Unit six

Nutrition and Metabolism

Fundamental course
 Fluid, Electrolyte, and Acid-base balance

• BODY FLUID- denotes both water and electrolytes.

• HOMEOSTASIS- refers to state of balance of body fluid
or equilibrium of the internal environment.
• FLUID BALANCE- is when water coming into the body
precisely equals the water being lost by the body each
day.
• ELECTROLYTE BALANCE- gains and losses of electrolytes
are equal.
• ACID-BASE BALANCE- when the production of H+ is
precisely offset H+ loss and/ HCO3- production.
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 Physiology of fluid and acid-base balance
 FLUID COMPARTMENTS
Three compartments for body fluid
- cells
- blood vessels
- tissue space ( space between the cells and
blood vessels):
Compartmentalized body fluid
- intracellular fluid – within the cell. 2/3 of body fluid
- intravascular fluid- within blood vessels.
- ¼ or 20% of ECF
- interstitial fluid – between cells (fluid that surrounds cells).
- ¾ or 80% of ECF 3
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 Types of body fluid
• Generally there are two types of fluids:
- Intracellular fluid
- Extracellular fluid ( includes intravascular and
interstitial fluid)- fluid is outside the cell.

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Key terms explaining movement of molecules
in body fluids
• Solute: substance dissolved in a solution
• Solvent: liquid that contains a substance in
solution
• Permeability: capability of a substance,
molecule, or ion to diffuse through a
membrane
• Semi permeable: selectively permeable

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 Body water distribution
• Water is the largest single constituent of the
body
o 45%-75% of the body’s total weight
• Main functions of water
- act as a solvent for the essential nutrients,
- transport nutrients and oxygen from blood to
cells and remove waste material and other
substance from the cells back to blood to be
exreted .
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What are functions

of water?
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 Function of water
• Give shape and form to the cells
• Regulate body temperature
• Act as a lubricant in joints
• Cushion body organs
• Maintain peak physical performance

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 Factors that affect Fluid and Electrolyte
Movement
• Membranes
• Osmosis
• Diffusion
• Facilitated diffusion
• Active transport
• Hydrostatic pressure
• Oncotic pressure

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 Membrane physiology
• Each of the fluid compartments are separated by
specific permeable membranes.
• Allow the movement of water and some solutes
• Permeability is selective; the composition of each
compartment maintains its own unique composition
• Specific permeable membranes include:-
- cell membranes – separates intracellular fluid
from interstitial and are composed of lipids and
proteins.

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• Capillary membranes:- separate intravascular
fluid from interstitial fluid
• Epithelial membranes:- separate interstitial
fluid and intravascular fluid from trans cellular
fluid - is the portion of total body water
contained within epithelial lined spaces.

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 Transport system
• Movement of water and solutes is determined
by:-
- osmosis
- diffusion
- active transport
- filtration

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 Osmosis
• Is passage of solvent from an area of lesser
concentration to an area of greater
concentration.
• Solvent molecules move across a membrane to
an area where there is a higher concentration
of solute that cannot pass through the
membrane.
• Doesn’t require
energy
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 Terms associated with osmosis
• Osmotic pressure: amount of pressure required to stop
osmotic flow of water.
- determined by the concentration of solutes
• Oncotic pressure: pressure exerted by colloids ( proteins such
as albumin)
- tends to pull water into the circulatorysystem
• Osmotic diuresis: increased urine output caused by the
substances mannitol, glucose or contrast medium.
- results due to a high concentration of osmotically active
substances in the renal tubules. E.g urea and sodium sulfate
which limit the reabsorption of water.

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• Osmolality: measurements of the solute concentration of a
solution i.e. an estimation of the osmolar concentration of plasma
and is proportional to the number of particles per kilogram of
solvent.
- the SI unit is mmol/kg but mOsmol/kg is
still widely used.
• Osmolarity: is an estimation of the osmolar concentration of
plasma and is proportional to the number of particles per liter of
solution.
- the SI unit is mmol/L.
• Determining the osmolality is important because it indicates
the water balance of the body.

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 Clinical relevance of osmolality
• Increased osmolality in the blood will stimulate
secretion of antidiuretic hormone.
- will result in increased water reabsorption, more
concentrated urine and less concentrated plasma
• A low serum osmolality will suppress the release
of ADH
• An increase of only 2% to 3% in plasma osmolality
will produce a strong desire to drink.

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 Measurements for osmolality
• Plasma osmolality – to investigate hyponatraemia
• Urine osmolality- frequently ordered along with
plasma osmolality to help with diagnosis
• Stool osmolality- help evaluate chronic diarrhea that
does not appear to be due to a bacterial or parasitical
infection. Stool may contain osmotically active
substance e.g. laxative
• Normal plasma osmolality is between 275 and 295 if
greater it indicates the concentration of particles is too
great termed as water deficit.
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 Osmotic movement of fluids
• Isotonic- fluid with same osmolality as cell
interior.
• Hypotonic- solutes are less concentrated than
cells.
• Hypertonic- solutes are more concentrated
than cells

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 Diffusion
• Random movement of particles in all directions
from an area of high concentration to low
concentration.
• Is driven by a gradient in chemical potential of the
diffusing particle.
e.g. - movement of 02 from alveoli of lungs
into blood stream
- when cations follow anions and vice versa
• Requires no energy
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 Active transport
• Relies on availability of carrier substances
• Utilizes energy ( ATP)
• Transport of Na++, K+, H+, glucose,
aminoacids
• Is the movement of molecules across a
membrane from a region of lower
concentration to a region of higher
concentration.

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 Examples of active transport
• Antiport pumps- pumps that transport one substance in one direction
while transporting another in the other way.

• Symport pumps- takes advantage of diffusion gradient.

• Endocytosis- large items, or large amount of ECF, may be taken into a cell
through the process of endocytosis.

• Exocytosis- the cell creates a vesicle to enclose something that is inside

itself to move it outside.
e.g. protein made in ER are packed into vesicle and sent to golgi apparatus

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 Filtration
• Movement of water and solutes from area of
high hydrostatic pressure to area of low
hydrostatic pressure that is created by ‘weight’
of fluid.
• Hydrostatic pressure is based on the pressure
exerted by the blood pushing against the walls of
the capillaries.
- is the force within a fluid compartment.
eg. Kidney filters 180L/day plasma
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 Fluid movement in capillaries
• Is determined by:
- capillary hydrostatic pressure
- plasma oncotic pressure
- interstitial hydrostatic pressure
- interstitial oncotic pressure

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 Fluid shifts
• Plasma to interstitial fluid shift results in Edema
(accumulation of fluid in the interstitium).
• Caused by:-
- elevation of hydrostatic pressure (hypertension, fluid
overload, heart failure, liver failure, obstruction of venous
return to heart)
- decrease in plasma oncotic pressure ( loss of electrolytes,
malnutrition, loss of plasma proteins, renal disorders)
- elevation of interstitial oncotic pressure ( trauma, burns
inflammation can damage capillary walls)

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- Interstitial fluid to plasma
- fluid drawn into plasma space with increase
in plasma osmotic or oncotic pressure.
- compression stockings decrease peripheral
edema

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 Fluid movement between ECF and ICF
• Water deficit (increased ECF osmolality)- pulls
water out of cells until both compartments have
similar osmolality.
- associated with symptoms that result from cell
shrinkage as water is pulled into vascular system.
- this affects neurological function as altered CNS
function as brain cells shrink
• Water excess (decreased ECF osmolality)
- develops from gain or retention of excess water
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 Fluid spacing
• First spacing – normal distribution of fluid in ICF and ECF

• Second spacing- abnormal accumulation of interstitial fluid (edema)

• Third spacing- fluid accumulation in part of body where it is not easily

exchanged with ECF; fluid trapped and unavailable for functional use (ascites)

- initially patients exhibit signs of hypovolemia, including hypotension,

tachycardia, decreased urine output.

- treatment includes fluid, electrolyte and plasma protein replacement.

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 Methods of assessing edema
• Daily weight
• Visual assessment
• Measurement of affected part
• Application of finger pressure to assess for pitting
edema. Evaluate on a scale +1-4(severe), 4 would
reveal a deeper ‘pit when finger removed.
- interventions – elevation of part, stockings,
diuretic, controlling cause, monitor labs and serum
albumin
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• +1 pitting edema = trace = barely perceptible
depression
• +2 pitting edema = mild = 0.6 cm depression
with rebound in less than 15 seconds
• +3 pitting edema = moderate = 0.6 to 1.3 cm
depression with rebound in 15 to 30 seconds
• +4 pitting edema = severe = 1.3 to 2.5 cm
depression with rebound of greater than 30
seconds
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3rd spacing, fluid shift from intravascular to
interstitial space; edema

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Sources of Body Water Gain and Loss
Fluid balance related to electrolyte balance
Intake of water and electrolytes rarely proportional
Kidneys excrete excess water through dilute urine or excess
electrolytes through concentrated urine
Body can gain water by
Ingestion of liquids and moist foods (2300mL/day)
Metabolic synthesis of water during cellular respiration
(200mL/day)
Body loses water through
Kidneys (1200-1500mL/day)
Evaporation from skin (300ml-400ml/day by diffusion, 1.5-3.5l
per hour by perspiration depending on environmental factors
and body temprature)
Exhalation from lungs (300mL/day-400ml/day)
Feces (200mL/day)

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Daily Water Gain and Loss

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 Regulation of body water gain
Mainly by volume of
water intake
Dehydration – when
water loss is greater than
gain
Decrease in volume,
increase in osmolarity
of body fluids
Stimulates thirst
center in
hypothalamus
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Regulation of water and solute loss
Elimination of excess body water mostly through urine
Extent of urinary salt loss is the main factor that
determines body fluid volume
Main factor that determines body fluid osmolarity is
extent of urinary water loss
3 hormones regulate renal Na+ and Cl- reabsorption
Angiotensin II and aldosterone promote urinary Na+ and
Cl- reabsorption when dehydrated
Atrial natriuretic peptide (ANP) promotes natriuresis,
excretion of Na+ and Cl- followed by water excretion to
decrease blood volume

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Hormonal Regulation of Na+ and Cl-

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 Antidiuretic Hormone (ADH)

Also known as vasopressin

Major hormone regulating water loss
Produced by hypothalamus, released from
posterior pituitary
Promotes insertion of aquaporin-2 into
principal cells of collecting duct
Permeability to water increases
Produces concentrated urine
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Movement of water between compartments

