Exam 2 Review

Bowel elimination (6-7 questions)

● Constipation
○ Constipation may be the result of conditions such as diseases within the colon or
rectum and injury to, or degeneration of, the spinal cord and megacolon
(extremely dilated colon).
○ CAUSES
■ MECHANICAL
● Common causes of mechanical obstruction are tumors of the colon
or rectum, diverticulum, adhesions from scar tissue, stenosis,
strictures, and hernia and volvulus (twisting of a part of the colon).
■ NON MECHANICAL
● Nonmechanical obstructions result from an inability of the
intestinal musculature to move the contents through the bowel.
● Examples of causes of nonmechanical obstruction include diseases
that weaken or paralyze the intestinal walls such as muscular
dystrophy, diabetes mellitus, and Parkinson’s disease.
● Manipulation of the bowel during surgery may also result in
paralytic ileus.
● Use of laxatives and its effects
○ Laxatives are drugs that induce emptying of the intestinal tract.
■ Bulk-forming laxatives such as psyllium hydrophilic mucilloid work by
absorbing water into the intestine to soften the stool and increasing stool
bulk.
■ Osmotic laxatives are not absorbable and work by bringing water into the
intestine.
■ Stimulant laxatives, such as bisacodyl and senna, improve defecation by
increasing motility through irritation of the intestinal mucosa and
increased water in the stool.
■ Other frequently used laxatives are the saline- osmotics, such as
magnesium hydroxide (milk of magnesia [MOM]) or magnesium citrate.
● Saline-osmotic laxatives act by drawing water into the intestines,
stimulating peristalsis, and are effective but should be used in
caution in those patients with renal disease.
● Magnesium hydroxide has antacid properties in small dosages and
laxative properties in larger doses.
○ Laxatives are sometimes necessary for people with limited activity or poor food
intake.
○ They are also used to empty the intestinal tract in preparation for surgery or
diagnostic tests.
○ Stool softeners such as docusate sodium may be used in conjunction with some
prescribed medications to counteract the medications’ constipating properties.
○ Occasional use of laxatives is not harmful for most people, but people should not
become dependent on them to induce regular bowel movements.
 ○ Patient education is important in the safe use of over-the-counter medications.
■ Because of their chemical action, laxatives should not be taken when a
patient is experiencing abdominal pain.
■ Increased peristalsis caused by laxative use in the presence of an
intestinal pathologic condition such as a bowel obstruction could
result in patient harm.
■ Although many people take laxatives because they believe they are
constipated, most are unaware that habitual use of laxatives may be the
cause of chronic constipation.
● Diarrhea and its effects
○ Diarrhea may result from bacterial and viral infection, malabsorption syndromes
(the inability of the digestive system to absorb one or more of the major vitamins,
minerals, or nutrients), neoplastic diseases (tumors), diabetic neuropathy (damage
to nerve cells), hyperthyroidism, and uremia (retention of urea in the blood).
○ Outbreaks of food poisoning can result in severe gastrointestinal symptoms,
including diarrhea.
○ Infections caused by certain types of Escherichia coli, particularly dangerous for
young children (under 10 years of age) and older adults, can progress quickly to
life-threatening hematologic and renal complications.
○ Severe abdominal cramping followed by watery or bloody diarrhea may signal
a microbial infection, which can be confirmed by a stool sample. Supportive
treatment, careful monitoring, and attentive nursing care are essential.
● Medical history for diarrhea and constipation
○ DIARRHEA
■ Diarrhea is a potential adverse effect of treatment with antibiotics such as
amoxicillin clavulanate. In this situation, using antidiarrheal drugs is not
recommended because its use would prolong the exposure of the intestinal
mucosa to the irritating effect of the antibiotic.
■ Medications with magnesium, such as over-the-counter antacids, can
also cause diarrhea.
■ Metformin, a common medication used to treat type 2 diabetes mellitus,
can cause diarrhea.
○ CONSTIPATION
■ Opioids are a common cause of medication-induced constipation and can
result in significant distress for the patient.
■ Antacids containing aluminum, iron sulfate, and anticholinergic
medications also decrease gastrointestinal motility, with the potential to
also cause constipation.
● Bowel sounds; paralytic ileus, hypoactive and absent bowel sounds
○ The frequency of bowel sounds may range from 5 to 30 bowel sounds per minute,
depending on the rate of peristalsis.
■ Hypoactive bowel sounds indicate diminished bowel motility, commonly
caused by abdominal surgery or late bowel obstruction.
■ Hyperactive bowel sounds indicate increased bowel motility, commonly
caused by diarrhea, gastroenteritis, or early/partial bowel obstruction.
 ■ Decreased or absent bowel sounds, evidenced only after listening for 2
minutes or longer, signify the absence of bowel motility, commonly
associated with peritonitis, paralytic ileus, and/or prolonged mobility
● Enema and the effective positions for enemas
○ Laxatives and enemas are dangerous because they may cause severe fluid and
electrolyte imbalance.
○ An enema is the introduction of a solution into the large intestine, usually to
remove feces.
○ Position: left side-lying Sims' position
○ It can also be used to administer certain medications. The instilled solution
distends the intestine and irritates the intestinal mucosa, thus increasing
peristalsis.
■ Enemas are generally classified as cleansing or retention enemas.
■ Rectal agents and manipulation, including enemas, are discouraged for
use with myelosuppressed patients and/or patients at risk for
myelosuppression and mucositis because they can lead to development
of bleeding, anal fissures, or abscesses, which are portals for infection.
■ Enemas should also be avoided in those with bowel obstruction or
paralytic ileus as they can increase the risk of perforation.
● Effects of surgeries on bowel sounds
○ Hypoactive bowel sounds indicate diminished bowel motility, commonly caused
by abdominal surgery or late bowel obstruction.

Highlighted text from slides for bowel elimination:

Colostomy should be formed

Ileostomy- liquid

When assessing, ask for any abdominal surgery?

High fiber allows for bowel movements

The autonomic nervous system innervates the muscles of the colon.

The parasympathetic nervous system stimulates movement, while the sympathetic system
inhibits movement.

Contractions of the circular and longitudinal muscles of the intestine, peristalsis, occur every 3 to
12 minutes, moving waste products along the length of the intestine continuously.

Abdominal assessment should be conducted in the sequence of inspection, auscultation

percussion and palpation as it disturbs normal peristalsis and bowel motility.
Defecation:
- When a person bears down to defecate, the increased pressures in the abdominal and
thoracic cavities result in decreased blood flow to the atria and ventricles, thus
temporarily lowering cardiac output.
- Once bearing down ceases, the pressure is lessened, and a larger than normal amount of
blood returns to the heart leading to increase in blood pressure. This act may cause the
heart rate to slow and result in syncope in some patients.

Factors affecting bowel elimination:

- Between the ages of 18 and 24 months, the nerve fibers innervating the internal and
external anal sphincters become fully developed, at which point voluntary control of
defecation becomes possible.
- Constipation is often a chronic problem for older adults and can be avoided by adding
high fiber diet to elderly.

Constipation:
● Common causes of mechanical obstruction are tumors of the colon or rectum,
diverticulum, adhesions from scar tissue, stenosis, strictures, and hernia and volvulus
(twisting of a part of the colon).
Medications:
- Because antibiotics are used so extensively in the health care setting, many patients are at
risk for infection with Clostridium difficile, a health care–acquired infection (HAI).
- CDIFF is contact precaution
Surgery and anesthesia:
- Direct manipulation of the bowel during abdominal surgery inhibits peristalsis,
causing a condition termed postoperative paralytic ileus.
- This temporary stoppage of peristalsis normally lasts 3 to 5 days.

When auscultating bowel sounds:

● If the patient has a nasogastric (NG) tube in place, disconnect it from suction during this
assessment to allow for accurate interpretation of sounds.

