2.

Nose → pharynx - shared pathway of food and air

OXYGENATION ● includes nasopharynx and oropharynx
○ supplied with lymphoid tissue
● traps and destroys pathogens entering
STRUCTURE OF THE RESPIRATORY SYSTEM 3. Pharynx → larynx - maintaining airway patency and protecting
Upper respiratory tract lower airways from swallowed food and fluids.
● Mouth ● During swallowing - epiglottis closes, routing food to the
● Nose esophagus.
● Pharynx ○ open during breathing
● Larynx 4. Larynx → trachea → right and left main bronchi (primary bronchi)
Lower respiratory tract → other conducting airways of the lungs
● trachea and lungs, with bronchi, bronchioles, alveoli, 5. Lungs
pulmonary capillary network, and pleural membranes. ● primary bronchi divide repeatedly, ending with the terminal
bronchioles.
● trachea and bronchi are lined with mucosal epithelium.
○ produce a thin layer of mucus
○ traps pathogens and microscopic particulate
matter.
○ foreign particles are swept upward toward larynx
and throat by cilia
● The cough reflex is triggered by irritants in the larynx,
trachea, or bronchi.
6. Bronchi → respiratory bronchioles & alveoli -gas exchange
● respiratory bronchioles, alveolar ducts & alveoli
● Alveoli - thin walls, single layer of epithelial cells covered
by thick mesh of pulmonary capillaries.
● alveolar and capillary walls = respiratory membrane
○ gas exchange b/n air on the alveolar side and
blood on the capillary side.
● airways move air to and from the alveoli
○ RV and pulmonary vascular systems transport
blood to capillary side of the membrane.
○ Ex: deoxygenated blood leaves right heart
through pulmonary artery and enters lungs and
capillaries.
■ Oxygenated blood returns via
capillaries to the pulmonary vein to the
heart
● permeable membrane of respiratory membrane
○ essential to normal gas exchange.
○ fluid or other materials in the alveoli interfere
with the respiratory process.
● outer surface of lungs - covered by pleura
○ parietal pleura lines thorax + surface of
diaphragm.
○ visceral pleura covering the external surface of
lungs.
○ b/n pleural layers = pleural fluid
■ prevents friction during movements of
breathing
■ keep layers adherent through surface
tension.