Normally, cells neither shrink or swell because

intracellular and interstitial fluids have the same
osmolarity
Increasing osmolarity of interstitial fluid draws water out of cells
and cells shrink
Decreasing osmolarity of interstitial fluid causes cells to swell
Changes in osmolarity most often result from changes in
Na+ concentration
Water intoxication – drinking water faster than the
kidneys can excrete it
Can lead to convulsions, coma or death

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Series of Events in Water Intoxication

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 Electrolytes in body fluids
Ions form when electrolytes dissolve and
dissociate
Have 4 general functions
Control osmosis of water between body fluid
compartments
Help maintain the acid-base balance
Carry electrical current
Serve as cofactors

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 Concentrations in body fluids

Concentration of ions typically expressed in

milliequivalents per liter (mEq/liter)
Na+ or Cl- number of mEq/liter = mmol/liter
Ca2+ or HPO42- number of mEq/liter = 2 x mmol/liter
Chief difference between 2 ECF
compartments (plasma and interstitial fluid)
is plasma contains many more protein anions
Largely responsible for blood colloid osmotic
pressure

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 ICF differs considerably from ECF

ECF most abundant cation is Na+, anion is Cl-

Sodium (NV-135-145 mEq/Lit)
Impulse transmission, muscle contraction,
fluid and electrolyte balance
Chloride(NV-95-105 mEq/Lit)
Regulating osmotic pressure, forming HCl in
gastric acid
Controlled indirectly by ADH and processes
that affect renal reabsorption of sodium

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 ICF differs considerably from ECF
cont…
 ICF most abundant cation is K+, anion are
proteins and phosphates (HPO42-)
Potassium(NV- 3.5-5.0 mEq/lit)
Resting membrane potential , action
potentials of nerves and muscles,
Maintain intracellular volume,
Regulation of pH,
Controlled by aldosterone
 Na+ /K+ pumps play major role in keeping K+
high inside cells and Na+ high outside cell
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 Fluid and electrolyte imbalance

 Fluid volume deficit (hypovolemia)

 Lose of ECF exceeds the intake of fluid.
 Contributing Factors
 Loss of water and electrolytes, as in vomiting, diarrhea,
fistulas, fever, excess sweating, burns, blood loss,
gastrointestinal suction, and third-space fluid shifts (from
the vascular system to other body spaces).
 Decreased intake, as in anorexia, nausea, and inability to
gain access to fluid.
 Diabetes insipidus and uncontrolled diabetes mellitus also
contribute to a depletion of extracellular fluid volume.
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 Clinical presentations

Acute weight loss

Decreased skin turgor
Oliguria, concentrated urine
Postural hypotension, weak rapid pulse, capillary
filling time prolonged, low central venous pressure
, ↓ blood pressure
Dizziness, weakness, thirst and confusion,
↑ pulse
Muscle cramps.

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 Labs Indicate
↑ hemoglobin and hematocrit
↑ serum and urine osmolality and
specific gravity,
↓ urine sodium,↑ BUN and creatinine

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 Management

 If the deficit is not severe, the oral route is preferred

 Provided the patient can drink.
 If fluid losses are acute or severe, the IV route is
required
 Isotonic electrolyte solutions are frequently used
 E.g. Lactated Ringer’s solution, 0.9% NaCl
 As the patient becomes normotensive, a hypotonic
electrolyte solution
 E.g. 0.45% NaCl
 Avoid fluid overload

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 Fluid volume excess (hypervolemia)

 Both the interstitial and vascular compartments have too

much fluid
 Contributing factors:
 Compromised regulatory mechanisms, such as renal
failure, heart failure, and cirrhosis.
 Consumption of excessive amounts of table or other
sodium salts.
 Overzealous administration of sodium-containing fluids.
 Prolonged corticosteroid therapy, severe stress, and
hyperaldosteronism

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 Clinical Manifestations

Acute weight gain,

Peripheral edema and ascites,
Distended jugular veins,
Crackles, shortness of breath and wheezing,
Increased BP and
Cough
 Labs indicate
 ↓ Hemoglobin and Hematocrit
 ↓ Serum and urine osmolality
 ↓ Urine sodium and specific gravity
 Chest x-ray may reveal pulmonary congestion

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 Management
 Management is directed at the causes
 Dietary restriction of sodium
 Symptomatic treatment consists of administering
diuretics and restricting fluids and sodium.
 Potassium supplements can be prescribed
 If renal function is so severely impaired
hemodialysis or peritoneal dialysis may be used
 To remove nitrogenous wastes and control
potassium and acid-base balance, and to remove
sodium and fluid.
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Electrolyte Imbalances

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 Hyponatremia

 Refers to a serum sodium level that is < 135 mEq/L

 Can be due to:
 Loss of sodium, as in use of diuretics, loss of GI fluids,
renal disease, and adrenal insufficiency.
 Gain of water, as in excessive administration of D5W.
 Disease states associated with syndrome of inappropriate
secretion of ADH(SIADH) such as head trauma.
 Medications associated with water retention (oxytocin
and certain tranquilizers)
 Hyperglycemia and heart failure cause a loss of Na.

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 Clinical manifestations

 Anorexia, nausea and vomiting

 Dry skin, increase pulse, decrease BP, weight gain,
edema.
 Headache, lethargy, dizziness, confusion
 Muscle cramps and weakness, muscular twitching,
seizures, papilledema

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 Management
Administration of sodium by mouth, nasogastric
tube, or a parenteral route
lactated Ringer’s solution or isotonic saline (0.9%
sodium chloride) solution may be used.
In a patient with normal or excess fluid volume,
hyponatremia is treated by restricting fluid.

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 Nursing interventions
• Administer comfort measures as needed
• Monitor level of consciousness
• Institute safety measures for seizures
• Assist with range of motion
• Administer IV isotonic solution (0.9%NaCl) per order
• Monitor v/s hrly, I/O
• Monitor daily intake of sodium and serum sodium level
• Teach client about adequate sodium intake (460-
920mg/day, 20-40 mmol/day) and side effects of diuretics
and causes of hyponatremia
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 Hypernatremia

 Is a serum sodium level higher than 145 mEq/L

 Can be caused by:
 Water deprivation in patients unable to drink is a common cause.
 Hypertonic tube feedings without adequate water supplements
 Severe GI loss (diarrhea and vomiting)
 Excessive insensible loss
 Excess sodium bicarbonate, and sodium chloride administration.
 Salt water near-drowning victims.
 Renal dysfunction, peritoneal dialysis with glucose solution
 Uncompensated diabetes insipidus
 CHF, nephrotic syndrome and cirrhosis

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 Clinical manifestations

Thirst
Elevated body temperature
Swollen dry tongue and sticky mucous membranes
Hallucinations, lethargy, restlessness, irritability,
seizures
Pulmonary edema
Hyperreflexia , twitching
Nausea, vomiting, anorexia
Increased pulse and BP
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 Management

 Gradual lowering of the serum sodium level by the

infusion of a hypotonic electrolyte solution ( 0.3%
sodium chloride) or an isotonic solution (D5W).
 The serum sodium level is reduced at a rate no
faster than 0.5 to 1 mEq/L/h
 Too-rapid reduction in the serum sodium level
renders the plasma temporarily hypo osmotic to
the fluid in the brain tissue, causing movement of
fluid into brain cells and dangerous cerebral
edema.
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 Nursing intervention
• Monitor the client’s level of consciousness
• Institue safety measures for seizures
• Maintain body alignment and assist with movement
• Administer oral hygiene hrly
• Monitor v/s hrly
• Administer oral fluids hypotonic solution 0.3%NaCl as
ordered
• Monitor I/O hrly, teach client about foods high in sodium
and about sodium retaining drugs such as cough
medicines, cortisone and laxative with sodium .
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 Potassium deficit (hypokalemia)

 Is when serum potassium <3.5 mEq/L.

 Contributing factors:
 Medications like thiazides and loop diuretics,
corticosteroids and amphotericin B.
 GI loss of potassium- diarrhea, vomiting and gastric
suction.
 Metabolic alkalosis that promotes the transcellular shift
of potassium : hydrogen ions move out of the cells in
alkalotic states to help correct the high pH, and potassium
ions move in to maintain an electrically neutral state.

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 Hyperaldosteronism increases renal potassium
wasting.
 Patients with persistent insulin hypersecretion
(insulin promotes the entry of potassium into
skeletal muscle and hepatic cells)
 Magnesium depletion causes renal potassium loss.

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 Clinical Manifestations

 Fatigue, anorexia, nausea, vomiting, muscle weakness, leg

cramps, decreased bowel motility, paresthesias and
dysrhythmias.
 If prolonged, inability of the kidneys to concentrate urine
(resulting in polyuria, nocturia) and excessive thirst.
 Potassium depletion suppresses the release of insulin and
results in glucose intolerance.
 Decreased muscle strength can be found on physical
assessment.
 Severe hypokalemia can cause death through cardiac or
respiratory arrest.

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 Management

 Increased intake in the daily diet or by oral

potassium supplements
 Foods high in potassium include most fruits and
vegetables, legumes, whole grains, milk, and meat.
 Cautiously IV replacement for patients with severe
hypokalemia (e.g. serum level of 2mEq/L)
 Monitor for sign of hyperkalemia; smooth muscle
hyperactivity can lead to hyperactive bowel
sounds.

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 Nursing intervention
• Administer potassium replacement therapy
- oral potassium should be diluted in 4-8 oz of water or juice
- dilute IV potassium20-40mEq in 1L of IV fluids
- monitor IV site for phlebitis and infiltration
-protect from injury
- Hrly I/O and v/s monitoring with closely monitoring of digitalis
toxicity ( premature atrial and ventricular beats)
- Teach client about potassium rich foods and how to prevent
excessive loss (abuse of laxatives and diuretics)

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 Potassium excess (hyperkalemia)

 Is when serum potassium >5.0 mEq/L

 It is less common than hypokalemia, but is usually
more dangerous, because cardiac arrest is more
frequently associated with high serum potassium levels.
 Three major causes are:
Decreased renal excretion of potassium
Rapid administration of potassium and
Movement of potassium from the ICF compartment
to the ECF compartment.

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 Medications commonly implicated are potassium
chloride, heparin, ACE inhibitors, NSAIDs, beta-
blockers, and potassium sparing diuretics.
 In acidosis, as hydrogen ions enter the cells to
buffer the pH of the ECF.