Education:
● Early colorectal cancer usually has no symptoms.
● Warning signs typically occur with more advanced disease.
● Encourage patients to schedule regular exams with their health care providers.
● Reinforce the importance of adhering to recommended screening for colorectal cancer,
including sigmoidoscopy, colonoscopy, and fecal testing for blood.
Diagnosis:
● In general, black stools indicate upper gastrointestinal bleeding, such as from a peptic
ulcer, due to a reaction between hemoglobin and gastric acid.
● Lower gastrointestinal bleeding, such as from hemorrhoids or a polyp, may produce
bright-red blood in the stool.
● Fecal occult blood testing (FOBT) is used to detect occult blood in the stool.

Bowel incontinence:
Bowel incontinence is the inability of the anal sphincter to control the discharge of fecal and
gaseous material. The cause of incontinence is often related to changes in the function of the
rectum and anal sphincter related to aging, neurologic disease, and childbirth.
● The patient may also not be able to perceive the urge to move the bowels or completely
empty the rectum after a bowel movement, which can also result in incontinence.
● Mental illness may also cause a patient to be indifferent to the passage of stool.
● Although bowel incontinence is seldom life-threatening, patients with bowel incontinence
suffer embarrassment, may become depressed, and pose a challenge for nurses because of
the risk for skin breakdown.

Pain and Comfort (5-6 questions)

● Types of pain (DURATION)

○ Acute pain
 ■ rapid in onset and varies in intensity from mild to severe. Acute pain
warns the person of tissue damage or organic disease and triggers
autonomic responses such as increased heart rate, the fight-or-flight
response, and increased blood pressure.
■ After its underlying cause is resolved, acute pain disappears. It should end
once healing occurs.
■ Causes of acute pain include a pricked finger, sore throat, or surgery.
○ Chronic pain is pain that lasts beyond the normal healing period. The time frame
associated with defining pain as chronic varies based on the cause and may be
anywhere between 1 and 6 months, with 3 months commonly used in practice
and 6 months used in research.
■ Chronic pain presentation varies greatly and can include pain that is
unrelenting and severe, pain that is consistent with or without periods of
remission (disease is present, but the person does not experience pain) and
exacerbation (the symptoms reappear). Patient with cancer may
experience period of remission and exacerbation.
■ Some providers are transitioning to use of the word persistent to describe
this type of pain.
● Quality and severity of pain

● Pain scales numeric rating scale

● NSAIDS and its effects and complications
○ Nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs
[NSAIDs]) OTC and prescription
■ drugs of choice for both acute and persistent moderate chronic pain.
■ Acetaminophen has long been viewed as one of the safest and best-
tolerated analgesics. It has proven to be an effective drug for acute pain
treatment.
● the risk of hepatotoxicity- used for a lengthy period or at larger
than the recommended dose (maximum of 4 grams/day).
● If pain is not controlled using the recommended dose of
acetaminophen, NSAIDs or an opioid analgesic may be required to
achieve pain relief.
■ NSAIDs also have an anti-inflammatory effect but are contraindicated in
patients with bleeding disorders (their action may interfere with platelet
function) or probable infections (NSAIDs can mask the signs of an
infection).
■ All NSAIDs, except for aspirin, increase the risk of myocardial
infarction (heart attack) or stroke.
■ The combination of nonopioid analgesics and opioids provides more
analgesia than either drug taken alone.
● Multimodal analgesic therapy is a relatively recent approach to
pain management. It combines two or more classes of analgesics
that target different sites in the peripheral and central nervous
systems to maximize pain relief with fewer adverse effects.
 ● The most common multimodal approach is a combination of
nonopioid, opioid, and adjuvant analgesics .
● Referred pain, cutaneous pain, somatic pain, nociceptive pain
○ Cutaneous pain (superficial pain) usually involves the skin or subcutaneous
tissue.
○ Deep somatic pain is diffuse or scattered and originates in tendons, ligaments,
bones, blood vessels, and nerves.
○ Visceral pain is poorly localized and originates in body organs in the thorax,
cranium, and abdomen.
○ Referred pain is the pain that can originate in one part of the body but be
perceived in an area distant from its point of origin.
○ Nociceptive pain is initiated by nociceptors that are activated by actual or
threatened damage to the peripheral tissue and is representative of the normal pain
process. Nociceptors are the peripheral somatosensory nerve fibers that transduce
and encode noxious stimuli.
● PCA pump and its management, safety and interventions (Patient-Controlled
Analgesia)
○ Provides effective individualized analgesia and comfort.
■ used to deliver analgesics intravenously, subcutaneously, or via the
epidural route.
■ The most frequently prescribed drugs for PCA administration are
morphine, fentanyl, and hydromorphone.
○ The PCA system consists of a computerized, portable infusion pump containing a
chamber for a syringe that is prefilled with the prescribed opioid analgesic.
■ The Joint Commission and the Institute for Safe Medication Practices
(ISMP) recommend standard doses and concentrations prepared in
prefilled syringes.
■ Initially, a loading dose is administered to raise blood levels to a
therapeutic level and control the pain.
■ Although a PCA pump can be set to deliver at a set rate (automatic dose or
basal rate), these pumps are more typically used to deliver a dose when
initiated by the patient. When the sensation of pain reoccurs, the patient
pushes a button that activates the PCA device to deliver a small preset
bolus dose of the analgesic.
● A dose interval that is programmed into the PCA unit (usually
6 to 8 minutes) prevents reactivation of the pump and
administration of another dose during that period.
● The pump mechanism can also be programmed to deliver only a
specified amount of analgesic within a given time interval (the
lock-out interval).
 ● This is most commonly every hour or, occasionally, every 4 hours.
● The 1-hour lock-out is viewed more favorably in opioid-naïve
patients. These safeguards limit the possibility of possible
overmedication.
● PCA pumps also have a locked safety system that prohibits any
tampering with the device.
● Effects of pain on different cultures
○ Nurses should keep in mind that to provide care, there must be an appreciation
that each patient’s response to pain is based on a host of experiences and
factors, and therefore requires an individualized care plan.
○ Be knowledgeable about cultural variations and develop an understanding of
cultural influences on pain tolerance, expressions of pain, and alternative practices
used to manage pain.
○ Asking direct questions regarding pain experiences, expectations, and
management will serve you well when dealing with patients from any
background.
● Effects of phantom pain and its response
○ The exact cause of neuropathic pain is unknown, but it can originate either
peripherally (e.g., phantom leg pain) or centrally (e.g., pain from spinal cord
injury).
■ Neuropathic pain can be of short duration but frequently is chronic. It
is often described as burning, electric, tingling, or stabbing.
○ The pain that often occurs with an amputated leg where receptors and nerves are
clearly absent, is a real experience for the patient. This type of pain is called
phantom pain or phantom limb pain and is without demonstrated physiologic
or pathologic substance.
○ Nurses should educate the patients about the phantom pain to exist after the limb
or part of the body is amputated.
● Pain meds administration: for activity or dressing change
○ ADMINISTERING ANALGESICS
■ An analgesic is a pharmaceutical agent that relieves pain. Analgesics
function to reduce the person’s perception of pain and to alter the person’s
responses to discomfort.
■ There are three general classes of drugs used for pain relief:
● Opioid analgesics (all controlled substances; e.g., morphine,
codeine, oxycodone, meperidine, hydromorphone, methadone)
● Nonopioid analgesics (acetaminophen and nonsteroidal anti-
inflammatory drugs [NSAIDs])
 ○ Use of NSAIDS or other analgesics prior to a dressing
change can significantly reduce pain associated with
dressing changes. 30 MINS BEFORE DRESSING
CHANGE
● Adjuvant analgesics (anticonvulsants, antidepressants,
multipurpose drugs)

Urinary Elimination (6-7 questions)