Adequate ventilation depends on several factors:
mechanisms work to keep airways open and clear
AIR ENTRANCE
1. Air enters thru nose - warmed, humidified and filtered
● Hairs at entrance of nares trap large particles
● smaller particles filtered and trapped as air changes
direction on contact with nasal turbinates and septum.
● Irritants in nasal passages initiate sneeze reflex.
○ air rapidly exits through nose and mouth during
a sneeze
○ clear nasal passages
PULMONARY VENTILATION
● accomplished through the act of breathing:
○ inspiration (inhalation) & expiration (exhalation)
● Clear airways
● intact CNS & resp. center (medulla & pons in brainstem)
● intact thoracic cavity - can expand and contract
● Adequate pulmonary compliance and recoil.
● ciliary action and the cough reflex
● defenses may be overwhelmed
○ inflammation, edema, and excess mucous
production = clog small airways → impair
ventilation of distal alveoli
● degree of chest expansion
○ @ normal breathing is minimal = little energy
expenditure.
○ In adults, 500 mL of air is inspired and expired
with each breath = tidal volume.
■ strenuous exercise or heart disease =
greater chest expansion and effort.
● > 1500 mL of air moved with
each breath.
Accessory muscles of respiration,
● anterior neck, intercostal, and muscles of abdomen
● Active use of muscles and noticeable effort in breathing in
clients wi obstructive pulmonary disease.
Lung compliance - expansibility or stretchability = ease of ventilation.
● At birth, fluid-filled lungs are stiff and resistant to expansion
○ with each subsequent breath, alveoli = more
compliant and easier to inflate
● Lung compliance dec. with aging
○ difficult to expand alveoli
○ inc. risk for atelectasis - collapse portion of lung.
○ necessary for normal inspiration
Lung recoil - tendency of lungs to collapse away fr chest wall.
● necessary for normal expiration.
● surface tension of fluid lining alveoli - greatest effect on
recoil.
● Surfactant - lipoprotein prod by specialized alveolar cells
○ dec. surface tension of alveolar fluid.
○ lung expansion is exceedingly difficult and lungs
collapse without it
ALVEOLAR GAS EXCHANGE
● After alveoli are ventilated = diffusion of O2 fr alveoli →
pulmonary blood vessels
● Diffusion - greater pressure or concentration → lower
pressure or concentration.
○ CO2 diffuses fr blood → alveoli
■ eliminated w expired air.
TRANSPORT OF OXYGEN AND CARBON DIOXIDE
transport of respiratory gases.
● O2 fr lungs → tissues
○ most combines loosely w hemoglobin in RBCs
○ carried to the tissues as oxyhemoglobin
● CO2 fr tissues → lungs
factors affect rate of O2 transport fr lungs to tissues:
1. Cardiac output
● pathologic condition that decreases cardiac output
● dec. amt of oxygen delivered to tissues.
● heart compensates for inadequate output by inc its
pumping rate or heart rate
○ w severe damage or blood loss = may not
restore adequate BF and O2 to tissues.
2. Number of erythrocytes and blood hematocrit
● hematocrit - % blood that is erythrocytes.
○ 40% to 54% in men and 37% to 50% in women.
○ Excessive increases = raise blood viscosity
■ reducing the cardiac output
■ reducing oxygen transport
○ Excessive reductions - reduce oxygen transport
■ Like in anemia
3. Exercise
● well-trained athletes - O2 transport inc. up to 20x
○ increased cardiac output
○ increased use of oxygen by cells
SYSTEMIC DIFFUSION
● diffusion of O2 & CO2 b/n capillaries and tissues and cells
○ concentration gradient similar to diffusion at
alveolar–capillary level.
● cells consume O2 = partial pressure of O2 in tissues dec.
○ O2 at arterial end of capillary diffuse → cells
○ cells consume more O2 during exercise or stress
= pressure gradient inc.
■ diffusion is enhanced
■ cells regulate their own flow of O2
● CO2 from metabolic processes accumulates in tissues
○ diffuses into capillaries - partial pressure is lower
● reduced blood flow states = capillary BF dec. = interfering
w tissue O2 delivery
RESPIRATORY REGULATION
neural and chemical controls to maintain correct conc of O2, CO2, H
● nervous system adjusts the rate of alveolar ventilations to
meet needs of body
○ PO2 and PCO2 remain relatively constant.
● body’s “respiratory center” - groups of neurons in medulla
oblongata and pons of the brain.
○ chemosensitive center in medulla oblongata =
responsive to inc. in blood CO2 or H ion conc.
○ By influencing other respiratory centers
■ inc. activity of inspiratory center
■ inc. rate and depth of respirations.
○ special neural receptors sensitive to dec. in O2
conc = located outside CNS in carotid bodies
and aortic bodies above and below aortic arch.
■ Dec. in arterial O2 conc = stimulate
chemoreceptors
● stimulate the respiratory
center to inc. ventilation.
● Of the three blood gasses, inc. CO2 conc has the
strongest effect on stimulating respiration/ effect on
chemoreceptors.
○ in clients w chronic lung ailments = oxygen conc
play a major role in regulating respiration
■ Ex: emphysema
○ For some clients, dec O2 conc = main stimuli for
respiration
■ chronically elevated CO2 levels in
emphysema “desensitize” central
chemoreceptors.
● called hypoxic drive.
■ Inc. concentration of oxygen
depresses respiratory rate.
FACTORS AFFECTING RESPIRATORY
FUNCTION
1. AGE
● At birth
○ fluid-filled lungs drain
○ PCO2 rises
○ neonate takes a first breath.
● 2 weeks of age
○ lungs expand with each subsequent breath
○ reaches full inflation (2 weeks)
● older adults - if compromised by infection, physical or
emotional stress, surgery, anesthesia, or other procedures.
○ Chest wall & airways - more rigid & less elastic
○ dec. amount of exchanged air
○ dec. cough reflex and cilia action
○ Mucous membranes drier and fragile
○ dec. in muscle strength and endurance
○ (+) osteoporosis - adequate lung expansion
compromised.
○ dec. in efficiency of immune system
○ Gastroesophageal reflux disease - inc risk of
aspiration.
■ causes bronchospasm
● inflammatory response
2. ENVIRONMENT
● Altitude, heat, cold, and air pollution
● higher the altitude, the lower the PO2
○ high altitudes - increased respiratory and cardiac
rates and increased respiratory depth
● Exposure to air pollution
○ stinging of the eyes, headache, dizziness, and
coughing.
○ history of existing lung disease and altered
respiratory function experience varying degrees
of respiratory difficulty
3. LIFESTYLE
● Physical exercise or activity increases rate and depth of
respirations = supply of oxygen in the body.
● Sedentary individuals - lack alveolar expansion and
deep-breathing patterns
○ less able to respond effectively to respiratory
stressors.
4. HEALTH STATUS
● Healthy indiv - respiratory system can provide sufficient
oxygen to meet the body’s needs.
● Diseases of the respiratory system - adversely affect the
oxygenation of the blood.
5. MEDICATIONS
● can decrease the rate and depth of respirations.
● benzodiazepine sedative–hypnotics and antianxiety drugs
(e.g., diazepam, lorazepam, midazolam), barbiturates
(e.g., phenobarbital), and opioids such as morphine.
○ carefully monitor respiratory status
○ Older clients are at high risk of respiratory
depression - require reduced dosages.
6. STRESS
● psychologic and physiologic responses
○ hyperventilate - arterial PO2 rises & PCO2 falls
○ light-headedness and numbness and tingling of
the fingers, toes, and around the mouth
● SNS is stimulated and epinephrine is released
○ bronchioles dilate
○ increasing blood flow and oxygen delivery to
active muscles.
ALTERATIONS IN RESPIRATORY FUNCTION
1. Patency (open airway)
2. movement of air into or out of the lungs
3. diffusion of O2 and CO2 b/n alveoli & pulmonary capillaries
4. transport of O2 and CO2 via blood to and from tissue cells.
CONDITIONS AFFECTING AIRWAY
completely or partially obstructed airway
● Upper airway obstruction
○ foreign object is present
○ tongue falls back into oropharynx (individual is
unconscious)
○ secretions collect in passageways
○ Partial obstruction
■ low-pitched snoring sound @
inspiration
○ Complete obstruction
■ extreme inspiratory effort - no chest
movement + inability to cough/speak
■ may also exhibit marked sternal and
intercostal retractions.
● Lower airway obstruction
○ partial or complete occlusion of passageways in
the bronchi and lungs
○ due to increased accumulation of mucus or
inflammatory exudate.
○ Stridor, harsh, high-pitched sound - @
inspiration.
○ altered arterial blood gas levels, restlessness,
dyspnea, and adventitious breath sounds
CONDITIONS AFFECTING MOVEMENT OF AIR
rate, volume, rhythm, and relative ease or effort of respiration.
1. Normal respiration (eupnea)
● quiet, rhythmic, and effortless
2. Tachypnea (rapid respirations)
● fevers, metabolic acidosis, pain, and hypoxemia
inspection, palpation, percussion, and auscultation.
3. Bradypnea
● abnormally slow respiratory rate
● drugs (morphine or sedatives), metabolic alkalosis, or
increased intracranial pressure
4. Apnea
● absence of any breathing
5. Hypoventilation,
● inadequate alveolar ventilation
● slow or shallow breathing, or both
● diseases of respiratory muscles, drugs, or anesthesia
● lead to inc. levels of CO2 (hypercarbia or hypercapnia) or
low levels of O2 (hypoxemia)
6. Hyperventilation
● inc. movement of air in and out of the lungs.
● rate and depth of respirations inc. = more CO2 is
eliminated than is produced.
sputum specimens, throat cultures, visualization procedures, venous
● occur in response to stress or anxiety.
and arterial blood specimens, and pulmonary function tests.
7. Orthopnea
● inability to breathe easily unless upright or standing
● Difficulty breathing or feeling short of breath
8. Dyspnea
● occur w varying levels of exertion or at rest
● observable (objective) signs
○ flaring of nostrils
○ labored-appearing breathing
○ increased heart rate
○ cyanosis
○ diaphoresis
● stem from cardiac or respiratory disorders.
CONDITIONS AFFECTING DIFFUSION
● Impaired diffusion affect levels of gasses in blood
○ O2 = does not diffuse readily like CO2
● Hypoxemia - reduced oxygen levels in the blood
○ conditions that impair diffusion at
alveolar–capillary level
■ pulmonary edema
■ atelectasis (collapsed alveoli)
■ low hemoglobin levels
○ cardiovascular system compensates by inc. HR
and CO → move adequate O2 to tissues.
■ If unable to compensate or hypoxemia
is severe = tissue hypoxia (insufficient
oxygen anywhere in the body)
● cellular injury or death
○ Cyanosis - low hemoglobin & dec. O2 saturation
■ present with hypoxemia or hypoxia
● Adequate oxygenation is essential for cerebral functioning.
○ cerebral cortex - tolerate hypoxia for only 3 to 5
minutes before permanent damage
● Acute hypoxia s/sx
○ face appears anxious, tired, and drawn.
○ assumes a sitting position, often leaning forward
to permit greater expansion of the thoracic cavity
CONDITIONS AFFECTING TRANSPORT
● oxygen → lungs and diffuses into capillaries
● cardiovascular system
○ carries oxygen to all body tissues
○ moves CO2 fr cells → lungs → exhaled fr body.
● Conditions that dec. cardiac output affect tissue
oxygenation and ability to compensate for hypoxemia
○ heart failure or hypovolemia
NURSING MANAGEMENT
ASSESSING
NHH
● data about current and past respiratory problems
● Lifestyle
● presence of cough, sputum (coughed-up material), or pain
● medications for breathing
● presence of risk factors for impaired oxygenation status.
PHYSICAL EXAM
● observe rate, depth, rhythm, and quality of respirations
○ noting position the client assumes for breathing.
● inspect for variations in shape of the thorax that
○ indicate adaptation to chronic respiratory
conditions.
○ Ex: emphysema - barrel chest.
● palpate thorax for bulges, tenderness, or abnormal
movements.
○ detect vocal (tactile) fremitus.
○ percussed for diaphragmatic excursion
■ movement of the diaphragm during
maximal inspiration and expiration
● auscultate chest to assess client’s breath sounds
DIAGNOSTIC STUDIES
● Measurement of arterial blood gases
○ Blood taken directly from the radial, brachial, or
femoral arteries or fr catheters placed in arteries.
 ○ high pressure of blood in arteries = prevent
hemorrhaging by applying pressure to puncture
site for 5 minutes
● noninvasive measurement of oxygen saturation (device
placed on the fingertip) for oxygenation of arterial blood.
DIAGNOSING
● altered respiratory status
● altered breathing pattern
● altered gas exchange
● inadequate physical energy for activities.
may also be the etiology of several other nursing diagnoses
● fatigue related to altered breathing pattern
● insomnia r/t orthopnea and required oxygen therapy
● social seclusion related to inadequate physical energy for
activities and inability to travel to usual social activities.
PLANNING
● Maintain a patent airway.
● Improve comfort and ease of breathing.
● Maintain/improve pulmonary ventilation and oxygenation.
● Improve ability to participate in physical activities.
● Prevent risks associated w oxygenation problems
○ skin & tissue breakdown, syncope, acid–base
imbalances, feelings of hopelessness & social
isolation.
● direction for planning interventions and criteria for
evaluating client progress.
PLANNING FOR HOME CARE
client’s learning needs and needs for assistance w care in the home.
● Home Care Oxygenation
● Planning - assessment of client’s and family’s knowledge
and abilities for self-care, financial resources, and
evaluation of need for referrals and home health services.
CLIENT
Self-care abilities
● ambulate and activities of daily living (ADLs) independently
Exercise and activity pattern
● type and regularity of usual exercise
● perceived and actual energy for desired and required
leisure activities
Assistive devices required
● oxygen, humidifier, nebulizer treatments, or inhalers
● walker, cane, or wheelchair
● grab bars, shower chair, and other devices
● scale to monitor weight on a regular basis
Home environment - impair airway clearance, gas exchange, or
activity tolerance
● indoor pollutants and allergens
● lack of humidity in the air
● barriers such as stairs
Current level of knowledge
● importance of avoiding smoking and other pollutants
● dietary salt and other restrictions (if appropriate)
● recommended activities
● Medications
● need to limit exposure to respiratory infections
● use of prescribed nebulizer, multidose inhaler, powdered
dose inhaler, or home oxygen
● activity level
FAMILY
Caregiver availability, skills, and responses
● ability and willingness to provide care as needed
Family role changes and coping
● financial status, parenting and spousal roles, sexuality,
social roles
Alternate potential primary or respite caregivers
● other family members, volunteers, church members, paid
caregivers, or housekeeping services
● available community respite care
COMMUNITY
Environment
Current knowledge of and experience with community resources
IMPLEMENTING
● nursing interventions to facilitate pulmonary ventilation
○ ensuring patent airway, positioning, encouraging
deep breathing and coughing, and ensuring
adequate hydration.
● suctioning, lung inflation techniques, administration of
analgesics before deep breathing and coughing, postural
drainage, and percussion and vibration.
● facilitate diffusion of gases thru alveolar memb
○ encouraging coughing, deep breathing, and
suitable activity.
● dependent nursing interventions
○ oxygen therapy, tracheostomy care, and
maintenance of a chest tube.
PROMOTING OXYGENATION
Changing position frequently, ambulating, and exercising
● Shallow respirations inhibit diaphragmatic excursion and
lung distensibility.
● result of inadequate chest expansion - pooling of
respiratory secretions
○ harbor microorganisms and promote infection.
● shallow respirations may potentiate alveolar collapse →
○ dec. diffusion of gasses, subsequent hypoxemia.
Interventions by the nurse to maintain normal respirations:
● Positioning client to allow for maximum chest expansion
● Encouraging or providing frequent changes in position
● Encouraging deep breathing and coughing
● Encouraging ambulation
● measures that promote comfort (pain medications).
● semi- or high-Fowler’s position - maximum chest
expansion (esp those w dyspnea)
● encourage clients to turn from side to side frequently
○ alternate sides = permitted maximum expansion.
● Clients w severe pneumonia or other pulmonary disease in
one lung, if positioned laterally = w the “good lung down”
○ improve diffusion of oxygen to blood from
functioning alveoli.
● Dyspneic clients - sit in bed and lean over their overbed
tables w a pillow for support.
○ adaptation of the high-Fowler’s position.
○ Some sit upright and lean on their arms or
elbows = tripod position.
○ forces diaphragm down and forward and
stabilizes chest
■ reduces work of breathing.
○ client in the orthopneic position can press lower
part of chest against the table to help in exhaling
DEEP BREATHING AND COUGHING
remove secretions from the airways.
● coughing raises secretions high enough
○ either expectorate (spit out) or swallow them.
● conditions that inc. secretions or impair mobilization of
secretions = encourage to cough and breathe deeply
○ chest surgery, COPD, or cystic fibrosis
Specialized breathing exercises - clients w chronic obstructive
diseases = part of pulmonary rehabilitation.
● require collaboration with other healthcare providers.
● pursed lip breathing = alleviate dyspnea.
○ breathe in normally through the nose
○ exhale thru pursed lips
■ blow slowly and purposefully,
tightening abdominal muscles
● Normal forceful coughing is highly effective
○ client inhaling deeply and then coughing twice
while exhaling.
Alternative cough techniques
● forced expiratory technique, or huff coughing
○ clients unable to perform normal forceful cough.
● Client w pulmonary condition (e.g., COPD)
○ exhale through pursed lips and with a “huff”
sound in mid-exhalation.
○ huff cough helps prevent high expiratory
pressures that collapse diseased airways.
 HYDRATION
maintains the moisture of the respiratory mucous membranes.
● when client is dehydrated or when environment has low
humidity = respiratory secretions → thick and tenacious
○ Hard for cilia to move
● Fluid intake should be as great as the client can tolerate.
● Humidifiers - devices that add water vapor to inspired air.
● Nebulizers - deliver humidity and medications.
○ may be used w oxygen delivery systems
○ provide moistened air directly to the client.
○ prevent mucous membranes from drying and
becoming irritated and loosen secretions
MEDICATIONS
Bronchodilators, anti-inflammatory drugs, leukotriene modifiers,
expectorants, and cough suppressants
1. Bronchodilators (sympathomimetic drugs and xanthines,)
● reduce bronchospasm
● opening tight or congested airways = ventilation
● administered orally or IV but preferred is by inhalation to
prevent many systemic side effects.
● enhance SNS = side effects of inc. HR, BP, anxiety, and
restlessness.
2. Anti-inflammatory drugs (glucocorticoids)
● Orally, IV, or by inhaler.
● dec. edema and inflammation in airways and allowing
better air exchange.
● If both bronchodilators and antiinflammatory drugs ordered
by inhaler
○ use bronchodilator inhaler first then
anti-inflammatory inhaler.
○ If bronchioles are dilated first = more tissue
exposed → antiinflammatory drugs act
● Newer formulations combine a long-acting bronchodilator
with an inhaled corticosteroid
○ improve client compliance w therapy
○ require less time and less frequent dosing
● leukotriene modifiers
○ dec. effects of leukotrienes on smooth muscle of
respiratory tract.
○ cause bronchoconstriction, mucous production,
and edema
● Expectorants “break up” mucus
○ more liquid and easier to expectorate.
○ Guaifenesin - expectorant found cough syrups
● Codeine
○ frequent or prolonged coughing interrupts sleep
● Medications used to improve oxygenation by improving
cardiovascular function.
○ digitalis glycosides - act directly on the heart
■ improve strength of contraction and
slow heart rate.
○ Beta-adrenergic stimulating agents (dobutamine)
■ increase cardiac output = improve
oxygen transport.
○ Betaadrenergic blocking agents (propranolol)
■ Affect SNS →reduce workload of heart
■ negatively affect people w asthma or
COPD = constrict airways by blocking
beta-2 adrenergic receptors.
PERCUSSION, VIBRATION AND POSTURAL
Percussion
● mechanically dislodge secretions fr bronchial walls
● Cupped hands trap air against chest.
○ trapped air sets up vibrations through chest wall
to the secretions.
Steps
● Cover the area with a towel or gown to reduce discomfort.
● Ask client to breathe slowly & deeply = relaxation.
● Alternately flex and extend wrists rapidly to slap the chest
● Percuss each affected lung segment for 1 to 2 minutes.
Vibration
● hands placed flat against client’s chest wall.
● used after percussion to inc. turbulence of exhaled air
○ loosen thick secretions.
○ done alternately with percussion.
Steps
● Place hands, palms down, on chest area to be drained,
one hand over other w fingers together and extended
○ hands may be placed side by side.
● inhale deeply and exhale slowly thru nose or pursed lips.
● During exhalation, tense all hand and arm muscles, using
the heel of hand, vibrate hands, moving them downward.
● Stop vibrating when client inhales.
○ Vibrate @ 5 exhalations over 1 lung segment
○ After each vibration, encourage client to cough
and expectorate
● Postural drainage - gravity
○ Secretions in lungs or respiratory airways =
bacterial growth and subsequent infection.
○ obstruct the smaller airways = atelectasis
○ in the major airways = coughed into pharynx
■ expectorated, swallowed, suctioned
variety of positions - drain all segments of the lungs
● lower lobes
○ require drainage most frequently bc upper lobes
drain by gravity.
● Before postural drainage - bronchodilator medication or
nebulization therapy to loosen secretions.
○ two or three times daily.
○ best times - before breakfast, before lunch, in
the late afternoon, and before bedtime.
○ avoid hours after meals
■ tiring and can induce vomiting.
● evaluate the client’s tolerance
○ assessing the stability of the client’s vital signs
■ pulse and respiratory rates
○ by noting signs of intolerance
■ pallor, diaphoresis, dyspnea, nausea,
and fatigue.
○ some become dyspneic in Trendelenburg’s
position and require moderate tilt or shorter time
sequence for PVD is usually as follows:
● positioning, percussion, vibration, and removal of
secretions by coughing or suction.
● Each position 10 to 15 minutes
● Following PVD = auscultate client’s lungs
○ compare the findings to the baseline data
○ document the amount, color, and character of
expectorated secretions.
MUCUS CLEARANCE DEVICES
● clients with excessive secretions
○ cystic fibrosis, COPD, and bronchiectasis.
● Flutter MCD
○ small, handheld device w a hard plastic
mouthpiece and perforated cover at other end.
■ Inside = steel ball
○ Inhale slowly, keeping cheeks firm, exhales fast
through device = steel ball move up and down.
■ causes vibrations that loosen mucus
OXYGEN THERAPY
Determining effectiveness of oxygen therapy measures:
● checking vital signs and peripheral blood O2 saturation
● Supplemental oxygen - clients who have hypoxemia
○ reduced ability for diffusion of O2 thru respiratory
membrane, hyperventilation, or substantial loss
of lung tissue d/t tumors or surgery.
● those w severe anemia or blood loss, or similar conditions
○ inadequate numbers of RBCs or hemoglobin to
carry oxygen.
When administering oxygen as an emergency measure
● nurse may initiate the therapy then contact healthcare
provider for an order.
supplied in two ways in healthcare facilities:
● portable systems (cylinders/tanks) & wall outlets (dry)
● dehydrate respiratory mucous membranes.
● Humidifying devices add water vapor to inspired air for liter
flows over 4 L/min
○ 20% to 40% humidity.
 ○ prevent mucous membranes from drying and
becoming irritated
○ loosen secretions
○ > bubbles created = > water vapor is produced.
● If client is breathing very low flow oxygen = atmospheric air
is inhaled (has water vapor) to prevent mucosal drying.
oxygen is not completely harmless
● inadequate amount (hypoxia) = cell death → death
● Pulmonary oxygen toxicity / hyperoxic acute lung injury
○ lead initially to pulmonary tissue damage
○ damage other internal organs.
○ develop from prolonged exposure to toxic levels
of oxygen (FiO2 Ú 0.70)
● lowest concentration needed to achieve desired blood
oxygen saturation (e.g., > 90% or prescribed by healthcare
provider)
OXYGEN DELIVERY SYSTEMS
Low-flow and high-flow systems
● choice of system depends on client’s oxygen needs,
comfort, and developmental considerations.
● Low-flow systems deliver oxygen via small-bore tubing.
○ nasal cannulas, face masks, oxygen tents, and
transtracheal catheters.
○ room air is also inhaled along with the
supplemental oxygen.
■ fraction of inspired oxygen (FiO2) will
vary depending on respiratory rate,
tidal volume, and liter flow.
● High-flow systems
○ supply all oxygen required during ventilation in
precise amounts
■ regardless of client’s respirations.
○ deliver precise and consistent FiO2 = Venturi
mask with large-bore tubing
CANNULA
low concentration of O2 (24% to 45%) at flow rates of 2 to 6 L/min.
● > 6 L/min = client tends to swallow air and FiO2 is not inc.
● Limitations of plain nasal cannula
○ can’t deliver higher concentrations of oxygen
○ drying and irritating to mucous membranes
Reservoir nasal cannulas
● oxygen-conserving devices
● used primarily in the home setting.
● stores oxygen in the reservoir while client breathes out and
delivers a 100% oxygen bolus when the client breathes in.
○ delivers a higher oxygen concentration at a
lower flow rate than plain nasal cannula
○ deliver FiO2 of 0.5 or greater, while providing
same benefits of plain nasal cannula.
● two styles of reservoir nasal cannulas (Oxymizers) =
mustache and pendant styles
● Humidification is not necessary
○ collects water vapor while client breathes out
○ returns it when client breathes in.
FACE MASK
● for oxygen inhalation
● Exhalation ports on sides of mask allow exhaled carbon
dioxide to escape.
● Some have reservoir bags - higher oxygen concentrations
○ air comes fr upper respiratory passages (e.g.,
the trachea and bronchi)
○ does not take part in gaseous exchange
■ oxygen concentration remains the
same as that of inspired air.
A variety of oxygen masks are marketed:
● simple face mask delivers oxygen concentrations from
35% to 65% at liter flows of 8 to 12 L/min
● partial rebreather mask delivers oxygen concentrations of
40% to 60% at liter flows of 6 to 10 L/min
○ oxygen reservoir bag attached allows client to
rebreathe the first third of exhaled air in
conjunction with oxygen
■ inc. FiO2 by recycling expired oxygen.
○ must not totally deflate during inspiration to
avoid carbon dioxide buildup.
■ inc. liter flow of oxygen so that bag
remains one-third to one-half full.
● non rebreather mask delivers the highest oxygen
concentration 60% to 100%, at liter flows of 6 to 15 L/min
○ One-way valves - prevent room air and client’s
exhaled air from entering the bag
■ only the oxygen in the bag is inspired
○ Sometimes, one of the side valves is removed
■ client can still inhale room air if oxygen
supply is accidentally cut off.
○ To prevent carbon dioxide buildup = must not
totally deflate during inspiration.
■ inc. liter flow of oxygen.
● Venturi mask delivers oxygen concentrations varying from
24% to 40% or 50% at liter flows of 4 to 10 L/min
○ wide-bore tubing and color-coded jet adapters =
precise oxygen concentration and liter flow.
■ blue adapter delivers a 24%
concentration of oxygen at 4 L/min
■ green adapter delivers a 35%
concentration of oxygen at 8 L/min.
○ may use a dial/setting for desired concentration.
○ Turning oxygen source flow rate higher than
specified by equipment manufacturer will not inc.
concentration delivered to the client.
Limitations of masks
● difficulty in achieving a proper fit
● poor tolerance by clients - feeling hot or “smothered.”
FACE TENT
● can replace oxygen masks
● provide varying concentrations of oxygen
○ 28-100% concentration of oxygen at 8-12 L/min.
● providing humidification and oxygenation
● oxygen concentration cannot be controlled
● Frequently inspect client’s facial skin for dampness or
chafing, and dry and treat as needed.
○ client’s facial skin must be kept dry.
TRANSTRACHEAL CATHETER
● placed through surgically created tract in lower neck
directly into trachea.
● Once healed, client removes and cleans catheter 2-4x/day
● Oxygen applied to catheter at greater than 1 L/min should
be humidified
○ high flow rates (15 to 20 L/min) can be
administered
NONINVASIVE POSITIVE PRESSURE VENTILATION
mechanical assistance to maintain adequate breathing
● delivery of air or oxygen under pressure
Conditions requiring noninvasive ventilation include
● acute and chronic respiratory failure
● pulmonary edema
● COPD
● obstructive sleep apnea (OSA).
Sleep apnea
● breathing stops (apnea), individual’s carbon dioxide level
rises, breathing is stimulated, and then it resumes.
● sleep apnea, OSA = most common
○ frequent episodes of partial / complete upper
airway obstruction for 10 seconds during sleep.
○ Risk factors
■ male, obesity, and age > 40
○ lead to a number of health problems
■ Hypertension
■ fatigue
■ memory problems
■ cardiovascular disease
■ increased perioperative complications
mask fitted over the client’s nose during sleep
● provides air under pressure during inhalation and
exhalation → airway is kept open
● mask and pump system = continuous positive airway
pressure (CPAP).
 ○ variation = bilevel positive airway pressure
(BiPap)
■ pressure delivered during exhalation <
pressure delivered during inhalation.
○ significant issues w adherence to CPAP due to
discomfort or other barriers
■ provide client education and support
■ collaborate with respiratory therapist
3 major oxygen systems for home care:
1. Cylinders (“green tanks”)
(+)
● deliver all liter flows (1 to 15 L/min)
● oxygen evaporation does not occur during storage
(-)
● heavy and awkward to move
● supply company must be notified when a refill is needed,
● costly for the high-use client
2. Liquid oxygen
● have two parts
○ stationary container
○ portable unit w lightweight tank
● store oxygen at 9212°C (9350°F) in a smaller amount of
space than compressed gas.
(+)
● lighter in weight and cleaner in appearance
● not as difficult to operate.
(-)
● many are not able to handle it
● oxygen evaporation occurs when unit is not used
● low flows (1 to 4 L/min) can be used or freezing occurs
● portable unit - carried over shoulder weighs 8 to 10 lbs.
○ burden to the typical COPD client
○ wheeled cart used to carry unit but awkward
3. Oxygen concentrators
● manufacture oxygen from room air
● 1 L/min = deliver a concentration of about 95% oxygen
○ concentration drops when flow rate increases
● oxygen delivered by pulse dose or continuous flow.
○ based on breathing
○ O2 delivered each time client takes a breath
(+)
● attractive - furniture rather than medical equipment
● eliminate need for regular delivery of oxygen or refilling
● alleviate the client’s anxiety about running out of oxygen
● economical system
(-)
● s expensive
● lacks real portability (small units weigh 28 pounds)
● Noisy
● powered by electricity
● heat produced by concentrator motor is a problem for
those who live in trailers, small houses, or warm climates
● checked periodically with an oxygen analyzer
oxygen enricher
● uses plastic membrane that allows water vapor to pass
through with oxygen,
○ eliminating need for a humidifying device.
● filter out bacteria present in air.
● oxygen concentration of 40% at all flow rates
● quieter than concentrator
● less chance of combustion (gas is only 40% oxygen),
● nebulizer can be operated off the enricher because of the
high flow rate.
ARTIFICIAL AIRWAYS
maintain a patent air passage
● airway - so that air can flow to and from the lungs.
● common types of airways
○ Oropharyngeal
○ Nasopharyngeal
○ Endotracheal
○ Tracheostomy
OROPHARYNGEAL AND NASOPHARYNGEAL
AIRWAYS
keep upper air passages open when secretions or tongue obstruct
● sedated, semicomatose, altered level of consciousness
● easy to insert and have a low risk of complications. S
nasopharyngeal airway
● well lubricated w watersoluble gel prior to inserting.
oropharyngeal airway
● lubricated w water or saline,
● stimulate the gag reflex
○ clients w altered levels of consciousness - no
gag reflex
To insert the airway:
● semi-Fowler’s position.
● Apply clean gloves.
● Hold lubricated airway by outer flange, distal end pointing
up or curved upward.
● Open client’s mouth and insert airway along top of tongue.
● distal end of airway reaches soft palate at back of mouth
○ Rotate airway 180 degrees downward
○ slip it past the uvula into the oral pharynx.
● place client in a side-lying position / head turned to side
● oropharynx may be suctioned as needed
do’s and don'ts
● Do not tape airway in place
○ remove it when client begins to cough or gag.
● Provide mouth care at least every 2 to 4 hours
● remove airway every 8 hours
○ assess mouth and provide oral care
○ Reinsert airway immediately.
● Nasopharyngeal airways - tolerated better by alert clients
○ does not cause the client to gag.
○ inserted thru nares, terminating in oropharynx.
■ use largest nostril
■ use a water-soluble lubricant
■ insert w curve of tube toward mouth.
■ Advance tube gently, straight in
● provide frequent oral and nares care
○ reinserting airway in other naris every 8 hours
■ prevent necrosis of the mucosa.
ENDOTRACHEAL TUBES
clients w general anesthetics or emergency situations where
mechanical ventilation is required.
● inserted by an anesthesiologist, primary care provider,
certified registered nurse anesthetist (CRNA), or
respiratory therapist with specialized education.
● inserted through mouth or nose → trachea
○ Using a laryngoscope as a guide
○ tube terminates superior to bifurcation of trachea
into the bronchi.
■ may have an air-filled cuff to prevent
air leakage around it.
● passes thru epiglottis and glottis = client is unable to speak
TRACHEOSTOMY
opening into trachea through the neck.
● tube inserted thru opening and artificial airway is created.
performed using one of two techniques:
● traditional open surgical method
○ operating room
● percutaneous insertion.
○ bedside in a critical care unit
How to insert:
● inserted to extend through the stoma into the trachea
● Tubes - different sizes and may be plastic, silicone, or
metal, and cuffed, uncuffed, or fenestrated.
○ fenestrated - opening allows air to pass thru to
vocal cords → can communicate.
● tubes have an outer cannula - inserted into trachea and a
flange that rests against the neck.
○ allows tube to be secured in place w
tracheostomy tapes or twill ties, or Velcro collars
● All tubes also have an obturator
○ used to insert outer cannula and then removed.
● Some tubes have an inner cannula
○ inserted & locked in place inside outer cannula.
○ prevent tube obstruction by allowing regular
cleaning or replacement.
 ○ plastic inner cannulas - cleaned w full or
half-strength hydrogen peroxide + sterile water.
○ outer cannula of the tracheostomy tube remains
in place to maintain a patent airway
● Cuffed tracheostomy tubes
○ surrounded by an inflatable cuff = airtight seal
between the tube and the trachea.
○ prevents aspiration of oropharyngeal secretions
and air leakage b/n tube and the trachea.
○ used immediately after a tracheostomy
○ essential when ventilating client with mechanical
ventilator.
■ Children do not require cuffed tubes
■ tracheas are elastic enough to seal air
space around tube.
● Low-pressure cuffs
○ distribute low, even pressure against trachea
■ Dec. risk of tracheal tissue necrosis.
○ do not need to be deflated periodically to reduce
pressure on the tracheal wall.
● Foam cuffed tracheostomy tubes
○ do not require injected air
○ when the port is opened, ambient air enters
balloon = conforms to the client’s trachea
○ Air is removed fr cuff prior to insertion or removal
of the tube.
● Initially tracheostomy need to be suctioned and cleaned as
often as every 1 to 2 hours.
○ After initial inflammatory response subsides,
care may only need to be done 1-2x/day
● After stoma has healed, clean gloves can be used while
changing the dressing and tie tapes.
○ written tracheostomy care protocols = important
to reduce variations in practice
○ establishing an evidence-based approach for
performing tracheostomy care
tracheostomy = air is no longer heated, humidified, and filtered
● Humidity provided with a mist collar.
● Clients may use heat and moisture exchanger device.
○ Collect heat and moisture from client’s breath
during expiration and use it to warm and
humidify the next inspired breath.
● wear a stoma protector - 4×4 gauze held in place with a
cotton tie over the stoma or light scarf to filter air as it
enters the tracheostomy
SUCTIONING
aspiration of secretions via catheter connected to a suction machine
● upper airways (oropharynx and nasopharynx) are not
sterile but sterile technique is recommended
● Nasotracheal - closer access to trachea
○ requires sterile technique.
● catheters are flexible, made of plastic, may open tipped or
whistle tipped
○ whistle-tipped = less irritating
○ open tipped = more effective for removing thick
mucous plugs.
● Oral / Yankauer suction tube = suction oral cavity
nurse decides when suctioning is needed
● assessing client for signs of respiratory distress
● evidence of not coughing up & expectorating secretions
● Dyspnea, bubbling or rattling (adventitious) breath sounds,
poor skin color, restlessness, tachycardia, or dec. oxygen
saturation (SpO2)
irritates mucous membranes
● increase secretions if performed too frequently
● Cause client’s oxygen saturation to drop further
● Bronchospasm
● head injury = intracranial pressure inc.
performed to:
● obtain secretions for diagnostic purposes
● prevent infection from accumulated secretions
nurse providing care in home setting (suctioning):
● Teach clients & families - infection control = hand washing
● Airway suctioning - clean procedure.
● catheter/Yankauer - flushed by suctioning boiled or distilled
water to rinse away mucus
○ suction air through device to dry internal surface
○ discourage bacterial growth
● outer surface wiped with alcohol or hydrogen peroxide.
● Yankauer suction tubes - cleaned, boiled, and reused.
Following endotracheal intubation or a tracheostomy
● trachea and surrounding respiratory tissues are irritated
and react by producing excessive secretions.
● Sterile suctioning - remove secretions fr trachea and
bronchi to maintain a patent airway.
○ frequency of suctioning depends on client’s
health and how recently intubation was done.
Suctioning several complications:
● Hypoxemia
● trauma to the airway
● healthcare-associated infection
● cardiac dysrhythmia
techniques are used to minimize complications:
● Suction only as needed.
○ suctioning client w an ETT or tracheostomy is
uncomfortable
○ hazardous because of hypoxemia
● Sterile technique
○ Infection of LRT @ tracheal suctioning.
● No saline instillation
○ thought to facilitate removal of secretions and
improve client’s oxygenation status.
■ adverse effects
■ hypoxemia and inc. risk of pneumonia
● Hyperinflation
○ giving client breaths > tidal volume on ventilator
thru ventilator circuit / manual resuscitation bag.
○ 3-5 breaths are delivered before and after each
pass of suction catheter.
● Hyperventilation
○ inc. number of breaths client is receiving
○ ventilator or using a manual resuscitation bag.
Both hyperinflation and hyperventilation help:
● prevent suction hypoxemia
● injury as a result of overdistention of the lungs.
● Hyperoxygenation
○ w manual resuscitation bag or thru ventilator
○ increasing the oxygen flow (to 100%) before
suctioning and between suction attempts.
■ avoid suction-related hypoxemia.
● Safe catheter size.
○ prevent hypoxia -tracheostomy & endotracheal
suctioning are administered
○ should not exceed one-half internal diameter of
artificial airway.
(-) open suction
● nurse wear PPE to avoid exposure to client’s sputum and
potential cost of one-time catheter use
● client disconnected from the ventilator.
(+) closed suction
● catheter attaches to the ventilator tubing
● client does not need to be disconnected from the ventilator.
● nurse is not exposed to any secretions - suction catheter is
enclosed in a plastic sheath.
● catheter can be reused
home care setting suctioning w tracheostomy or endotracheal tube:
● client should be encouraged to clear airway by coughing.
● Clean gloves
● instruct caregiver
○ how to determine need for suctioning
○ correct process and rationale underlying practice
● importance of adequate hydration - thins secretions = aid
in the removal of secretions by coughing or suctioning.
home care setting requiring tracheostomy care:
● tracheostomies older than 1 month = clean technique
● importance of good hand hygiene
● Tap water may be used for rinsing inner cannula.
● Periodically QSEN reassess caregiver knowledge and
tracheostomy care technique
● Inform s/sx indicating infection of stoma site / lower airway
 CHEST TUBES AND DRAINAGE SYSTEMS
thin, double-layered pleural membrane is disrupted by lung disease,
surgery, or trauma
● negative pressure b/n pleural layers may be lost.
● lung collapses → no longer drawn outward as diaphragm
and intercostal muscles contract during inhalation.
○ air collects in the pleural space = pneumothorax
○ hemothorax = accumulation of blood in pleural
space
○ pleural effusion = excess fluid in pleural space
air, blood, or fluid in pleural space = pressure on lung tissue and
interferes with lung expansion.
● Chest tubes inserted into the pleural cavity
○ restore negative pressure
○ drain collected fluid or blood
● Bc air rises
○ chest tubes for pneumothorax are placed in
upper anterior thorax
○ chest tubes used to drain blood and fluid are
placed in the lower lateral chest wall.
● When inserted = connected to sealed drainage system or
a one-way valve
○ allows air and fluid to be removed fr chest cavity
○ prevents air from entering from the outside
systems typically have a suction control chamber, a water-seal
chamber, and a closed collection chamber, for drainage
● water-seal system
○ when client inhales, water prevents air from
entering system from the atmosphere.
○ During exhalation air can exit the chest cavity,
bubbling up through the water.
○ Suction can be added to facilitate removing air
and secretions from the chest cavity.
● drainage system
○ always kept below the level of the client’s chest
○ prevent fluid and drainage from being drawn
back into the chest cavity.
● Heimlich valve - used for ambulatory clients.
○ one-way flutter valve
○ allows air to escape fr chest cavity, but prevents
air from reentering.
○ No collection chamber
● Pneumostat - one-way valve and
○ Has a small built-in collection chamber
○ for clients with a pneumothorax
■ have small amounts of fluid.
Nursing responsibilities regarding drainage systems
● Monitor & maintain patency & integrity of drainage system.
● Assess vital signs, oxygen saturation, cardiovascular
status, and respiratory status.
○ Check breath sounds bilaterally
○ check for symmetry of breath sounds.
● Observe dressing site at least every 4 hours.
○ Inspect dressing for excessive and abnormal
drainage
■ bleeding or foul-smelling discharge.
○ Palpate around dressing site,
○ listen for a crackling sound = subcutaneous
emphysema.
■ air in the subcutaneous tissues
■ result fr poor seal at chest tube
insertion site.
● Determine level of discomfort w/w/o activity and medicate
for pain if indicated.
● deep-breathing exercises and coughing every 2 hours
○ Have client sit upright to perform exercises
○ splint chest around tube insertion site w pillow or
with a hand to minimize discomfort.
● Reposition the client every 2 hours.
○ When lying on the affected side, place rolled
towels beside the tubing.
■ prevent occlusion of chest tube by
client’s weight.
○ promote drainage, prevent complications, and
provide comfort.
● Assist w range-of-motion exercises for affected shoulder
○ three times per day to maintain joint mobility.
● Ensure that connections are securely taped and chest tube
is secured to client’s chest wall.
● Keep collection device below client’s chest level.
● Frequently check water-seal and suction control chambers.
○ water can evaporate
■ may need to add to the chamber.
○ Should fluctuate with respiratory effort.
● Assess drainage in tubing and collection chamber.
○ drainage - measured at regularly
○ date & time at fluid level on drainage chamber.
● Avoid aggressive chest tube manipulation
○ Milking - requires a healthcare provider’s order.
○ Stripping - no longer considered acceptable
● Avoid clamping the chest tube
○ inc risk of a tension pneumothorax.
○ If tube is disconnected, submerge end in 2.5 cm
of sterile saline or water to maintain the seal.
○ If chest tube is pulled out, wound immediately
covered with a dry sterile dressing.
○ If you can hear air leaking out of the site, ensure
that the dressing is not occlusive.
■ If air cannot escape = tension
pneumothorax.
■ occurs when there is buildup of air in
pleural space and it cannot escape,
● increased pressure
● compromise cardiovascular
function
● When transporting and ambulating the client:
○ Keep water-seal unit below chest level & upright.
○ Disconnect drainage system fr suction apparatus
before moving client
■ make sure air vent is open.
● Removal of a chest tube is a brief but quite painful
○ Medicate client before the removal.
○ Remove dressing around the tube and prepare
dressing that will cover the insertion site.
■ occlusive dressing if no purse-string
suture around insertion site
■ prevent air from entering the chest.
EVALUATING
● Collect data to evaluate the effectiveness of interventions.
If outcome “Respirations unlabored and rate is within expected
range” is not met, questions considered:
● client’s perception of the problem?
● client complaining of shortness of breath or difficulty
breathing?
● taking medications or performing treatments - percussion,
vibration, and postural drainage as prescribed?
● client been exposed to an upper respiratory infection that
is affecting breathing?
● Do other factors need to be considered, such as the
client’s psychologic stress level?
if outcome “Able to complete ADLs without fatigue” is not met:
● other factors affecting client’s ability to complete ADLs?
● Is the client getting adequate sleep? If not, what is
interfering with the client’s rest?
● assistive devices (e.g., a shower chair, clothing that is easy
to put on) that could help the client achieve this goal?
● Does client need help with housework and other ADLs?
● Client’s diet adequate to meet nutritional needs?
URINARY AND FECAL ELIMINATION (STUDY
GUIDE)
COLOR OF URINE
Color Common causes
Clear; colorless ● Large amount of liquids
● Conditions
○ diabetes insipidus -
impaired tubular
reabsorption
 ○ diabetes mellitus INTERVENTIONS
● Diuretics (particularly if overused)
● Maintaining and Promoting urinary Elimination
● Liver disorders (e.g., acute
viral hepatitis, cirrhosis) ● Preventing Urinary Tract Infections
● Managing Urinary Incontinence
Bright, neon yellow ● Vitamin supplements ● Managing urinary Retention
● Urinary Catheterization
Cloudy ● Urine left standing - phosphates
precipitate out FACTORS AFFECTING DEFECATION
● Pyuria (pus in the urine) ● Age/Developmental Factors
● UTI, bacteriuria
● Diet
● Epithelial cells
● Blood ● Fluid Intake and Output
● Leukocytes (white blood cells) ● Activity and Exercise
● Kidney stones ● Psychological Factors
● Defecation Habits
Green ● Pseudomonas infection ● Medications
● Bile pigments ● Diagnostic Procedures
● Anesthesia and Surgery
Dark yellow, gold ● Low fluid intake ● Pathologic Conditions
● Dehydration (concentrated urine) ● Pain
● Inability of kidneys to dilute urine
● Bile COMMON BOWEL ELIMINATION PROBLEMS