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 Clinical Manifestations

 Muscle weakness, tachycardia, dysrhythmias and

cardiac arrest.
 Flaccid paralysis, paresthesia
 Nausea, Intestinal colic, cramps, abdominal
distention, and diarrhea.
 Irritability, anxiety

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 Management

 In nonacute situations, restriction of dietary

potassium and potassium-containing medications
may correct the imbalance.
 If serum potassium levels are dangerously elevated,
administer IV calcium gluconate
 Calcium antagonizes the action of hyperkalemia
on the heart, but it does not reduce the serum
potassium concentration
 Monitor the BP hence hypotension may result from
the rapid IV administration of calcium gluconate
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 IV administration of sodium bicarbonate, regular
insulin and a hypertonic dextrose solution
 May be necessary to alkalinize the plasma,
cause a temporary shift of potassium into the
cells.
 Loop diuretics increase excretion of potassium
 Beta-2 agonists, such as albuterol are highly
effective in decreasing potassium
 They move potassium into the cells

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 Calcium deficit (hypocalcemia)

 Occur when serum calcium level is lower than 8.6

mg/dl.
 Contributing factors:
 Hypoparathyroidism (primary or post
surgical(thyroidectomy or Parathyroidectomy)
 After radical neck dissection
 Excessive secretion of glucagon from the inflamed
pancreas, which results in increased secretion of
calcitonin.

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 Patients with renal failure
 Because these patients frequently have elevated
serum phosphate levels which causes a drop in
the serum calcium level.
 Inadequate vitamin D consumption
 Medications like aluminum-containing antacids,
aminoglycosides, caffeine, and corticosteroids.

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 Clinical Manifestations

Tetany; a general muscle hypertonia with:

 Numbness and tingling in extremities

 Stiffness of hands and feet

 Bronchospasm, laryngeal spasm, carpopedal

spasm,
 Photophobia, cardiac dysrhythmias and
seizures.
 Hyperactive deep tendon reflexes.

Impaired clotting time, dry and brittle hair, diarrhea.

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Positive:
Trousseau’s sign
 Carpopedal spasm is induced by occluding the blood
flow to the arm for 3 minutes with a blood pressure cuff.
Chvostek’s sign
 when a sharp tapping over the facial nerve just in front
of the parotid gland and anterior to the ear causes spasm
or twitching of the mouth, nose, and eye.
Osteoporosis
 Abnormal loss of bony tissue resulting in fragile
porous bones

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 Management

 Acute symptomatic hypocalcemia is life-threatening

and requires prompt treatment with IV
administration of a calcium salt
 Calcium gluconate, calcium chloride, and calcium
gluceptate
 Calcium should be diluted in D5W and administered
as a slow IV bolus or a slow IV infusion.
 0.9% sodium chloride solution should not be used
with calcium because it increases renal calcium loss.

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 The patient is kept in bed during IV infusion, and
blood pressure should be monitored.
 Vitamin D therapy can increase calcium
absorption from the GI tract.
 Aluminum hydroxide, calcium acetate, or calcium
carbonate antacids may be prescribed to decrease
elevated phosphorus levels.
 Increasing the dietary intake of calcium to at least
1000 to 1500 mg/day in the adult is recommended.

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 Calcium excess (hypercalcemia)

 Occurs when serum calcium level is greater than

10.2 mg/dl.
 Reduces neuromuscular excitability because it
suppresses activity at the myoneural junction.
 The most common causes are malignancies and
hyperparathyroidism.

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 Other factors include:
 Immobilization after severe or multiple
fractures or spinal cord injury
 Thiazide diuretics reducing urinary calcium
excretion
 Prolonged period with milk and alkaline
antacids.
 Vitamin A and D intoxication

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 Clinical manifestations

 Decreased tone in smooth and striated muscle may cause

symptoms such as:-
 Muscle weakness,

 Incoordination,

 Anorexia,

 Nausea, vomiting, constipation and

 Dehydration.

 Patients with chronic hypercalcemia may develop

symptoms similar to those of peptic ulcer disease
 Because hypercalcemia increases the secretion of acid
and pepsin by the stomach.

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 Confusion, impaired memory, slurred speech,
lethargy, acute psychotic behavior, or coma may
occur.
 Hypercalcemic crisis refers to an acute rise in the
serum calcium level to 17 mg/dl or higher.
 Severe thirst and polyuria are characteristically
present.
 Can result in life-threatening neurologic,
cardiovascular and renal symptoms.

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 Management
 Treating the underlying cause (e.g.chemotherapy for a
malignancy or partial parathyroidectomy for
hyperparathyroidism)
 Administering fluids to dilute serum calcium and promote its
excretion by the kidneys.
 Phosphate therapy to promote calcium deposition in bone and
reducing GI absorption of calcium.
 Loop diuretics promote renal excretion of calcium.
 Calcitonin IM increases the deposit of calcium and in the
bones, and increases urinary excretion of calcium.
 Mobilizing the patient to promote bone retention of calcium.
 Restricting dietary calcium intake.

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 Acid-Base Balance
Major homeostatic challenge is keeping H+
concentration (pH) of body fluids at
appropriate level
Diets with large amounts of proteins produce
more acids than bases which acidifies blood
Several mechanisms help maintain pH of
arterial blood between 7.35 and 7.45
Buffer systems, exhalation of CO2, and kidney
excretion of H+ / reabsorption of HCO3-

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 Buffer systems
Act to quickly temporarily bind H+
Raise pH but do not remove H+
Most consist of weak acid and salt of that
acid functioning as weak base
Major buffer systems: proteins, carbonic
acid/bicarbonate

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 Buffer systems

Protein buffer system

Most abundant buffer in ICF and blood plasma
Hemoglobin in RBCs
Albumin in blood plasma
Free carboxyl group acts like an acid by releasing H+
Free amino group acts as a base to combine with H+
Side chain groups on 7 of 20 amino acids also can
buffer H+
h20+co2→H+ + HCO3-

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 Buffer Systems
Carbonic acid / bicarbonate buffer system
Based on bicarbonate ion (HCO3-) acting as weak
base and carbonic acid (H2CO3) acting as weak
acid
HCO3- is a significant anion in both ICF and ECF
Because CO2 and H2O combine to form this
buffer system cannot protect against pH changes
due to respiratory problems in which there is an
excess or shortage of CO2

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 Exhalation of carbon dioxide

Increase in carbon dioxide in body fluids

lowers pH of body fluids
Because H2CO3 can be eliminated by
exhaling CO2 it is called a volatile acid
Changes in the rate and depth of breathing
can alter pH of body fluids within minutes
Negative feedback loop

90
 Kidney excretion of H+

Metabolic reactions produce nonvolatile acids

One way to eliminate this huge load is to excrete H+ in
urine
In the proximal convoluted tubule, Na+/H+ antiporters
secrete H+ as they reabsorb Na+
Intercalated cells of collecting duct include proton
pumps that secrete H+ into tubule fluid; reabsorb K+
and HCO3-
Urine can be up to 1000 times more acidic than blood
2 other buffers can combine with H+ in collecting duct
HPO42- and NH3

91
Results If either bicarbonate or carbonic acid is increased
or decreased so that the 20:1 ratio is no longer
maintained.
Normal pH range of arterial blood 7.35-7.45
Acidosis – blood pH below 7.35
Alkalosis – blood pH above 7.45
Major physiological effect of
Acidosis – depression of synaptic transmission in CNS
Alkalosis – overexcitability of CNS and peripheral
nerves

92
93
 Metabolic Acidosis(Base Bicarbonate Deficit)

Is characterized by a low pH (increased H+ concentration)

and a low plasma bicarbonate concentration.
 Results from:
Direct loss of bicarbonate, as in diarrhea, lower intestinal
fistulas, and use of diuretics.
Administration of parenteral nutrition without bicarbonate
or bicarbonate-producing solutes (e.g. lactate).
Excessive administration of chloride
Excessive accumulation of fixed acid occurs in ketoacidosis,
lactic acidosis, and the late phase of salicylate poisoning.

94
 Clinical Manifestations

Signs and symptoms vary with the severity of the acidosis.

Headache, confusion, drowsiness, increased respiratory rate
and depth.
Nausea and vomiting
Peripheral vasodilation and decreased cardiac output occur
when the pH falls below 7.
Decreased BP, cold and clammy skin, dysrhythmias, and
shock .
The cardinal feature is a decrease in the serum bicarbonate
level(less than 22 mEq/L).
Low pH(less than 7.35).

95
 Management
 Treatment is directed at correcting the metabolic defect.
 e.g. If the problem results from excessive intake of
chloride, eliminating the source.
 Bicarbonate is administered if the pH is less than 7.1 and
the bicarbonate level is less than 10 mEq/L.
 In chronic metabolic acidosis, hemodialysis or peritoneal
dialysis may also be included.
 Although hyperkalemia occurs with acidosis,
hypokalemia may occur with reversal of the acidosis and
subsequent movement of potassium back into the cells.
 Therefore, the serum potassium level is monitored closely.

96
 Metabolic Alkalosis (Base Bicarbonate Excess)

 Characterized by a high pH (decreased H+

concentration) and a high plasma bicarbonate
concentration.
 The most common cause is vomiting or gastric
suction with loss of hydrogen and chloride ions
(loss of this highly acidic fluid increases the
alkalinity of body fluids).

97
 Hypokalemia
 The kidneys conserve potassium, and thus H+
excretion increases; and
 Cellular potassium moves out of the cells into
the ECF in an attempt to maintain near-normal
serum levels thus, H+ must enter to maintain
electroneutrality.
 Excessive alkali ingestion from antacids containing
bicarbonate.
 Chronic ingestion of milk

98
 Clinical Manifestations

 Tingling of the fingers and toes, dizziness, and

hypertonic muscles.
 Atrial tachycardia, respirations are depressed as a
compensatory action by the lungs.
 As the pH increases >7.6 and hypokalemia
develops, ventricular disturbances may occur.
 Evaluation of arterial blood gases reveals a PH
greater than 7.45 and a serum bicarbonate
concentration greater than 26 mEq/L.

99
 Management

Treatment is aimed at reversing the underlying

disorder.
Chloride supplementation for the kidney allows
excretion of excess bicarbonate.
Restoring normal fluid volume by administering
sodium chloride fluids.
Potassium is administered as KCl to replace both
K+ and Cl− losses
Monitor patient’s fluid intake and output

100
 Respiratory acidosis (Carbonic acid
excess)
 Is a condition in which the pH is <7.35 and the PaCO2 is >42
mm Hg.
 Is always due to inadequate excretion of CO2 with inadequate
ventilation, resulting in elevated plasma CO2 levels and thus
elevated carbonic acid (H2CO3) levels and a decrease in
PaO2
 It can also occur in diseases that impair respiratory muscles,
such as muscular dystrophy, myasthenia gravis, and Guillain-
Barre syndrome.
 Chronic respiratory acidosis occurs with pulmonary diseases
such as chronic emphysema and bronchitis, obstructive sleep
apnea, and obesity.