● Effects of diuretics on urinary elimination

○ Diuretics cause increased urine production, resulting in the need for increased
urination and possibly urge incontinence (the involuntary loss of urine that occurs
soon after feeling an urgent need to void).
○ Diuretics, which commonly are used in the treatment of hypertension and other
disorders, prevent the reabsorption of water and certain electrolytes in the tubules.
○ Diuretics can lighten the color of urine to pale yellow.
● Swelling in lower extremities and its effects on urinary output
○ Bladder outlet obstruction, including mechanical obstruction such as swelling at
the meatus (which can occur after childbirth), or an enlarged prostate in men may
cause retention.
○ If the catheter was in place for more than a few days, decreased bladder muscle
tone and swelling of the urethra may cause the patient to have trouble voiding or
an inability to void.
● Sterile urine specimen collection
○ Sterile Specimen
■ Sterile urine specimens may be obtained by catheterizing the patient’s
bladder or by taking the specimen from an indwelling catheter already in
place.
■ Use the special port for specimens.
■ Gather equipment, including a syringe, an antiseptic swab, a sterile
specimen container, nonsterile gloves, and possibly a clamp.
■ A urine culture requires about 3 mL, whereas routine urinalysis requires at
least 10 mL of urine.
■ If urine is not present in the tube, clamp the tube below the access port
briefly (not to exceed 30 minutes) to allow urine to accumulate.
■ Clean the access port with an antiseptic swab, and carefully attach the
syringe to the port.
■ Aspirate urine into the syringe, remove the syringe, release the clamp if
one was used, and transfer the specimen to the appropriate container.
■ Label the specimen with the patient’s name, date, and time of collection;
then package and transport the specimen according to facility policy.
● Voiding, urinating and micturition and its meaning and its effects
○ The process of emptying the bladder is known as urination, micturition, or
voiding.
○ Micturition reflex is the act of bladder contractions and need to void.
 ○ The person feels a desire to void, usually when the bladder fills to about 150 to
250 mL in an adult.
○ The voluntary control of voiding is limited to initiating, restraining, and
interrupting the act.
○ Sometimes, increased abdominal pressure—such as occurs during coughing and
sneezing—forces an involuntary escape of urine. This is a particular problem for
some women because the urethra is shorter.
○ Any involuntary loss of urine that causes such a problem is referred to as urinary
incontinence.
● When RN encourage, restrict or enforce fluids and its effects
○ ENFORCE
■ Nursing care to promote normal urination includes interventions to
support normal voiding habits, fluid intake, strengthening of muscle tone,
stimulating urination and resolving urinary retention, and assisting with
toileting.
■ Many people routinely drink less fluid than is optimal to promote healthy
urinary functioning.
■ Adults with no disease-related fluid restrictions should drink 2,000 to
2,400 mL (8 to 10 8-oz glasses) of fluid daily.
■ If a good proportion of the daily fluid intake is water, the kidneys and
urinary structures are well flushed, and waste products, including
potentially harmful bacteria, are removed.
■ Monitor fluid intake for excessive amounts of caffeine-containing
beverages, high-sodium beverages, and high-sugar beverages.
■ Provide fresh water, juices, and fluids of preference to patients with
alterations in mobility.
■ Remind children and patients who are confused to drink. Fluid restrictions
may be ordered for patients with certain health problems.
○ RESTRICT
■
● Terms such as polyurea, dysuria, oliguria etc.
○ Polyuria- excessive output of urine (diuresis)
○ Dysuria- painful or difficult urination due to infection or trauma
○ Oliguria- 24-hr urine output is less than < 400 mL
● How does the RN assess for bladder distention and where?
 ○
○ The bladder is normally positioned below the symphysis pubis and cannot be
palpated or percussed when empty.
○ When the bladder is distended, it rises above the symphysis pubis and may reach
to just below the umbilicus.
○ Observe the lower abdominal wall, noting any swelling, and palpate this area for
tenderness.
○ If distended, note the smoothness and roundness of the bladder; measure the
height of the edge of the bladder above the symphysis pubis.
○ Check bladder for distention between the symphysis pubis and umbilicus

● UTIs and its symptoms and manifestations and complaints

○ People who habitually urinate infrequently develop more UTIs and kidney
disorders than those who urinate at least every 3 to 4 hours.
○ Urinary tract infections (UTIs) are the second most common type of infection in
the body and are a leading cause of systemic infections in older adults.
○ UTIs can affect both the upper urinary tract, involving the kidneys and ureters
(pyelonephritis) and lower urinary tract, involving the bladder and urethra
(cystitis).
○ The presence of bacteria in a clean-catch midstream or sterile urine specimen,
accompanied by symptoms (e.g., dysuria, urinary frequency or urgency, or cloudy
urine with a foul odor), indicates a UTI.
○ Those at greatest risk for a UTI include the following:
■ Sexually active women: During intercourse, perineal bacteria can migrate
into the urethra and bladder (Women are especially vulnerable to UTIs
 because the female urethra is shorter and in closer proximity to the vagina
and rectum)
■ Postmenopausal women: Urinary stasis, which is common at this age,
provides an optimal environment for bacteria to multiply; in addition,
decreased estrogen contributes to loss of protective vaginal flora.
■ People with an indwelling urinary catheter in place:
● UTIs are the most common type of healthcare-associated infection
(HAI), and up to 75% of these UTIs are associated with the
presence of an indwelling urinary catheter.
● Although a break in sterile technique during placement can lead to
an infection, most pathogens are introduced via handling of the
catheter and drainage device after placement.
■ People with diabetes mellitus: Changes in the body’s defense system
related to diabetes may increase the risk for UTIs.
■ Older adults: The physiologic changes associated with aging predispose
older people to the development of UTIs.
■ In addition, enlargement of the prostate as men age can contribute to the
development of UTIs in older men.
■ Treatment
● A short-course antibiotic regimen (one large dose vs. 3 or 7 days of
smaller doses) usually eradicates infections of the lower urinary
tract; longer antimicrobial therapy is required for upper UTIs.
Highlighted text from slides:

Sometimes, increased abdominal pressure—such as occurs during coughing and sneezing—

forces an involuntary escape of urine. This is a particular problem for some women because the
urethra is shorter

Toilet Training Voluntary control of the urethral sphincters occurs between 18 and 24 months of
age.

Nocturnal enuresis (nighttime bedwetting) usually subsides by 6 years of age.

Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color.

Diuretics can lighten the color of urine to pale yellow.

Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine.

The measurement of fluid intake and output may be delegated to unlicensed personnel.

Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to 10 8-oz
glasses) of fluid daily
Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by
treatable factors, such as confusion secondary to acute illness, infection, and as a result of
medical treatment, such as the use of diuretics or intravenous fluid administration.

Stress incontinence occurs when there is an involuntary loss of urine related to an increase in
intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other
physical activities.

Stress and Adaptation (5-6 questions)