Pink, red ● Hematuria - blood in urine ● Constipation

○ kidney or bladder infection, ● Bowel incontinence
cancer ● Flatulence
● Some laxatives ● Diarrhea
● Some foods
NURSING MANAGEMENT FOR BOWEL ELIMINATION
Orange, red brown ● Some medications PROBLEMS
○ rifampin, phenazopyridine,
warfarin, doxorubicin ● NHH, PE
● Some foods ○ abdomen, rectum, and anus
● Some food coloring ● Inspecting the feces
● Dehydration ● data obtained from relevant diagnostic exam
● Nursing problems:
Blue, green ● Some medications ○ Bowel incontinence
○ amitriptyline, indomethacin ○ Constipation
● Some foods (e.g., asparagus)
○ Risk for Constipation
● Some food dyes
○ Perceived Constipation
Smoky, hazy ● Hemoglobin (remnants of RBCs) ○ Diarrhea
● Chyle ○ Dysfunctional Gastrointestinal Motility
○ prod of digestion emptied
into venous system NURSING SKILLS IN CARING FOR BOWEL
● Prostatic fluid ELIMINATION PROBLEMS
● Yeast infection
● Giving and removing bedpan
Yellow, brown ● Bile ● Administering enema

URINARY ELIMINATION
Dark brown, black ● Methylene blue
● Typhus infection ● Only when a problem arises do most individuals become
● Some medications (e.g., iron) aware of their urinary habits and any associated
● Some foods and food dyes symptoms.
● Hematuria (blood in urine)
● An individual’s urinary habits depend on sociaL, culture,
● Liver disorders
○ light stools and jaundice personal habits, and physical abilities.
● Personal habits regarding urination are affected by the
○ social politeness of leaving to urinate
NURSING MANAGEMENT
○ the availability of a private clean facility
prevent further complications ○ and initial bladder training
● impaired kidney functions ● Urinary elimination is essential to health, and voiding
● changes in fluid volume and electrolytes can be postponed for only so long before the urge
● skin breakdown normally becomes too great to control.
● changes in quality of life
PHYSIOLOGY OF URINARY ELIMINATION
ASSESSMENT
● NHH, PE
KIDNEYS
● Urine volume and color ● The paired kidneys are situated on either side of the
spinal column, behind the peritoneal cavity.
DIAGNOSIS
● The right kidney is slightly lower than the left due to the
● Diagnostic tests r/t urinary elimination position of the liver.
○ Urinalysis ● They are the primary regulators of fluid and acid–base
○ Blood urea nitrogen (BUN) balance in the body.
○ Creatinine clearance ● The functional units of the kidneys, the nephrons, filter the
● Ndx blood and remove metabolic wastes.
○ impaired urinary elimination ● In the average adult 1200 mL of blood, or about 21% of
○ readiness for enhanced urinary elimination the cardiac output, passes through the kidneys every
● may become the etiology for other problems minute.
○ Ex: risk for infection ● Each kidney contains approximately 1 million
nephrons.

URETERS
● Once the urine is formed in the kidneys, it moves through
the collecting ducts into the calyces of the renal pelvis and
from there into the ureters.
● In adults the ureters are from 25 to 30 cm (10 to 12 in.)
long and about 1.25 cm (0.5 in.) in diameter.
● The upper end of each ureter is funnel shaped as it
enters the kidney.
● The lower ends of the ureters enter the bladder at the
posterior corners of the floor of the bladder.
● At the junction between the ureter and the bladder, a
flaplike fold of mucous membrane acts as a valve to
prevent reflux (backflow) of urine up the ureters.
BLADDER
● The urinary bladder is a hollow, muscular organ that
serves as a reservoir for urine and as the organ of
excretion.
○ When empty, it lies behind the symphysis pubis.
● In men, the bladder lies in front of the rectum and
above the prostate gland
● In women it lies in front of the uterus and vagina .
● The wall of the bladder is made up of smooth muscle
layers called the detrusor muscle.
○ The detrusor muscle allows the bladder to
expand as it fills with urine, and to contract to
release urine to the outside of the body during
voiding.
● The trigone at the base of the bladder is a triangular area
marked by the ureter openings at the posterior corners and
the opening of the urethra at the anterior inferior corner
● The bladder is capable of considerable distention
because of rugae (folds) in the mucous membrane lining
and because of the elasticity of its walls.
○ When full, the dome of the bladder may extend
above the symphysis pubis; in extreme
situations, it may extend as high as the
umbilicus.
● Normal bladder capacity is between 300 and 600 mL of
urine.
URETHRA
● The urethra extends from the bladder to the urinary meatus
(opening).
● The male urethra is approximately 20 cm (8 in.) long and
serves as a passageway for semen as well as urine.
○ The meatus is located at the distal end of the
penis.
● In the adult woman, the urethra lies directly behind the
symphysis pubis, anterior to the vagina, and is between 3
and 4 cm (1.5 in.) long.
○ The urethra serves only as a passageway for
the elimination of urine.
○ The urinary meatus is located between the
labia minora, in front of the vagina and below the
clitoris.
● In both men and women, the urethra has a mucous
membrane lining that is continuous with the bladder and
the ureters.
○ Thus, an infection of the urethra can extend
through the urinary tract to the kidneys.
○ Women are particularly prone to urinary tract
infections (UTIs) because of their short urethra
and the proximity of the urinary meatus to the
vagina and anus.
PELVIC FLOOR
● The vagina, urethra, and rectum pass through the pelvic
floor, which consists of sheets of muscles and ligaments
that provide support to the viscera of the pelvis.
● These muscles and ligaments extend from the
symphysis pubis to the coccyx forming a sling.
● Specific sphincter muscles contribute to the continence
mechanism.
○ The internal sphincter muscle situated in the
proximal urethra and the bladder neck is
composed of smooth muscle under involuntary
control.
■ It provides active tension designed
to close the urethral lumen.
○ The external sphincter muscle is composed of
skeletal muscle under voluntary control,
allowing the individual to choose when urine
is eliminated.
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.
○ The stretch receptors transmit impulses to the
spinal cord, specifically to the voiding reflex
center located at the level of the second to fourth
sacral vertebrae, causing the internal
sphincter to relax and stimulating the urge to
void.
● If the time and place are appropriate for urination → the
conscious portion of the brain relaxes the external
urethral sphincter muscle and urination takes place
● If the time and place are inappropriate → the micturition
reflex usually subsides until the bladder becomes more
filled and the reflex is stimulated again.
● Voluntary control of urination is possible
○ only if the nerves supplying the bladder and
urethra, the neural tracts of the cord and brain,
and the motor area of the cerebrum are all
intact.
○ Injury to any of these parts of the nervous
system → results in intermittent involuntary
emptying of the bladder.
○ Older adults whose cognition is impaired may
not be aware of the need to urinate or able to
respond to this urge by seeking toilet facilities.
FACTORS AFFECTING VOIDING
DEVELOPMENTAL ACTORS
INFANTS
● Urine output varies according to fluid intake
○ but gradually increases to 250 to 500 mL a day
during the first year.
 ○ An infant may urinate as often as 20 times a
day.
○ The urine of the neonate is colorless and
odorless and has a specific gravity of 1.008.
○ Because newborns and infants have immature
kidneys, they are unable to concentrate urine
very effectively
○ Infants are born without urinary control
■ Most will develop this between the
ages of 2 and 5 years
■ Control during the daytime normally
precedes night-time control
PRESCHOOLERS
● The preschooler is able to take responsibility for
independent toileting.
● Children often forget to wash their hands or flush the toilet
and need instruction in wiping themselves
● Girls should be taught to wipe from front to back to prevent
contamination of the urinary tract by feces.
PRESCHOOLERS
● The school-age child’s elimination system reaches
maturity during this period.
● The kidneys double in size between ages 5 and 10
years.
● During this period, the child urinates six to eight times a
day.
● Enuresis
○ the involuntary passing of urine when control
should be established (about 5 years of age),
○ can be a problem for some school-age children.
● About 10% of all 6-year-olds experience difficulty
controlling the bladder
● Nocturnal enuresis
○ Bed-wetting
○ The involuntary passing of urine during sleep
○ occurs because the client fails to awaken when
the bladder empties.
○ should not be considered a problem until
after the age of 6
○ incidence of nocturnal enuresis declines as the
child matures.
● Secondary enuresis
○ appears after the child has achieved dryness for
a period of 6 consecutive months
○ often related to another problem such as
■ Constipation
■ Stress
■ Illness
OLDER ADULTS
● The excretory function of the kidney diminishes with age
● Blood flow can be reduced by arteriosclerosis, impairing
renal function
● With age, the number of functioning nephrons decreases
to some degree → impairs the kidney’s filtering abilities
● Conditions that alter normal fluid intake and output such
as having influenza or having surgery can compromise the
kidney’s ability to
○ Filter
○ maintain acid–base balance
○ maintain electrolyte balance in older adults.
● The decrease in kidney function also places the older adult
at higher risk for toxicity from medications if excretion
rates are longer
● The more noticeable changes with age are those related
to the bladder.
● Complaints of urinary urgency and urinary frequency are
common.
○ men
■ often due to an enlarged prostate
gland
○ Women
■ due to weakened muscles supporting
the bladder or weakness of the
urethral sphincter.
● The capacity of the bladder and its ability to completely
empty diminish with age.
○ This explains the need for older adults to arise
during the night to void (nocturnal frequency)
and the retention of residual urine →
predisposing the older adult to bladder infections
PSYCHOLOGICAL FACTORS
● a set of conditions helps stimulate the micturition reflex.
○ Privacy
○ normal position
○ sufficient time
○ running water. (occasionally)
● Circumstances that do not allow for the client’s
accustomed conditions → produce anxiety and muscle
tension → t unable to relax abdominal and perineal
muscles and the external urethral sphincter → voiding is
inhibited.
○ People also may voluntarily suppress urination
FLUID AND FOOD INTAKE
● When the amount of fluid intake increases, the output
normally increases
● Alcohol
○ increase fluid output by inhibiting the production
of antidiuretic hormone
● Fluids that contain caffeine (e.g., coffee, tea, and cola
drinks)
○ increase urine production.
● Food and fluids high in sodium
○ cause fluid retention because water is retained
to maintain the normal concentration of
electrolytes
● Some foods and fluids can change the color of urine
○ beets can cause urine to appear red
○ foods containing carotene can cause the urine
to appear yellower than usual
MEDICATIONS
● medications affecting the autonomic nervous system
interfere with the normal urination process
○ may cause retention
● Diuretics (e.g., chlorothiazide and furosemide)
○ increase urine formation by preventing the
reabsorption of water and electrolytes from the
tubules of the kidney into the bloodstream.
● Some medications may alter the color of the urine
 ○ or may be associated with diseases such as
MUSCLE TONE
diabetes mellitus, diabetes insipidus, and
● Good muscle tone chronic nephritis
○ maintain the stretch and contractility of the ● Polyuria can cause excessive fluid loss, leading to intense
detrusor muscle so the bladder can fill thirst, dehydration, and weight loss.
adequately and empty completely
● Clients who require a retention catheter for a long period OLIGURIA AND ANURIA
○ may have poor bladder muscle tone because ● The terms oliguria and anuria are used to describe
continuous drainage of urine prevents the decreased urinary output.
bladder from filling and emptying normally. ● Oliguria
● Pelvic muscle tone also contributes to the ability to store ○ low urine output
and empty urine. ○ usually less than 500 mL a day or 30 mL an
hour for an adult.
PATHOLOGICAL CONDITIONS
○ Although oliguria may occur because of
● Diseases of the kidneys may affect the ability of the abnormal fluid losses or a lack of fluid intake, it
nephrons to produce urine often indicates
○ Abnormal amounts of protein or blood cells may ■ impaired blood flow to the kidneys or
be present in the urine ■ impending renal failure and should be
○ or the kidneys may virtually stop producing urine promptly reported to the primary care
altogether, a condition known as renal failure provider.
● Heart and circulatory disorders such as heart failure, ● Anuria
shock, or hypertension ○ refers to a lack of urine production
○ affect blood flow to the kidneys, ● mechanisms of filtering the blood are necessary to
○ interfere with urine production prevent illness and death.
● If abnormal amounts of fluid are lost through another ○ renal dialysis
route (e.g., vomiting or high fever) ■ fluids and molecules pass through a
○ the kidneys retain water and urinary output falls semipermeable membrane according
● urinary stone (calculus) to the rules of osmosis
○ may obstruct a ureter → blocking urine flow from ■ two most common methods of dialysis
the kidney to the bladder ● Hemodialysis
● Hypertrophy of the prostate gland ○ blood flows
○ common condition affecting older men through vascular
○ may obstruct the urethra → impairing urination catheters →
and bladder emptying passes by the
dialysis solution in
SURGICAL AND DIAGNOSTIC PROCEDURES
an external
● The urethra may swell following a cystoscopy machine → then
● surgical procedures on any part of the urinary tract may returns to the
result in some postoperative bleeding → the urine may be client.
red or pink tinged for a time ● peritoneal dialysis
● Spinal anesthetics can affect the passage of urine ○ The dialysis
○ because they decrease the client’s awareness of solution is instilled
the need to void. into the
● Surgery on structures adjacent to the urinary tract (e.g., the abdominal cavity
uterus) through a catheter
○ affect voiding because of swelling in the lower → allowed to rest
abdomen there while the
fluid and
ALTERED URINE PRODUCTION molecules
● most people void about five to six times a day exchange → then
● People usually void when they first awaken in the morning, removed through
before they go to bed, and around mealtimes the catheter.
■ Both hemodialysis and peritoneal
dialysis must be performed at
frequent intervals until the client’s
kidneys can resume the filtering
function

ALTERED URINARY ELIMINATION

● Frequency, nocturia, urgency, and dysuria often are
manifestations of underlying conditions such as a UTI.
● Enuresis, incontinence, retention, and neurogenic bladder
may be either a manifestation or the primary problem
affecting urinary elimination

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

FREQUENCY AND NOCTURIA
● Urinary frequency
○ voiding at frequent intervals, more than four to
six times per day
○ increased intake of fluid causes some increase
in the frequency of voiding
○ Conditions such as UTI, stress, and pregnancy
can cause frequent voiding of small quantities
(50 to 100 mL) of urine
○ Total fluid intake and output may be normal.
● Nocturia
○ voiding two or more times at night
○ it is usually expressed in terms of the number of
times the person gets out of bed to void,
■ for example: “nocturia × 4.”
URGENCY
● 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.
● Urgency 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
● 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.
● The burning may be described as severe, like a hot poker,
or more subdued, like a sunburn.
● Often, urinary hesitancy (a delay and difficulty in initiating
voiding) is associated with dysuria.
ENURESIS
● involuntary urination in children beyond the age when
voluntary bladder control is normally acquired, usually 4 or
5 years of age
● Nocturnal enuresis
○ irregular in occurrence and affects boys more
often than girls.
● Diurnal (daytime) enuresis
○ may be persistent and pathologic in origin.
○ affects women and girls more frequently.
URINARY INCONTINENCE
● involuntary leakage of urine or loss of bladder control
● It a health symptom, not a disease
● only normal in infants
STRESS URINARY INCONTINENCE
● occurs because of weak pelvic floor muscles and/or
urethral hypermobility → urine leakage with such activities
as laughing, coughing, sneezing, or any body movement
that puts pressure on the bladder
● Facts that make women more likely to experience SUI
○ shorter urethras
○ trauma to the pelvic floor associated with
childbirth
○ changes related to menopause.
● For men, SUI may result after a prostatectomy
● SUI is not related to emotional stress
○ but is “caused by increased pressure or
‘stress’ on the bladder as well as anatomical
changes to the urethra, and pelvic floor muscle
weakness”
URGE URINARY INCONTINENCE
● urgent need to void and the inability to stop micturition
(passage of urine)
● urine leakage can range from a few drops to soaking of
undergarments
● Urge incontinence is a major symptom of an overactive
bladder
MIXED URINARY INCONTINENCE
● diagnosed when symptoms of both stress UI and
urgency UI are present
● very common among middle-age and older women
● Treatment is usually based on which type of UI is the most
bothersome to the client
OVERFLOW INCONTINENCE
● “continuous involuntary leakage or dribbling of urine that
occurs with incomplete bladder emptying”
● can be seen in
○ Men with an enlarged prostate
○ clients with a neurologic disorder (e.g., multiple
sclerosis, Parkinson’s disease, spinal cord
injury)
● impaired neurological function can interfere with the normal
mechanisms of urine elimination → resulting in a
neurogenic bladder
○ a client with a neurogenic bladder does not
perceive bladder fullness → unable to control
the urinary sphincters
● The bladder may become flaccid and distended or spastic,
with frequent involuntary urination
URINARY RETENTION
● When emptying of the bladder is impaired, urine
accumulates and the bladder becomes overdistended
→ urinary retention
● Overdistention of the bladder causes poor contractility of
the detrusor muscle
○ further impairing urination
● Common causes of urinary retention
○ prostatic hypertrophy (enlargement)
○ Surgery
○ some medications
● Acute urinary retention
○ most common complication in the first 2 to 4
hours postoperatively (Palese, Buchini, Deroma,
& Barbone, 2010)
● Causes of chronic urinary retention
○ Paraplegia
○ Quadriplegia
○ multiple sclerosis
○ urethral or perineal trauma
● Clients with urinary retention may experience overflow
incontinence
○ eliminating 25 to 50 mL of urine at frequent
intervals.
○ the bladder is firm and distended on palpation
and may be displaced to one side of the midline.
NURSING MANAGEMENT
ASSESSMENT
NURSING HISTORY
● The nurse determines the
○ Client’s normal voiding pattern and frequency
○ appearance of the urine and any recent changes
○ any past or current problems with urination
○ the presence of an ostomy
 ○ factors influencing the elimination pattern. ● Place the container under the urine collection bag so that
PHYSICAL ASSESSMENT the spout of the bag is above the container but not
touching it
● Complete physical assessment of the urinary tract usually ● The calibrated container is not sterile, but the inside of the
includes percussion of the kidneys to detect areas of collection bag is sterile
tenderness. ● Open the spout and permit the urine to flow into the
● Palpation and percussion of the bladder are also container
performed, if the client’s history or current problems ● Close spout, then proceed as described in previous list.
indicate a need for it
○ the urethral meatus of both male and female
clients is inspected for swelling, discharge, and
inflammation.
● problems with urination can affect the elimination of wastes
from the body
○ It is important for the nurse to assess the skin for
color, texture, and tissue turgor as well as the
presence of edema.
● If incontinence, dribbling, or dysuria is noted in the history,
○ the skin of the perineum should be inspected for
irritation because contact with urine can
excoriate the skin
ASSESSING URINE

● Normal urine consists of 96% water and 4% solutes.

