish black due to iron intake), and shape (e.g.,
ribbon shape due to obstruction, pencil shape due
to mucosal inflammation).
 Maintain standard precautions, such as performing
frequent hand hygiene and wearing gloves when
providing perineal care and assisting with fecal
elimination.
 Assist with elimination, such as providing privacy
and encouraging the patient to sit in an upright
position, lean forward at the hips, apply manual
pressure over the abdomen, and bear down while
exhaling to prevent straining.
 Encourage toileting after meals or offer a warm
drink before a patient’s attempt to defecate to take
advantage of the gastrocolic reflex.
o GASTROCOLIC REFLEX is the initiation of
peristaltic waves when food enters the
stomach, particularly when the stomach is
empty.
 Administer prescribed medications, such as
laxatives and cathartics.
 Administer ordered enemas, such as oil retention,
small volume hypertonic solution, tap water or
soapsuds.
FECAL INCONTINENCE
Description.
 Involuntary passage of feces and flatus from the
anus.
 Extent of incontinence ranges from partial (e.g.,
occasional episodes of seepage of stool) to total
(e.g., complete loss of control of bowel movements)
loss of control of the passage of stool.
Clinical manifestations.
 Inability to control exit of feces from the body.
 Embarrassment due to soiling.
Precipitating factors.
 Inability to recognize the urge to defecate
 Impaired anal sphincter control or its nerve supply
 Decreased muscle tone.
 Diarrhea
NURSING CARE FOR PATIENTS WHO HAVE FECAL
INCONTINENCE
 Maintain a nonjudgmental environment;
understand that incontinence may be viewed by the
patient as regression.
 Provide privacy and positive reinforcement.
 Provide prompt hygiene care.
 Use an incontinence device, such as Depends; avoid
using the word “diaper,” which is demeaning.
 Encourage attempts to defecate (e.g., in the
morning, evening, and after meals to take
advantage of the gastrocolic reflex).
NMR ♡
FLATULENCE  Indirect - reflex response to intense pain - bladder
Description and kidneys
 Flatus: Gas in the stomach and intestines as a o stimulating the vomiting center, for example.
natural by-product of digestion; expelled through metabolic acidosis or brain lesions
the anus.  Direct - irritation of the stomach mucosa by toxic
 Flatulence: Excessive gas in the stomach and substances
intestines that leads to distention of these organs
precipitating physical discomfort. ALTERATIONS IN FLUID BALANCE
Fluid Volume Deficit (FVD)
Clinical manifestations of flatulence. 1. Hypovolemia: Loss of both fluid and electrolytes in
 Hyperactive bowel sounds. equal or isotonic proportions.
 Cramping and/or abdominal pain. 2. Dehydration: Loss of fluid without a significant loss
 Abdominal distention. of electrolytes, resulting in a hyperosmolar
imbalance.
Precipitating factors.
 Absent or decreased GI motility due to such factors Causes.
as inadequate fiber in the diet, immobility, a. Decreased fluid intake.
anesthesia, and opioids. b. Loss of plasma or blood.
 Gas-forming foods and fluids, such as beans, peas, c. GI losses by vomiting, diarrhea, or gastric
cabbage, onions, cauliflower, highly spicy foods, decompression.
milk and milk products, and carbonated beverages. d. Sweating.
 Swallowing of air that accompanies the intake of e. Adrenal insufficiency.
food and fluid. f. Excessive urination (polyuria), possibly due to
 Inspect the abdomen for abdominal distention diuretics or diabetes
 Auscultate bowel sounds for hypoactivity or
hyperactivity; be aware that the absence of bowel CLINICAL MANIFESTATION
sounds may indicate cessation of peristalsis  Weight loss.
(paralytic ileus).  Flushed, dry skin and mucous membranes.