● Effects of caregiver burden on stress and various stressors

○ Caring for a family member at home for long periods can also cause prolonged
stress.
■ Called caregiver burden, this stress response includes chronic fatigue,
sleep problems, and an increased incidence of stress-related illnesses, such
as high blood pressure and heart disease.
■ Prolonged stress can seriously threaten mental health of a caregiver. The
family is an integral part in the assessment, planning, nursing
interventions, and evaluation of actions to prevent ACEs and promote
adaptation to stress.
● Describe stress and anxiety and its different kinds
○ Stress: —a word taken from the term distress—is a part of life: Everyone feels
stress at one time or another.
■ Stress is a condition in which the human system responds to changes in its
normal balanced state.
● PHYSIOLOGIC STRESS
○ •The specific effect is an alteration of normal body
structure and function.
○ Primary physiologic stressors include chemical agents
(drugs, poisons), physical agents (heat, cold, trauma),
infectious agents (viruses, bacteria), nutritional imbalances,
hypoxia, and genetic or immune disorders.
● PSYCHOLOGICAL STRESS
○ Psychosocial stressors include both real and perceived
threats. The person’s responses are continuous and include
individualized coping mechanisms for responding to
anxiety, guilt, fear, frustration, and loss.
○ Eustress is the term used for short-term stress that promotes positive emotional,
intellectual, and physiologic adaptation and development.
● General adaptation syndrome
○ The general adaptation syndrome (GAS) is a biochemical model of stress. The
GAS describes the body’s general response to stress, a concept essential in all
areas of nursing care.
 ○ The three stages in the GAS are alarm reaction, stage of resistance, and stage of
exhaustion.
○ Although the alarm stage is short term (minutes to hours), the length of the
resistance and exhaustion stages varies greatly, depending on such variables as the
severity and duration of the stressor, the person’s previous health and coping
mechanisms, and the immediacy and effectiveness of health care interventions.
○ The GAS is a physiologic response to stress, but it is important to remember
that the response results from either physical or emotional stressors.
○ The stages occur with either physical or psychological damage to the person.
Obvious examples are seen in patients with severe injury or an illness, but GAS is
also a factor in mental illness, social isolation, and loss of (or lack of) human
relationships
● Mind-Body interaction
○
● Local adaptation syndrome
○ The local adaptation syndrome (LAS) is a localized response of the body to
stress. It involves only a specific body part (such as a tissue or organ) instead of
the whole body. The stress precipitating the LAS may be traumatic or pathologic.
LAS is a primarily homeostatic, short-term adaptive response. Although the body
has many localized stress responses, the two most common responses that
influence nursing care are the reflex pain response and the inflammatory
response.
■ REFLEX
● The reflex pain response is a response of the central nervous
system to pain. It is rapid and automatic, serving as a protective
mechanism to prevent injury.
● The reflex depends on an intact, functioning neurologic reflex arc
and involves both sensory and motor neurons.
■ INFLAMMATORY
● The inflammatory response is a local response to injury or
infection. It serves to localize and prevent the spread of infection
and promote wound healing. When you cut your finger, for
example, you often develop the symptoms of the inflammatory
response: pain, swelling, heat, redness, and changes in function.
● Alarm Reaction
 ○ Alarm is initiated when a person perceives a specific stressor and various defense
mechanisms are activated.
○ The perception of threat may be conscious or unconscious.
○ The hypothalamic–pituitary–adrenal (HPA) axis controls the neuroendocrine
response, and hormone and catecholamine levels rise to prepare the body to react.
○ The sympathetic nervous system initiates the fight-or-flight response, preparing
the body to either fight off the stressor or to run away from it (usually not literally
in the modern world).
○ This phase of the alarm reaction, called the shock phase, is characterized by an
increase in energy levels, oxygen intake, cardiac output, blood pressure, and
mental alertness.
● Effects of anxiety, mild and severe anxiety and its management
○ Anxiety: The most common human response to stress is anxiety. Anxiety is a
vague, uneasy feeling of discomfort or dread, the source of which is often
unknown or nonspecific. It is also a feeling of apprehension caused by
anticipating a perceived danger. Anxiety is a sign that alerts you to impending
danger and enables you to take measures to manage a threat.
○ As illustrated in the list that follows, coping behaviors may be positive or
negative in terms of how they affect health.
 ■ Crying, laughing, sleeping, cursing
■ Physical activity, exercise
■ Smoking, drinking
■ Lack of eye contact, withdrawal
■ Limiting relationships to those with similar values and interests
■ Ineffective Individual Coping
● MILD ANXIETY
○ Can have a positive effect, increases alertness and
perceptual fields. Motivates learning and growth
● MODERATE ANXIETY
○ Moderate anxiety is manifested by a quavering voice,
tremors, increased muscle tension, a complaint of
“butterflies in the stomach,” and slight increases in
respirations and pulse.
○ Focus is on immediate concerns, with inattention to other
communications and details.
● SEVERE ANXIETY
○ Severe anxiety is characterized by extreme fear of a danger
that is not real, by emotional distress that interferes with
everyday life, and by avoiding situations that cause anxiety.
○ It is manifested by difficulty communicating verbally,
increased motor activity, a fearful facial expression,
headache, nausea, dizziness, tachycardia, and
hyperventilation.
○ At this point, anxiety is no longer functioning as a signal
for danger or motivation for a needed change, but instead
results in maladaptive behaviors and emotional
disability that signal the presence of an anxiety disorder.
○ The person has impaired learning ability and any education
or learning need should be delayed or postponed until the
stage is resolved or got better.
● PANIC
○ Panic causes the person to lose control and experience
dread and terror.
○ Panic is manifested by difficulty communicating verbally,
agitation, trembling, poor motor control, sensory changes,
sweating, tachycardia, hyperventilation, dyspnea,
palpitations, a choking sensation, and sensations of chest
pain or pressure.
○ The person is unable to learn, concentrates only on the
present situation, and often experiences feelings of
impending doom. This level of anxiety can lead to
exhaustion and death.
● Stress in Health and illness
 ○ The process of responding to stress is constant and dynamic, and is essential to a
person’s physical, emotional, and social well-being. Stress is a major factor in
health and illness.
■ Stress in a healthy person may promote health and prevent illness.
■ The effects of stress on a sick or injured person are, in contrast, usually
negative.
● Stress can make illness worse, and illness can cause stress.

Complimentary Modalities (6-7 questions)

- Many people in the United States are using complementary health approaches (CHAs)
and integrative health (IH) care to promote health and assist with healing from illness.
- complementary health approaches refers to interventions that can be used with
conventional medical interventions and thus complement them.
- The term integrative health refers to the combination of complementary health and
conventional health approaches in a coordinated way.

● Holistic choices of foods-

holistic nutrition include unrefined, unprocessed, organic and locally grown whole foods. It's an
approach to eating that very consciously considers everything that's eaten and focuses on eating
for health above all else.
- diet of fruits and vegetables, whole grains, fortified and fiber-rich grain foods, low-fat
and fat-free milk, cheese and yogurt or fortified plant-based alternatives, lean meats,
poultry, fish, eggs, soy such as tofu and tempeh, beans, lentils

● Holism
○ Holism is a theory and philosophy that focuses on connections and interactions
between parts of the whole.
○ In contrast, the prevailing scientific approach has focused on reductionism, the
goal of which is to reduce all phenomena to the smallest possible atom, particle,
or interaction.
○ Using a holistic perspective, all living organisms, including humans, are
continuously connecting and interacting with their environment.
○ Further, parts of the organism, whether they are systems, subsystems, or cells, are
also continuously interacting and changing.
○ This continual interaction and change means that the body is not the sum of its
parts (as in reductionism) but that it is a unified, dynamic whole.
● Holistic Nursing
○ Holistic nursing is nursing practice built on a holistic philosophy.
○ Healing the whole person is its goal.
○ Since holism is a philosophy and not a specific nursing role, holistic nurses can be
found in all varieties of health care settings as well as in independent practice
settings.
○ In addition, holistic nurses frequently add CHA (complementary health
approaches) to their practice.
○ Most holistic nurses use CHA for self-care, an essential component of holistic
practice.
○ The American Holistic Nurse Association (AHNA) promotes the education of
nurses, other health care professionals, and the public in all aspects of holistic
caring and healing.
○ Nurses need to be knowledgeable about CHA is that many nurses are expanding
their clinical practice by incorporating CHA.
○ Many state boards of nursing recognize select complementary modalities as part
of nursing practice and have provisions for the safe practice of these modalities by
registered nurses.
○ Although CHA may seem totally safe, some therapies have led to harmful and, at
times, potentially lethal outcomes.
○ Nurses play an important role in educating the public about how these therapies
can be used safely and effectively.

● Effects of Herbal and prescribed medications and its interactions

○ American adults are very likely to use CHA for pain conditions such as back,
neck, or joint pain.
○ Alternative therapies, such as herbs, are used most frequently for chronic
conditions such as depression or headaches.
○ However, certain herbs may interact with each other or with prescribed
medications, causing negative effects.
○ Ask further questions if the patient is taking herbs to treat any condition.
● Effects of Ginkgo Biloba and aspirin and its complications
○ Ginkgo biloba, the most widely sold herb in Europe and used by many to improve
memory, affects platelet function and thus should not be used concurrently with
warfarin or aspirin.
○ Can increase risk of bleeding
● Complimentary therapies and its effects
○ Whole (or alternative) medical systems are like the Western allopathic model, in
that they are complete systems of theory and practice. They consist of a set of
beliefs about the origin of diseases, ways to promote health, and types of
treatment.
○ Mind–body practices use a variety of techniques designed to enhance the mind’s
ability to affect bodily function and symptoms. Examples include yoga,
meditation, acupuncture, energy medicine, manipulative and body-based practices
(e.g., chiropractic), and others.
■ Many people recognize that there is a strong mind–body connection.
■ For example, students may experience insomnia related to anxiety the
night before a major examination or suffer a migraine headache triggered
by a fight with a spouse or good friend.
■ Mind and body communicate with each other.
■ Many neuropeptide receptor sites lie along the gastrointestinal tract to
explain as people experience a large variety of gastrointestinal symptoms
in response to emotional situations.
 ○ Natural products include the use of botanicals (herbs), animal-derived extracts,
vitamins, minerals, fatty acids, amino acids, proteins, prebiotics and probiotics,
whole diets, and functional foods.