○ Organic solutes
■ Urea
■ Ammonia MEASURING RESIDUAL URINE
■ Creatinine ● Postvoid residual (PVR)
■ uric acid. ○ urine remaining in the bladder following voiding
■ Urea ○ normally 50 to 100 mL
● the chief organic solute ○ a bladder outlet obstruction (e.g., enlargement of
○ Inorganic solutes the prostate gland) or loss of bladder muscle
■ Sodium tone may interfere with complete emptying of the
■ Chloride bladder
■ Potassium ○ Manifestations of urine retention
■ Sulfate ■ frequent voiding of small amounts
■ Magnesium (e.g., less than 100 mL in an adult)
■ Phosphorus ■ urinary stasis
■ Sodium chloride ■ UTI
● most abundant inorganic ○ PVR is measured to
salt ■ assess the amount of retained urine
● Variations in color can occur after voiding
MEASURING URINARY OUTPUT ■ determine the need for interventions
● Normally, the kidneys produce urine at a rate of (e.g., medications to promote detrusor
approximately 60 mL/h or about 1,500 mL/day. muscle contraction).
● Urine output is affected by many factors ○ The amount of urine voided and the amount
○ fluid intake obtained by catheterization or bladder scan are
○ body fluid losses through other routes measured and recorded
■ Perspiration ○ An indwelling catheter may be inserted if the
■ Breathing PVR exceeds a specified amount.
■ Diarrhea DIAGNOSTIC TESTS
■ cardiovascular and renal status
● Urine outputs below 30 mL/h may indicate low blood ● Blood levels of two metabolically produced substances,
volume or kidney malfunction and must be reported. urea and creatinine, are routinely used to evaluate renal
steps: function
● Wear clean gloves to prevent contact with microorganisms ● The kidneys through filtration and tubular secretion
or blood in urine. normally eliminate both urea and creatinine
● Ask the client to void in a clean urinal, bedpan, commode, ● Urea, the end product of protein metabolism, is measured
or toilet collection device (“hat”) as blood urea nitrogen (BUN).
● Instruct the client to keep urine separate from feces and to ● Creatinine is produced in relatively constant quantities by
avoid putting toilet paper in the urine collection container. the muscles
● Pour the voided urine into a calibrated container. ● The creatinine clearance test uses 24-hour urine and
● Hold the container at eye level, read the amount in the serum creatinine levels to determine
container. Containers usually have a measuring scale on ○ glomerular filtration rate, a sensitive indicator
the inside. of renal function
● Record the amount on the fluid intake and output sheet,
which may be at the bedside or in the bathroom DIAGNOSIS
● Rinse the urine collection and measuring containers with ● Impaired Urinary Elimination
cool water and store appropriately ○ dysfunction in urine elimination
● Remove gloves and perform hand hygiene ● Readiness for Enhanced Urinary Elimination
● Calculate and document the total output at the end of each ○ a pattern of urinary functions for meeting
shift and at the end of 24 h on the client’s chart. eliminatory needs, which can be strengthened.
measuring urine from a client who has a urinary catheter steps: ● It is suggested that a more specific diagnostic label be
● Apply clean gloves used when possible
● Take the calibrated container to the bedside ○ Functional Urinary Incontinence
○ Overflow Urinary Incontinence
 ○ Reflex Urinary Incontinence
○ Stress Urinary Incontinence
○ Urge Urinary Incontinence
○ Risk for Urge Urinary Incontinence
○ Urinary Retention
Problems of urinary elimination also may become the etiology for
other problems experienced by the client. Examples:
● Risk for Infection
○ if the client has urinary retention or undergoes
an invasive procedure such as catheterization or
cystoscopic examination
● Situational Low Self-Esteem or Social Isolation
○ if the client is incontinent
○ incontinence can be physically and emotionally
distressing to clients because it is considered
socially unacceptable
○ Often the client is embarrassed about dribbling
or having an accident and may restrict normal
activities for this reason.
● Risk for Impaired Skin Integrity
○ if the client is incontinent
○ Prolonged skin dampness leads to dermatitis
(inflammation of the skin) and subsequent
formation of dermal ulcers
● Toileting Self-Care Deficit if the client has functional
incontinence.
● Risk for Deficient Fluid Volume or Excess Fluid Volume
○ if the client has impaired urinary function
associated with a disease process
● Disturbed Body Image if the client has a urinary diversion
ostomy
● Deficient Knowledge if the client requires self-care skills
to manage (e.g., a new urinary diversion ostomy)
● Risk for Caregiver Role Strain if the client is incontinent
and being cared for by a family member for extended
periods
● Risk for Social Isolation if the client is incontinent.
PLANNING
● The goals established will vary according to the diagnosis
and defining characteristics.
● Examples of overall goals for clients with urinary
elimination problems may include the following:
○ Maintain or restore a normal voiding pattern.
○ Regain normal urine output
○ Prevent associated risks such as infection, skin
breakdown, fluid and electrolyte imbalance, and
lowered self-esteem
○ Perform toileting activities independently with or
without assistive devices
○ Contain urine with the appropriate device,
catheter, ostomy appliance, or absorbent
product.
PLANNING FOR HOME CARE
● To provide for continuity of care, the nurse needs to
consider the client’s needs for teaching and assistance
with care in the home
● Discharge planning includes assessment of the client and
family’s resources and abilities for self-care, available
financial resources, and the need for referrals and home
health services
IMPLEMENTING
MAINTAINING NORMAL URINARY ELIMINATION
● Promoting Fluid Intake
○ Increasing fluid intake increases urine
production, which in turn stimulates the
micturition reflex
○ A normal daily intake averaging 1,500 mL of
measurable fluids is adequate for most adult
clients
○ Many clients have increased fluid requirements,
necessitating a higher daily fluid intake.
■ clients who are perspiring excessively
(have diaphoresis)
■ Clients’ experiencing abnormal fluid
losses through vomiting, gastric
suction, diarrhea, or wound drainage
require fluid to replace these losses in
addition to their normal daily intake
requirements
○ Clients who are at risk for UTI or urinary calculi
(stones) should consume 2,000 to 3,000 mL of
fluid daily.
○ Dilute urine and frequent urination reduce the
risk of UTI as well as stone formation.
○ Increased fluid intake may be contraindicated for
some clients such as people with kidney failure
or heart failure.
■ For these clients, a fluid restriction
may be necessary to prevent fluid
overload and edema.
● 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
● Assisting with Toileting
○ Clients who are weakened by a disease process
or impaired physically may require assistance
with toileting
○ The nurse should assist these clients to the
bathroom and remain with them if they are at risk
for falling
■ The bathroom should contain an
easily accessible call signal to
summon help if needed
■ Clients also need to be encouraged to
use handrails placed near the toilet.
○ For clients unable to use bathroom facilities, the
nurse provides urinary equipment close to the
bedside (e.g., urinal, bedpan, commode) and
provides the necessary assistance to use them.
PREVENTING URINARY TRACT INFECTIONS
● The rate of UTI is greater in women than men because of
the short urethra and its proximity to the anal and vaginal
areas
● Most UTIs are caused by bacteria common to the intestinal
environment (e.g., Escherichia coli)
● For women who have experienced a UTI, nurses need to
provide instructions about ways to prevent a recurrence
● Guidelines
○ Drink eight 8-ounce glasses of water per day to
flush bacteria out of the urinary system
○ Practice frequent voiding (every 2 to 4 hours) to
flush bacteria out of the urethra and prevent
organisms from ascending into the bladder. Void
immediately after intercourse
○ Avoid use of harsh soaps, bubble bath, powder,
or sprays in the perineal area. These substances
can be irritating to the urethra and encourage
inflammation and bacterial infection
 ○ Avoid tight-fitting pants or other clothing that
creates irritation to the urethra and prevents
ventilation of the perineal area
○ Wear cotton rather than nylon underclothes.
Accumulation of perineal moisture facilitates
bacterial growth. Cotton enhances ventilation of
the perineal area
○ Girls and women should always wipe the
perineal area from front to back following
urination or defecation in order to prevent
introduction of gastrointestinal bacteria into the
urethra
○ If recurrent urinary infections are a problem,
take showers rather than baths. Bacteria present
in bath water can readily enter the urethra.
MANAGING URINARY INCONTINENCE
● It is important to remember that UI is not a normal part of
aging and often is treatable
● The preliminary assessment and identification of the
symptoms of UI are truly within the scope of nursing
practice
● Older adults who are incontinent while in their home or
who manage to contain or conceal their incontinence from
others do not consider themselves incontinent.
○ Therefore, if asked if they are incontinent, they
may deny it
○ However, asking if they lose urine when they
cough, sneeze, or laugh or if they need to use
some type of incontinence product may provide
more accurate information (Keyock & Newman,
2011).
● Independent nursing interventions for clients with UI
include
○ (a) a behavior-oriented continence training
program that may consist of bladder retraining,
habit training, and pelvic floor muscle exercises;
○ (b) meticulous skin care; and
○ (c) for males, application of an external drainage
device (condom-type catheter device)
● Continence (Bladder) Retraining requires the
involvement of the nurse, the client, and support people
○ Education of the client and support people
○ Bladder retraining
■ requires that the client postpone
voiding, resist or inhibit the sensation
of urgency, and void according to a
timetable rather than according to the
urge to void
■ goals are to gradually lengthen the
intervals between urination to correct
the client’s frequent urination, to
stabilize the bladder, and to diminish
urgency
■ Initially, voiding may be encouraged
every 2 to 3 hours except during sleep
and then every 4 to 6 hours.
■ A vital component of bladder training
is inhibiting the urge-to-void
sensation.
● To do this, the nurse
instructs the client to
practice deep, slow
breathing until the urge
diminishes or disappears.
● This is performed every time
the client has a premature
urge to void.
○ Habit training, also referred to as scheduled
toileting
■ attempts to keep clients dry by having
them void at regular intervals, such as
every 2 to 4 hours
■ The goal is to keep the client dry and
is a common therapy for frail older
clients and those who are bedridden
or have Alzheimer’s disease
● Pelvic Floor Muscle Exercises
○ (PFM), or Kegel, exercises help to strengthen
pelvic floor muscles
○ can reduce or eliminate episodes of
incontinence
○ two types of muscle contractions to practice
PFM
■ a quick 2-second contraction where
the client squeezes the pelvic muscle
quickly and hard and then relaxes
immediately
■ a slow 3- , 5-, or 10-second long
contraction
● The pelvic muscle is relaxed
after the sustained
contraction
● The client gradually builds
up to the 10-second
sustained contraction.
○ When the exercise is properly performed,
contraction of the muscles of the buttocks and
thighs is avoided
○ PFM can be performed anytime, anywhere,
sitting or standing
● Maintaining Skin Integrity
○ Skin that is continually moist becomes
macerated (softened)
○ Urine that accumulates on the skin is converted
to ammonia, which is very irritating to the skin.
○ To maintain skin integrity, the nurse washes the
client’s perineal area with mild soap and water or
a commercially prepared no-rinse cleanser after
episodes of incontinence.
○ The nurse then rinses the area thoroughly if
soap and water were used, and dries it gently
and thoroughly.
○ The nurse applies barrier ointments or creams to
protect the skin from contact with urine.
○ If it is necessary to pad the client’s clothes for
protection, the nurse should use products that
absorb wetness and leave a dry surface in
contact with the skin.
○ Specially designed incontinence drawsheets
provide significant advantages over standard
drawsheets for incontinent clients confined to
bed.
■ These sheets are like a drawsheet but
are double layered, with a quilted
upper nylon or polyester surface and
an absorbent viscose rayon layer
below.
■ The rayon soaker layer generally has
a waterproof backing on its underside.
■ Fluid (i.e., urine) passes through the
upper quilted layer and is absorbed
and dispersed by the viscose rayon,
leaving the quilted surface dry to the
touch.
■ This absorbent sheet helps maintain
skin integrity; it does not stick to the
skin when wet, decreases the risk of
bedsores, and reduces odor
● Applying External Urinary Draining Devices
○ The application of a condom or external catheter
connected to a urinary drainage system can be
used for incontinent males
○ Use of a condom appliance is preferable to
insertion of a retention catheter because the risk
of UTI is minimal.
○ The nurse needs to follow the manufacturer’s
instructions when applying a condom.
○ First the nurse determines when the client
experiences incontinence
 ■ Some clients may require a condom ● The retention, or Foley, catheter is a double-lumen
appliance at night only, others catheter
continuously ○ The outside end of this two-way retention
catheter is bifurcated
MANAGING URINARY RETENTION
■ it has two openings
● The primary care provider may order a cholinergic drug ● one to drain the urine
such as bethanechol chloride (Urecholine) to stimulate ● the other to inflate the
bladder contraction and facilitate voiding balloon
● Clients who have a flaccid bladder (weak, soft, and lax ○ The larger lumen drains urine from the bladder
bladder muscles) may use manual pressure on the bladder and the second smaller lumen is used to inflate
to promote bladder emptying the balloon near the tip of the catheter to hold
○ This is known as Credé’s maneuver or Credé’s the catheter in place within the bladder
method
■ not advised without a primary care
provider or nurse practitioner’s order
and is used only for clients who have
lost and are not expected to regain
voluntary bladder control
● When all measures fail to initiate voiding, urinary
catheterization may be necessary to empty the bladder
completely.
○ An indwelling Foley catheter may be inserted
until the underlying cause is treated.
○ Alternatively, intermittent straight catheterization
(every 3 to 4 hours) may be performed because
the risk of UTI may be less than with an
indwelling catheter
URINARY CATHETERIZATION ● A variation of the indwelling catheter is the coudé
(elbowed) catheter
● introduction of a catheter into the urinary bladder ○ has a curved tip
● usually performed only when absolutely necessary, ○ sometimes used for men who have a
because the danger exists of introducing microorganisms hypertrophied prostate
into the bladder ■ because its tip is somewhat stiffer than
○ The most frequent health care–associated a regular catheter and thus it can be
infection is a UTI better controlled during insertion, and
○ A catheter-associated urinary tract infection passage is often less traumatic
(CAUTI)
■ a “urinary tract infection that occurs
while an indwelling catheter is in place
or within 48 hours of its removal”
● Clients with a CAUTI remain in the hospital longer and
need to be placed on antibiotic therapy, which increases
health care costs.
● Another hazard is trauma
○ Damage to the urethra can occur if the catheter
is forced through strictures or at an incorrect
angle
○ In males, the urethra is normally curved, but it
can be straightened by elevating the penis to a
position perpendicular to the body
● Catheters are commonly made of rubber or plastics ● Clients who require continuous or intermittent bladder
although they may be made from latex, silicone, or irrigation may have a three-way Foley catheter
polyvinyl chloride (PVC). ○ has a third lumen through which sterile irrigating
● They are sized by the diameter of the lumen using the fluid can flow into the bladder
French (Fr) scale ○ the fluid then exits the bladder through the
○ the larger the number, the larger the lumen drainage lumen, along with the urine
● straight catheter is a single-lumen tube with a small eye
or opening about 1.25 cm (0.5 in.) from the insertion tip

● The purpose of the catheter balloon is to secure the

catheter in the bladder
 ● Retention catheters are usually connected to a closed
gravity drainage system
○ This system consists of the catheter, drainage
tubing, and a collecting bag for the urine
○ A closed system cannot be opened anywhere
along the system, from catheter to collecting bag
CLEAN INTERMITTENT SELF-CATHETERIZATION
● performed by many clients who have some form of
neurogenic bladder dysfunction such as that caused by
spinal cord injury and multiple sclerosis
● Clean or medical aseptic technique is used
● Intermittent self-catheterization has these benefits:
○ Enables the client to retain independence and
gain control of the bladder
○ Reduces incidence of UTI
○ Protects the upper urinary tract from reflux
○ Allows normal sexual relations without
incontinence
○ Reduces the use of aids and appliances
○ Frees the client from embarrassing dribbling.
● The procedure for self-catheterization is similar to that
used by the nurse to catheterize a client.
● The procedure requires physical and mental preparation,
client assessment is important. The client should have:
○ Sufficient manual dexterity to manipulate a
catheter
○ Sufficient mental ability
○ Motivation and acceptance of the procedure
○ For women, reasonable agility to access the
urethra
○ Bladder capacity greater than 100 mL
● Before teaching CISC, the nurse should establish the
client’s voiding patterns, the volume voided, fluid intake,
and residual amounts.
● CISC is easier for males to learn because of the visibility of
the urinary meatus
● Females need to learn initially with the aid of a mirror
URINARY IRRIGATIONS
● An irrigation is a flushing or washing-out with a specified
solution
● Bladder irrigation is carried out on a primary care
provider’s order, usually to wash out the bladder and
sometimes to apply medication to the bladder lining.
● Catheter irrigations may also be performed to maintain or
restore the patency of a catheter
○ for example, to remove pus or blood clots
blocking the catheter.
● Sterile technique is used.
● The closed method is the preferred technique for catheter
or bladder irrigation because it is associated with a lower
risk of UTI
● Closed catheter irrigations may be either continuous or
intermittent
○ This method is most often used for clients who
have had genitourinary surgery
○ continuous irrigation
■ helps prevent blood clots from
occluding the catheter.
○ A three-way, or triple lumen, catheter is
generally used for closed irrigation.
○ irrigating solution flows into the bladder through
the irrigation port of the catheter and out through
the urinary drainage lumen of the catheter
● Occasionally an open irrigation may be necessary to
restore catheter patency
○ the risk of injecting microorganisms into the
urinary tract is greater with open irrigations,
because the connection between the indwelling
catheter and the drainage tubing is broken
● The open method of catheter or bladder irrigation is
performed with double-lumen indwelling catheters
SUPRAPUBIC CATHETER CARE
● A suprapubic catheter is inserted surgically through the
abdominal wall above the symphysis pubis into the urinary
bladder.
● The suprapubic catheter may have a balloon or pigtail that
holds it in the bladder depending on the manufacturer
● The health care provider inserts the catheter using local
anesthesia or during bladder or vaginal surgery.
● The catheter may be secured in place with sutures to
reinforce the security of the catheter and is then attached
to a closed drainage system.
● The suprapubic catheter may be placed for temporary
bladder drainage until the client is able to resume normal
voiding (e.g., after urethral, bladder, or vaginal surgery) or
it may become a permanent device (e.g., urethral or pelvic
trauma)
● Care of the catheter insertion site involves sterile technique
● Dressings around the newly placed suprapubic catheter
are changed whenever they are soiled with drainage to
prevent bacterial growth around the insertion site and
reduce the potential for infection
URINARY DIVERSIONS
● A urinary diversion is the surgical rerouting of urine from
the kidneys to a site other than the bladder.
● Clients with bladder cancer often need a urinary diversion
when the bladder must be removed or bypassed.
● Incontinent
○ clients have no control over the passage of urine
and require the use of an external ostomy
appliance to contain the urine
○ Urinary diversions may or may not involve the
removal of the bladder (cystectomy)
■ A ureterostomy is when one or both
of the ureters may be brought directly
to the side of the abdomen to form
small stomas
● disadvantage: stomas
provide direct access for
microorganisms from the
skin to the kidneys, the
small stomas are difficult to
fit with an appliance to
collect the urine, and they
may narrow, impairing urine
drainage
■ nephrostomy diverts urine from the
kidney via a catheter inserted into the
renal pelvis to a nephrostomy tube
and bag
■ vesicostomy may be formed when
the bladder is left intact but voiding
through the urethra is not possible
 (e.g., due to an obstruction or a
neurogenic bladder)
● The ureters remain
connected to the bladder,
and the bladder wall is
surgically attached to an
opening in the skin below
the navel, forming an
opening (stoma) for urinary
drainage
○ The most common incontinent urinary diversion
is the ileal conduit or ileal loop
■ a segment of the ileum is removed
and the intestinal ends are reattached.
■ One end of the portion removed is
closed with sutures to create a pouch,
and the other end is brought out
through the abdominal wall to create a
stoma
■ The ureters are implanted into the ileal
pouch
● Continent urinary diversion
○ involves creation of a mechanism that allows
the client to control the passage of urine, either
by intermittent catheterization of the internal
reservoir (e.g., Kock pouch) or by creating a
neobladder or internal pouch
● The Kock (pronounced “coke”) pouch, or continent ileal
bladder conduit
○ also uses a portion of the ileum to form a
reservoir for urine
○ In this procedure, nipple valves are formed by
doubling the tissue backward into the reservoir
where the pouch connects to the skin and the
ureters connect to the pouch
○ These valves close as the pouch fills with urine,
preventing leakage and reflux of urine back
toward the kidneys
○ The client empties the pouch by inserting a
clean catheter approximately every 2 to 3 hours
at first
■ and increases to every 5 to 6 hours as
the pouch expands.
○ Over time, the pouch can expand to between
600 and 1,000 mL
● A continent diversion with a neobladder involves replacing
a diseased or damaged bladder with a piece of ileum and
colon that is located in the same location as the bladder
that was removed
EVALUATION
● If the desired outcomes are not achieved, explore the
reasons before modifying the care plan.
● examples of questions that need to be considered include:
○ What is the client’s perception of the problem?
○ Does the client understand and comply with the
health care instructions provided?
○ Is access to toilet facilities a problem?
○ Can the client manipulate clothing for toileting?
Can adjustments be made to allow easier
disrobing?
○ Are scheduled toileting times appropriate?
○ Is there adequate transition lighting for
night-time toileting?
○ Are mobility aids such as a walker, elevated
toilet seat, or grab bar needed? If currently used,
are they appropriate or adequate?
○ Is the client performing pelvic floor muscle
exercises appropriately as scheduled?
○ Is the client’s fluid intake adequate? Does the
timing of fluid intake need to be adjusted (e.g.,
restricted after dinner)?
○ Is the client restricting caffeine, citrus juice,
carbonated beverages, and artificial sweetener
intake?
○ Is the client taking a diuretic? If so, when is the
medication taken? Do the times need to be
adjusted (e.g., taking second dose no later than
4 pm)?
○ Should continence aids such as a condom
catheter or absorbent pads be used?
FECAL ELIMINATION
PHYSIOLOGY OF DEFECATION
LARGE INTESTINE
● Extends from the ileocecal (ileocolic) valve, which lies between
the small and large intestines, to the anus
● Measures about 125 to 150 cm (50 to 60 in.) long in adults
● seven parts
○ Cecum
 ○ Ascending
○ Transverse
○ descending colons
○ sigmoid colon
○ Rectum
○ anus
● The large intestine is a muscular tube lined with mucous
membrane.
● The muscle fibers are both circular and longitudinal, permitting
the intestine to enlarge and contract in both width and length.
○ The longitudinal muscles are shorter than the
colon and therefore cause the large intestine to form
pouches, or haustra.
● The colon’s main functions
○ absorption of water and nutrients
○ mucoid protection of the intestinal wall
○ fecal elimination
● The contents of the colon normally represent foods ingested
over the previous 4 days, although most of the waste products
are excreted within 48 hours of ingestion (the act of taking in
food)
● The waste products leaving the stomach through the small
intestine and then passing through the ileocecal valve are called
chyme
● The ileocecal valve, located at the junction of the ileum of the
small intestine and the first part of the large intestine, regulates
the flow of chyme into the large intestine and prevents
backflow into the ileum.
● As much as 1,500 mL of chyme passes into the large intestine
daily, and all but about 100 mL is reabsorbed in the proximal
half of the colon.
○ The 100 mL of fluid is excreted in the feces
● The colon also serves a protective function in that it secretes
mucus
○ This mucus contains large amounts of bicarbonate
ions.
○ The mucous secretion is stimulated by excitation of
parasympathetic nerves.
○ Mucus
■ serves to protect the wall of the large
intestine from trauma by the acids formed
in the feces,
■ and it serves as an adherent for holding
the fecal material together
■ Mucus also protects the intestinal wall
from bacterial activity
● colon - transport along its lumen the products of digestion,
which are eventually eliminated through the anal canal
○ Flatus
■ largely air and the by-products of the
digestion of carbohydrates
○ Feces
● Movements in the large intestines
○ Haustral churning
■ movement of the chyme back and forth
within the haustra
■ In addition to mixing the contents, this
action aids in the absorption of water and
moves the contents forward to the next
haustra.
○ Peristalsis
■ wavelike movement produced by the
circular and longitudinal muscle fibers of
the intestinal walls
■ it propels the intestinal contents forward
■ Colon peristalsis is very sluggish and is
thought to move the chyme very little along
the large intestine.
○ Mass peristalsis
■ The third type of colonic movement
■ involves a wave of powerful muscular
contraction that moves over large areas of
the colon.
■ Usually mass peristalsis occurs after
eating, stimulated by the presence of food
in the stomach and small intestine
■ In adults, mass peristaltic waves occur
only a few times a day
RECTUM AND ANAL CANAL
● The rectum in the adult is usually 10 to 15 cm (4 to 6 in.)
long
○ the most distal portion, 2.5 to 5 cm (1 to 2 in.)
long, is the anal canal
● The rectum has folds that extend vertically.
○ Each of the vertical folds contains a vein and an
artery
○ It is believed that these folds help retain feces
within the rectum.
○ When the veins become distended, as can
occur with repeated pressure, a condition known
as hemorrhoids occurs
● The anal canal is bounded by an internal and an external
sphincter muscle.
○ The internal sphincter is under involuntary
control
■ innervated by the autonomic nervous
system
○ the external sphincter normally is voluntarily
controlled
■ innervated by the somatic nervous
system
DEFECATION
● expulsion of feces from the anus and rectum
● also called a bowel movement
● The frequency of defecation is highly individual
○ varying from several times per day to two or
three times per week.
● The amount defecated also varies from person to person.
● When peristaltic waves move the feces into the sigmoid
colon and the rectum, the sensory nerves in the rectum
are stimulated and the individual becomes aware of the
need to defecate
● When the internal anal sphincter relaxes, feces move into
the anal canal.
● After the individual is seated on a toilet or bedpan, the
external anal sphincter is relaxed voluntarily.
● Expulsion of the feces is assisted by contraction of the
abdominal muscles and the diaphragm, which increases
abdominal pressure, and by contraction of the muscles of
the pelvic floor, which moves the feces through the anal
canal.
● Normal defecation is facilitated by
○ (a) thigh flexion, which increases the pressure
within the abdomen
○ (b) a sitting position, which increases the
downward pressure on the rectum.
● If the defecation reflex is ignored, or if defecation is
consciously inhibited by contracting the external sphincter
muscle, the urge to defecate normally disappears for a few
hours before occurring again.
● Repeated inhibition of the urge to defecate can result in
expansion of the rectum to accommodate accumulated
feces and eventual loss of sensitivity to the need to
defecate → Constipation
 FACTORS AFFECTING DEFECATION