 Encourage activity.  Decreased tissue turgor; pinched skin over sternum
o Encourage in-bed activity when on bed rest, or on forehead takes several seconds to return to
such as turning from side to side. original position
o Increase ambulation; progressive ambulation  Thirst.
after surgery.  Low-grade fever.
 Administer prescribed medications, such as anti-  Sunken eyeballs.
flatulents or bulk cathartics.  Hypotension, orthostatic hypotension.
 Insert a lubricated rectal tube as ordered (4 to 5  Weak, thready, rapid pulse.
inches for 15 to 20 minutes every 3 to 4 hours).  Flat neck veins.
 Administer a return-flow enema (Harris flush).  Decreased capillary refill.
 Teach the patient to avoid gas-forming foods and  Atonic muscles.
fluids.  Lethargy.
 Mental confusion.
VOMITING  Decreased urine output (oliguria, anuria).
 is the forceful emptying of stomach and intestinal  Hemoconcentration results in:
contents through the mouth o increased hematocrit (>50%)
 the vomiting center lies in the medulla oblongata o INC. blood urea nitrogen (>21 mg/dL)
and includes the reticular formation and tractus o INC. urine specific gravity (>1.029)
solitarius nucleus
 stimulation of the vomiting center occurs directly by Fluid Volume Excess (FVE)
irritants or indirectly. Hypervolemia: Excessive amount of fluid and sodium in
isotonic proportions.
Cause of:
 the sudden expansion of the stomach and Causes.
duodenum in the sudden accumulation of contents  Excessive sodium intake via diet.
 Excessive IV fluids containing sodium.

NMR ♡
 Congestive heart failure.
 Kidney disease.
 Cirrhosis of the liver.
 Increased aldosterone.
 Increased ADH
Clinical manifestations.
 Weight gain.
 Pale, cool skin.
 Edema (dependent, generalized [anasarca],
periorbital, pulmonary); increased tissue turgor; use
scale for objective measurement of edema
 Third heart sound (S3 gallop) on auscultation of the
heart.
 Increased, shallow respirations; dyspnea.
 Crackles on auscultation of the lungs.
 Hypertension.
 Full, bounding, rapid pulse.
 Distended neck veins.
 Muscle weakness, fatigue.
 Mental confusion.
 Diluted urine, possibly with increased volume.
 Hemodilution results in decreased hematocrit and
BUN
Nursing Care for Patients with Fluid Imbalances
Commonalities of nursing care for patients with a
fluid imbalance.
 Obtain a health history to identify possible causes.
 Obtain vital signs, including temperature, pulse,
respirations, and blood pressure.
 Assess breath sounds and characteristics of
breathing; be aware that crackles and dyspnea
indicate possible fluid overload.
 Assess mucous membranes, presence of thirst, and
skin turgor; determine the extent of edema or
presence of tenting
 Obtain a daily weight.
o Use the same scale every time
o Weigh the patient at same time every day, such
as before breakfast after the first voiding.
o Weigh the patient each day wearing similar
clothes or use similar linens when using a bed
scale.
o Notify the primary health-care provider of a
change in weight of equal to or more than 2 lb
(2.2 lb equal 2,000 mL of fluid) in a day or equal
to or more than 5 lb in 1 to 2 weeks.
 Monitor intake and output (I&O).
o Institute I&O for patients who are unstable,
critically ill, or febrile; are receiving diuretics,
continuous or intermittent IV infusions, or tube
feedings; have had a procedure; or have fluid
restrictions
o Measure all fluid that goes into the body, such
as oral, IV, tube feedings, and instillations into
the GI tract or urinary bladder.
o Measure all fluid that exits from the body, such
as urine, liquid feces, vomitus, wound drainage,
and fluid from gastric decompression; and
identify characteristics of output (e.g., color,
clarity, and odor)
 Assess level of consciousness, energy level, and
changes in behavior.
 Monitor laboratory results, such as hematocrit,
blood urea nitrogen, serum electrolytes, and urine
specific gravity.