101
 Clinical Manifestations

 Increased PR, RR and BP

 Mental cloudiness, and feeling of fullness in the
head.
 Cerebrovascular vasodilation and increased
cerebral blood flow.
 In severe form ,sign of increased ICP (papilledema
and dilated conjunctival blood vessels)
 Cyanosis and tachypnea
 Hyperkalemia(shift of potassium out of the cell).

102
 Management
 Treatment is directed at improving ventilation
Bronchodilators to reduce bronchial spasm
Antibiotics for respiratory infections
Anticoagulants for pulmonary emboli
Pulmonary hygiene measures, to clear the respiratory tract of
mucus and purulent drainage.
Hydration (2–3 L/day) to keep the mucous membranes moist and
thereby facilitate the removal of secretions.
Supplemental oxygen
Mechanical ventilation
Placing the patient in a semi-Fowler’s position facilitates
expansion of the chest wall.

103
 Respiratory alkalosis (Carbonic acid
deficit
 A condition in which the arterial pH is >7.45 and
the PaCO2 is less than 38 mm Hg.
 Is always due to hyperventilation, which causes
excessive “blowing off” of CO2 and, hence, a
decrease in the plasma carbonic acid
concentration
 Causes can include extreme anxiety, hypoxemia,
the early phase of salicylate intoxication, gram-
negative bacteremia, and inappropriate ventilator
settings.
104
 Clinical Manifestations

Lightheadedness due to vasoconstriction and

decreased cerebral blood flow.
Numbness and tingling from decreased calcium
ionization.
Tinnitus, Inability to concentrate, at times loss of
consciousness.
Tachycardia and ventricular and atrial
dysrhythmias.

105
 Management

 Treatment is directed at correcting the underlying

problem.
 If the cause is anxiety, the patient is instructed to
breathe more slowly to allow CO2 to accumulate
or to breathe into a closed system (such as a paper
bag).
 A sedative may be required to relieve
hyperventilation in very anxious patients.

106
107
 Interpreting Arterial Blood Gases
(ABG)
This blood test is from arterial blood, usually
from the radial artery.
Determine if the patient is demonstrating an
acidotic (pH <7.35) or alkalotic (pH > 7.45)
condition.
 Note
If the patient is acidotic with a PaC02 > 45 mmHg
it is Respiratory acidosis
If the patient is acidotic with a HCO3- < 22 mEq/L
it is Metabolic acidosis
108
 Interpreting Arterial Blood Gases
(ABG)

If the patient is alkalotic with a PaC02 < 35

mmHg it is Respiratory alkalosis
If the patient is alkalotic with a HCO3- > 26
mEq/L it is Metabolic alkalosis

109
 Nursing process
o Assessment
* Subjective Data:
- Dysfunction identification
- Risk identification
- Functional pattern identification
- Objective Data:
- Physical assessment: monitor intake
and output (I & O)

110
• Intake: any oral and parenteral fluids
• Output measurements include urine, liquid stool, vomit,
drainage from wound site
• Body weight: daily weight are ordered
• Integumentary assessment: any change in the skin for
dryness, moisture, skin turgor, and edema.
• Vital signs:
• Neck veins:
• Hand veins:
• Bowel Assessment:

111
Laboratory and Diagnostic Tests
- Serum electrolyte
- Serum Osmolality
- Hematocrit
- Urine specific gravity
- Arterial blood gases

112
o Nursing Diagnosis
• Fluid volume deficit
• Fluid volume excess
• Examples
• Fluid volume deficit related to active fluid volume
loss manifested by decreased urine output,
increased urine concentration, weight loss,
decreased venous filling.
• Risk to fluid volume deficit related to fluid loss with
vomiting
113
o Planning
• Patient goals
• Will reestablish normal fluid and electrolyte
balance
• Will demonstrate knowledge regarding
how to promote future fluid and electrolyte
balance

114
o Implementation
• Nursing Interventions for Altered Fluid and Electrolyte
• Increase oral fluids: for deficit
• Restrict oral Fluids: for fluid excess
• Electrolyte Replacement: diet teaching, electrolyte
supplements
• Intravenous therapy: isotonic, hypotonic, and hypertonic
• Nursing Interventions to Promote Health and Function
• Teaching people in community: in variety of setting
school, work area,

115
o Evaluation
• The preset goal will assessed for its
achievement using outcome criteria

116
 Intravenous therapy
• Intravenous therapy is used frequently in
hospitalized patient to prevent or treat fluid
and electrolyte imbalances.
• Nurses are responsible for initiating,
monitoring, and discontinuing the
intravenous infusion.

117
 Purpose of IV therapy

• To provide a patient with fluid in case of

can not obtain adequate oral intake
• To provide the patient with electrolyte to
maintain the normal balance
• To provide patient with glucose to use as
energy source
• To provide venous access to administer
treatment and/or blood products

118
 Types of Intravenous therapy in accordance to
tonicity of fluid relative to normal blood plasma/280-
295mOsm/l/
• Isotonic solution: the solution that have the same osmotic pressure, used to
expand the intravascular compartment and increase the circulating volume.
Examples include Normal saline (0.9% NaCl) and Lactate Ringer. Excess
infusion causes cardiac overload.
• Hypotonic fluid: the solutions have less osmotic pressure than the cells and
it lowers the serum osmolarity.
• It causes the body fluid to shift out of the blood vessels and into the cell
when cell hydration is needed. Example include half normal saline (0.45%
NaCl). Excess amount will cause water intoxication.
• Hypertonic fluids: is the solution with greater osmotic pressure than the
cell. It raises the serum osmolarity, when administered. Indicated for
postoperative patient to maintain circulating volume and prevent edema.
Examples include 5% dextrose in Normal saline, in half normal saline, and
in Ringer Lactate. Excess causes cellular dehydration.

119
120
121
 Precautions

• Monitoring IV infusion:
• Calculating flow rate using drops per
minute = Total volume infused X Drop
factor/ Total time for infusion in minutes.
• Manual regulation of the infusion: the
roller clamp used to adjust the rate of flow.
The nurses count the drops as they fall
into the drip chamber.

122
 Complication of IV Therapy
• Infiltration: occurs when fluid enters the
subcutaneous tissue. Manifested with pain and
swelling around the infusion site.
• Phlebitis: refers to inflammation of the vein. It
may occur as a result of increased length of time
the catheter remains in the vein, infusion of
irritating substance such as KCl and antibiotics,
using small veins. Manifested with discomfort,
warm, red, and hard (cord like) vein, and the IV
flow will be sluggish.
123
• Infection: can occur systemic or at the IV
infusion sites due to remaining longer IV in one
site. Sign and symptoms include redness,
warmth, or purulent drainage at the site.
• Air embolism: air entering the blood stream and
moving in the vessel.
• Fluid overload: may occur if IV fluid runs too
rapidly. Patient may complain of headache, neck
vein distention, increased BP, increased
respiratory rate and dyspnea.

124
 Equipments for IV insertion
• Administration set
- plastic disposal tubing
- insertion spike with a protective cap,
- a drip chamber,
- tubing with a slide clamp and regulating
(roller) clamp,
- a rubber injection port,
- a protective cap over the needle adapter

125
• Cannula- is a hollow needle or more often a
length of flexible plastic tubing which has been
inserted into the vein using a needle
• Two different kinds of veins for insertion are:
1. Peripheral line- is attached to a peripheral vein.
Usually inserted into arm or hand, sometimes
leg or food.
2. Central line- is attached to a vein in the chest
wall or neck vein.
126
 Needles and Venous
Peripheral-Short Catheters

• A variety of devices are available in different sizes to

complement the age of the client, the type and duration of the
therapy, and to protect the user from injury.
• The nurse considers the client’s age, body size, and the type of
solution to be administered when selecting the gauge of the
needle or catheter:
- Infants and small children, 24 gauge
- Preschool through preteen, 24 or 22 gauge
- Teenagers and adults, 22 or 20 gauge
- Geriatric, 22 or 24 gauge

127
• Butterfly (scalp vein or wing-tipped) needles are
short,beveled needles with plastic flaps attached to the shaft.
- The flaps (which are flexible) are held tightly together to
facilitate ease of insertion and then flattened against the skin
to prevent dislodgement during infusion. These needles are
commonly used for short-term or intermittent therapy and for
infants and children

128
129
Preparing an IV solution

130
131
132
133
 Initiating IV Therapy

• When initiating IV therapy, the nurse should assess for a

venipuncture site

134
 Procedure:
• Perform hand hygiene
• Explain the procedure to the client
• Prepare all necessary equipment
• Select the visible vein of the hand or forearm
• Maintain privacy by closing the curtain or door
• Assist client to spine or semi-Fowler’s with arm extended to
form straight line

135
• Put on disposable gloves
• Check the solution with the physicians orders
• Label solution container with patient’s name, additives, date, and
time hung.
• Open new tubing package then close the clamp on the tubing, and
Prepare solution container for spiking, remove protective cover
from spike in maintaining its sterility, and spike into solution
container.
• Hang container on IV pole and “prim” drip chamber by
squeezing gently, allow filling one-half full.
• Remove protective cap from catheter adapter and adjust roller
clamp to flash tubing with fluid in order to remove air from
tubing.

136
• Apply tourniquet 5 to 10 cm above venipunctur site
selected, by encircle the extremity and pull one end of
tourniquet tightly over other, looping one end under
other.
• Ask client to open and close fist several times.
Quickly inspect extremity for best venipuncture site,
and palpate selected vein with finger.
• Cleanse venipuncture site with alcohol swab, moving
in circular motion from site approximately 5 cm.
• Have access device either angiocatheter or butterfly,
remove the cover, and inform client that stick lasting
few seconds.

137
• Place thumb or finger of non-dominant hand 2.5 cm
below site and gently pull skin taut, until vein is
stabilized.
• Slowly insert needle into vein and look for blood
return
• Connect access device to tubing and secure tubing with
adhesive tape on position
• Adjust clamp to regulate flow rate, according to orders.
• Remove glove and discard soiled equipment
• Record the procedure

138
 Discontinuing an IV Infusion
• An IV infusion is discontinued when all
ordered fluids have infused or when
complications develop.
• Don disposable glove
• Stop the flow of fluid by moving the roller
clamp toward the off position.
• Remove tapes carefully, while supporting the
catheter

139
• Place a gauze pad over the venipuncture site as
the catheter is withdrawn, then pressure is
applied over the site.
• Apply band-aid (tape) if necessary
• Document the time when the infusion
discontinued, or if any complication of therapy
occurred, and nursing measures taken (like
application of warm compress).