DEVELOPMENT
NEWBORNS AND INFANTS

Meconium
● first fecal material passed by newborn (24 hrs after birth)
● It is black, tarry, odorless, and sticky
Transitional stools
● follow for about a week
● generally greenish yellow
● contain mucus and are loose.
Types of stools
● Infants pass stool frequently, often after each feeding.
● intestine is immature, water is not well absorbed and the
stool is soft, liquid, and frequent.
● When the intestine matures
○ bacterial flora increase.
● After solid foods are introduced
○ the stool becomes less frequent and firmer.
● Infants who are breast-fed have light yellow to golden
feces
○ infants who are taking formula will have dark
yellow or tan stool that is more formed
TODDLERS

● Some control of defecation

FECES
● Normal feces are made of about 75% water and 25%
solid materials.
● soft but formed
● If the feces are propelled very quickly along the large
intestine, there is no time for most of the water in the
chyme to be reabsorbed and the feces will be more fluid,
containing perhaps 95% water
● Normal feces require a normal fluid intake
○ feces that contain less water may be hard and
difficult to expeL
● Feces are normally brown
SCHOOL-AGED CHILDREN AND ADOLESCENTS
○ due to the presence of stercobilin and urobilin,
which are derived from bilirubin (a red pigment in
bile).
○ Another factor that affects fecal color is the
action of bacteria such as Escherichia coli or
staphylococcus, which are normally present in
the large intestine
○ The action of microorganisms on the chyme is
also responsible for the odor of feces
The amount of gas produced per day varies among individuals
● 13 to 21 times a day is normal
● carbon dioxide, methane, hydrogen, oxygen, nitrogen
● May be
○ swallowed with food and fluids
○ formed through action of bacteria on the
chyme in the large intestine
○ diffuses from the blood into the GI tract
○ starts at 1 1/2 to 2 years of age
● By this time, children have learned to walk, and the
nervous and muscular systems are sufficiently well
developed to permit bowel control.
● A desire to control daytime bowel movements and to use
the toilet generally starts when the child becomes aware of
○ (a) the discomfort caused by a soiled diaper
and
○ (b) the sensation that indicates the need for a
bowel movement.
● Daytime control is typically attained by age 2 1/2, after a
process of toilet training
● School-age children and adolescents have bowel habits
similar to those of adults.
● Patterns of defecation vary in frequency, quantity, and
consistency.
● Some school-age children may delay defecation because
of an activity such as play.
OLDER ADULTS
● Toner and Claros (2012) state that “up to half of all older
adults suffer from constipation” (p. 32).
○ due, in part, to reduced activity levels,
inadequate fluid and fiber intake, and muscle
weakness.
● Many older people believe that “regularity” means a bowel
movement every day.
○ Those who do not meet this criterion often seek
over-the-counter (OTC) preparations to relieve
what they believe to be constipation.
● Older adults should be advised that normal patterns of
bowel elimination vary considerably.
○ For some, a normal pattern may be every other
day; for others, twice a day.
● Constipation can be relieved by increasing the fiber intake
to 20 to 35 grams per day, unless contraindicated
(Tabloski & Connell, 2014).
● Adequate roughage in the diet, adequate exercise, and 6
to 8 glasses of fluid daily are other essential preventive
measures for constipation.
○ A cup of hot water or tea at a regular time in the
morning is helpful for some.
● Responding to the gastrocolic reflex (increased
peristalsis of the colon after food has entered the stomach)
is also an important consideration.
 ○ For example, toileting is recommended 30
minutes after meals, especially after breakfast
when the gastrocolic reflex is strongest (Toner &
Claros, 2012)
● The older adult should be warned that consistent use of
laxatives inhibits natural defecation reflexes and is
thought to cause rather than cure constipation.
○ The habitual user of laxatives eventually
requires larger or stronger doses because the
effect is progressively reduced with continual
use.
○ Laxatives may also interfere with the body’s
electrolyte balance and decrease the absorption
of certain vitamins.
● The reasons for constipation can range from lifestyle habits
(e.g., lack of exercise) to serious malignant disorders (e.g.,
colorectal cancer).
○ The nurse should evaluate any complaints of
constipation carefully for each individual.
○ A change in bowel habits over several weeks
with or without weight loss, pain, or fever should
be referred to a primary care provider for a
complete medical evaluation.
DIET
● Sufficient bulk (cellulose, fiber) in the diet is necessary to
provide fecal volume
● Inadequate intake of dietary fiber contributes to the risk of
developing obesity, type 2 diabetes, coronary artery
disease, and colon cancer.
Fiber
● Insoluble fiber
○ promotes the movement of material through the
digestive system and increases stool bulk
○ Sources of insoluble fiber include whole-wheat
flour, wheat bran, nuts, and many vegetables.
● Soluble fiber
○ dissolves in water to form a gel-like material
○ help lower blood cholesterol and glucose levels
(Mayo Clinic, 2012).
○ Sources of soluble fiber include oats, peas,
beans, apples, citrus fruits, carrots, barley, and
psyllium
● The Mayo Clinic recommends the following daily amount of
fiber:
○ Men ages 50 and younger: 38 grams
○ Men ages 51 and older: 30 grams
○ Women ages 50 and younger: 25 grams
○ Women ages 51 and older: 21 grams
● It is important to drink plenty of water because fiber
works best when it absorbs water.
● Bland diets and low-fiber diets are lacking in bulk and
therefore create insufficient residue of waste products to
stimulate the reflex for defecation.
● Low-residue foods, such as rice, eggs, and lean meats,
move more slowly through the intestinal tract.
○ Increasing fluid intake with such foods increases
their rate of movement.
Certain foods are difficult or impossible for some people to digest.
● digestive upsets, sometimes passage of watery stools.
Irregular eating can also impair regular defecation.
● physiological response to food intake and pattern of
peristaltic activity in the colon.
Spicy foods can produce diarrhea and flatus in some individuals
Excessive sugar can also cause diarrhea.
Other foods that may influence bowel elimination include:
● Gas-prod =cabbage, onions, cauliflower, bananas, apples
● Laxative-prod =bran, prunes, figs, chocolate, and alcohol
● Constipation-prod = cheese, pasta, eggs, and lean meat
FLUID INTAKE AND OUTPUT
● Even when fluid intake is inadequate or output (e.g., urine
or vomitus) is excessive for some reason, the body
continues to reabsorb fluid from the chyme as it passes
along the colon.
○ The chyme becomes drier than normal,
resulting in hard feces
○ reduced fluid intake slows the chyme’s
passage along the intestines, further increasing
the reabsorption of fluid from the chyme.
● Healthy fecal elimination usually requires a daily fluid
intake of 2,000 to 3,000 mL.
○ If chyme moves abnormally quickly through the
large intestine, however, there is less time for
fluid to be absorbed into the blood; as a result,
the feces are soft or even watery.
ACTIVITY
● Activity stimulates peristalsis, thus facilitating the
movement of chyme along the colon.
● Weak abdominal and pelvic muscles are often ineffective
in increasing the intra-abdominal pressure during
defecation or in controlling defecation.
● Weak muscles can result from lack of exercise, immobility,
or impaired neurological functioning. Clients confined to
bed are often constipated.
PSYCHOLOGICAL FACTORS
● Some people who are anxious or angry experience
increased peristaltic activity and subsequent nausea or
diarrhea.
● In contrast, people who are depressed may experience
slowed intestinal motility, resulting in constipation.
● How a person responds to these emotional states is the
result of individual differences in the response of the
enteric nervous system to vagal stimulation from the brain.
DEFECATION HABITS
● Early bowel training may establish the habit of defecating
at a regular time.
○ Many people defecate after breakfast, when the
gastrocolic reflex causes mass peristaltic waves
in the large intestine.
● If a person ignores this urge to defecate, water continues
to be reabsorbed, making the feces hard and difficult to
expel.
● When the normal defecation reflexes are inhibited or
ignored, these conditioned reflexes tend to be
progressively weakened.
● When habitually ignored, the urge to defecate is
ultimately lost.
● Adults may ignore these reflexes because of the pressures
of time or work.
● Hospitalized clients may suppress the urge because of:
○ embarrassment about using a bedpan
○ lack of privacy
○ defecation is too uncomfortable
MEDICATIONS
side effects that can interfere with normal elimination.
● Some cause diarrhea
● Large doses of certain tranquilizers and repeated
administration of morphine and codeine = constipation
○ decrease gastrointestinal activity through their
action on the central nervous system.
● Iron supplements act more locally on the bowel mucosa
and can cause constipation or diarrhea.
○ Some medications directly affect elimination.
○ Laxatives are medications that stimulate bowel
activity and so assist fecal elimination.
● Other medications soften stool, facilitating defecation.
● Certain medications suppress peristaltic activity and may
be used to treat diarrhea.
Medications can also affect the appearance of the feces.
● Any drug that causes gastrointestinal bleeding (e.g.,
aspirin products) can cause the stool to be red or black.
● Iron salts lead to black stool because of the oxidation of
the iron
● antibiotics may cause a gray-green discoloration
● Antacids can cause a whitish discoloration or white
specks in the stool.
 ● Pepto-Bismol, a common OTC drug, causes stools to be
black
DIAGNOSTIC PROCEDURES
● Before certain diagnostic procedures, such as visualization
of the colon (colonoscopy or sigmoidoscopy), the client is
restricted from ingesting food or fluid.
● The client may also be given a cleansing enema prior to
the examination.
● In these instances normal defecation usually will not occur
until eating resumes
ANAESTHESIA AND SURGERY
● General anesthetics cause the normal colonic
movements to cease or slow by blocking parasympathetic
stimulation to the muscles of the colon.
○ Clients who have regional or spinal anesthesia
are less likely to experience this problem.
● Surgery that involves direct handling of the intestines can
cause temporary cessation of intestinal movement.
○ This condition, called ileus, usually lasts 24 to
48 hours
○ Listening for bowel sounds that reflect
intestinal motility is an important nursing
assessment following surgery
PATHOLOGIC CONDITIONS
● Spinal cord injuries and head injuries can decrease the
sensory stimulation for defecation.
● Impaired mobility may limit the client’s ability to respond
to the urge to defecate and the client may experience
constipation.
● Or, a client may experience fecal incontinence because of
poorly functioning anal sphincters.
PAIN
● Clients who experience discomfort when defecating (e.g.,
following hemorrhoid surgery) often suppress the urge to
defecate to avoid the pain.
○ clients can experience constipation as a result.
● Clients taking narcotic analgesics for pain may also
experience constipation as a side effect of the medication.
FECAL ELIMINATION PROBLEMS
CONSTIPATION
● Constipation may be defined as fewer than three bowel
movements per week.
● This infers the passage of dry, hard stool or the passage of
no stool.
● It occurs when the movement of feces through the large
intestine is slow, thus allowing time for additional
reabsorption of fluid from the large intestine.
● Associated with constipation are difficult evacuation of
stool and increased effort or straining of the voluntary
muscles of defecation.
● The person may also have a feeling of incomplete stool
evacuation after defecation.
○ However, it is important to define constipation in
relation to the person’s regular elimination
pattern.
● Some people normally defecate only a few times a week;
other people defecate more than once a day.
● Careful assessment of the person’s habits is necessary
before a diagnosis of constipation is made.
causes and factors contribute to constipation:
● Insufficient fiber intake
● Insufficient fluid intake
● Insufficient activity or immobility
● Irregular defecation habits
● Change in daily routine
● Lack of privacy
● Chronic use of laxatives or enemas
● Irritable bowel syndrome (IBS)
● Pelvic floor dysfunction or muscle damage
● Poor motility or slow transit
● Neurologic conditions (e.g., Parkinson’s disease), stroke,
or paralysis
● Emotional disturbances such as depression or mental
confusion
● Medications such as opioids, iron supplements,
antihistamines, antacids, and antidepressants
● Habitual denial and ignoring the urge to defecate
Health problems
● In children - associated with changes in activity, diet, and
toileting habits
● Straining - often is accompanied by holding the breath.
○ Valsalva maneuver present serious problems to
people with heart disease, brain injuries, or
respiratory disease.
○ increases intrathoracic pressure and vagal tone,
slowing pulse rate.
FECAL IMPACTION
● Fecal impaction is a mass or collection of hardened
feces in the folds of the rectum.
● Impaction results from prolonged retention and
accumulation of fecal material.
● In severe impactions the feces accumulate and extend well
up into the sigmoid colon and beyond.
● A client who has a fecal impaction will experience the
passage of liquid fecal seepage (diarrhea) and no normal
stool.
○ The liquid portion of the feces seeps out around
the impacted mass.
○ Along with fecal seepage and constipation,
symptoms include frequent but nonproductive
desire to defecate and rectal pain.
○ A generalized feeling of illness results; the client
becomes anorexic, the abdomen becomes
distended, and nausea and vomiting may occur.
● Impaction can also be assessed by digital examination of
the rectum, during which the hardened mass can often be
palpated.
● The causes of fecal impaction are usually poor defecation
habits and constipation.
● Also, the administration of medications such as
anticholinergics and antihistamines will increase the
client’s risk in the development of a fecal impaction.
● The barium used in radiologic examinations of the upper
and lower gastrointestinal tracts can also be a causative
factor.
○ Therefore, after these examinations, laxatives or
enemas are usually given to ensure removal of
the barium.
● Although fecal impaction can generally be prevented,
treatment of impacted feces is sometimes necessary.
● When fecal impaction is suspected, the client is often given
an oil retention enema, a cleansing enema 2 to 4 hours
later, and daily additional cleansing enemas,
suppositories, or stool softeners.
● If these measures fail, manual removal is often
necessary
DIARRHEA
● Diarrhea refers to the passage of liquid feces and an
increased frequency of defecation.
● It is the opposite of constipation and results from rapid
movement of fecal contents through the large intestine.
○ Rapid passage of chyme reduces the time
available for the large intestine to reabsorb water
and electrolytes.
● Some people pass stool with increased frequency, but
diarrhea is not present unless the stool is relatively
unformed and excessively liquid.
● The person with diarrhea finds it difficult or impossible to
control the urge to defecate.
● Diarrhea and the threat of incontinence are sources of
concern and embarrassment.
● Often, spasmodic cramps are associated with diarrhea.
● Bowel sounds are increased.
● With persistent diarrhea, irritation of the anal region
extending to the perineum and buttocks generally results.
● Fatigue, weakness, malaise, and emaciation are the
results of prolonged diarrhea.
● When the cause of diarrhea is irritants in the intestinal
tract, diarrhea is thought to be a protective flushing
mechanism.
● It can create serious fluid and electrolyte losses in the
body, however, that can develop within frighteningly short
periods of time, particularly in infants, small children, and
older adults
● Clostridium difficile–associated disease, which
produces mucoid and foul-smelling diarrhea, has been
increasing in recent years.
● Clients at the highest risk for the development of C. difficile
○ immunosuppressed individuals
○ clients on chemotherapy
○ those who have recently used antimicrobial
agents, usually fluoroquinolones
● The irritating effects of diarrhea stool increase the risk for
skin breakdown.
○ Therefore, the area around the anal region
should be kept clean and dry and be protected
with zinc oxide or other ointment.
BOWEL INCONTINENCE
● also called fecal incontinence, refers to the loss of
voluntary ability to control fecal and gaseous
discharges through the anal sphincter.
● The incontinence may occur at specific times, such as after
meals, or it may occur irregularly.
● Two types of bowel incontinence
○ Partial incontinence is the inability to control
flatus or to prevent minor soiling.
○ Major incontinence is the inability to control
feces of normal consistency
● Fecal incontinence is generally associated with impaired
functioning of the anal sphincter or its nerve supply,
such as in some neuromuscular diseases, spinal cord
trauma, and tumors of the external anal sphincter muscle
● The prevalence of bowel incontinence increases with
age.
○ Seven percent of women under the age of 40
years’ experience bowel incontinence.
■ That percentage increases to 22% or
more by the sixth decade of life.
○ In nursing homes the rate exceeds 50% and a
significant number experience both fecal and
urinary incontinence (Gallagher & Thompson,
2012, p. 95).
● Bowel incontinence is an emotionally distressing
problem that can ultimately lead to social isolation.
○ Afflicted individuals withdraw into their homes or,
if in the hospital, the confines of their room, to
minimize the embarrassment associated with
soiling.
● Several surgical procedures are used for the treatment of
fecal incontinence.
○ These include repair of the sphincter and bowel
diversion or colostomy
FLATULENCE
three primary sources of flatus
● (1) action of bacteria on the chyme in the large intestine
● (2) swallowed air
● (3) gas that diffuses between the bloodstream and the
intestine.
○ Most gases that are swallowed are expelled
through the mouth by eructation (belching).
○ However, large amounts of gas can accumulate
in the stomach, resulting in gastric distention.
○ The gases formed in the large intestine are
chiefly absorbed through the intestinal capillaries
into the circulation.
● Flatulence is the presence of excessive flatus in the
intestines and leads to stretching and inflation of the
intestines (intestinal distention).
● Flatulence can occur in the colon from a variety of
causes, such as foods (e.g., cabbage, onions), abdominal
surgery, or narcotics.
● If the gas is propelled by increased colon activity before it
can be absorbed, it may be expelled through the anus.
● If excessive gas cannot be expelled through the anus, it
may be necessary to insert a rectal tube to remove it.
BOWEL DIVERSION OSTOMIES
● An ostomy is an opening for the gastrointestinal, urinary,
or respiratory tract onto the skin.
● types of intestinal ostomies
○ Gastrostomy
■ an opening through the abdominal
wall into the stomach
○ jejunostomy
■ opens through the abdominal wall into
the jejunum
○ Ileostomy
■ opens into the ileum (small bowel),
and a colostomy opens into the colon
(large bowel)
● Gastrostomies and jejunostomies are generally
performed to provide an alternate feeding route.
● The purpose of bowel ostomies is to divert and drain
fecal material.
Bowel diversion ostomies are often classified according to
● (a) status as permanent or temporary
● (b) anatomic location
● (c) the construction of the stoma
○ opening created in the abdominal wall by the
ostomy.
○ A stoma is generally red in color and moist.
○ Initially, slight bleeding may occur when the
stoma is touched and this is considered normal.
○ A person does not feel the stoma because there
are no nerve endings in the stoma.
PERMANENCE
● Colostomies can be either temporary or permanent.
○ Temporary colostomies
■ generally performed for traumatic
injuries or inflammatory conditions
of the boweL
■ allow the distal diseased portion of the
bowel to rest and heal.
○ Permanent colostomies
■ performed to provide a means of
elimination when the rectum or anus
is nonfunctional as a result of a birth
defect or a disease such as cancer of
the bowel.
ANATOMIC LOCATION
● ileostomy
○ generally empties from the distal end of the
small intestine
 ● cecostomy
○ empties from the cecum (the first part of the
ascending colon)
● ascending colostomy
○ empties from the ascending colon
● transverse colostomy from the transverse colon
● descending colostomy from the descending colon
● sigmoidostomy from the sigmoid colon