● Complimentary and integrative therapy; meditation, Chinese medications, yoga and

acupuncture
○ Meditation refers to a group of techniques, such as mantra meditation, relaxation
response, mindfulness meditation, and Zen Buddhist meditation. In meditation, a
person learns to focus attention.
○ Some forms of meditation instruct the practitioner to become mindful of thoughts,
feelings, and sensations and to observe them in a nonjudgmental way.
○ This practice is believed to result in a state of greater calmness and physical
relaxation, as well as psychological balance.
○ Meditation is usually practiced in a quiet place with as few distractions as
possible.
○ A specific, comfortable posture: Depending on the type being practiced,
meditation can be done while sitting, lying down, standing, walking, or in other
positions.
○ Yoga is a mind and body practice with historical origins in ancient Indian
philosophy.
○ The various physical postures that are practiced promote strength and flexibility,
increase endurance, promote relaxation, and reduce a person’s response to stress.
○ Traditional Chinese medicine aims to restore the body's balance and harmony
between the natural opposing forces of yin and yang, which can block qi and
cause disease. Traditional Chinese medicine includes acupuncture, diet, herbal
therapy, meditation, physical exercise, and massage.
○ Acupuncture- Acupuncture points are believed to stimulate the central nervous
system. This, in turn, releases chemicals into the muscles, spinal cord, and brain.
These biochemical changes may stimulate the body's natural healing abilities and
promote physical and emotional well-being.
○ Acupuncture can help to resolve pain, and improve sleep, digestive function, and
sense of well-being.

● Healing touch and its effects

○ Healing touch (HT) uses a collection of energy techniques to assess and treat the
human energy system, thus effecting physical, emotional, mental, and spiritual
health and healing.
 ○ Healing touch may reduce the client's anxiety, stimulate wound healing, relieve
pain, and promote health.
○ The goal of HT is to restore wholeness through harmony and balance, enhancing
the person’s ability to self-heal .
○ Treatment involves the health care provider placing their hands either on or near
the body in patterns identified by Healing Touch International and/or the Healing
Touch Program

● Relaxation techniques
○ promote parasympathetic nervous system activity, helping to reduce sympathetic
activity and restore the balance of the two systems. The complex
psychophysiological processes can contribute to symptoms such as increased
blood pressure, cool hands and feet, tight muscles, increased heart rate, and
increased anxiety .
○ The goal is to increase the parasympathetic system influence in the mind–body
and thus reduce the effect of stress and stress-related illness on the body.
○ Relaxation can be useful whether a patient is experiencing a single stressful event,
such as surgery or chronic stress.
○ Patient benefits include reduced anxiety, reduced muscle tension and pain,
improved functioning of the immune system, enhanced sleep and rest, and an
improved overall sense of well-being.
○ Several relaxation techniques, including meditation and modern relations methods
such as progressive muscle relaxation, autogenic training, biofeedback, body
scanning, and hypnosis.
○ Nurses can assist patients and others to begin to achieve a relaxation response by
focusing on their breathing.
○ It is helpful to use a mental device such as a repetitive phrase to remind the body
to relax.

Fluids and Electrolytes (6-7 questions)

● Blood transfusion and its complications and adverse effects

○ A blood transfusion is the infusion of whole blood or a blood component such as
plasma, red blood cells, cryoprecipitate, or platelets into the patient’s venous
circulation.
○ A blood product transfusion is given when a patient’s red blood cells, platelets, or
coagulation factors decrease to levels that compromise a patient’s health.
○ Blood transfusions are not without risk.
 ○ Life-threatening complications include a severe allergic reaction (anaphylaxis),
hemolytic reaction, transfusion-related acute lung injury, and circulatory
overload, and transmission of infectious diseases are a risk associated with blood
product transfusion.
○ It is always important that the potential benefits of the transfusion be considered
against the potential risks.
○ Human error and hemolytic transfusion reactions are among the leading causes of
transfusion-related deaths.

Initiation and transfusion of blood: (additional info from slides)

● Patient monitoring during transfusion of blood products is essential because of
continued risk for transfusion reaction
● The nurse should always follow facility blood product transfusion policies and
protocols.
● In an in-patient or long-term care setting, the nurse confirms that this information
matches th e information on the patient’s identification band.
● The patient’s blood type and Rh factor should also be checked against the blood
type and Rh factor of the transfusion product.
● The nurse should always confirm the donation identification number (a code to
track the blood back to its donor) and the expiration date and date/time of issue of
the blood product.
● Bar codes on blood products provide an additional safety measure to identify,
track, and assign data to transfusions.
● Prior to administering PRBC, the nurse would verify that the client has given
consent for the blood transfusion.
● The nurse would obtain baseline vital signs.
● Any change in vital signs during transfusion may indicate an adverse reaction to
the blood; stop the blood and alert the MD immediately.
● Two nurses verify the order for the blood, the client identification, and blood
product information that includes blood group and type; expiration date; and
absence of clots, clumping, or air bubbles in the PRBC.
● The nurse wears clean gloves when preparing the blood for administration to
prevent exposure to the blood.
● If the patient’s temperature is 100°F (37.8°C) or higher, notify the primary care
provider.
● Return blood that has not been used within 30 minutes after its arrival from the
blood bank.
● Nurses need to check the patient’s vital signs prior to transfusion, within 5 to 15
minutes after initiating the transfusion, after the transfusion is completed, and as
needed depending on patient condition.
 ● The nurse primes the administration set with saline; dextrose may lead to
clumping of red blood cells and hemolysis.
● Discontinue blood that has been infusing for more than 4 hours.
● Blood would be administered over approximately 2 hours but less than 4 hours

● Cross matching and type and screen for the blood:

○ Before a blood product can be given to a patient, it must be determined that the
blood of the donor is compatible with that of the patient.
○ If incompatible, clumping and hemolysis of the recipient’s blood cells result, and
death can occur.
○ The laboratory examination to determine a person’s blood type is called blood
typing.
○ The process of determining compatibility between blood specimens is cross-
matching which is ordered before the surgery.
○ Blood type, an inherited trait, is determined by the type of antigens and
antibodies present in the blood.
○ The four main blood types or groups in the ABO system of blood typing are A, B,
AB, and O.

● Sterile technique of IV site and IVF infusion to conduct properly and safely
○ Sterile technique must be observed when accessing a vein to avoid possible
catheter-related infection.
○ Disposable infusion tubing and needles are used to help eliminate many possible
sources of contamination and to reduce the cost of equipment aftercare.
○ IV catheters are plastic tubes that have been mounted on a needle or are threaded
through a needle for insertion.
○ Once inserted, the needle is withdrawn, and the flexible catheter remains in the
vein.
○ Many devices are available that minimize the potential for injury and promote
safety when connecting, accessing, or disposing of IV equipment, including
needleless systems and needle-housing systems in which the needle is recessed
and protected.
○ The primary purpose of needleless connectors is to protect health care personnel
by eliminating needles and associated needlestick injuries when attaching
administration sets and/or syringes to the vascular access device hub.
○ A short extension tubing set is often used between the venous access device and
the needleless connector to reduce catheter manipulation.
 ○ It is important to follow the manufacturers’ recommendations for appropriate
sequencing of clamping and final syringe disconnection when flushing and/or
using the connector to reduce the amount of blood reflux into the venous access
device lumen and subsequent potential occlusion of the venous access device
from intraluminal thrombosis.