140
 Blood Transfusion
• Blood transfusion refers to the introduction of whole blood or
blood components (packed red cells, plasma, platelets)
• Purpose
• To replace blood volume or components lost through trauma,
surgery, or disease process.
• To administer white blood cells, or granulocytes for cancer
patient
• To administer platelets to initiate blood clotting
• To administer whole plasma to correct hypo-volemia in case
of extensive burn.
• To administer albumin
• To administer cryoprecipitate (rich in fibrinogen and blood
clotting factor VIII) in case of hemophiliacs.

141
 Precautions
• Blood compatibility: the donor’s blood must be
compatible to the patient’s blood for blood type and
RH-factor.
• Selection of blood Donor’s: by interviewing to rule
out any history of infectious exposure (hepatitis,
syphilis, malaria, and HIV).
• To protect the blood donor, some people are not
allowed to donate such as pregnant, anemic, weight
not fall within the restriction, abnormal BP, or have
donated whole blood within the last 56 days.
• Blood should be tested for antibodies to HIV and
Hepatitis B viruses.

142
Complication of Blood Transfusion
• Administration of blood and blood product
involves a number of risks:
• Febrile reaction: occurs because of
hypersensitivity to donor’s blood cells
• Allergic reactions: occurs because of
hypersensitivity to plasma protein
• Hemolytic reactions: most serious acute
complication
• Circulatory overload: occurs when blood product
infused too quickly.
143
144
145
 Equipment
• Packaged blood component from blood bank
according to agency protocol
• Container of sterile normal saline, blood
administration set with filter
• Blood warmer and pressure bag (optional)
• Alcohol swabs and adhesive tape

146
 Procedure
• Explain procedure to patient. Have patients sign of consent if
required by the hospital policy
• Obtain patient’s vital signs to include temperature
• Verify the blood product and the patient’s identity by
comparing the laboratory blood record with another RN
colleague.
• Verify the blood type and expiration date. Document
verification by both RN signatures on transfusion record.
• Wash hands
• Open Y-type blood transfusion set (if available) and clamp
both rollers completely
• Prepare normal saline container

147
• Spike blood or blood component unit with second spike.
Keep roller clamp shut
• Remove primary IV tubing from catheter hub and cover
ends with sterile protector
• Attach blood administration tubing to catheter hub and
secure with tape
• Close clamp to normal saline container tubing.
• Open clamp to blood product, begin transfusion
• Infuse blood slowly for the first 15 minutes (10 drops
per minute).
148
• Monitor and document vital signs every 5 minutes during
the first 15 minutes. Assess for chilling, back pain,
headache, nausea or vomiting, tachycardia, hypotension,
tachypnea, or skin rash. If any adverse reaction occurs,
close clamp to blood, open clamp to normal saline.
• If no adverse reactions occur after 15 minutes regulate
clamp to increase infusion according to physicians order.
• When transfusion completed, clamp roller to blood and
open to normal saline. Infuse until tubing is clear.
• Obtain and document post-transfusion vital signs.

149
• If second blood component unit is to be transfused, slow
normal saline to keep vein open until next unit available.
Follow verification procedure and vital sign monitoring.
• If second blood component unit is to be transfused, slow
normal saline to keep vein open until next unit available.
Follow verification procedure and vital sign monitoring.
• If transfusion orders are completed, disconnect the blood
administration tubing from the catheter hub. Reconnect
the primary intravenous solution and tubing and adjust to
desired rate.
• Wash hand and document the procedure.

150
151
152
153
154
155
 Nutrition and metabolism
• Physiology of nutrition
Nutrition is the process by which the body
metabolizes and utilizes nutrients.
• Nutrients are classified as energy nutrients,
organic nutrients, and inorganic nutrients

156
157
 Digestion

•refers to the mechanical and chemical processes that convert nutrients into a physically

absorbable state.

•The mouth prepares foodstuffs for digestion by mastication (chewing, tearing, or grinding of

food by the teeth into fine particles and the mixing with enzymes in saliva).

•Deglutition (swallowing of food) begins in the mouth and continues in the pharynx and

esophagus.

•Digestion begins in the stomach and is completed in

the small intestines.

158
• Peristalsis (coordinated, rhythmic, serial
contraction of the smooth muscle lining of the
intestines) forces chyme (an acidic, semifluid
paste) through the small intestines to the large
intestines and promotes the absorption of
vitamins, minerals, and water.

159
 Absorption

• is the process by which the end products of digestion—

monosaccharides (simple sugars), amino acids, glycerol, fatty acid
chains, vitamins, minerals, and water—pass through the epithelial
membranes in the small and large intestines into the blood or lymph
systems.
• Most absorption occurs in the small intestines through the processes of
osmosis, diffusion, and active transport.
• The main functions of the large intestines are to absorb water and
collect food residue.
• Dietary fiber is the part of food that body enzymes cannot digest and
absorb, such as outer hulls of corn kernels,
grains of wheat, celery strings, and apple skins

160
 Metabolism

• is the aggregate of all chemical reactions and processes in

every body cell, such as growth, generation of energy,
elimination of wastes, and other bodily functions as they
relate to the distribution of nutrients
in the blood after digestion.
Glycolysis refers to the breakdown of glucose by
enzymes located inside the cell’s cytoplasm. This process
produces adenosine triphosphate (ATP) and pyruvate, which
provide the cell with energy.

161
• Pyruvate may be used in two different metabolic functions.
- In aerobic metabolism, pyruvate enters the cell’s
mitochondria and in the presence of oxygen is converted to
acetyl-CoA.
- In anaerobic metabolism (metabolism without the
presence of oxygen) lactate is produced in the cytoplasm by
an enzyme (lactate dehydrogenase); this type of metabolism
takes place when the oxygen supply is limited, as in the
muscles and red blood cells, which lack mitochondria.

162
• When pyruvic acid is formed by glycolysis, it is then
converted into acetyl-CoA.
• This conversion begins a cyclic metabolic pathway called
the Krebs cycle (citric acid cycle or tricarboxylic acid
cycle).
• The Krebs cycle extracts energy through oxidation of
acetyl-CoA within the mitochondria of body cells.
• The Krebs cycle is a pathway common to all energy
nutrients because acetylCoA may be formed from
carbohydrates, proteins, and fats

163
Nutrient Absorption in the Small Intestines

164
Energy Nutrients and the Krebs Cycle
165
 Energy

• Metabolic rate refers to the rate of heat liberation

during chemical reactions; it is expressed in units
called calories.
• The basal metabolic rate (BMR) refers to the
energy needed to maintain essential physiological
functions, such as respiration, circulation, and
muscle tone, when a person is at complete rest both
physically and mentally.

166
 Excretion

• Digestive and metabolic waste products are

excreted through the intestines and rectum.
Other excretory organs are the kidneys, sweat
glands, skin, and lungs;
• The skin and sweat glands remove water,
toxins, salts, and nitrogen wastes; the lungs
remove carbondioxide and water

167
 NUTRIENTS

• Water
- Water is the most abundant nutrient in the body and
accounts for 60% to 70% of an adult’s total body
weight and 77% of an infant’s weight.
- Water and electrolytes are substances that must be
acquired from the diet.
• The estimated water requirement for infants, children,
and adults is 1.5 ml/kcal of energy expenditure.

168
• Vitamins
- are organic compounds that regulate cellular
metabolism, assisting the biochemical
processes that release energy from digested
food.

169
170
171
172
 Minerals

• Are inorganic elements which serve as catalysts in biochemical

reactions.
• are classified according to their daily requirement:
- Macro minerals (quantities of 100 mg or greater): calcium,
phosphorus, and magnesium
- Micro minerals (trace elements, quantities less than 100
mg): copper, fluoride, iodine, iron, selenium, and zinc
• Copper and iron are needed for hemoglobin formation.
• Iron is needed for the synthesis of vitamins, purines, and antibodies.
• Iodine is the basic component of thyroid hormones.

173
 Carbohydrates

• are organic compounds composed of carbon, hydrogen, and oxygen.

• play a significant role in providing cells with energy and supporting the
normal functioning of the body.
• Carbohydrates are classified according to the number of saccharides
(sugar units):
- Monosaccharides (simple sugars) include glucose, galactose, and
fructose.
- Disaccharides (double sugars) include sucrose, lactose, and maltose.
- Polysaccharides (complex sugars) include glycogen, cellulose (fiber),
and starch.
• Glucose supplies the major source of energy needed for cellular activity,
such as muscle contractions and nerve impulse transmission.

174
• Carbohydrates have a protein-sparing action,
based on a minimum daily ingestion of 50 to
100 grams (200–400 kcal) to spare the
metabolism of protein.
• When dietary intake is below minimum
requirement, triglycerides (lipid compounds
consisting of three fatty acids and a glycerol
molecule) and proteins are metabolized to
produce energy
175
 Major sources of dietary carbohydrates

•starches (non animal foods, primarily grains)

•lactose(milk)
•sucrose (cane sugar)
•Cells are unable to store large quantities of carbohydrates.
•The liver converts excess galactose and fructose
into glucose and stores it in the form of glycogen.
•Insulin (pancreatic hormone) aids in the diffusion of glucose into the
liver and muscle cells and in the synthesis of glycogen.
•Glucose metabolism is dependent on the availability of insulin.

176
• An increase in blood glucose levels can cause
hyperglycemia (a blood glucose level greater than
110mg/dl).
• diabetes mellitus (a disease in which the pancreas
fails to secrete adequate levels of
insulin to accommodate blood glucose levels).
• When hyperglycemia occurs, ketones (the end
product of incomplete fat metabolism) build up in the
bloodstream, causing metabolic acidosis.

177
• In hypoglycemia, the blood glucose level is
below normal (less than 80 mg/dl) because the
supply of insulin is so high that most of the
glucose moves from the blood into the cells.
• Because brain tissue requires a constant
source of glucose for energy, hypoglycemia
can alter the normal functions of the brain.

178
• Glucose (dextrose) is a common substance in
intravenous therapy (dextrose-5%-water)
because it is readily
absorbed into the body’s cells.
• This solution provides 170 kcal/L

179
 Proteins

• are organic compounds that contain carbon,hydrogen, oxygen,

and nitrogen atoms; some proteins also contain sulfur.
• There are 20 identified amino acids, which are categorized as
either essential or nonessential:
- Nonessential amino acids can be synthesized
(manufactured) in the cells.
- Essential amino acids must be ingested in the diet
because they cannot be synthesized in the body.