Loop
● loop of bowel is brought out onto the abdominal wall and
supported by a plastic bridge or by a piece of rubber tubing
● Has two openings:
○ proximal or afferent end, which is active,
○ distal or efferent end, which is inactive.
● loop colostomy =performed in an emergency procedure
location of the ostomy influences the character and management and is often situated on the right transverse colon
of the fecal drainage ● It is a bulky stoma that is more difficult to manage than
● The farther along the bowel, the more formed the stool a single stoma
(because the large bowel reabsorbs water from the fecal
mass) and the more control over the frequency of
stomal discharge can be established
● An ileostomy produces liquid fecal drainage.
○ Drainage is constant and cannot be regulated.
○ Ileostomy drainage contains some digestive
enzymes, which are damaging to the skin.
○ For this reason, ileostomy clients must wear an
appliance continuously and take special
precautions to prevent skin breakdown.
○ Compared to colostomies, however, odor is
minimal because fewer bacteria are present. Divided
● An ascending colostomy ● consists of two edges of bowel brought out onto the
○ similar to an ileostomy in that the drainage is abdomen but separated from each other
liquid and cannot be regulated, and digestive ● The opening from the digestive or proximal end is the
enzymes are present. colostomy.
○ Odor, however, is a problem requiring control. ● The distal end in this situation is often referred to as a
● A transverse colostomy mucous fistula, since this section of bowel continues to
○ produces a malodorous, mushy drainage secrete mucus.
because some of the liquid has been ● often used in situations where spillage of feces into the
reabsorbed. distal end of the bowel needs to be avoided
○ There is usually no control.
● A descending colostomy
○ produces increasingly solid fecal drainage
● Stools from a sigmoidostomy are of normal or formed
consistency, and the frequency of discharge can be
regulated.
○ People with a sigmoidostomy may not have to
wear an appliance at all times, and odors can
usually be controlled
● Over time, the stool becomes more formed
○ because the remaining functioning portions of
the colon tend to compensate by increasing
water reabsorption

SURGICAL CONSTRUCTION OF THE STOMA

double barreled
Stoma constructions are described as ● resembles a double-barreled shotgun
Single ● proximal and distal loops of bowel are sutured together for
● created when one end of the bowel is brought out through about 10 cm (4 in.) and both ends are brought up onto
an opening onto the anterior abdominal wall. abdominal wall
● This is referred to as an end or terminal colostomy
● the stoma is permanent

NURSING MANAGEMENT
ASSESSMENT
NURSING HISTORY
● helps the nurse ascertain the client’s normal pattern
● The nurse elicits a description of usual feces and any
recent changes and collects information about
○ any past or current problems with elimination
○ the presence of an ostomy
○ factors influencing the elimination pattern
● Deficient Knowledge (Bowel Training, Ostomy
Management) related to lack of previous experience
● Anxiety related to
○ a. Lack of control of fecal elimination secondary
to ostomy
○ b. Response of others to ostomy
PLANNING
major goals for clients with fecal elimination problems are to:
● Maintain or restore normal bowel elimination pattern
● Maintain or regain normal stool consistency.
● Prevent associated risks such as fluid and electrolyte
imbalance, skin breakdown, abdominal distention, and
pain.
Appropriate preventive and corrective nursing interventions that
relate to these must be identified.
● Specific nursing activities associated with each of these
interventions selected to meet client’s individual needs
PLANNING FOR HOME CARE

● Clients who have bowel diversion ostomies, who wear

● The number of questions to ask is adapted to the individual
client, according to the client’s responses in the first three
categories.
pouches, or who have other ongoing elimination problems
will need continuing care in the home setting.
● In preparation for discharge, the nurse needs to assess
the client’s and family’s ability to meet specific care
needs

PHYSICAL EXAMINATION IMPLEMENTING

● Physical examination of the abdomen in relation to fecal PROMOTING REGULAR DEFECATION

elimination problems includes
The nurse can help clients achieve regular defecation by attending to
○ Inspection
● (a) the provision of privacy
○ Auscultation
● (b) timing
○ Percussion
● (c) nutrition and fluids
○ Palpation
● (d) exercise
● Auscultation precedes palpation
● (e) positioning
○ because palpation can alter peristalsis
PRIVACY
● Examination of the rectum and anus includes inspection
● Important to many people
and palpation
● The nurse should therefore provide as much privacy as
INSPECTING THE FECES possible for such clients but may need to stay with those
who are too weak to be left alone.
● Observe the client’s stool for color, consistency, shape,
● Some clients also prefer to wipe, wash, and dry
amount, odor, and the presence of abnormal constituents.
themselves after defecating.
DIAGNOSTIC STUDIES ● A nurse may need to provide water and a washcloth and
towel for this purpose.
● Diagnostic studies of the gastrointestinal tract include TIMING
○ direct visualization techniques ● A client should be encouraged to defecate when the urge
○ indirect visualization techniques is recognized.
○ laboratory tests for abnormal constituents ● To establish regular bowel elimination, the client and nurse
DIAGNOSIS can discuss when mass peristalsis normally occurs and
provide time for defecation.
NANDA International (Herdman & Kamitsuru, 2014) includes the ● Many people have well-established routines.
following diagnostic labels for fecal elimination problems: ● Other activities, such as bathing and ambulating, should
● Bowel Incontinence not interfere with the defecation time
● Constipation NUTRITION AND FLUIDS
● Risk for Constipation ● The diet a client needs for regular normal elimination
● Perceived Constipation varies depending on:
● Diarrhea ○ kind of feces the client currently has
● Dysfunctional Gastrointestinal Motility ○ the frequency of defecation
Fecal elimination problems may affect many other areas of human ○ the types of foods that the client finds assist with
functioning - may be the etiology of other NANDA diagnoses. normal defecation
● Risk for Deficient Fluid Volume and/or Risk for Electrolyte ● For Constipation
Imbalance related to ○ Increase daily fluid intake, and instruct the
○ a. Prolonged diarrhea client to drink hot liquids, warm water with a
○ b. Abnormal fluid loss through ostomy squirt of fresh lemon, and fruit juices, especially
● Risk for Impaired Skin Integrity related to prune juice. Include fiber in the diet, that is,
○ a. Prolonged diarrhea foods such as raw fruit, bran products, and
○ b. Bowel incontinence whole-grain cereals and bread.
○ c. Bowel diversion ostomy ● For Diarrhea
● Situational Low Self-Esteem related to ○ Encourage oral intake of fluids and bland
○ a. Ostomy food
○ b. Fecal incontinence ○ Eating small amounts can be helpful because
○ c. Need for assistance with toileting small amounts are more easily absorbed
● Disturbed Body Image related to ○ Excessively hot or cold fluids should be avoided
○ a. Ostomy because they stimulate peristalsis
○ b. Bowel incontinence
 ○ In addition, highly spiced foods and high fiber
foods can aggravate diarrhea
● For Flatulence
○ Limit carbonated beverages, the use of drinking
straws, and chewing gum
■ all of which increase the ingestion of
air.
○ Gas-forming foods, such as cabbage, beans,
onions, and cauliflower, should also be
avoided
EXERCISE
● Regular exercise helps clients develop a regular
defecation pattern.
● A client with weak abdominal and pelvic muscles (which
impede normal defecation) may be able to strengthen
them with the following isometric exercises:
○ In a supine position, the client tightens the
abdominal muscles as though pulling them
inward, holding them for about 10 seconds and
then relaxing them.
■ This should be repeated 5 to 10 times,
four times a day, depending on the
client’s health.
○ Again in a supine position, the client can
contract the thigh muscles and hold them
contracted for about 10 seconds, repeating the
exercise 5 to 10 times, four times a day.
■ This helps the client confined to bed
gain strength in the thigh muscles,
thereby making it easier to use a
bedpan.
POSITIONING
● Although the squatting position best facilitates defecation,
on a toilet seat the best position for most people seems to
be leaning forward.
● For clients who have difficulty sitting down and getting up
from the toilet, an elevated toilet seat can be attached to a
regular toilet.
● Clients then do not have to lower themselves as far onto
the seat and do not have to lift as far off the seat.
● Elevated toilet seats can be purchased for use in the
home.
● A bedside commode, a portable chair with a toilet seat
and a receptacle beneath that can be emptied, is often
used for the adult client who can get out of bed but is
unable to walk to the bathroom.
○ Some commodes have wheels and can slide
over the base of a regular toilet when the waste
receptacle is removed, thus providing clients the
privacy of a bathroom.
○ Some commodes have a seat and can be used
as a chair
○ Potty chairs are available for children.
TEACHING ABOUT MEDICATIONS
Cathartics and Laxatives
Cathartics
● drugs that induce defecation.
● They can have a strong, purgative effect.
● Examples of cathartics are castor oil, cascara,
phenolphthalein, and bisacodyl
Laxative
● mild in comparison to a cathartic
● It produces soft or liquid stools that are sometimes
accompanied by abdominal cramps
● Laxatives are contraindicated in the client who has
nausea, cramps, colic, vomiting, or undiagnosed
abdominal pain.
● Clients need to be informed about the dangers of laxative
use.
● Continual use of laxatives to encourage bowel evacuation
weakens the bowel’s natural responses to fecal
distention, resulting in chronic constipation.
● To eliminate chronic laxative use, it is usually necessary to
teach the client about dietary fiber, regular exercise, taking
sufficient fluids and establishing regular defecation habits.
● any medication regimen should be examined to see
whether it could cause constipation
● Some laxatives are given in the form of suppositories.
○ These act in various ways:
■ by softening the feces
■ by releasing gases such as carbon
dioxide to distend the rectum
■ by stimulating the nerve endings in the
rectal mucosa.
○ The best results can be obtained by inserting the
suppository 30 minutes before the client’s
usual defecation time or when the peristaltic
action is greatest, such as after breakfast
Antidiarrheal Medications
● These medications slow the motility of the intestine or
absorb excess fluid in the intestine
Antiflatulent Medications
● Antiflatulent agents such as simethicone do not decrease
the formation of flatus but they do coalesce the gas
bubbles and facilitate their passage by belching through
the mouth or expulsion through the anus.
● A combination of simethicone and loperamide (Imodium
Advanced) is effective in relieving abdominal bloating and
gas associated with acute diarrhea
○ however, no convincing evidence has been
shown for common flatulence (“Relief from
intestinal gas,” 2013).
● Carminatives are herbal oils known to act as agents that
help expel gas from the stomach and intestines.
● Suppositories can also be given to relieve flatus by
increasing intestinal motility.
DECREASING FLATULENCE
● There are a number of ways to reduce or expel flatus,
including exercise, moving in bed, ambulation, and
avoiding gas-producing foods
● Movement stimulates peristalsis and the escape of flatus
and reabsorption of gases in the intestinal capillaries
Certain medications can decrease flatulence.
● Probiotics may be helpful in the management of flatulence
and bloating
○ Because each probiotic is a different mixture of
bacteria, they need to be treated as different
medications.
○ Recent studies have shown different probiotics
to be helpful for various gastrointestinal
disorders (Lacy, Gabbard, & Crowell, 2011).
● Bismuth subsalicylate (Pepto-Bismol) can be effective
○ however, it should not be used as a continuous
treatment because it contains aspirin and could
cause salicylate toxicity.
● Alpha-galactosidase (Beano) is effective for reducing
flatulence caused by eating fermentable carbohydrates
(e.g., beans, bran, fruit)
ADMINISTERING ENEMAS
enema
● A solution introduced into the rectum and large intestine.
 ● The action of an enema is to distend the intestine and
sometimes to irritate the intestinal mucosa, thereby
increasing peristalsis and the excretion of feces and flatus.
● The enema solution should be at 37.7°C (100°F) because
a solution that is too cold or too hot is uncomfortable and
causes cramping.
● Enemas are classified into four groups: cleansing,
carminative, retention, and return-flow enemas.
Cleansing enemas
● 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
● given primarily to expel flatus
● The 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.
○ This process is repeated five or six times until
the flatus is expelled and abdominal distention is
relieved
DIGITAL REMOVAL OF A FECAL IMPACTION
● Digital removal involves breaking up the fecal mass
digitally and removing it in portions.
● Because the bowel mucosa can be injured during this
procedure, some agencies restrict and specify the
personnel permitted to conduct digital disimpactions.
● Rectal stimulation is also contraindicated for some
people because it may cause an excessive vagal response
resulting in cardiac arrhythmia.
● Before disimpaction it is suggested an oil retention enema
be given and held for 30 minutes.
● After a disimpaction, the nurse can use various
interventions to remove remaining feces, such as a
cleansing enema or the insertion of a suppository
● Because manual removal of an impaction can be painful,
the nurse may use, if the agency permits, 1 to 2 mL of
lidocaine (Xylocaine) gel on a gloved finger inserted into
the anal canal as far as the nurse can reach.
● The lidocaine will anesthetize the anal canal and rectum
and should be inserted 5 minutes before the disimpaction.
● Disimpacting the client requires great sensitivity and a
caring, yet matter-of-fact, approach.
● Be aware of personal facial expressions or anything that
may convey distaste or disgust to the client.
○ When dealing with fecal matter, many clients
feel a sense of shame that relates to childhood
experiences that may have been traumatic in
some way.
For digital removal of a fecal impaction:
● 1. If indicated, obtain assistance from a second person
who can comfort the client during the procedure.
● 2. Ask the client to assume a right or left side-lying
position, with the knees flexed and the back toward the
nurse.
○ When the person lies on the right side, the
sigmoid colon is uppermost; thus, gravity can aid
removal of the feces.
○ Positioning on the left side allows easier access
to the sigmoid colon.
● 3. Place a disposable absorbent pad under the client’s
buttocks and a bedpan nearby to receive stool.
● 4. Drape the client for comfort and to avoid unnecessary
exposure of the body.
● 5. Apply clean gloves and liberally lubricate the gloved
index finger.
● 6. Gently insert the index finger into the rectum and move
the finger along the length of the rectum.
● 7. Loosen and dislodge stool by gently massaging around
it.
○ Break up stool by working the finger into the
hardened mass, taking care to avoid injury to the
mucosa of the rectum.
● 8. Carefully work the stool downward to the end of the
rectum and remove it in small pieces.
○ Continue to remove as much fecal material as
possible.
○ Periodically assess the client for signs of fatigue,
such as facial pallor, diaphoresis, or change in
pulse rate.
○ Manual stimulation should be minimal.
● 9. Following disimpaction, assist the client to clean the anal
area and buttocks.
○ Then assist the client onto a bedpan or
commode for a short time because digital
stimulation of the rectum often induces the urge
to defecate.
BOWEL TRAINING PROGRAMS
● For clients who have chronic constipation, frequent
impactions, or fecal incontinence, bowel training programs
may be helpful.
○ The program is based on factors within the
client’s control and is designed to help the client
establish normal defecation.
○ Such matters as food and fluid intake, exercise,
and defecation habits are all considered.
○ Before beginning such a program, clients must
understand it and want to be involved.
The major phases of the program are as follows:
● Determine the client’s usual bowel habits and factors that
help and hinder normal defecation.
● Design a plan with the client that includes the following:
○ a. Fluid intake of about 2,500 to 3,000 mL/day
○ b. Increase in fiber in the diet
○ c. Intake of hot drinks, especially just before the
usual defecation time
○ d. Increase in exercise.
● Maintain the following daily routine for 2 to 3 weeks:
○ a. Administer a cathartic suppository (e.g.,
Dulcolax) 30 minutes before the client’s
defecation time to stimulate peristalsis.
○ b. When the client experiences the urge to
defecate, assist the client to the toilet or
commode or onto a bedpan. Note the length of
time between the insertion of the suppository
and the urge to defecate.
○ c. Provide the client with privacy for defecation
and a time limit; 30 to 40 minutes is usually
sufficient.
 ○ d. Teach the client to lean forward at the hips, to
apply pressure on the abdomen with the hands,
and to bear down for defecation.
■ These measures increase pressure on
the colon.
■ Straining should be avoided because
it can cause hemorrhoids.
● Provide positive feedback when the client successfully
defecates.
○ Refrain from negative feedback if the client fails
to defecate.
● Offer encouragement to the client and convey that
patience is often required.
○ Many clients require weeks or months of training
to achieve success.
FECAL INCONTINENCE POUCH
● To collect and contain large volumes of liquid feces, the
nurse may place a fecal incontinence collector pouch
around the anal area
● The purpose of the pouch is to prevent progressive
perianal skin irritation and breakdown and frequent linen
changes necessitated by incontinence.
pouch is replacing the traditional approach to this problem
● that is, inserting a large Foley catheter into the client’s
rectum and inflating the balloon to keep it in place—a
practice that may damage the rectal sphincter and rectal
mucosa.
● rectal catheter also increases peristalsis and incontinence
by stimulating sensory nerve fibers in the rectum.
● fecal collector is secured around the anal opening and
may or may not be attached to drainage.
● Pouches are best applied before the perianal skin
becomes excoriated.
○ If perianal skin excoriation is present, the nurse
either
■ (a) applies a dimethicone-based
moisture barrier cream or alcohol-free
barrier film to the skin to protect it from
feces until it heals and then applies
the pouch, or
■ (b) applies a skin barrier or
hydrocolloid barrier underneath the
pouch to achieve the best possible
seal.
Nursing responsibilities for clients with a rectal pouch include
● (a) regular assessment and documentation of perianal skin
● (b) changing bag every 72 hours or sooner if w leakage
● (c) maintaining the drainage system,
● (d) explanations and support to client and support people
OSTOMY CARE
● Clients with fecal diversions need considerable
psychological support, instruction, and physical care.
● Many agencies have access to a wound ostomy
continence nurse (WOCN) to assist these clients.
● It is common for a client with a new ostomy to feel
frightened and alone.
● Talking with another person who has gone through a
similar experience may help the client realize that he or
she is not alone and others are willing to listen and help.
STOMA AND WOUND 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.
○ This is particularly true of 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
● An ostomy appliance should protect the skin, collect stool,
and control odor.
● The appliance consists of a skin barrier and a pouch.
● Some clients may prefer to also wear an adjustable ostomy
belt, which attaches to an ostomy pouch to hold the pouch
firmly in place
● Appliances can be one piece where the skin barrier is
already attached to the pouch or an appliance can consist
of two pieces: a separate pouch with a flange and a
separate skin barrier with a flange where the pouch fastens
to the barrier at the flange (
● The pouch can be removed without removing the skin
barrier when using a two-piece appliance.
○ Pouches can be closed or drainable
○ A drainable pouch usually has a clip where the
end of the pouch is folded over the clamp and
clipped
● Closed pouches
○ often used by people who have a regular stoma
discharge (e.g., sigmoid colostomy) and only
have to empty the pouch 1 or 2 times a day
○ Some people find it easier to change a closed
pouch than emptying a drainable pouch, which
requires some dexterity
○ Odor control is essential to clients’ self-esteem.
■ As soon as clients are ambulatory,
they can learn to work with the ostomy
in the bathroom to avoid odors at the
bedside.
○ Selecting the appropriate kind of appliance
promotes odor control.
■ An intact appliance contains odors.
■ Most pouches contain odor-barrier
material.
■ Some pouches also have a pouch
filter that allows gas out of the pouch
but not the odor.
● The type of ostomy and amount of output influence how
often the pouch is emptied.
○ The pouch is emptied when it is one third to one
half full.
○ If the pouch overfills, it can cause separation of
the skin barrier from the skin and allow stool to
come in contact with the skin.
■ This results in the entire appliance
needing to be removed and a new one
applied.
COLOSTOMY IRRIGATION
● management used only for clients who have a sigmoid or
descending colostomy
● The purpose of irrigation is to distend the bowel sufficiently
to stimulate peristalsis, which stimulates evacuation.
● When a regular evacuation pattern is achieved, the
wearing of a colostomy pouch is unnecessary.
not routinely taught to most clients.
● Routine daily irrigations for control of the time of
elimination ultimately become client’s decision.
● Some clients prefer to control the time of elimination
through rigid dietary regulation and not be bothered with
irrigations, which can take up to an hour to complete.
● When regulation by irrigation is chosen, it should be done
at the same time each day.
● Control by irrigation also necessitates some control of the
diet.
○ For example, laxative foods that might cause an
unexpected evacuation need to be avoided. For
most clients, a relatively small amount of fluid
(300 to 500 mL) stimulates evacuation.
● For others, up to 1,000 mL may be needed because a
colostomy has no sphincter and the fluid tends to return as
it is instilled.
○ This problem is reduced by the use of a cone on
the irrigating catheter.
○ The cone helps to hold the fluid within the bowel
during the irrigation.
● Clients who choose to practice colostomy irrigation need to
be motivated to master the procedure.
 ○ In addition, good manual dexterity and eyesight, ○ evidence of clinical infection
along with uninterrupted time (approximately 60 ○ purulent drainage or necrosis.
minutes) is needed ● Partial thickness wounds
○ These requirements may deter clients from using ○ confined to the skin
this alternative method of regaining bowel ■ dermis and epidermis
control. ○ heal by regeneration
● Full thickness wounds
EVALUATION ○ dermis, epidermis, subcutaneous tissue, and
● The goals established during the planning phase are possibly muscle and bone
evaluated according to specific desired outcomes, also ○ require connective tissue repair
established in that phase.
ACCORDING TO CAUSE
● If outcomes are not achieved, the nurse should explore the
reasons.
Type Cause Description and characteristics
● nurse might consider some or all of the questions:
○ Were the client’s fluid intake and diet
Incision Sharp instrument Open wound
appropriate? deep or shallow
○ Was the client’s activity level appropriate? Once edges are sealed → closed
○ Are prescribed medications or other factors wound
affecting the gastrointestinal function?
○ Do the client and family understand the provided Contusion Blow from a blunt Closed wound
instructions well enough to comply with the instrument skin appears ecchymotic (bruised)
required therapy? - damaged blood vessels.
○ Were sufficient physical and emotional support
provided? Abrasion Surface scrape Open wound involving the skin
(un/intentional)
SKIN INTEGRITY AND WOUND CARE
Puncture Penetrate of skin Open wound
and underlying
SKIN INTEGRITY tissues by sharp
instrument
influenced by internal factors
(un/intentional)
● Genetics and heredity - skin color, sensitivity to sunlight,
and allergies.
Laceration Tissues torn Open wound
● Age - skin integrity (accidental) Edges are jagged
○ Wounds tend to heal more rapidly in infants and
children, however. Penetrating Penetrate skin + Open wound
● chronic illnesses and their treatments wound underlying tissue
○ impaired peripheral arterial circulation - skin on unintentional
legs that damages easily.
● Some medications (like corticosteroids) CLASSIFICATION ACCORDING TO PROGRESSION
○ thinning of skin - much more readily harmed.
ACUTE
○ increase sensitivity to sunlight → sunburns
● Caused by trauma and/or surgical incision
■ antibiotics (e.g., tetracycline and
● Heals in an orderly & timely process
doxycycline)
○ results in function/integrity
■ chemotherapy (e.g., methotrexate)
○ Little tissue loss
■ psychotherapeutic drugs (e.g., tricyclic
● Heals by primary intention
antidepressants)
○ healing of a clean wound without tissue loss.
● Poor nutrition - affect appearance & function of normal skin
○ wound edges are brought together = adjacent to
TYPES OF WOUNDS each other (re-approximated).
● Wound closure - sutures, staples, or adhesive tape or glue.
Intentional trauma ● Minimal scarring
● during therapy CHRONIC
● Ex: surgery for therapeutic purposes → surgeon cuts skin ● Does not heal orderly & timely to produce integrity
= traumatizing it ● Loss of tissue (pressure ulcer, burns) D/T
Unintentional wounds ○ vascular compromise
● Accidental ○ chronic inflammation
● tissues are traumatized without a break in skin ○ repeated compromise of tissue
● wound is open - skin or mucous membrane is broken ● May heal by secondary intention (wound edges are not
Description of wounds approximated)
● how they are acquired ● Wound is left open to heal (until filled by scar tissue).
likelihood and degree of wound contamination and depth: ● If scarring is severe > loss of tissue function
● Clean wounds - uninfected ● Wound heals by
○ no/minimal inflammation ○ granulation tissue formation
○ Respiratory, GI, genital, and urinary tracts are ○ wound contraction
not entered. ○ epithelialization
○ closed wounds ● Chance of infection is greater
● Clean-contaminated wounds - surgical wounds ● Tertiary intention: used for contaminated wounds
○ Respiratory, GI, genital, or urinary tract has been ● Wound left open until risk of infection is resolved
entered.
○ no evidence of infection PRESSURE INJURIES
○ Lack unusual contamination
injury to the skin or underlying tissue
● Contaminated wounds
● usually over a bony prominence
○ open, accidental, and surgical wounds
● result of force alone or in combination with movement.
○ Surgical wounds w major break in sterile
● problem in both acute and long-term care settings
technique
○ substantially preventable
○ spillage fr GI
● development of stage 3 or 4 or unstageable pressure injury
○ evidence of inflammation.
= serious reportable event
● Dirty or infected wounds

