NSG- 300 Exam 2 Study Guide

Topic 4:
Examine the factors that places clients at risk for impaired skin integrity:
 Loss of profusion-
o dermal ulceration or necrosis.
 Immunologic reaction-
o allergic response or psoriasis.
 Trauma/injury-
o deep penetrating wound or superficial abrasion/scrape.
 Infections and infestations-
o bacterial, fungal, viral infections or mites and lice.
 Thermal or radiation injury-
o sunburn to scald burns or radiation injury
 Lesions-
o invasive malignant tumors or benign skin growths.
List the elements of a comprehensive wound assessment:
 Identify location of the wound
 Determine the etiology of wound (what caused it?)
 Determine wound classification and/or stage
 Measure size of wound (length, width, and depth),
 Measure amount of wound tunneling and undermining,
 Assess the wound bed, exudate, surrounding skin, wound edges, s/s of wound infection,
pain, document findings.
Identify the body’s key physiologic defenses against infection:
 increased temperature release interferon (increase the temp),
 Increase WBC (neutrophil and monocytes are the main ones),
 Inflammation mast cells,
 Vasodilation in the capillaries around the wound.
Recognize factors that promote healing and the prevention of infection in clients
with impaired skin integrity:
 Principles to maintain a healthy wound environment:
o Prevent and manage infection, clean the wound, remove nonviable tissue,
manage exudate, maintain the wound in a moist environment,
o Protect the wound, prevent and manage infection:
 Cleaning the wound.
 Pressure ulcers: use noncytotoxic wound cleaners; NS (normal
saline) is the preferred cleaning agent, commercial wound
cleaners.
 Other wounds: cytoxic wound cleaners: Dakin’s solution, Acetic
acid, Povidone-iodine, Hydrogen peroxide, Irrigation is a common
method of delivering wound-cleaning solution to the wound.
 o protect the wound by applying a sterile or clean dressing.
o for surgical wounds that heal by primary intention, it is common to remove the
dressings as soon as the drainage stops to expose it to oxygen.
o for wounds healing by secondary intention the dressing material becomes a means for
providing moisture to the wound or assessing in debridement.
o Nutritional status: therapeutic diet or enteral or parenteral nutrition; increased caloric
intake helps replace subcutaneous tissue; patients will receive vitamin and mineral
supplements if suspected or known deficiencies exist, Vitamin C- promoted collagen
synthesis, capillary wall integrity, fibroblast function, and immunological function;
protein promotes wound healing
Differentiate among wound types:
 Acute wound:
 wound that proceeds through an orderly and timely reparative process that results
in sustained restoration of anatomical and functional integrity (ex. trauma
or surgical wounds),
 Chronic wound:
 wound that fails to proceed through an orderly and timely process to produce
anatomical and functional integrity (ex. vascular compromise or chronic
inflammation).
Wound classification:
 Primary intention: no skin loss, can be sown back up, wound that is closed (ex.
surgical incision)
 Secondary intention: want to heal from the inside out, want to see granulation tissue,
wound edges not approximated (ex. pressure ulcers
or surgical wounds that have tissue loss),
 Tertiary intention: would that is left open for several days, then wound edges are
approximated,

 Penetrating wounds: trauma is usually by a sharp and pointed instruments like needles,
basically any object with sharp edges,
 Non-penetrating wounds: wounds that are often caused by friction against the skin that
doesn’t cause the outer dermal layer to break; they may also include injured caused by
blunt trauma.
 Lacerations: a deep cut or tear in the skin
 Abrasions: the process of scraping or wearing away,
 Contusions: a region of injured tissue or skin in which blood capillaries have been
ruptured (ex. a bruise).
 Pressure ulcer: a localized injury to the skin and other underlying tissue, usually over a
boney prominence, as a result of pressure or pressure in combination with shear and/or
friction.
o Classification of pressure ulcers:
  Stage I: intact skin with nonblanchable redness; discoloration of the skin,
warmth, edema, hardness, or pain may also be present.
 Stage II: partial-thickness tissue loss; a shallow open ulcer with a red-pink
wound bed without slough.
 Stage III: full-thickness tissue loss with visible fat; subcutaneous fat may
be visible; some slough may be present; may include undermining and
tunneling.
 Stage IV: full-thickness tissue loss with exposed bone, muscle, or tendon;
slough or eschar may be present; often includes undermining and
tunneling.
 Unstageable/ unclassified: full-thickness skin or tissue loss, depth
unknown; base of wound cannot be visualized, and depth of injury is
unknown; either a stage III or IV.
Identify the major trends in wound treatment and nursing interventions to
promote wound healing:
 Assess the skin beneath the tape
 perform thorough hand hygiene before and after wound care
 wear sterile gloves before directly touching an open or fresh wound
 remove or change any dressings over closed wounds when they become wet or if the
patient has signs or symptoms of infection, and as ordered.
 Clean the wound/drain site: Clean in a direction from least contaminated (incision site)
to most contaminated (skin surrounding); use gentle friction when applying solutions
locally to the skin; when irrigating, allow the solution to flow from the least to the most
contaminated area.
 Wound drains: Penrose drain (looks like a noodle or not inflated balloon animal),
Jackson-Pratt, Hemovac, Pad bony prominences.
 Partial thickness wound repair: inflammatory response, reproduction, migration and
reestablish layers.
 Full thickness wound repair: hemostasis,Inflammatory, proliferative and maturation.
 Dark skin with impaired integrity: use natural light or well-lit environment to assess for
pressure ulcer.
o Color: doesn’t blanch, previous ulcer can show up lighter than original skin.
o Inflammation is purple or blue color.
o Edema is shiny or taut.
o Sensitive or tender to touch or hard and lumpy to palpation.
o Debridement: removal of dead tissue.
o Eschar: dead black, brown tan or necrotic tissue.
o Induration: hardening of tissue. Sanguineous: bright red bleeding.
o Serosanguineous: pale pink fluid.
o Purulent: thick yellow green tan or brown.
o Serous: clear watery plasma.
o Dehiscence: separation of wound layers.
o Evisceration: separation of wound layers.
 o Braden Scale for pressure ulcer risks.