180
181
• The surplus amino acids are sent back to the
liver, where they are degraded (nitrogen is split
from the amino acid); the remaining parts are
used for energy or converted to carbohydrate or
fat and
stored as glycogen or adipose tissue.
• Carbon dioxide, water, and nitrogen are the end
products of amino acid metabolism.

182
• The degradation of amino acids begins the
process of deamination- the removal of the
amino groups from the amino acids.
• During protein deamination, several other
physiological processes of clinical significance
occur:

183
• Gluconeogenesis - the conversion of amino acids into glucose or
glycogen
• Ketogenesis- the conversion of amino acids into keto acids or fatty acids
• Nitrogen balance- the net result of intake and loss of nitrogen that
measures protein anabolism and catabolism
• Positive nitrogen balance- the condition that exists when nitrogen intake
exceeds output (protein anabolism exceeds catabolism)
• Negative nitrogen balance- the condition that exists when nitrogen
output exceeds intake (protein catabolism exceeds anabolism)
• Obligatory loss of proteins- the degrading of the body’s own proteins
into amino acids, which are then deaminated and oxidized (occurs when a
person fails to ingest adequate amounts of proteins)

184
• Nitrogen balance measures protein equilibrium and is used
to evaluate the client’s nutritional status. Clients on bed
rest or with a fever are in a catabolic state that produces a
negative nitrogen balance.
• N.B. Electrolytes
Potassium and magnesium enhance the utilization
of protein by the body.
• These electrolytes assist with the transport of amino acids
into the cells.

185
 Lipids

• are organic compounds that are insoluble

in water but soluble in organic solvents such as ether and
alcohol.
• Fatty acids are basic structural units of most lipids.
- Saturated fatty acids form fats, glycerol esters of organic
acids whose carbon atoms are joined by single bonds (all the
carbon atoms are saturated with hydrogen).
- Unsaturated fatty acids form glycerol esters of organic
acids whose carbon atoms are joined by double or triple
bonds (at least two carbon atoms in the fattyacid chains in
the esters are unattached to hydrogen atoms).

186
• Monounsaturated fatty acids are fatty acids that
form esters with one double or triple bond; foods in
this category are nuts, fowl, and olive oil.
• Polyunsaturated fatty acids form esters that have
many carbons unbonded to hydrogen atoms. Foods
such as fish, corn,sunflower seeds, soybeans,
cottonseeds, and safflower oil contain such esters.

187
 Most important lipids are:

• Triglycerides are lipid compounds composed of three fatty

acid molecules attached to a glycerol molecule.
• Phospholipids are composed of one or more fatty acid
molecules and one phosphoric acid radical, and usually
contain a nitrogenous base.
• Cholesterol (a lipid that is produced by the body and
used in the synthesis of steroid hormones and
excreted in bile), is considered a fat and is found in
whole milk and egg yolk.

188
 PROMOTING
PROPER NUTRITION

• Hunger means a craving for food and is a

subjective sensation.
• Appetite means the desire for specific types of
food instead of food in general.
• Satiety means a feeling of fulfillment from
food.

189
 Dietary Reference Intakes and
Recommended Daily Allowances

• are recommended allowances of essential

nutrients (protein, fatsoluble and water-soluble
vitamins, and minerals) by age
category, inclusive of weight and height.
• RDAs represent the normal nutritional
needs of 97% to 98% of the people in each
specific category; the RDAs do not take into
consideration an individual’s specific needs or
physiological disorders
190
• The Dietary Reference Intake (DRI) is a generic term that refers to at least
three types of reference values:
- Estimated Average Requirement (EAR) -is the intake value that is
estimated to meet the requirement defined by a specific indicator of
adequacy in 50% of an age-specific and gender-specific group.
- RDA
- Tolerable Upper Intake Level (UL)- is the maximum level of
daily nutrient intake that is unlikely to pose risks of adverse
health effects to almost all of the individuals in the group for
whom it is designed.

191
 The Food Guide Pyramid

• outlines in graphic presentation six groups of

food and the number of servings
based on the dietary guidelines and the basic
four food groups.

192
 Weight Management

•Average weight is relative to energy balance, the situation in which energy intake equals energy
output.
•Overweight
- indicates a positive energy balance and is
defined as weight 10% to 20% above average; obesity refers to weight 20% above average.
•Underweight
- a negative energy balance, is weight at least 10% to 15% below average.
- Anorexia nervosa (self-starvation)
- Bulimia nervosa - food-gorging binges followed by purging of food, usually through self-
induced vomiting or laxative abuse

193
 FACTORS AFFECTING
NUTRITION

• Age
• Lifestyle
• Ethnicity, Culture,and Religious Practices

194
 ASSESSMENT

o Nutritional History - methods used in

collecting these subjective data are:
- 24-hour recall
- food frequency questionnaire
- food record, and diet history

195
•Physical Examination
-Intake and Output (I&O)
- Anthropometric Measurements
-body mass index (BMI)
-Skinfold Measurements
-Mid-Upper-Arm Circumference
-Abdominal-Girth Measurement
•Diagnostic and Laboratory Data
-Protein Indices
- Serum Albumin
- Serum Transferrin
-Hemoglobin Level

196
 NURSING DIAGNOSIS

• Imbalanced Nutrition: Less Than Body Requirements

• Imbalanced Nutrition: More Than Body Requirements or Risk for More Than
Body Requirements

197
 OUTCOME IDENTIFICATION
AND PLANNING

• Nursing diagnoses of life-threatening conditions, such as Impaired

Swallowing related to decreased or absent gag
reflex, are given first priority.
• Other diagnoses that are actual problems take priority over high-risk
problems.
• In the planning phase, the nurse identifies and
explains to the client the need for and basis of the therapy. The nurse
takes into consideration the client’s
dietary habits, likes, dislikes, needs, and nutritional
assessment data in defining goals and developing outcomes in
collaboration with the client.

198
 IMPLEMENTATION

•Monitoring Weight and Intake

•Initiating Diet Therapy
-Nothing by Mouth
-Clear-Liquid Diet
-Liquid Diet
-Soft Diet
-Mechanical Soft Diet
-Pureed Diet
-Low-Residue Diet identify how to accomplish such
-High-Fiber Diet such therapy. Reading ass.
-Liberal Bland Diet
-Fat-Controlled Diet
-Sodium-Restricted Diet
-Lactose Intolerance Diet
-Candidiasis Diet

199
Assistance with Feeding

200
 Providing Nutrition Support

• Nutrition support is prescribed for those clients at risk for

protein-energy malnutrition.
• two routes for delivery of nutrition support
(NS) in adult clients:
- Enteral nutrition includes both the ingestion of food
orally and the delivery of nutrients through a
gastrointestinal tube.
• Parenteral nutrition -refers to nutrients bypassing the
small intestine and entering the blood directly.

201
 Indicators for determining the feeding route
and nutrition support formula

• GI function,
• expected duration of therapy,
• aspiration risk
• potential for or the actual development of
organ dysfunction.

202
 Clinical Decision Algorithm (Reprinted from the

American Society for Parenteral and Enteral Nutrition [ASPEN].

203
 Providing Enteral Nutrition

• Enteral tube feedings are contraindicated in clients with the

following:
• Diffused peritonitis
• Intestinal obstruction that prohibits
normal bowel functioning
• Intractable vomiting; paralytic ileus
• Severe diarrhea
• An enteral tube feeding is used with caution in clients with
severe pancreatitis, enterocutaneous fistulae, and GI ischemia.
• These feedings are not recommended during the early stages
of short-bowel syndrome or in the presence of severe
malabsorption.
204
Insertion of Enteral Feeding Tubes

205
Inserting a nasogastric or nasointestinal tube for
suction and enteral feeding
Equipments

206
 NGT INSERTION AND FEEDING

• DEMONSTRATION CLASS

207
 PROVIDING PARENTERAL NUTRITION
•is the infusion of a solution directly into a vein to meet the
client’s daily nutritional requirements.
• formerly called hyperalimentation, it is frequently
referred to as total parenteral nutrition (TPN), the
intravenous infusion of a solution containing dextrose,
amino acids, fats, essential fatty acids, vitamins, and
minerals. Other terms used interchangeably with TPN are
3 in 1 (dextrose, amino acids, and fats) and total nutrient
admixtures (TNA).

208
• PN is used to treat malnourished clients or clients who have the
potential for becoming malnourished and who are not candidates for
enteral support.
• Peripheral parenteral nutrition (PPN) is used for short-term treatment
to deliver isotonic or mildly hypertonic solutions into a peripheral
vein; the volume is usually limited to between 2,000 and 3,000
ml/day, providing a caloric value of about 2,000 kcal/day.
• Central parenteral nutrition (CPN) is used for longterm therapy to
infuse highly hypertonic solutions directly into the superior vena
cava.

209
 Components of Parenteral Nutrition

• Carbohydrates, primarily in the form of monohydrous glucose, ranging

from 5% solution for PPN to
50% to 70% hypertonic solution for CPN; provides
the client with 60% to 70% of caloric (energy) needs.
• Amino acids, in the form of synthetic crystalline
amino acid solutions; provides 5% to 15% of the
total calories (CPN solutions contain sufficient
amino acids for tissue synthesis).
• Lipid (fat emulsions), prepared from safflower and
soybean oil with egg phospholipids; supply up to
30% of the client’s caloric (energy) intake; additional lipid emulsions and
glucose or amino acids
provide for a TNA isotonic solution

210
• Other ingredients, called admixtures, provide for the client’s
biochemical needs (electrolytes, vitamins, and trace elements
such as zinc, selenium, chromium, magnesium, iodine,
copper, iron, and molybdenum).
• Medications, such as heparin, may also be added to the TPN
solution.
• Identify clients candidate for PPN OR CPN
therapy
• Nursing interventions for client receiving TPN

211
 Unit seven: SKIN INTEGRITY AND WOUND
HEALING
• A disruption in the integrity of body tissue is called a wound.
 Physiology of Wound Healing
1. Defensive (Inflammatory) Phase
- occurs immediately after injury
- lasts about 3-4 days
- stage of hemostasis and inflammation
2. Reconstructive (Proliferative) Phase
- lasts 2-3 wks
- collagen desposition, angiogenesis, granulation tissue development and
wound contraction
3. Maturation phase
- begins at 21st day – 2 yrs or more
- scar tissue is remodeled
- capillaries disappear- avascular scar ( white scare
212
 Types of Healing

• Primary intention healing occurs in wounds that have

minimal tissue loss and edges that are well approximated
(closed).
• Secondary intention healing is seen in wounds with
extensive tissue loss and wounds in which the edges cannot be
approximated.
• Tertiary intention healing, also known as delayed or
secondary closure, is indicated when primary closure of
a wound is undesirable.
-Conditions in which healing by tertiary intention may occur
include poor circulation or infection.