 Provide for safety, such as by assisting the patient
with getting out of bed.
 Change position and massage dependent areas
(except calves) every 2 hours to prevent pressure
ulcers.
 Facilitate oral fluid intake or restriction
ADMINISTERING ENEMA
 is the instillation of a solution into the rectum and
sigmoid colon.
 primary reason for an enema is to promote
defecation by stimulating peristalsis.
 volume of fluid instilled breaks up the fecal mass,
stretches the rectal wall, and initiates the
defecation reflex.
ENEMA
 Enemas are also a vehicle for medications that exert
a local effect on rectal mucosa
 most common use for an enema is temporary relief
of constipation.
 Other indications include:
o removing impacted feces
o emptying the bowel before diagnostic tests or
surgery
o beginning a program of bowel training.
CLEANSNG ENEMA
Cleansing enemas are intended to remove feces. They
are given chiefly to:
 Prevent the escape of feces during surgery.
 Prepare the intestine for certain diagnostic tests
such as x-ray or visualization tests (e.g.,
colonoscopy).
 Remove feces in instances of constipation or
impaction
CARMINATIVE ENEMA
 A carminative enema is given primarily to expel
flatus.
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 solution instilled into the rectum releases gas,
which in turn distends the rectum and the colon,
thus stimulating peristalsis.
 For an adult, 60 to 80 mL of fluid is instilled
RETENTION ENEMA
 A retention enema introduces oil or medication into
the rectum and sigmoid colon.
 The liquid is retained for a relatively long period
(e.g., 1 to 3 hours).
 An oil retention enema acts to soften the feces and
to lubricate the rectum and anal canal, thus
facilitating passage of the feces.
Antibiotic enemas are used to treat infections locally,
anthelmintic enemas to kill helminths such as worms
and intestinal parasites, and nutritive enemas to
administer fluids and nutrients to the rectum.
RETURN-FLOW ENEMA
 A return-flow enema, also called a Harris flush, is
occasionally used to expel flatus.
 Alternating flow of 100 to 200 mL of fluid into and
out of the rectum and sigmoid colon stimulates
peristalsis.
 process is repeated five or six times until the flatus
is expelled and abdominal distention is relieved.
BOWEL DIVERSION OSTOMY
 OSTOMY – an opening for the gastrointestinal,
urinary, or respiratory tract into the skin
 PURPOSE - Divert and drain fecal material
CLASSIFICATION OF BOWEL DIVERSION OSTOMIES
BASED on the status
 PERMANENT – to provide means of elimination
when the rectum or anus is non-functional (birth
defect/cancer)
 TEMPORARY – for traumatic injuries or
inflammatory conditions of the bowel, allowing the
bowel to rest and heal
Anatomical location - influences the character and
management of fecal drainage.
TYPES OF INTESTINAL OSTOMY:
 GASTROSTOMY – opening through the abdominal
wall in the stomach
 JEJUNOSTOMY - opening through the abdominal
wall in the
 JEJUNUMILEOSTOMY - opening through the
abdominal wall in the
 ILEUMCOLOSTOMY - opening through the
abdominal wall in the colon
TYPE OF DRAINAGE
1. ILEOSTOMY / ASCENDING COLOSTOMY
o Liquid fecal drainage; no control
o Odor is minimal because fewer bacteria are
present
o Instruct client to wear appliance continuously
and take special precautions to prevent skin
breakdown
2. TRANSVERSE COLOSTOMY
o Malodorous, mushy drainage
o liquid has been reabsorbed
o no control
STOMA AND SKIN CARE
 Care of the stoma and skin is important for all
clients who have ostomies.
 The fecal material from a colostomy or ileostomy is
irritating to the peristomal skin.
 stool from an ileostomy, which contains digestive
enzymes.
 It is important to assess the peristomal skin for
irritation each time the appliance is changed.
 Any irritation or skin breakdown needs to be
treated immediately.