● IV site inflammation and its management

○ Regularly assess venous access sites to detect common complications of IV
therapy including infiltration (inadvertent leakage of nonvesicant [agent capable
of causing tissue damage] IV solution into surrounding tissue.
○ Extravasation (inadvertent leakage of vesicant IV solution into surrounding
tissue
○ Phlebitis (site is reddish in color and showing inflammation of the wall of a vein)
○ Thrombophlebitis (blood clot in a vein, causing inflammation), and infection.
○ Central venous catheters are now available that are impregnated with antiseptics
and coated with antibiotics; their use is recommended for patients at high risk for
acquiring a catheter-related infection, such as expected dwell time of more than 5
days or those with enhanced risk of infection, including neutropenic, transplant,
burn, or critically ill patients
○ An additional recommendation to prevent intravascular catheter-related infections
is the use of a 2% chlorhexidine wash for daily skin cleansing, particularly when
other central line–associated bloodstream infection (CLABSI)
○ If the patient is uncomfortable, check that the infusion is entering the vein as
intended, the flow rate is not too rapid, the patient’s position is satisfactory, and
the circulatory status of the patient is intact.
○ Encourage patients to report any changes in the catheter site or any new
discomfort
If you are concerned an IV is infiltrated, follow your facility policy and as a general guideline,
discontinue the site and relocate the IV. If the infiltration is severe, apply warm compresses,
elevate the arm, monitor the site and be sure to inform the healthcare provider.

● Infiltration, phlebitis and its effects and management

○ Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged
needle that has penetrated a vessel wall. Signs and symptoms include swelling,
pallor, coldness, or pain around the infusion site, and significant decrease in the
flow rate
 ○ IV infiltration can lead to excessive fluid in one or more compartments of the
arm, causing damage to nerves, arteries, and muscles.
○ Cool skin can indicate infiltration while warm skin can indicate phlebitis or
infection.
○ Pale or blanched skin can be a sign of infiltration, whereas red skin can indicate
inflammation related to phlebitis or infection.
○ Pus at the IV site indicates infection, while leaking fluid at the site indicates
infiltration.
○ Phlebitis: redness, swelling, warmth, tenderness.

● When does the RN discontinue the IV and why?

○ The common reasons to discontinue IV fluids are: the patient's fluid volume has
returned to baseline; the patient is being discharged from the facility; the IV
catheter needs to be replaced; or the IV site has become unfavorable due to
infection, infiltration, extravasation, or phlebitis.

Highlighted text from Fluid & Electrolyte slides:

Body fluid compartments:

- Intracellular fluid (ICF) is the fluid within cells, constituting about 70% of the total
body water or 40% of the adult’s body weight.
- Extracellular fluid (ECF) is all the fluid outside the cells, accounting for about 30% of
the total body water or 20% of the adult’s body weight.
- ECF includes two major areas, the intravascular and interstitial compartments. A
third, usually minor, compartment is the transcellular fluid.
- Intravascular fluid, or plasma, is the liquid component of the blood (i.e., fluid found within
the vascular system).

- Interstitial fluid is the fluid that surrounds tissue cells and includes lymph.

- Transcellular fluids include cerebrospinal, pericardial, synovial, intraocular, and pleural

fluids, as well as sweat and digestive secretions.

- The capillary walls and cell membranes separate the intracellular and extracellular
compartments.

Fluid Balance:
 ● Fluid intake averages 2,600 mL per day, with approximately 1,300 mL coming from
ingested water, 1,000 mL coming from ingested food, and 300 mL from metabolic
oxidation.
● Fluid is lost from the body through sensible and insensible losses. Sensible losses can be
measured and include fluid lost during urination, defecation, and wounds. Insensible
losses cannot be measured or seen and include fluid lost from evaporation through the
skin and as water vapor from the lungs during respiration.
● The desirable amount of fluid intake and loss in adults ranges from 1,500 to 3,500 mL
each 24 hours, with most people averaging 2,500 to 2,600 mL per day.

Isotonic Solution: The concentration of particles in a solution, or its pulling power, is referred to
as the osmolarity of a solution. A solution that has about the same osmolarity as plasma (between
275 and 295 mOsm/L) is considered an isotonic solution. An isotonic fluid remains in the
intravascular compartment without any net flow across the semipermeable membrane.

Hypertonic solution has a greater osmolarity than plasma (>295 mOsm/L). Hypertonic solution
has a greater osmolarity, water moves out of the cells and is drawn into the intravascular
compartment, causing the cells to shrink.

Hypotonic solution has less osmolarity than plasma (<275 mOsm/L). Because of a lower
osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space
and into ICF, causing cells to swell and possibly burst.

PH;

•Normal blood plasma is slightly alkaline and has a normal pH range of 7.35 to 7.45, with 7.4
being the optimal blood pH.

•Acidosis is the condition characterized by an excess of H ions or loss of base ions (bicarbonate)
in ECF in which the pH falls below 7.35.

•Alkalosis occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH
exceeds 7.45.

Accumulation of fluid in the interstitial space is known as edema.

Nutrition (6-7 questions)

● Anorexia and its reasons and manifestations:

○ Anorexia, or the lack of appetite, may be related to systemic and local diseases;
numerous psychosocial causes, such as fear, anxiety, depression, or pain; and
impaired ability to smell and taste—or it may occur secondary to drug therapy or
medical treatments.
○ Others who may have limited food intake include those who have difficulty
chewing and swallowing, those who experience chronic GI problems or undergo
certain surgical procedures, those with certain chronic illnesses (such as cancer),
and those with inadequate food budgets

● Pureed diet, full liquid diet for which patients and complications
○ Pureed diet also known as a blenderized liquid diet because the diet is made up
of liquids and foods blenderized to liquid form. All foods are allowed. The
indications are after oral or facial surgery; chewing and swallowing difficulties
resulted from stroke due to dysphagia

○ Full liquid diets contain all the items on a clear liquid diet. Additional items
allowed include milk and milk drinks, puddings, custards, plain frozen desserts,
pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in
addition to clear liquids. A full liquid diet contains liquids that can be poured at
room temperature. This diet is for those preparing for a test or surgery, have
difficulty swallowing or chewing
● Proper position for the tube feeding patients
○ Head of bed should be up
○ Verify correct placement of the nasogastric tube after the initial insertion, before
beginning a feeding or instilling medications or liquids, and at regular intervals
during continuous feedings.
○ Verify by x-ray, ph testing of stomach, eternal length marking, aspirate
characteristics, and carbon dioxide monitoring
○ This ensures that the tip of the tube is situated in the stomach or intestine,
preventing inadvertent administration of substances into the wrong place.
○ Check gastric residual (feeding remaining in the stomach) before each feeding or
every 4 to 6 hours during a continuous feeding (according to institution policy).
○ High gastric residual volumes (200 to 250 mL or greater) can be associated with
high risk for aspiration and aspiration-related pneumonia.
 ○ It is important to flush the feeding tube with water after checking gastric residual,
to help prevent tube occlusions.

● Why patients receive NG tube:

○ For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is
usually selected.
○ A nasogastric (NG) tube is inserted through the nose and into the stomach.
○ The patient is at risk for aspirating the tube feeding solution into the lungs, a
disadvantage for using this route.
○ used for decompression of the stomach in the setting of intestinal obstruction or
ileus, but can also be used to administer nutrition or medication to patients who
are unable to tolerate oral intake.
● Why patients receive G tube:
○ When enteral feeding is required for a long-term period, an enterostomal tube
may be placed through an opening created into the stomach (gastrostomy) or into
the jejunum (jejunostomy).
○ A gastrostomy is also the preferred route to deliver enteral nutrition in the patient
who is comatose because the gastroesophageal sphincter remains intact, making
regurgitation and aspiration less likely than with NG tube feedings.
● Primary purpose of NPO
○ Before surgery to prevent aspiration related to anesthesia and after surgery until
bowel sounds return, patients may be given nothing by mouth (NPO).
○ NPO may also be necessary for patients undergoing certain medical tests; for
patients experiencing severe nausea and vomiting, an inability to chew or
swallow, or various acute or chronic GI abnormalities; for those who are
comatose; and for women during labor and delivery.
○ The stress of illness, surgery, or prolonged periods of time on simple intravenous
therapy without oral intake places hospitalized clients at risk for developing
protein-calorie malnutrition.
○ This can result in weakness, poor wound healing, mental apathy, and edema.