213
 Kinds of Wound Drainage

• Exudates may vary in composition but all have similar

functions.
1.Dilution of toxins produced by bacteria and dying cells

2. Transport of leukocytes and plasma proteins, including

antibodies, to the site

3. Transport of bacterial toxins, dead cells, debris, and other

products of inflammation away from the site

214
Serous exudate is composed primarily of serum
(the clear portion of blood), is watery in
appearance, and has a low protein count.
• mild inflammation resulting in minimal
capillary permeability changes and minimal
protein molecule escape (e.g., seen in blister
formation after a burn).

215
Purulent exudate is also called pus.
• It occurs with severe inflammation
accompanied by infection.
• Purulent exudate is thicker than serous exudate
because of the presence of leukocytes
(particularly neutrophils), liquefied dead tissue
debris, and dead and living bacteria.

216
Hemorrhagic exudate has a large component of red blood
cells (RBCs) due to capillary damage, which allows RBCs
to escape.
• This type of exudate is usually present with severe
inflammation.
• The color of the exudate (bright red versus dark red)
reflects whether the bleeding is fresh or old.
• Serosanguineous exudate is clear with some blood tinge
and is seen with surgical incisions.

217
Factors Affecting Wound Healing

218
• Hemorrhage
• Infection
• Dehiscence ( partial or complete separation of
wound edges) and evisceration ( occurs when
the client’s viscera protrude through disrupted
wound)

219
 Wound Classification

• Cause of wound
- Intentional wounds occur during treatment or
therapy. These wounds are usually made under aseptic
conditions.
- Examples include surgical incisions and
venipunctures.
- Unintentional wounds are unanticipated and are
often the result of trauma or an accident.
- These wounds are created in an unsterile
environment and therefore pose a greater risk of
infection. 220
• Cleanliness of Wound
- Clean wounds are intentional wounds that were created under conditions in which no
inflammation was encountered and the respiratory, alimentary, genitourinary, and
oropharyngeal tracts were not entered.
- Clean-contaminated wounds are intentional wounds that were created by entry into the
alimentary, respiratory, genitourinary, or oropharyngeal tract under controlled conditions.
- Contaminated wounds are open, traumatic wounds or intentional
wounds in which there was a major break in aseptic technique, spillage
from the gastrointestinal tract, or incision into infected urinary or biliary
tracts.
- These wounds have acute non-purulent inflammation present.
- Dirty and infected wounds are traumatic wounds with retained dead
tissue or intentional wounds created in situations where purulent drainage
was present.

221
• Classification by Thickness of Skin Loss
- is based on the depth of the wound and is used for
wounds whose etiology is other than pressure wounds
such as skin tears, donor sites, vascular ulcers, surgical
wounds, or burns.

222
• Superficial epidermal (first degree) are confined to the epidermis
layer, which comprises the four outermost layers of skin.
• Partial-thickness (first to second degree)- involves the epidermis
and upper dermis, which is the layer of skin beneath the epidermis.
• Deep (second degree) involves the epidermis and deep dermis.
• Fullthickness (third degree) refers to skin loss that extends
through the epidermis and the dermis, and into subcutaneous fat and
deeper structures.
• Fourth degree are deeper than full-thickness loss, extending into
the muscle and bone

223
 The RYB Wound Classification System

•Red wounds are the color of normal granulation tissue and are in the
proliferative phase of wound repair.
-These wounds need to be protected and kept moist and clean.
•Yellow wounds have either fibrinous slough or purulent exudate from
bacteria.
- These wounds need to be cleansed of the purulent exudate, and
nonviable slough needs to be removed.
• Black wounds contain necrotic tissue (eschar).
- Eschar may be either black, gray, brown, or tan. These wounds need
debridement, which is the removal of nonviable necrotic tissue. Mixed
color wounds often occur.

224
 Reading assignment

• Identify the following terms

- bruise
- laceration
- abrasion
- avulsion
- Puncture

225
 Assessment
• Health history
• Location
• Size
• General appearance
• Pain
• Lab data such as wound culture, WBC count,
leukocyte count, serum albumin

226
 Nursing diagnosis
1. Impaired Tissue Integrity related to surgical incision, pressure, shearing
forces, decreased blood flow, immobility, mechanical irritants, mechanical
(pressure, shear, friction), radiation, nutritional deficit or
excess, thermal, irritants, including body excretions, secretions, and
medications.
2. Risk for Infection related to malnutrition, decreased defense mechanisms
3. Pain related to inflammation, infection
4. Disturbed Body Image related to changes in body appearance secondary to
scars, drains, removal of body parts
5. Deficient Knowledge (wound care) related to lack of exposure to
information, misinterpretation, lack of interest in learning.

227
 Outcome Identification
and Planning

• After identifying the nursing diagnoses, the

nurse establishes targeted outcomes for wound
healing.
• When formulating outcomes, keep in mind that
they should be based on the client’s identified
needs and should be individualized on the basis
of the client’s
condition.

228
 Implementation

• Initiate emergency measures

• Cleanse the wound
principles
- use standard precautions at all times
- using swab or gauze from clean to dirtier area
- when irrigating use warm solution
• Dressing the wound
puproses
- keep wound moist
- protect wound from physical trauma or bacterial invasion
- monitor drainage of wounds
- provide suture care
- checking bandages, binders and sling

229
 Unit eight: ADMINISTER HEAT AND
COLD THERAPY

• Heat is one of the oldest nursing measures used to reduce

pain and promote healing. Heat causes vasodilation and
increases blood flow to the affected area, producing skin
redness and warmth.
• Heat produces maximum vasodilation in 20 to 30 minutes;
after this period, reflex vasoconstriction occurs along with
tissue congestion. Periodic removal and reapplication of
heat will restore vasodilation.
• Prolonged exposure to heat damages epithelial cells and
results in redness, tenderness, and even blister formation.

230
• The application of cold lowers the temperature of
the skin and underlying tissues and causes vasoconstriction.
• Vasoconstriction reduces blood flow to the affected
area and produces skin pallor or a bluish discoloration
and coolness. Maximum vasoconstriction is achieved at 15°C
(60°F); at temperatures below 15°C, the vessels begin to dilate.
• Prolonged exposure to cold results in a reflex vasodilation.
Initially the skin is reddened, but
later it takes on a bluish purple mottled appearance
with numbness and pain because of impaired circulation and
tissue ischemia.

231
 Conditions that necessitate precautions in
the use of heat and cold applications:

• Neurosensory impairment: Clients with reduced perception of sensory or

painful stimuli (e.g., spinal cord injuries) are at an increased risk for tissue
injury.
• Impaired mental status: Clients who are confused or unconscious need to
be monitored and assessed frequently to ensure safety.
• Impaired circulation: Clients with cardiovascular and peripheral vascular
problems or diabetes may not have the ability to dissipate heat through
dilation of blood vessels and are at an increased risk for tissue
injury.
• Skin and tissue integrity (open wounds, broken skin, scar formation,
edema): Subcutaneous tissues are more sensitive to temperature variations
than are superficial tissues (e.g., cold can decrease blood flow to an open
wound, thereby inhibiting healing).

232
 Evaluation

• Goals for clients with wounds generally focus

on wound healing, prevention
of infection, and client education

233
 PRESSURE ULCERS

• also known as bedsores or decubitus

ulcers, are localized areas of tissue necrosis that tend to
develop when soft tissue is compressed between a bony
prominence and an external surface for a prolonged
period of time.
• are due to ischemia, or decreased blood supply, and
commonly occur in areas subject to high pressure from
body weight on bony prominences.

234
 Physiology of Pressure Ulcers

• Shearing is the force exerted against the skin

when a client is moved or repositioned in bed
by being pulled or allowed to slide down in
bed.
• Friction is the force of two surfaces moving
across one another.

235
 Risk factors for pressure ulcer
• Immobility
• Inactivity
• Incontinence
• Malnutrition
• Decreased mental status
• Diminished sensation
• Age related changes

236
 Assessment
• Stage I - Nonblanchable erythema of intact skin
- In individuals with darker skin, discoloration of the skin, warmth,
edema, induration, or hardness
• Stage II- Partial thickness skin loss involving epidermis or dermis.
- The ulcer is superficial and presents clinically as an abrasion, blister,
or shallow crater.
• Stage III- Full-thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia.
-The ulcer presents clinically as a deep crater with or without
undermining of adjacent tissue.
• Stage IV- Full-thickness skin loss with extensive destruction, tissue necrosis,
or damage to muscle, bone, or supporting structures.
- Undermining and sinus tracts may also be associated with Stage
IV pressure ulcers.

237
238
 Implementation
• Ensure proper hygiene and skin care
• Provide proper positioning
• Employ support surfaces
EVALUATION
• Will consider physical signs of healing and
client’s adaptation to altered skin integrity

239
 Demonstration class
• Wound cleaning and dressing
• Wound irrigation
• Hot and cold application

240
 Preoperative nursing
• Perioperative refers to the management and treatment of the client
during the three phases of surgery:
-preoperative- refers to the time interval that
begins when the decision is made for surgery until the client is
transferred to the operating room (OR)
- intraoperative- begins when the client is
transferred to the OR and ends with client
transfer to a postanesthesia care unit (PACU).
- postoperative -this phase continues until the client is
discharged from the care of the surgeon.

241
 SURGICAL INTERVENTIONS

• Surgeries are categorized according to the degree of urgency

(timely intervention of surgery):
1. Emergency surgery requires immediate intervention
to sustain life.
2. Urgent surgery dictates intervention as necessary to
maintain health in situations that are not life-
threatening.
3. Elective surgery is usually performed at a time
convenient to the client, with the delay presenting no
physiological harm

242
243
 PREOPERATIVE PHASE

• The primary goal of preoperative nursing care

is to place the client in the best possible
condition for surgery through careful
assessment and thorough preparation.

244
 Pre operative Assessment

• Nursing history
- medical history
- medications
- allergies
- age related factors
- social and cultural considerations
- spiritual and psychosocial consideration
• Physical assessment
- general survey
- head and neck
- upper and lower extremities
- anterior and posterior chest and abdomen

245
 Nursing diagnosis
• The nurse formulates nursing diagnoses based
on an analysis of assessment data and the
nature of surgery.
• Physical assessment findings are compared
against diagnostic test results; for example,
cardiovascular findings are analyzed with
blood chemistry and ECG
results.