 The skin is kept clean by washing off any excretion
and drying thoroughly
CHANGING A BOWEL DIVERSION OSTOMY APPLIANCE
PURPOSES
 To assess and care for the peristomal skin
 To collect stool for assessment of the amount and
type of output
 To minimize odors for the client’s comfort and self-
esteem
ASSESSMENT
Determine the following:
 The type of ostomy and its placement on the
abdomen.
o Surgeons often draw diagrams when there are
two stomas.
o If there is more than one stoma, it is important
to confirm which is the functioning stoma.
 The type and size of appliance currently used and
the special barrier substance applied to the skin.
 STOMA COLOR: appear red, similar in color to the
mucosal lining of the inner cheek and slightly moist.
o Very pale or darker-colored stomas with a
dusky bluish or purplish hue indicate impaired
blood circulation to the area. Notify the surgeon
immediately.
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 STOMA SIZE AND SHAPE: Most stomas protrude
slightly from the abdomen.
o New stomas normally appear swollen, but
swelling generally decreases over 2 or 3 weeks
or for as long as 6 weeks.
o Failure of swelling to recede may indicate a
problem, for example, blockage.
 STOMAL BLEEDING: Slight bleeding initially when
the stoma is touched is normal, but other bleeding
should be reported.
 STATUS OF PERISTOMAL SKIN: Any redness and
irritation of the peristomal skin—the 5 to 13 cm (2
to 5 in.) of skin surrounding the stoma—should be
noted.
o Transient redness after removal of adhesive is
normal.
 AMOUNT AND TYPE OF FECES: Assess the amount,
color, odor, and consistency. Inspect for
abnormalities, such as pus or blood.

MEDICATIONS ASSOCIATED WITH FECAL ELIMINATION

 Antidiarrheals: Decrease diarrhea and increase the
production of formed stool
 Laxatives and Cathartics: Prevent or treat
constipation; evacuate the bowel for diagnostic
tests or surgery
 Antiflatulents: Decrease the amount of intestinal
gases

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 NCMA113: FUNDAMENTALS OF NURSING PRACTICE (LAB)
WEEK 17: POST – MORTEM CARE
3RD SEMESTER | S.Y 2021 – 2022
LECTURER: PATRICK RANALO
POST MORTEM CARE
 In Latin, mortem is a form of the word for "death,"
and post means "after." A postmortem, logically
enough, is something that happens after death,
usually an examination or the provision of nursing
care to a deceased patient.
CLASSIFICATIONS OF DEATH
 Clinical death. The first stage is called Clinical
Death. This happens when the heart stops beating
and it not necessarily permanent. An individual’s
brain can stay alive for about 4-6 minutes
“WINDOW OF SURVIVAL” after breathing and
heartbeat have stopped.
 Biological death. If more than 4-6 minutes elapse,
however, the individual will most likely experience
permanent and irreversible brain damage or
Biological Death.
Changes in the body after Death
 Rigor mortis is the stiffening of the body that occurs
about 2 to 4 hours after death.
 Algor mortis is the gradual decrease of the body’s
temperature after death.
 Livor mortis is referred as the discoloration of the
skin. After blood circulation has ceased, the red
blood cells break down, releasing hemoglobin,
which discolors the surrounding tissues. It appears
in the lowermost or dependent areas of the body
CARE AFTER DEATH
 Management of the dead person often elicits
anxiety to the nursing staff. Protocols of the
institutions should be followed.
 Government and state laws require institutions to
develop policies and procedures for certain events
that occur after death
 Management of the dead person often elicits
anxiety to the nursing staff. Protocols of the
institutions should be followed.
 Government and state laws require institutions to
develop policies and procedures for certain events
that occur after death
ORGAN DONATION
 Even though a patient who is brain dead is legally
declared dead, he or she remains on life support to
provide the vital organs with blood and oxygen
TRANSCRIBED BY: NICOLE ROMERO
before transplant. However, tissues that are not
vital are taken at the time of death without
artificially maintaining vital functions.