● Reasons and effects of malnutrition

○ unsuitable dietary choices.
○ having a low income.
○ difficulty obtaining food.
○ various physical and mental health conditions.
○ Malnourished patients are more likely to have slower wound healing and to
develop complications.
 ○ Investigate the variety of community services and programs that are available to
provide nutritional support to patients at home.
○ The stress of illness, surgery, or prolonged periods of time on simple intravenous
therapy without oral intake places hospitalized clients at risk for developing
protein-calorie malnutrition.

● My plate
○ MyPlate food guidance graphic is part of a communication initiative based on the
Dietary Guidelines for Americans to help consumers make better food choices to
follow a healthy heating pattern across the lifespan, using a familiar image, a
place setting for a meal.
○ MyPlate illustrates the five food groups: Fruits, Vegetables, Grains, Protein, Dairy
○ The goals of the recommendations are to balance calories by encouraging
consumers to enjoy food, but eat less, and avoid oversized portions. Consumers
are also advised to increase the intake a variety of nutrient-dense foods across and
within all food groups.
○ MyPlate also encourages the consumption of water instead of sugary drinks.
○ The importance of activity and exercise are emphasized, including the
recommendations for children and adolescents to be physically active for 60
minutes or more a day and adults to engage in activity that requires moderate
effort, such as brisk walking for two and a half hours or more a week.

● BMIs- ratio of weight (kg) to height (meters)

○ Indicator of total body fat stores in the general population
○ A person with a BMI below 18.5 is underweight
○ A BMI of 18.5 to 24.9 is a healthy weight
○ BMI of 25 to 29.9 indicates an overweight person
○ BMI of 30 or greater indicates obesity
○ BMI of 40 or greater indicates extreme obesity
○ BMI also provides an estimation of relative risk for diseases such as heart disease,
diabetes, and hypertension.
○ BMI may not be accurate for certain groups of people, such as athletes, people
with a muscular build, people with edema or dehydration, and older people and
others who have lost muscle mass .

Highlighted text from Nutrition slides:

Body Weight Standards : if a person’s energy intake does not equal energy expenditure, weight
will fluctuate. Ideal body weight (IBW) or healthy body weight is an estimate of optimal weight
for optimal health.
- Height and weight tables are commonly used for infants and children.
- However, the preferred methods to establish ideal body weight include body mass index
(BMI) for adults and children and measurement of waist circumference for adults only.

Waist circumference:
- Waist circumference is measured by placing a measuring tape snugly around the patient’s
waist at the level of the umbilicus.
- This measurement is a good indicator of abdominal fat.

Water intake (an average of 2,200 to 3,000 mL/day for adults usually equals water output.

Peristalsis moves the food through the esophagus and into the stomach.

Food intake:

- A combination of physiologic and physical factors that influence nutrient requirements

and, or in combination with, sociocultural and psychosocial factors can affect a person’s
nutritional intake, resulting in a decrease or increase in food intake.

** Nurses who role model good health behaviors are more effective teachers.

Nutritional screening:
 - Nutritional screening is an important part of the nursing assessment. This is secondary
prevention
- The Mini Nutritional Assessment tool (MNA) is an example of a screening tool used to
detect older adults at risk for malnutrition before changes in albumin level and the BMI

Assess for barriers to eating:

- Dysphagia (difficulty swallowing or the inability to swallow) can be the result of poor
dental health, cancer, or a neurologic disease, such as stroke, Parkinson’s disease, or
dementia, and may reduce the patient’s nutritional intake.
- Dysphagia also is associated with an increased risk for aspiration, the misdirection of
oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract.
- Dental problems are associated with impaired chewing and avoidance of foods that may
be difficult to chew, such as meat, fruit, and vegetables.
- Patients who experience weakness and fatigue may find eating to be a chore to avoid.
- Diminished sensor abilities, such as sight, taste, smell, and hearing, may also impact a
patient’s nutritional intake.

Biochemical data:
- Hemoglobin, the oxygen-carrying protein of the red blood cells, and hematocrit, the
volume of red blood cells packed by centrifugation in each volume of blood, are
measures of plasma protein that also reflect a person’s iron status.
- Protein status - measuring serum albumin and transferrin levels and by a total
lymphocyte count.
- Serum albumin levels are a good indicator of a patient’s nutritional status a few weeks
prior to when the blood is drawn and can help identify chronic nutrition problems.
- Creatinine levels are directly proportional to the body’s muscle mass; a reduction in this
value reflects severe malnutrition.
Nursing implementation:
- Providing proper and adequate nourishment to the patient is a collaborative effort
implemented in a variety of settings.
- Encourage patients to wash hands and clean food contact surfaces frequently when
handling and preparing foods.
- Serve small, frequent meals to avoid overwhelming the person with large amounts of
food.
-
Oxygenation (6-7 questions)

Heavy and thick secretions management and its effects on breathing pattern:

● Airway resistance is the result of any impediment or obstruction that air meets as it
moves through the airway.
● Obstruction can also result from secretions (e.g., excessive or thickened secretions) or
tissues (e.g., tumors or edema of the respiratory tract).
● Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous
(intermittent) popping sounds. They are produced by air passing through fluid in the
airways or alveoli and opening of deflated small airways and alveoli.
● They occur due to inflammation or congestion and are associated with pneumonia, heart
failure, bronchitis, and COPD.
● Wheezes are continuous musical sounds, produced as air passes through airways
constricted by swelling, narrowing, secretions, or tumors. They are often heard in patients
with asthma, tumors, or a buildup of secretions

Heavy and thick secretions management:

Patients can help keep their secretions thin by drinking 1.9 to 2.9 L (2 to 3 quarts) of fluids daily
to aid airway clearance.

Encourage increase in fluids

Voluntary coughing
 - Coughing early in the morning after rising removes secretions that have accumulated
during the night.
- At bedtime, coughing removes any buildup of secretions and improves sleep patterns

Cough Suppressants

- Observation of the patient’s breathing and coughing characteristics is necessary to

determine the appropriate type of medication.

Cough Medications:

- Various medications can be used to promote coughing, aiding in the movement of mucus
through the respiratory tract, and in controlling coughing to allow the patient to rest.

Expectorants:

- Expectorants are drugs that facilitate the removal of respiratory tract secretions by
reducing the viscosity of the secretions.
- Patients with extremely tenacious (thick) secretions may need the secretions liquefied for
their cough to be effective.
- Guaifenesin is widely used as an expectorant in cold and cough medications (e.g.,
Robitussin).
- Adequate fluid intake and air humidification act as effective expectorants as well.

Nasopharyngeal suction:

- Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva,
pulmonary secretions, blood, vomitus, or foreign material from the pharynx.

Inhaled medications:

- Inhaled medications may be administered to open narrowed airways (bronchodilators), to

liquefy or loosen thick secretions (mucolytic agents), or to reduce inflammation in
airways (corticosteroids).
- These medications typically are administered via nebulizer, metered-dose inhaler (MDI),
or dry powder inhaler (DPI).
- Nebulizers disperse fine particles of liquid medication into the deeper passages of the
respiratory tract, where absorption occurs

Advantages and disadvantages of nasal cannula

 ○ Advantages of nasal cannula: does not impede eating or speaking and isz used
easily in the home.
○ Oxygen can be a low-flow or high-flow system. High-flow systems aerosolize
oxygen and warmed normal saline with the ability to provide higher flow rates
with resulting higher oxygen concentrations.
○ Disadvantages of using a nasal cannula include that it can be dislodged easily,
and low-flow rates can cause dryness of the nasal mucosa. In addition, if a patient
breathes through the mouth, it is difficult to determine the amount of oxygen the
patient is actually receiving.
○ Can be taken off, cause pressure ulcers

Advantages and disadvantages of non rebreather mask

Advantages:

○ For patients who require sustained high-concentration oxygen therapy

○ Emergency situations
○ Pts who have nasal irritation

Disadvantages:

● Difficult to keep mask in position over nose and mouth

● Uncomfortable for pt while eating or talking
● At risk for suffocation

Safety of using portable oxygen

○ Oxygen supports combustion. To prevent fires and injuries, take the following
precautions:
○ Check to see that electrical equipment used in the room, such as electric bell
cords, razors, radios, and suctioning equipment, is in good working order and
emits no sparks.
○ Avoid wearing and using synthetic fabrics that build up static electricity.
○ Avoid using oils in the area. Oil can ignite spontaneously in the presence of
oxygen.
○ No smoking!!!