ASSESSING COMMON PRESSURE SITES
● Assess for discoloration, abrasions and excoriations
● Palpate
○ surface of skin for temperature
○ Bony prominences and dependent body areas
for edema
ETIOLOGY OF PRESSURE INJURIES
due to localized ischemia
● deficiency in the blood supply to the tissue.
● tissue is compressed b/n two surfaces
○ blood cannot reach tissue = cells are deprived of
oxygen and nutrients
○ waste products of metabolism accumulate in
cells → tissue dies.
○ Prolonged, unrelieved pressure damages small
blood vessels.
● After skin has been compressed, it appears pale
(blanched), as if the blood had been squeezed out of it.
When pressure is relieved = skin takes on a bright red flush
(erythema) = reactive hyperemia.
● dark skinned clients = difficult to detect.
● Compare reactions of questionable areas with other parts
of the client’s skin.
● flush is due to vasodilation
○ extra blood floods to area
○ compensate for preceding period of impeded
blood flow.
● lasts one-half to three-quarters as long as the duration of
impeded blood flow to the area.
● If redness disappears in that time, no tissue damage is
anticipated.
○ If redness does not disappear = tissue damage
has occurred.
RISK FACTORS
FRICTION AND SHEARING
Friction - acting parallel to the skin surface.
● abrade skin - remove superficial layers → prone to b/d
Shearing force - combination of friction and pressure
● when a client assumes a sitting position in bed
○ body slides downward toward foot of the bed.
● downward movement = transmitted to sacral bone and
deep tissues.
○ skin over sacrum tends not to move d/t
adherence b/n skin and bed linens.
○ skin and superficial tissues = relatively unmoving
in relation to bed surface
■ but deeper tissues - firmly attached to
skeleton and move downward.
● shearing force - deeper and superficial tissues meet.
● damages the blood vessels and tissues in this area.
IMMOBILITY
reduction in the amount and control of movement an individual has.
● paralysis, extreme weakness, pain, or any cause of
decreased activity
○ hinder ability to change positions independently
and relieve pressure
INADEQUATE NUTRITION
weight loss, muscle atrophy, and the loss of subcutaneous tissue.
● reduce amount of padding b/n skin and the bones
inadequate intake of protein, carbohydrates, fluids, zinc, and vit C
● pressure injury formation
● Hypoproteinemia - d/t inadequate intake or abnormal loss
○ predisposes client to dependent edema
○ skin more prone to injury by dec elasticity,
resilience, and vitality.
○ increases the distance b/n capillaries and cells
■ Slowing diffusion of oxygen to tissue
cells and metabolites away fr cells.
FECAL AND URINARY INCONTINENCE
Moisture from incontinence
● skin maceration - tissue softened by prolonged soaking
○ Epidermis easily eroded & susceptible to injury.
Digestive enzymes in feces, urea in urine, and gastric tube drainage
● skin excoriation - area of loss superficial layers of the skin
● accumulation of secretions or excretions
○ irritating to the skin
○ harbors microorganisms
○ skin breakdown and infection.
Skin or tissue injury due primarily to moisture
● moisture-related skin damage (MASD) or
incontinence-associated dermatitis (IAD).
● MASD or IAD = “outside-in” damage
○ true pressure injuries - considered “inside-out.”
DECREASED MENTAL STATUS
reduced level of awareness,
● low recognition and response - pain fr prolonged pressure.
DIMINISHED SENSATION
● Paralysis, stroke, or other neurologic disease
● reduces an individual’s ability to respond to trauma
● impairs body’s ability to recognize and provide healing
mechanisms for a wound.
EXCESSIVE BODY HEAT
● elevated body temperature = inc. metabolic rate
○ increasing cells’ need for oxygen.
○ increased need is severe in cells of area under
pressure = already oxygen deficient.
● Severe infections w elevated body temperatures = affect
body’s ability to deal w effects of tissue compression.
ADVANCED AGE
changes include the following:
● Loss of lean body mass
● Generalized thinning of the epidermis
● Decreased strength and elasticity of skin d/t changes in
collagen fibers of the dermis
● Increased dryness due to a decrease in the amount of oil
produced by the sebaceous glands
● low pain perception - reduction in number of cutaneous
end organs
○ sensation of pressure and light touch
● low venous and arterial flow due to aging vascular walls.
CHRONIC MEDICAL CONDITION
diabetes and cardiovascular disease
● skin breakdown and delayed healing.
● compromise oxygen delivery to tissues by poor perfusion
○ poor, delayed healing + risk of pressure injuries
OTHER FACTORS
● poor lifting and transferring techniques
● incorrect positioning
● hard support surfaces
● incorrect application of pressure-relieving devices.
 STAGES OF PRESSURE INJURIES
Stage 1 Skin is intact w non-blanching
erythema
Stage 2 Partial-thickness skin w loss of
epidermis and some of dermis
Stage 3 Full-thickness loss of skin w
epidermis and dermis gone,
damage to or necrosis of
subcutaneous tissues
Stage 4 Full-thickness loss of skin w
extensive destruction, tissue
necrosis and damage to bone,
muscle or supporting structures
Unstageable pressure ulcers Full-thickness tissue loss, base
of ulcer is covered by slough or
eschar
Suspected deep tissue injury Area of localized discolored
intact skin (purple or maroon)
RISK ASSESSMENT TOOLS
most preventable alteration of skin integrity = pressure injuries
● risk assessment tools - provide nurse w systematic means
of identifying clients at high risk for pressure injury
● tool chosen - should include data collection in areas of
immobility, incontinence, nutrition, level of consciousness.
Braden Scale for Predicting Pressure Sore Risk
● six subscales: sensory perception, moisture, activity,
mobility, nutrition, and friction and shear
● total of 23 points is possible
○ below 18 or 19 points - at risk
Norton’s Pressure Area Risk Assessment Scoring System
● categories of general physical condition, mental state,
activity, mobility, and incontinence.
● possible score of 24
○ 15 or 16 - indicators, not predictors, of risk.
Braden and Norton tools
● used when client first enters healthcare agency and
whenever client’s condition changes.
● increases awareness of specific risk factors and serves as
assessment data
○ plan goals and interventions to either maintain or
improve skin integrity.
WOUND HEALING
● primary care provider’s decision
○ allow the wound to seal itself
○ purposefully close the wound
TYPES OF WOUND HEALING
influenced by amount of tissue loss.
● Primary intention healing - tissue surfaces have been
approximated (closed)
○ minimal or no tissue loss
○ form minimal granulation tissue and scarring.
○ Ex: closed surgical incision, use of tissue
adhesive to seal clean lacerations or incisions
● secondary intention healing - extensive wound
○ considerable tissue loss
○ edges cannot or should not be approximated
○ Ex: pressure injury
Secondary differs from primary intention healing:
1. repair time is longer
2. scarring is greater
3. susceptibility to infection is greater
Wounds that are left open for 3 to 5 days
● allow edema or infection to resolve
● exudate to drain and are then closed
● for tertiary intention healing - delayed primary intention.
PHASES OF WOUND HEALING
● same for all wounds but rate & extent of depend on factors
○ type of healing, location & size, health of client
INFLAMMATORY PHASE
immediately after injury and lasts 3 to 6 days.
Hemostasis (the cessation of bleeding)
● fr vasoconstriction of larger blood vessels in affected area
● retraction (drawing back) of injured blood vessels
● deposition of fibrin (connective tissue)
● formation of blood clots in the area.
○ matrix of fibrin - framework for cell repair.
○ scab - clots and dead and dying tissue
■ hemostasis and inhibit contamination
of wound by microorganisms.
● Below scab = epithelial cells migrate → wound from edges.
○ barrier between body and environment
● In inflammatory phase - blood supply to wound increases
○ bringing oxygen and nutrients
○ appears reddened and edematous
Phagocytosis
 ● Exudate of fluid and cell debris - helps cleanse the wound.
○ lasts 1 to 3 days
● Overproduction = impair wound healing
● @ cell migration, neutrophils → interstitial space
○ replaced 24 hours after injury by macrophages.
■ engulf microorganisms and cellular
debris
○ secrete angiogenesis factor - stimulates
formation of epithelial buds at end of injured BVs
● microcirculatory network that results = sustains healing
PROLIFERATIVE PHASE
day 3 or 4 to about day 21 postinjury.
● Fibroblasts migrate into wound starting about 24 hours
after injury → synthesize collagen.
● Collagen - adds tensile strength to the wound.
○ If wound is sutured, raised “healing ridge”
appears under intact suture line.
○ If not sutured, new collagen is visible.
● Capillaries grow across the wound - inc. blood supply.
○ Fibroblasts move from bloodstream → wound
■ depositing fibrin
● capillary network develops = tissue → granulation tissue
○ fragile and bleeds easily
○ matured = marginal epithelial cells migrate to it
■ proliferating over connective tissue
base to fill wound.
● If wound does not close by epithelialization = area is
covered with dried plasma proteins and dead cells.
○ called eschar
● wounds healing by secondary intention seep blood-tinged
(serosanguineous) drainage.
○ if not covered by epithelial cells → covered w
thick, gray, fibrinous tissue → dense scar tissue.
MATURATION PHASE
day 21 and can extend 1 or 2 years after the injury.
● Fibroblasts synthesize collagen
● wound is remodeled and contracted
● scar - stronger but area is never as strong as og tissue.
○ can result in a hypertrophic scar, or keloid.
TYPES OF WOUND EXUDATE
material escaped from blood vessels during inflammatory process
● deposited in tissue or on tissue surfaces
● nature and amount of exudate vary according to
○ tissue involved
○ intensity and duration of the inflammation
○ presence of microorganisms
3 major types of exudate are serous, purulent, and sanguineous
1. serous exudate - consists of serum (clear portion of the blood).
● It looks watery and has few cells.
● Ex: fluid in a blister from a burn.
2. purulent exudate - thicker than serous exudate
● presence of pus
○ leukocytes, liquefied dead tissue debris, and
dead and living bacteria.
● process of pus formation - suppuration.
● vary in color depending on the causative organism.
○ Yellow, green, tan, brown
3. sanguineous exudate - large amounts of red blood cells
● indicate damage to capillaries
○ severe - allow escape of RBCs fr plasma.
● seen in open wounds.
● Bright red, active bleeding
Mixed types of exudates are often observed.
● serosanguineous exudate = clear and blood tinged
drainage → in surgical incisions.
○ Pale, red watery
● purosanguineous discharge = pus and blood → new
wound infected.
COMPLICATIONS OF WOUND HEALING
HEMORRHAGE
dislodged clot, slipped stitch, or erosion of a blood vessel
● Internal hemorrhaging - detected by swelling or distention
○ sanguineous drainage fr a surgical drain.
○ Hematoma may be present - localized collection
of blood under the skin
■ reddish blue swelling (bruise).
■ large hematoma - places pressure on
BVs + other structures → obstruct flow
● risk of hemorrhage - greatest @ 48 hours after surgery.
● apply pressure dressings to wound & monitor client’s VS.
INFECTION
● Contamination - colonizing organisms
○ compete w new cells for oxygen and nutrition
○ by-products interfere w healthy surface condition
○ impair wound healing → infection.
● Infection - change in wound color, pain, odor, or drainage
○ confirmed by performing a culture of the wound
● Severe infection - fever + elevated white blood cell count.
● wound can be infected with microorganisms at the time of
injury, during surgery, or postoperatively.
○ Surgery involving the intestines = infection from
microorganisms inside the intestine.
○ Surgical infection - apparent 2 to 11 days
postoperatively
DEHISCENCE WITH POSSIBLE EVISCERATION
Dehiscence - partial or total rupturing of a sutured wound.
● involves abdominal wound = layers below skin separate.
● obesity, poor nutrition, multiple trauma, failure of suturing,
excessive coughing, vomiting, and dehydration
○ Sudden straining - coughing or sneezing
○ feel that “something has given way.
● occur 4 to 5 days postoperatively before extensive
collagen is deposited in wound.
Evisceration - protrusion of internal organs through an incision.
What to do when this happens
● wound should be quickly supported by large sterile
dressings soaked in sterile normal saline.
● Place client in bed w knees bent
○ decrease pull on the incision.
● surgeon must be notified immediately
Possible complications: formation of a fistula
● connection b/n any two organs or surfaces
● when surgery involves GI system and pathway evolves b/n
internal surgical site and wound and skin.
● contents drain thru fistula → skin surface = impair healing
● Treatment and care
○ protection of the surrounding skin
○ dressings appropriate to type and loc. of fistula.
FACTORS AFFECTING WOUND HEALING
DEVELOPMENTAL CONSIDERATIONS
● children and adults - heal quicker than older adults
○ reduced liver function - impair the synthesis of
blood clotting factors.
NUTRITION
● Wound healing places additional demands on the body
○ diet rich in protein, carbohydrates, lipids,
vitamins A and C, minerals, (iron, zinc, copper)
● Malnourished clients - require time to improve nutritional
status before surgery.
● Obese clients - increased risk of wound infection and
slower healing
○ adipose tissue has minimal blood supply
LIFESTYLE
● exercise regularly - good circulation
○ blood brings oxygen and nourishment to wound
● Smoking reduces functional hemoglobin in the blood
○ limiting oxygen-carrying capacity of blood
○ constricts arterioles
MEDICATIONS
● Anti-inflammatory drugs (e.g., steroids and aspirin) and
antineoplastic agents interfere with healing.
 ● Prolonged antibiotics - client susceptible to wound infection
by resistant organisms
NURSING MANAGEMENT
ASSESSING
SKIN INTEGRITY
Removing barriers to assessment is very important.
● Antiembolic stockings, braces, or devices
NHH
● skin diseases, previous bruising, general skin condition,
skin lesions, and usual healing of sores.
● Inspection and palpation
○ skin color distribution, turgor, presence of
edema, and characteristics of lesions
● skin condition in areas most likely to break down:
○ skinfolds - under the breasts
○ frequently moist - perineum
○ receive extensive pressure - bony prominences
ASSESSMENT WOUNDS
assess both untreated and treated wounds
Untreated - seen shortly after an injury
Treated - assessed to determine the progress of healing
● inspected during changing of a dressing
○ If wound can’t be inspected = dressing inspected
● Dressings - ensure they are clean, dry, and intact.
● Excessive drainage - hemorrhage, infection, open wound.
○ describe degree to which dressing is saturated.
■ Minimal - only stains dressing
■ moderate - saturate dressing w/o leak
prior to scheduled dressing change
■ heavy - overflows dressing prior to
scheduled changes.
● wound may extend under the skin surface = undermining
○ edges of wound around an open center may be
raw or appear healed
○ undermining = sinus tract or tunnel that extends
wound beyond the main wound surface.
○ To fully assess the size of the wound = explores
undermined area with a sterile swab.
○ depth - place second swab parallel to first
■ measure distance fr edge of wound to
tip of exposed swab
● Sinus tracts - caused by infection
○ significant drainage
○ Treat w antibiotics, irrigation, surgical incision to
open and drain tract, or negative pressure
therapy for large tracts.
PRESSURE INJURIES
note the following:
● Location of injury, related to a bony prominence.
● Size of injury in centimeters.
○ greatest length, width, and depth.
● Presence of undermining or sinus tracts, location
described by position on clock, 12 o’clock as client’s head.
● Stage of the injury
● Color of wound bed and location of necrosis (dead tissue)
or eschar.
● Condition of wound margins.
● Integrity of surrounding skin.
● Clinical signs of infection
○ redness, warmth, swelling, pain, odor, and
exudate
documenting wound size and shape
● Use disposable wound measuring guides
● For irregularly shaped wounds = use two layers of
transparent film
○ trace wound margins on top layer
○ discard bottom layer that came in contact w
wound.
● To measure area on a curved portion of the body = use a
flexible measure
● Electronic devices = improved determination of total wound
area
Document status of skin and wounds
● determine how these change over time.
● Pressure Ulcer Scale for Healing (PUSH) tool created by
National Pressure Ulcer Advisory Panel (NPUAP)
○ assigns scores to injury length, width, amount of
exudate, and tissue type.
○ change in total score over time = indication of
healing
LABORATORY DATA
support nurse’s clinical assessment of wound’s progress in healing.
● dec. leukocyte
○ delay healing & inc. possibility of infection
● hemoglobin level below normal range
○ poor oxygen delivery to tissues
● Blood coagulation - prolonged
○ excessive blood loss
○ prolonged clot absorption
● Hypercoagulability
○ intravascular clotting
○ deficient blood supply to wound area
● Serum protein analysis
○ indicate nutritional reserves for rebuilding cells
● Albumin
○ indicator of nutritional status.
○ < 3.5 g/dL - poor nutrition
○ increase the risk of poor healing and infection.
DIAGNOSIS
● potential for developing pressure injury
● actual, or potential for developing, altered skin integrity
Risk for Pressure Ulcer:
● vulnerable to localized injury to skin / underlying tissue
● usually over a bony prominence
● result of pressure, or pressure in combination with shear
Risk for Impaired Skin Integrity:
● vulnerable to alteration in epidermis and/or dermis
Impaired Skin Integrity:
● altered epidermis and/or dermis
● applies to pressure ulcers and wounds extending through
the epidermis but not through the dermis.
Impaired Tissue Integrity:
● damage to mucous membrane, cornea, integumentary
system, muscular fascia, muscle, tendon, bone, cartilage,
joint capsule, and/or ligament
Additional Ndx:
● clients with existing impaired skin or tissue integrity.
● Risk for Infection:
○ skin impairment is severe
○ client is immunosuppressed, or wound is
caused by trauma
● Acute Pain:
○ nerve involvement w/in tissue impairment or as a
consequence of procedures to treat wound.
PLANNING
● goals for risk for pressure injury development
○ maintain skin integrity
○ avoid potential associated risks
IMPLEMENTING
● preventing pressure injuries and MASD
● treating, cleaning, dressing wounds
● removing staples or sutures
● applying heat and cold
PREVENTING PRESSURE INJURIES AND MASD
● identifying clients at risk and implementing prevention
strategies
● pressure injury admission assessment for all clients
○ reassesses risk for all hospitalized clients daily.
● For clients at risk
○ optimizes nutrition and hydration
 ○ inspects skin daily
○ minimizes pressure
○ manage moisture - keep client dry + moisturize
skin
PROVIDING NUTRITION
calories, protein, vitamins, and iron
● Monitor weight regularly - assess nutritional status.
● Pertinent laboratory work
○ lymphocyte count, protein (albumin), hemoglobin
MAINTAINING SKIN HYGIENE
● Obtain baseline data then reassess the skin at least daily
in the hospital and weekly at home.
● When bathing the client = minimize force and friction
○ mild cleansing agents = minimize irritation and
dryness, do not disrupt skin’s “natural barriers.”
○ avoid hot water = inc. dryness and irritation
■ minimize dryness by avoiding
exposure to cold and low humidity.
● skin = clean and dry and free of irritation and maceration
by urine, feces, sweat, or incomplete drying after a bath.
Apply skin protection if indicated.
● Dimethicone-based creams or alcohol-free barrier films
○ prevent moisture/drainage fr collecting on skin.
○ apply without a primary care provider’s order.
AVOIDING SKIN TRAUMA
● smooth, firm, and wrinkle free foundation
● clients positioned, transferred, and turned correctly
○ prevent injury due to friction and shearing forces.
○ For bedridden clients = shearing force reduced
by elevating head of bed to no more than 30°
● When the head of the bed is raised, the skin and
superficial fascia stick to the bed linen while the deep
fascia and skeleton slide down toward the bottom of the
bed. As a result, blood vessels in the sacral area become
twisted, and the tissues in the area can become ischemic
and necrotic.
● Baby powder & cornstarch = never for friction/moisture
prevention.
○ harmful abrasive grit = damaging to tissues
○ respiratory hazard when airborne.
○ Instead, use moisturizing creams and protective
films (transparent dressings + alcohol-free
barrier films)
● Frequent shifts in position
○ Shift weight 10° to 15° every 15 to 30 minutes
and, whenever possible
○ exercise or ambulate to stimulate blood
circulation.
● using devices or lift team to lift the client
○ weight off the bed surface method
■ prevent back injuries to nurses.
● Any at-risk client confined to bed - repositioned at least
every 2 hours
○ allow another body surface to bear the weight.
○ Six body positions can usually be used: prone,
supine, right and left lateral (side-lying), and right
and left Sims positions.
■ lateral position - avoid positioning the
client directly on trochanter and
instead position client on a 30° angle.
● written schedule for turning and repositioning.
● massage over bony prominences should be avoided.
○ massage to stimulate blood circulation =
preventing pressure injuries.
PROVIDING SUPPORTIVE DEVICES
For clients on bedrest support surfaces = relieve pressure
● overlay mattress - applied on top of the standard bed
mattress. A replacement mattress is used instead of the
standard mattress; most are made of foam and gel
combinations. Specialty beds replace hospital beds. They
provide pressure relief, eliminate shearing and friction, and
decrease moisture.
● Examples are high-air-loss beds, low-air-loss beds, and
beds that provide kinetic therapy. Kinetic beds provide
continuous passive motion or oscillation therapy, which is
intended to counteract the effects of a client’s immobility..
● When a client is confined to bed or a chair, pressure
reducing devices, such as pillows made of foam, gel, air, or
a combination of these, can be used. When the client is
sitting, weight should be distributed over the entire seating
surface so that pressure does not center on just one area.
● To protect a client’s heels in bed, supports such as wedges
or pillows can be used to raise the heels completely off the
bed. Doughnut-type devices should not be used since they
limit blood flow and can cause tissue damage to the areas
in direct contact with the device.
TREATING WOUNDS
Pressure injuries, MASD, and IAD
RYB COLOR CODE
protect (cover) red
● usually in late regeneration phase of tissue repair (i.e.,
developing granulation tissue)
● need to protect to avoid disturbance to regenerating tissue.
○ gentle cleansing
○ protecting periwound w alcohol-free barrier film
○ filling dead space w hydrogel or alginate;
○ covering w an appropriate dressing
○ changing dressing as infrequently as possible.
cleanse yellow
● liquid to semiliquid “slough”
● accompanied by purulent drainage or previous infection.
● nurse cleanses yellow wounds to remove nonviable tissue.
○ applying damp-to-damp normal saline dressings
○ irrigating the wound
○ using absorbent dressing materials
○ consulting w primary care provider abt need for
topical antimicrobial = minimize bacterial growth.
debride black
● covered with thick necrotic tissue, or eschar.
● stable black wound - firm surface
○ left in place
○ Blood flow in tissue under = poor
○ wound is susceptible to infection
○ Eschar - natural barrier to infection by keeping
bacteria from entering wound.
● unstable black wound - loose, spongy, soft surface
○ removed thru debridement for healing
Debridement - achieved in four different ways: sharp, mechanical,
chemical, and autolytic.
● Sharp - scalpel/scissors to separate & remove dead tissue.
● Mechanical - scrubbing force or damp-to-damp dressings.
● Chemical - more selective than sharp or mechanical
○ Collagenase enzyme agents - papain urea
● Autolytic debridement, dressings such as hydrocolloid and
clear absorbent acrylic dressings trap the wound drainage
against the eschar.
● The body’s own enzymes in the drainage break down the
necrotic tissue. Although this method takes longer than the
other three, it is the most selective and therefore causes
the least damage to healthy surrounding and healing
tissues. The use of fly larvae (maggots, Phaenicia sericata
and other species) can be extremely effective in cleansing
chronic wounds because the maggots secrete enzymes
that break down necrotic tissue (while leaving healthy
tissue untouched), eat bacteria, and decrease bacterial
growth through the rise in surface pH that results from their
presence
CLEANING WOUNDS
● removal of debris - foreign materials, excess slough,
necrotic tissue, bacteria, and other microorganisms.
CLEANING SURGICAL WOUNDS
Surgical drains
● permit drainage of excessive serosanguinous fluid and
purulent material
● promote healing of underlying tissues.
 ● inserted and sutured through the incision line,
○ commonly inserted through stab wounds a few
centimeters away from incision line
■ so incision itself may be kept dry.
● Without a drain, some wounds would heal on surface and
trap the discharge inside
○ abscess might form
● have an open end that drains onto a dressing
● main surgical incision is considered cleaner than surgical
stab wound made for drain insertion.
○ main incision is cleaned first
WOUND DRAINAGE SYSTEMS
● A closed wound drainage system consists of a drain
connected to either an electric suction or a portable
drainage suction, such as a Hemovac or Jackson-Pratt
● The closed system reduces the potential entry of
microorganisms into the wound through the drain.
● The drainage tubes are sutured in place and connected to
a reservoir.
○ For example, the Jackson-Pratt drainage tube is
connected to a reservoir that maintains constant
low suction.
● These portable wound suctions also provide for accurate
measurement of the drainage.
● The surgeon inserts the wound drainage tube during
surgery.
● Generally the suction is discontinued 3 to 5 days
postoperatively or when the drainage is minimal.
● When emptying the container, the nurse should wear
gloves and avoid touching the drainage port
● To reestablish suction, the nurse places the container on a
solid, flat surface with the port open, and cleanses the
opening and plug with an alcohol swab.
● The palm of one hand then presses the top and bottom
together while the other hand replaces the drainage plug
before releasing hand pressure to reestablish the vacuum
necessary for the closed drainage system to work
WOUND IRRIGATION AND PACKING
● An irrigation (lavage) is the washing or flushing out of an
area.
● Sterile technique is required for a wound irrigation
because there is a break in the skin integrity.
● Irrigation pressures should range from 4 to 15 pounds per
square inch (psi).
○ Below 4 psi, such as when using a bulb syringe,
the irrigation may not be effective, and above 15
psi it may damage tissues.
○ A 30- to 60-mL piston syringe with a 19-gauge
needle or catheter provides approximately 8 psi.
○ Using piston syringes instead of bulb syringes to
irrigate a wound also reduces the risk of
aspirating drainage.
● Commercially prepared normal saline irrigation is available
in pump spray, aerosol cans, and prefilled, single-dose
plastic vials called bullets.
● For deep wounds with small openings, a sterile straight
catheter may also be necessary.
● Frequently used irrigation solutions are sterile normal
saline, lactated Ringer’s solution, and antibiotic solutions.
DRESSING WOUNDS
● Protect wound from mechanical injury
● Protect wound from microbial contamination
● provide or maintain moist wound healing
● provide thermal insulation
● absorb drainage or debride a wound or both
● prevent hemorrhage (when applied as pressure dressing
or with elastic bandages)
● splint or immobilize wound site = healing, prevent injury.
Gauze packing
● damp-to-damp technique - wounds requiring debridement
● moist 4*4 non–cotton-filled gauzes are packed in wound to
absorb exudate
○ not allowed to dry before removal.
Negative pressure wound therapy or vacuum assisted closure (VAC)
wound VAC, vacuum sealing, and topical negative pressure
● suction equipment = apply (-) pressure to wound types.
● speed tissue generation
● reduce swelling around the wound
● enhance wound healing - moist and protected env.
● Sterile foam sponges placed into a clean wound and
covered with a transparent adhesive drape
○ hole cut in drape = allow insertion of vacuum
tubing.
○ applied for almost 24 hours each day
TYPES OF DRESSINGS
● location, size, and type of the wound
● amount of exudate
● whether the wound requires debridement or is infected
● frequency of dressing change, ease or difficulty of dressing
application, and cost
TRANSPARENT
wounds including ulcerated or burned skin areas.
(+)
● act as temporary skin
● nonporous, nonabsorbent, self-adhesive - do not require
changing
○ often left in place until healing
● wound can be assessed through them
● Semiocclusive = wound remains moist and can retain a
small amount of serous exudate
○ promotes epithelial growth, hastens healing, and
reduces risk of infection.
● Elastic = placed over a joint w/o disrupting client’s mobility.
● adhere only to the skin area around wound and not to the
wound itself = keep the wound moist.
● allow client to bathe without removing the dressing
HYDROCOLLOID
used over pressure injuries.
(+)
● last 3 to 7 days
● do not need a “cover” dressing = water resistant
● can be molded to uneven body surfaces.
● act as temporary skin - bacterial barrier.
● decrease pain = reduce the need for analgesics.
● absorb moderate drainage - on slowly draining wounds
● contain wound odor
(-)
● occlusive, opaque, and obscure wound visibility.
● limited absorption capacity
● facilitate anaerobic bacterial growth.
● soften and wrinkle at edges with wear and movement.
● difficult to remove and may leave a residue on the skin.
● not be used for infected wounds / w deep tracts or fistulas.
SECURING
1. Place tape so that dressing cannot be folded back to
expose the wound.
● Place strips at ends of dressing
● space tapes evenly in the middle.
2. Ensure that tape is long and wide enough to adhere to
several inches of skin on each side of the dressing
3. Place the tape in opposite direction from the body action
● Ex: across a body joint or crease, not lengthwise
Montgomery straps (tie tapes)
● for wounds requiring frequent dressing changes
● prevent skin irritation and discomfort caused by removing
adhesive each time dressing is changed.
Medical tape
● can cause injuries if used incorrectly.
● Blisters form
○ if too much tension is applied while placing tape,
○ edema has collected after tape was placed
○ alcohol or benzoic-based prep solutions used
under the tape.
SUTURES AND STAPLES
suture - thread used to sew body tissues together.
 ● used to attach tissues beneath the skin
● made of absorbable material - disappears in several days
Skin sutures
● made of a variety of nonabsorbable materials - silk, cotton,
linen, wire, nylon, and Dacron (polyester fiber).
○ Wire clips or staples are also available.
● sutures and staples are removed 7 - 10 days after surgery.
● Types:
1. interrupted - each stitch tied & knotted
separately
2. continuous - one thread runs in a series of
stitches, tied only at beginning and end of run
Retention sutures
● used in addition to skin sutures for some incisions
● attach underlying tissues of fat and muscle as well as skin
● used to support incisions
○ Obese individuals or healing is prolonged.
● left in place longer than skin sutures (14 to 21 days).
● To prevent from irritating the incision
○ surgeon may place tubing over them or a roll of
gauze under them extending down incision line.
The primary care provider orders the removal of sutures.
● Sterile technique & special suture scissors
○ scissors - short, curved cutting tip that readily
slides under the suture
○ Wire clips or staples - removed with a special
instrument that squeezes the center of the clip to
remove it from the skin
Guidelines for removing sutures and staples follow:
● Before removing skin sutures, verify
○ orders for suture removal
■ only alternate sutures are removed
one day, remaining sutures are
removed a day or two later
○ If dressing is applied following suture removal.
● Inform Client that suture removal may prod discomfort.
● Remove dressings
clean the incision in accordance with agency protocol.
● Cleaning the suture line with an antimicrobial solution
before and after suture removal may help prevent infection.
● Apply gloves.
Remove sutures as follows:
● Grasp suture at the knot with a pair of forceps or hemostat.
● Place the curved tip of the suture scissors under suture as
close to the skin as possible
○ either on side opposite knot / directly under knot
○ Cut suture.
■ as close to skin as possible on one
side of visible part
■ suture material visible to eye is in
contact w resident bacteria of the skin
● must not be pulled beneath
the skin during removal.
● Pull suture out in one piece.
○ Inspect suture carefully to make sure that all
suture material is removed.
○ Suture material left beneath skin acts as a
foreign body and causes inflammation.
Discard suture onto piece of sterile gauze or into moisture-proof bag,
● careful not to contaminate the instrument tips.
Remove staples as follows:
● Remove dressings and clean incision.
● Place the lower tips of a sterile surgical staple remover
under the staple.
● Squeeze handles together until they are completely closed
○ Pressing handles together causes the staple to
bend in the middle
○ pulls edges of the staple out of the skin
○ Don’t lift staple remover when squeezing handle
● When both ends of staple are visible, gently move staple
away from the incision site.
● Hold staple remover over a disposable container and
release staple remover handles, which releases the staple.
Continue to remove every other suture or staple, that is, the third,
fifth, seventh, and so forth.
○ Alternates are removed = remaining sutures
keep skin edges in close approximation
● If no dehiscence occurs, remove the remaining sutures or
staples. If dehiscence does occur, do not remove the
remaining sutures, and report to the nurse in charge
● Some primary care providers order reinforced bandage
strips (known as Steri-Strips or butterfly closures) to
provide additional support to the healing wound. If ordered
by the primary care provider, apply them to the wound after
removing the sutures or staples.
Reapply a dressing, if indicated.
Document the suture or staple removal
● number removed; appearance of the incision; application
of a dressing, bandage, or tape; client teaching; client
tolerance of the procedure
BANDAGING AND BINDERS
● Supporting a wound (fractured bone)
● Immobilizing a wound (strained shoulder)
● Applying pressure (elastic bandages - lower extremities to
improve venous blood flow)
● Securing a dressing (extensive abdominal surgical wound)
● Retaining warmth (flannel bandage on a rheumatoid joint)
BANDAGES
Gauze
● light and porous
● readily molds to the body
● used to retain dressings on wounds
● fingers, hands, toes, and feet.
● supports dressings and permits air to circulate
● can be impregnated with petroleum jelly or other
medications for application to wounds.
Elasticized bandages
● provide pressure to an area.
● provide support and improve the venous circulation in legs.
● width of the bandage depends on size of body part
Padding
● cover bony prominences (elbow)
● separate skin surfaces (fingers) before bandaging.
BASIC TURNS FOR ROLLER BANDAGES
● Circular turns - anchor bandages and to terminate them.
○ not applied directly over a wound
● Spiral turns - parts of body that are fairly uniform in
circumference
● Recurrent turns - distal parts of the body
● Figure-eight turns - elbow, knee, or ankle
○ permit some movement after application
CIRCULAR TURNS
● Hold the bandage in your dominant hand, keeping roll
uppermost, and unroll 8 cm (3 in.)
○ allows good control for placement and tension.
● Apply the end of the bandage to the part of the body to be
bandaged.
○ Hold end down with the thumb of the other hand
● Encircle body part a few times or as often as needed,
○ make sure that each layer overlaps one-half to
two thirds of the previous layer.
■ even support the area.
● the bandage should be firm, but not too tight.
○ tight bandage - interfere with circulation
○ loose bandage - no adequate protection.
● Secure end of the bandage with tape/clips, Velcro fastener.
SPIRAL TURNS
● Make two circular turns to anchor the bandage.
● Continue spiral turns at a 30° angle
○ each turn overlapping preceding one by
two-thirds the width of the bandage
● Secure end as described for circular turns.
RECURRENT TURNS
● Anchor bandage with two circular turns.
● Fold bandage back on itself → bring it centrally over the
distal end to be bandaged.
● Bring bandage back over end to right of center bandage
○ overlapping it by two-thirds width of bandage.
 ● Bring bandage back on left side - overlapping first turn by
two-thirds width of the bandage.
● Continue the pattern of alternating right and left until the
area is covered.
○ Overlap preceding turn by two thirds the
bandage width each time.
● Terminate bandage w two circular turns and secure end
FIGURE-8 TURNS
Anchor the bandage with two circular turns.
● Carry bandage above joint, around it, and then below it,
● Continue above and below the joint, overlapping the
previous turn by two-thirds width of bandage.
● Terminate bandage above joint with two circular turns, and
then secure the end appropriately
BINDERS
designed for a specific body part
● Ex: triangular binder (sling) fits the arm.
● support large areas of the body
● Commercial binders - hook-and-loop (Velcro) binder
○ easier to use, expensive, and less modifiable
ARM SLING
Ask client to flex elbow to 80° angle or less
● the thumb should be facing upward or inward toward the
body.
● 80° angle = support the forearm, prevent swelling of hand,
and relieve pressure on the shoulder joint
a more acute angle is preferred if there is swelling of the hand.
● triangle sling = place one end of unfolded binder over the
shoulder of uninjured side
○ binder falls down front of chest
○ triangle (apex) under elbow of injured side.
● Take the upper corner, and carry it around the neck until it
hangs over the shoulder on the injured side.
● Bring the lower corner of the binder up over the arm to
shoulder of the injured side.
○ square knot to secure this corner to upper corner
at the side of the neck on the injured side
■ the square knot will not slip.
○ Tying knot at side of the neck prevents pressure
on bony prominences of vertebral column
● Fold sling neatly at elbow, secure it with safety pins or tape
● If commercial sling is used = include second strap that
goes around back of client’s chest from finger end of the
sling to the elbow
○ strap holds the arm close to the body
○ shoulder immobilization
● Make sure the wrist is supported = maintain alignment.
● Remove the sling periodically = inspect skin for indications
of irritation
STRAIGHT ABDOMINAL BINDER
● Place binder smoothly around body
○ commonly w upper border of binder at waist and
lower border at level of the gluteal fold.
○ If over waist = interferes w respiration
○ If too low = interferes w elimination & walking.
● Apply padding over iliac crests if the client is thin.
● Bring ends around the client, overlap them, and secure
them with pins, clips, or Velcro
○ orient pins horizontally - comfort when bending
HEAT AND COLD APPLICATIONS
LOCAL EFFECTS OF HEAT
● remedy for aches and pains
● causes vasodilation and increases blood flow
○ bring O2, nutrients, antibodies, and leukocytes.
● promotes soft tissue healing and increases suppuration.
● disadvantage
○ increases capillary permeability = ECF and
plasma proteins pass through the capillary walls
○ edema or an increase in preexisting edema.
● used for clients w musculoskeletal problems
○ joint stiffness (arthritis), contractures, l. back pain
LOCAL EFFECTS OF COLD
● causes vasoconstriction
● reduces blood flow
○ reduces the supply of oxygen and metabolites
○ decreases the removal of wastes
○ produces skin pallor and coolness
● Prolonged exposure
○ impaired circulation
○ cell deprivation
○ damage tissues - lack of oxygen & nourishment
● for sports injuries to limit post injury swelling and bleeding.
THERMAL TOLERANCE
Specific conditions necessitate precautions in use of hot/cold
● Neurosensory impairment
○ risk for burns
○ can’t perceive discomfort from cold & tissue
injury.
● Impaired mental status
○ confused or altered level of consciousness
● Impaired circulation
○ peripheral vascular disease, diabetes, or
congestive heart failure
○ lack normal ability to dissipate heat via blood
circulation → risk for tissue damage w heat and
cold applications.
● Immediately after injury or surgery
○ Heat increases bleeding and swelling.
● Open wounds
○ Cold - dec. BF to wound = inhibiting healing
REBOUND PHENOMENON
occurs at time of maximum therapeutic effect of hot or cold
application is achieved and opposite effect begins.
● Ex: heat prod maximum vasodilation in 20 to 30 minutes
○ continuation of application beyond 30 minutes =
tissue congestion → blood vessels constrict.
○ If heat application is continued = risk for burns
■ constricted blood vessels are unable
to dissipate heat adequately via blood
circulation.
● Ex: cold applications, max vasoconstriction at 15°C (60°F).
○ Below 15°C, vasodilation begins.
○ protective: prevent freezing of body tissues
exposed to cold
○ Continued cold = alternating vasodilation and
vasoconstriction (Lewis Hunting effect)
APPLYING HEAT AND COLD
Heat - dry and moist forms
1. Dry heat - hot water bottle, aquathermia pad, disposable
heat pack, or electric pad.
2. Moist heat - compress, hot pack, soak, or sitz bath.
3. Dry cold - cold pack, ice bag, ice glove, or ice collar.
● continuous cold therapy (cryotherapy) following
joint surgery/injury = cooling unit like
aquathermia pad.
4. Moist cold - compress or a cooling sponge bath
Guidelines:
● Determine client’s ability to tolerate the therapy.
● Identify conditions that might contraindicate treatment
○ bleeding, circulatory impairment
● Explain application to the client.
● Assess the skin area where heat or cold will be applied.
● Ask the client to report any discomfort.
● Return to the client 15 minutes after = observe skin area.
● Remove the equipment
● Examine the area and record the client’s response.
AQUATHERMIA PAD
constructed with tubes containing water.
● attached to electrically powered control unit
● Has opening for water and temperature gauge
● May have an absorbent surface
○ moist heat can be applied
 ● other surface of the pad is waterproof - disposable
Application:
● Fill reservoir unit two-thirds full of water
○ Set the desired temperature
● Cover pad and plug in the unit.
○ Check for leaks or malfunctions before use.
● Apply pad to body part
○ 30 minutes
● Use tape or gauze ties to hold the pad in place.
● If unusual redness or pain occurs, discontinue treatment,
and report the client's reaction.
ELECTRIC HEATING PAD
constant, even heat, are lightweight, and can be molded to body
parts.
● Electric pads - can burn clients if the setting is too high.
Guidelines:
● Do not insert sharp objects (e.g., pins) into the pad.
○ pin could damage a wire = electric shock
● Ensure that the body area is dry unless there is a
waterproof cover on the pad.
● Do not place the pad under the client
○ Heat will not dissipate = client may be burned
ICE BAGS, ICE GLOVES AND ICE COLLARS
filled with ice chips or alcohol-based solution
● provide cold to a localized area
COMPRESSES
either warm or cold
● moist gauze dressing applied to a wound or injury
SOAKS
● skin status over bony prominences
● nutritional and fluid intake
● mental status
● signs of healing if an injury is present
Determine whether:
● Etiology of skin impairment was addressed
● Wound healing was supported by provision of wound base
w moist protected environment
● Nutritional assessment
If outcomes are not achieved
● Has the client’s physical condition changed?
● Were risk factors correctly identified?
● Were appropriate devices and techniques used?
● Was the client unable to comply with instructions about
moving and turning? Why?
● Were appropriate pressure-relieving devices used, and
were they applied correctly?
● Was the repositioning schedule adhered to?
● Are the client’s nutritional and fluid intake adequate?
● Were appropriate measures used to control incontinence
and protect the client’s skin?
● Was the wound supported and immobilized effectively?
● Were stringent aseptic practices implemented when
cleaning and changing dressings to prevent infection?
● Was the client receiving antineoplastic or anti-inflammatory
medications that interfere with healing?
● Was nonviable tissue removed by autolytic, chemical,
mechanical, or surgical debridement?
● Was the appropriate dressing applied to maintain moist
wound healing or absorb excess drainage?