 If the deceased has not left behind instructions
concerning organ and tissue donation, the family
gives or denies consent at the time of death.
 Also consider that in some culture, organ donation
may not be acceptable.
AUTOPSY
 Family members give consent for an autopsy (i.e.,
the surgical dissection of a body after death) to
determine the exact cause and circumstances of
death or discover the pathway of a disease.
 In most cases a medical examiner determines the
need to perform an autopsy
Certifying and documenting the occurrence of a death
 Documentation of a death provides a legal record
of the event.
 Institution’s policies and procedures should be
followed carefully to provide an accurate and
reliable medical record of all assessments and
activities surrounding a death.
Postmortem care
 When a patient dies in an institutional or home care
setting, nurses provide or delegate postmortem
care, the care of a body after death.
 Above all, a human body deserves the same respect
and dignity as a living person and needs to be
prepared in a manner consistent with the patient’s
cultural and religious beliefs.
 Death produces physical changes in the body quite
quickly; so it is imperative to perform postmortem
care as soon as possible to prevent discoloration,
tissue damage, or deformities.
Nursing Care of the Dead – Postmortem Care
 Post-mortem care is one of the most difficult things
to do as a nurse. It is something nobody enjoys
doing but it is something that must be done after a
patient’s death.
Be Respectful
 Dead patients should still be treated with respect
and dignity. This is especially true in the presence of
family and relatives.
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 Hearing is widely thought to be the last sense to go should reach past their head, all the way down past
in the dying process. Some people may still be able their feet.
to hear while in an unresponsive state at the end of 17. Then turn the patient onto their other side and
their life. NEVER assume the person is unable to finish putting on the fitted sheet and unroll the rest
hear you of the bag.
18. You should then be able to zip up the bag.
PREPARE SUPPLIES FOR POSTMORTEM CARE 19. Don't forget to tie the two zippers together with
1. A body bag another name tag.
2. Name tag 20. Stretch the flat sheet over the bed completely
3. Patient labels covering the body bag. Out of respect, you do not
4. Fitted and flat sheet want visitors in the hallways to clearly see the
5. Hospital gown and person in a bag while they are taken to the morgue.
6. Supplies for bed bath 21. Don't forget that dentures and glasses go in the
body bag with the patient and the last name tag
POSTMORTEM CARE should go with the patient's remaining belongings.
1. If there is a sign that you are supposed to place Make sure the belongings get to the patient's family
outside of the door in the hallway, make sure you
do that first.
2. Close the door and pull the curtain.
3. Prepare the water for the bed bath.
4. Raise the bed up and flatten it out.
5. Remove all sheets, blankets, and the gown from the
patient.
6. Remove any drains and tubes from them such as IVs
and foley catheters and heart monitors. If you are
unsure of whether something should be removed or
this is beyond your scope of practice, call the
patient's nurse for assistance.
7. Dentures and glasses should go in a container and
placed to the side. They should later be placed
inside the body bag with the patient.
8. Give the bed bath like you would if the patient was
still alive. Just because they can't feel anything
doesn't mean you shouldn't be thorough or should
be extra rough on them.
9. Some facilities require you to put a fresh hospital
gown on them while others want them to be placed
in the body bag naked. Check your policy or ask
your supervisor if you are unsure which is preferred.
10. You should now tie one of the name tags onto the
patient's big toe.
11. You will have to unfold the body bag and unzip it all
of the way.
12. Then roll up half of the bag long ways.
13. One of you should then turn the patient on their
side.
14. The other caregiver should then tuck the old linens
underneath the patient and place the clean fitted
sheet on the mattress.
15. Tuck the fitted sheet under the patient as far as
possible
16. Now tuck the rolled end of the bag underneath the
patient. Make sure the bag is placed in such a way
so the patient will be able to fit. This means the bag

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