246
 Outcome Identification
and Planning

• The nurse develops goals with client-focused expected outcomes based

on relevant nursing diagnoses.
• Nurses collaborate with other health care team members and the client
in establishing the goals and outcomes.
• The overall goal is to protect the client from injury related to anesthesia
and surgery. The plan of care directs the selection of specific nursing
interventions that promote the client’s achievement of expected
outcomes, forexample, client teaching.
• Discharge planning needs are incorporated into the,plan of care on
admission.
• The following considerations are included in discharge planning:

247
• Psychosocial and spiritual support systems and
community resources
• Financial aspects of the illness
• The degree of illness or disability
• Rehabilitation
• Preventive care
• Client teaching needs

248
 Implementation

• Surgical consent form

• Preoperative checklist
• Client teaching
- preparation activities
- post operative exercise
- proper application and usage of medical
devices
- physical and evironmental challenges after surgery
• Physical preparation
- skin preparation
- nutrition
- gastrointestinal preparation

249
 Evaluation

• Evaluation of actual and expected outcomes of

the perioperative client is done over the three
phases.
• Preoperative evaluation focuses on the client’s
ability to verbalize and demonstrate the
exercises.

250
 INTRAOPERATIVE PHASE

• The goal of nursing care during this phase

is to ensure client safety.
• Maintaining a safe environment includes
protecting the client from injury, infection, and
complications arising from anesthetic
agents,hazards, and the surgical procedure

251
 Surgical Environment

• The surgical area usually consists of three zones: --

1. Unrestricted - is designed for personnel to enter in street
clothes: receiving desk, holding area, and locker rooms
2. Semirestricted- Surgical attire (scrub clothes, disposable
shoe covers, and caps). Hallways and storage areas
3. Restricted- Surgical attire (scrub clothes, disposable shoe
covers, and caps). (controlled and germ-free areas)
include the OR and rooms where sterile instruments are
prepared.

252
 Surgical Team

• Surgeon: Scrubbed and in surgical attire to perform the surgery.

• Anesthesia provider: Masked and in clean scrub attire
to administer the anesthesia.
• Surgical assistant (first assistant): Can be another
physician, a nurse, or physician’s assistant (PA) who is
scrubbed, in sterile attire, and assists the surgeon to
ligate, suction, and suture.
• Scrub nurse or technician: Scrubbed and in sterile attire;
prepares the instrument tray and passes the instruments,
sponges, needles, and sutures to the surgeon.
• Circulating nurse: In clean scrub attire and mask;
obtains supplies, delivers materials, pours solutions,
handles specimens, positions the client and surgical
drapes, and disposes of soiled items

253
 Assessment

• Assessment of proper positioning to ensure comfort

and safety includes:
• Checking for client alterations that can affect positioning during the
procedure, such as previous skeletal or joint surgery, presence of a
joint or vascular
prothesis, poor nutrition, and skin integrity
• Making sure the OR bed is prepared to receive the
client: for example, warming mattress on bed, proper
orientation of bed, bed wheels locked
• Ensuring that accessories are clean and readily available for a
specific position: for example, Wilson
frame, chest rolls, pillows, headrest

254
 Nursing Diagnoses

• Common intraoperative nursing diagnoses

promote client comfort, safety, and support
during the surgical procedure

255
Outcome Identification
and Planning

256
 Interventions

• Nursing interventions are selected to facilitate caring and to

achieve the expected outcomes, such as the client is free from
infection 72 hours postoperatively.
• Because anesthesia inhibits the client’s ability to protect self, the
OR staff implements surgical asepsis, safe positioning, and other
interventions that promote client safety.
Surgical Asepsis
- refers to hand washing, wearing surgical attire, handling sterile
instruments and equipment, and establishing and maintaining sterile
fields.

257
Skin Preparation - is performed to decrease the risk for infection by reducing the
resident microbial count on the skin and inhibiting rebound growth of microbes
when the skin is incised during surgery.
• The second phase of the surgical skin preparation is usually done by OR
personnel before surgery to prevent the growth of microorganisms.
• The skin preparation should comply with the CDC recommendations to avoid
unnecessary hair removal and to shave immediately before an operation.
• Hair can be removed by clipping, depilatory, and shaving with a razor.
• A dry shave refers to the removal of hair by clipping or the use of a depilatory.
• Shaving with a razor and a warm, antiseptic solution is often called a
wet shave.

258
Positioning and Draping
• The surgical client is usually sedated or anesthetized
and therefore is unable to communicate any discomfort.
• Proper positioning ensures client comfort and safety,
preserves vascular supply, and prevents neuromuscular damage to tissue.
• also provides access to the surgical site, airway, intravenous lines, and all monitoring devices.
Electrical Hazards
• During surgery the client can be exposed to an electrical surgical generator (electrocautery
device to eliminate bleeding and reduce contamination).
• Electricity cannot flow unless a circuit is complete; thus, electricity introduced into the body
has to find a pathway back to the generator.
• A ground pad is provided for that purpose.

259
Heat Loss
• during surgery,body heat is lost by positioning on a cold
OR table (conduction); administration of cold gases
(convection); exposure of large operative sites, such as
thoracic and abdominal areas (evaporation); and exposure
to cold
OR temperatures (radiation).
• Anesthetic agents can also alter thermoregulation and
lower metabolism.

260
• Body temperature is maintained by applying warming mattresses or
warmed blankets, warming and humidifying inhaled gases, warming
irrigating and intravenous solutions, and increasing room temperature
when the client is exposed, for example, for skin preparation and
positioning.
Monitoring Physiological Functioning
After intubation and induction of anesthesia, the client is monitored for:
• Ventilation and circulation
• ECG and oxygen analyzer alterations
• Fluid intake, urinary output, and calculated blood loss
• Behavioral changes
• Body temperature
• Diagnostic testing (collection of specimens and cultures, x-rays and
fluoroscopy)
• Placement of medical devices (ground pad, position support, drains,
catheters, implants, packings, and dressings) 261
 Evaluation

• Evaluation is based on reassessment findings of the client during and after surgery.
• The nurse documents the specific data on the OR record, which usually reflects
AORN standards of intraoperative care and other direct care issues pertinent to client
outcomes.
Transfer to Postanesthesia Care Unit
• Planning for personnel and equipment needed to safely transfer the client is usually
handled by the circulating nurse.
• Moving the semi anesthetized client from the OR table to the PACU stretcher for
transport requires coordinated effort of at least four persons.
• Assurance is made that a sufficient number of staff are available to move the client
while maintaining proper body alignment and preventing the dislodgement of any
tubes, drains, or monitoring devices.

262
• Once on the stretcher, the client is quickly transported by a nurse and
anesthetist to the PACU.
• The client at this time is at high risk for injury related to the effects of
residual anesthesia: airway distress, vomiting and aspiration, and
circulatory alterations.
• The anesthetist stays with the client while the OR nurse gives a report to
the PACU nurse assigned to the client.
• The report should include all pertinent anesthesia and surgery information.
• After giving the report, the OR nurse documents the time of discharge,
method and disposition of transfer, and a general statement regarding the
client’s status.

263
 POSTOPERATIVE PHASE

• The primary goal of nursing care during the immediate postoperative

phase is to maintain the “A-B-Cs”: airway, breathing, and circulation.
• Extubation is performed by the anesthetist before the client leaves the
OR or in the PACU when assessment data confirm adequate gas
perfusion.
• The endotracheal tube is usually removed on the first postoperative
day.
• Intubated clients are usually transferred to intensive care units for 2 or
3 day

264
Assessment

265
266
 Nursing Diagnosis

• Clients with preexisting conditions, identified during the

preoperative period, will continue to require special nursing care.
Outcome Identification and Planning
• Care planning is done in two parts: immediate care
rendered in the PACU area and ongoing post-PACU
care.
• Nursing care in PACU usually lasts 1 to 3 hours and is
directed toward returning the client to a safe
physiological level of functioning after anesthesia.

267
 Interventions
Maintaining Respiratory Status
- high humidity oxygen and pulse oximeter
- If client is extubated and experiences difficulty in breathing
- chin forward, hyperextend neck and turn head to the side.
- If obstruction is unrelieved, insert nasal or oral airway and suction
- If client is intubated, position in high fowler’s position.
- remove secretion by suctioning on basis of assessment finding’s
such as:
- ronchi, low pitched musical wheezes despite bronchodilator
therapy, Increased peak airway pressure in clients receiving
mechanical ventilation

268
Maintaining Circulatory Status
• The client is monitored carefully for the signs of hypotension
and hypovolemic shock.
• Passive range of motion and the application of
antiembolism hose or other devices promote circulation
of the intubated or semiconscious client.

269
Maintaining Neurologic Status
•Monitoring the client’s level of consciousness is done in relation to how the
airway is maintained:
• The unconscious client with an absence of the cough
and gag reflex will have an endotracheal tube or airway.
• The semiconscious client with partial return of all
reflexes will have an oral or nasal airway.
• The conscious client with full return of all reflexes will
breathe without assistance from an artificial airway.
•The nurse monitors clients who had spinal anesthesia for return of reflexes,
sensation, and movement of extremities below the level of anesthesia.
•Extremities are assessed for color, temperature, and pedal pulses.

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Maintaining Fluid and Metabolic Status
• The goal of intravenous therapy is to maintain the circulating
fluid volume. Infusion sites are inspected for patency
immediately when the client arrives in the PACU.
• Secretions from tubes, drains, and the incision site are
measured to determine output.
• The client’s total output is compared against the volume
of intravenous replacement fluids.
Managing Pain

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 Evaluation and Discharge
from the PACU

• The anesthetist is responsible for releasing the client from the

PACU.
• standards of care that have to be met before discharge.
The client is conscious, oriented, and can move all extremities.
- The client demonstrates full return of reflexes.
- The client can clear the airway and cough effectively.
- Vital signs have been stable or within baseline ranges for 30
minutes.
- Intake and urinary output are adequate to maintain the
circulating blood volume.
- The client is afebrile, or a febrile condition has been treated
accordingly.
- Dressings are dry or have only minimal drainage 272
 Elimination

• Physiology of elimination
The urinary system is composed of the kidneys,
ureters,bladder, and urethra.
- kidneys form the urine.
- ureters carry urine to the bladder.
- bladder acts as a reservoir for the urine.
- urethra is the passageway for the urine to
exit the body.

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• The gastrointestinal tract is composed of the stomach, small
intestine, large intestine, and rectum.
- small intestine absorbs nutrients
- large intestine absorbs fluids
- remaining nutrients
- distal portion of the large intestine collects and stores
the remaining solid waste until elimination occurs.

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 Urinary Elimination

• Structures of the Urinary Tract

Upper Urinary Tract
- includes the kidneys, renal pelvis, and ureters

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