Different oxygen delivery methods and its uses; nasal cannula, oxygen mask, oxygen hood etc.

○ Nasal cannula: flow is 1 - 6 L/min Face mask 5 - 10 L Venturi mask 2-15 L Non-
rebreather 10 - 15 L
 ○ Nasal cannulas. A nasal cannula is a tube that runs into your nose. It delivers a
small amount of oxygen consistently for a long period of time. Some people will
use a nasal cannula for months or years if they have lung damage or COPD.
○ Oxygen masks cover the nose and mouth. They deliver oxygen in emergency
situations. The non rebreather mask consists of a face mask connected to a
reservoir bag that’s filled with a high concentration of oxygen. A simple face
mask is used to deliver a low to moderate amount of oxygen. It has holes on the
sides to let exhaled air through and to prevent suffocation.
○ Oxygen hood is for those who can breathe on their own but still need extra
oxygen. In cases of mild respiratory event. It is mainly for short term use. Oxygen
can be warmed and humidified without pressure

Flu vaccination-

○ Best way to prevent the flu is by getting vaccinated

○ All people 6 months of age and older should be vaccinated each year
○ Influenza is a contagious respiratory illness that causes mild to severe illness and
even death
○ High risk for flu complications- young children, pregnant women, people with
chronic health conditions like asthma or heart and lung disease and people 65
years and older

Pulse oximeter-

○ Noninvasive technique that measures the arterial oxyhemoglobin saturation

(SpO2) of arterial blood.
○ Does NOT replace ABG analysis
○ Normal range is 95% to 100%
○ values less than or equal to 90% are abnormal, indicate that oxygenation to the
tissues is inadequate and should be investigated for potential hypoxia or error
○ Desaturation (decreased level of SpO2) indicates gas exchange abnormalities

Incentive spirometer:

○ Assists the patient to breath slowly and deeply and to sustain maximal inspiration.
Encourages the patient to maximize lung inflation and prevent or reduce
atelectasis (lung collapse)
○ Optimal gas exchange is supported, and secretions can be cleared and
expectorated. Incentive spirometers are not recommended for routine prophylactic
use in postoperative adult and pediatric patients.
○ Always educate patient on using the equipment properly.
Highlighted text from Oxygen slides:

Gas exchange- the intake of oxygen and the release of carbon dioxide, is made possible by
pulmonary ventilation, respiration, and perfusion.

Pulmonary ventilation refers to the movement of air into and out of the lungs.

Respiration involves gas exchange between the atmospheric air in the alveoli and blood in the
capillaries.

Perfusion is the process by which oxygenated capillary blood passes through body tissues

The accessory muscles of the abdomen, neck, and back are used to maintain respiratory
movements at times when breathing is difficult. These muscles are used to facilitate breathing;
the movement is called retraction.

Lung compliance refers to the ease with which the lungs can be inflated.

Emphysema, a chronic lung condition, and the normal changes associated with aging are
examples of conditions that result in decreased elasticity of lung tissue, which, in turn, decreases
compliance.

Airway resistance is the result of any impediment or obstruction that air meets as it moves
through the airway.
- Bronchial constriction in asthma is an example of airway resistance related to a decrease
in the size of air passages.

Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure
changes and the exchange of gas by diffusion in the lungs.

Oxygenated capillary blood passes through the tissues of the body in the process called
perfusion.
- Perfusion is greater in dependent areas.

Alterations in Respiratory Function:

● If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur.

● Hypoxia is a condition in which an inadequate amount of oxygen is available to cells.
 ● The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated
blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor,
and cyanosis.

Heart failure occurs when the heart is unable to pump a sufficient blood supply, resulting in
inadequate perfusion and oxygenation of tissues.
● It can be the result of many heart conditions, including chronic hypertension,
coronary artery disease, and disease of the heart valves.
● Symptoms include shortness of breath, edema (swelling), and fatigue.

Because hemoglobin also carries carbon to the lungs, anemia results in diminished carbon
dioxide exchange.

Medication considerations:
● Opioids are chemical agents that depress the medullary respiratory center. As a result, the
rate and depth of respirations decrease.
● Be alert for the possibility of respiratory depression or arrest when administering any
narcotic or sedative.
● Other medications decrease heart rate, with the potential to alter the flow of blood to
body tissues.

Cigarette smoking is the most important risk factor for COPD.

Normal breath sounds:

- vesicular (low-pitched, soft sounds heard over peripheral lung fields),
- bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx),
- bronchovesicular (medium-pitched blowing sounds heard over the major bronchi)
sounds.

Spirometry:

● Spirometry measures the volume of air in liters exhaled or inhaled by a patient over time.
● It evaluates lung function and airway obstruction through respiratory mechanics.
● Spirometry can be used to measure the degree of airway obstruction and evaluates
response to inhaled medications.
● The patient inhales deeply and exhales forcefully into a spirometer, an instrument that
measures lung volumes and airflow.
● Patients also use spirometers to promote deep breathing while recovering from surgery,
and to monitor health status in management of chronic asthma.

Peak expiratory flow rate (PEFR) refers to the point of highest flow during forced expiration.
People with dyspnea and orthopnea are most comfortable in a high-Fowler’s position because
accessory muscles can easily be used to promote respiration.

Promoting proper breathing:

- Deep breathing
- Incentive spirometry
- pursed - lip breathing (also helps the pt to control the rate and depth of respiration,
helping to reduce feelings of dyspnea)
Cough Suppressants:
- Suppressants are drugs that depress a body function such as the cough reflex. Codeine,
which is present in many cough preparations, is generally considered the preferred cough
suppressant ingredient. However, codeine can be addictive, and because of possible
abuse, most states require a prescription for its use.
- Drowsiness is a side effect; thus, it may not be safe to use codeine when the person must
remain alert, such as when driving a car.

Administering Inhaled Medications:

● Inhaled medications may be administered to open narrowed airways (bronchodilators), to
liquefy or loosen thick secretions (mucolytic agents), or to reduce inflammation in
airways (corticosteroids).
● These medications typically are administered via nebulizer, metered-dose inhaler (MDI),
or dry powder inhaler (DPI).
● Nebulizers disperse fine particles of liquid medication into the deeper passages of the
respiratory tract, where absorption occurs.
● An MDI delivers a controlled dose of medication with each compression of the canister.
Common mistakes that patients make when using MDIs include the following:
● Failing to shake the canister
● Holding the inhaler upside down
● Inhaling through the nose rather than the mouth
● Inhaling too rapidly
● Stopping the inhalation when the cold propellant is felt in the throat
● Failing to hold their breath after inhalation
● Inhaling two sprays with one breath

DPIs ( Dry Powder inhales):

are another type of delivery method for inhaled medications. DPIs are breath activated.
● A quick deep breath by the patient activates the flow of medication, eliminating the need
to coordinate activating the inhaler (spraying the medicine) while inhaling the medicine
at the same time.
● DPIs require less manual dexterity than do MDIs.
 ● DPIs are actuated by the patient’s inspiration, so there is no need to coordinate the
delivery of puffs with inhalation.
● Some have to be loaded with a dose of medication each time they are used. Some hold a
preloaded number of doses.
● One disadvantage of DPIs is that the medication in DPIs will clump if exposed to
humidity.

A spacer is also recommended for patients using inhaled corticosteroid agents because it reduces
the risk of acquiring an oral fungal infection.

Humidification:
● Most institutions do not require humidification with very–low-flow oxygen (4 L/min or
less) delivered by nasal cannula (see oxygen delivery systems to follow) when
administered to adults
● However, because oxygen dries and dehydrates the respiratory mucous membranes,
humidifying devices (supplying 20% to 40% humidity) are commonly used when oxygen
is delivered at higher flow rates. Distilled or sterile water is commonly used to humidify
oxygen.

Dosage questions X 4

- D/H x volume (mL)