immersing body parts in solution or wrapping in gauze dressings and

then saturating with solution.
● Sterile technique for open wounds
● Hot soaks - soften and remove encrusted secretions and
dead tissue.
SITZ BATHS

soak a client’s perineal or rectal area

● temperature from 40°C to 43°C (104°F to 110°F)
● duration of the bath is generally 20 minutes
steps to provide a sitz bath:
● Assist clients into baths.
○ support feet = prevent pressure on back of thigh
● Provide a bath blanket for the client's shoulders, and
eliminate drafts to prevent chilling.
● Observe for signs of faintness, dizziness, weakness,
accelerated pulse rate, and pallor.
● Maintain water temperature.
● Following the bath, assist the client out and help the client
to dry.
COOLING SPONGE BATHS

reduce a client’s fever - heat loss thru conduction and vaporization.

● only for clients w very high temperatures < 40°C (104°F),
○ rapid skin temperature drop = chills → increase
heat production.
● bath is accompanied by antipyretic medication
○ reset the hypothalamus set point.
● temperatures 27°C to 37°C (80°F to 98°F).
Application:
● Sponge face, arms, legs, back, and buttocks.
● Leave each area wet and cover with a damp towel.
● Place ice bags and cold packs on the forehead for comfort
and in each axilla and at the groin.
○ areas contain large superficial BVs that help
transfer of heat.
● Sponge one body part and then another.
○ 30 minutes
● Discontinue - pale/cyanotic/shivers, pulse rapid or irregular
● Reassess VS at 15 minutes and after completing the bath.

EVALUATION
use data collected during care