Topic 5
Define the steps of the nursing process (assessment, diagnosis, planning,
implantation, and evaluation) and their relationship to providing holistic, client-
centered care:
 The nursing process is the set of standards that set forth the framework necessary for
critical thinking in the application of the five-step process.
 Assessment: gather information about the patient’s condition. Two stages of
assessment: (1) collection and verification of data and (2) the and the analysis of data.
Take quality time to be with the patient to establish a nurse-patient therapeutic
relationship, this allows you to know the patient as a person. Types of assessments:
Patient-centered interview during a nursing health history.
o Phases of an interview: (1) orientation and setting an agenda- introduce
yourself, explain the purpose of the interview; explain why you are collecting the
data and assure the patient that all of the information will be confidential; ask
the patient for his or her list of concerns/ problems; this strengthens the nurse-
patient relationship (2) working phase: ask open ended questions; use attentive
listening and other therapeutic communication techniques that encourage a
patient to tell their story; do not rush the patient (3) termination: summarize
your discussion with a patient and check for accuracy of info collected; give your
patient a clue that the interview is coming to an end and end it in a friendly
manner telling the patient when you will return to provide care.
o Physical examination- Periodic assessment that you make during rounding and
administering care.
o Types of data: subjective and objective.
o Sources of data: patient, family/ significant others, health care team, medical
records, other records/scientific literature, nurse’s experience.
o Diagnosis: identify the patient’s problems; make clinical judgments from the
assessment to identify the patient’s response to health problems in the form of a
nursing diagnosis.
o Plan: set goals of care and desired outcomes and identify appropriate nursing
actions.
o Implementation: perform the nursing actions identified in planning.
o Evaluation: determine if goals and expected outcomes were achieved; evaluate
the patient’s response and determine whether the interventions were effective.
o The nursing process requires a nurse to use the general and specific critical
thinking competencies to focus on patient’s focused needs
Select and prioritize nursing diagnoses based on client manifestations and
assessment data:
o Types of nursing diagnoses:
o Problem-focused: describes a clinical judgment concerning an undesirable human
response to a health condition/life process that exists in an individual, family, or
community; defining characteristics support each problem-focused diagnosis; a related
factor is an etiological or causative factor for the diagnosis and allows you to
individualize a problem-focused nursing diagnosis.
o Risk: a clinical judgment concerning the vulnerability of an individual, family, group, or
community for developing an undesirable response to heal conditions/life processes;
has risk factors.
o Health promotion: clinical judgment concerning motivation and desire to increase well-
being and actualize human health potential; these responses are expressed by a
readiness to enhance specific health behaviors and can be used in any health state; may
apply to an individual, family, group, or community; diagnoses have only defining
characteristics, although a related factor may be used to improve understanding of the
diagnosis.
o Establishing priorities: Classification of priorities:
o High: emergent; if left untreated will result in harm to the patient or others
(airway status, circulation, safety, pain) have the highest priority.
o Intermediate: non-life threatening; priority diagnoses involve nonemergent non-
life-threatening needs of patients.
o Low: affect patient’s future well-being; priority nursing diagnoses are not always
directly related to a specific illness or prognosis but affect a patient’s future well
being

Prioritize nursing interventions based on client needs and change in condition:

o A nursing intervention is any treatment based on clinical judgment and knowledge that
a nurse preforms to enhance patient outcomes.
o Types of interventions:
o Nurse-initiated: independent, actions that a nurse takes; these require no order and no
supervision/direction from others; these include ADL’s, health education and
promotion, and counseling.
o Health care provider initiated: dependent, require an order from a physician or other
health care professional; these interventions are based on the health care providers
response to treat/manage a medical diagnosis.
o Collaborative: interdependent, require a combined knowledge, skill, and expertise of
multiple health care professionals.
o Don’t be afraid to question the order or call up the provider and ask to clarify bc it is as
much your error as the person’s who wrote the order.
o 6 factors to consider: Desired patient outcomes, Characteristics of the nursing
diagnosis, Research based knowledge for the intervention, Feasibility of the
interventions, Acceptability to the patient, Nurse’s competency.
Apply concepts of the nursing process to ensure a safe client environment:
o Plans and interventions are designed around and with the patient so that they are
involved and the limitations are set to the patient not a standard.
o Evaluate frequently to monitor the patient’s progress and allow for changes to be made
when needed for best outcomes.

Design a holistic plan of care based on the needs of the client, including
complementary and alternative therapies:
o Complimentary: something you use with medication/medical treatment (ex. meditation
and pain killers)
o Alternative: using something instead of medication (ex. meditation only no pain killers)

Topic 6
Discuss key physiologic processes related to metabolism and nutrition:
o BMR: energy needed at rest to maintain life sustaining
activities for a specific amount of time.
o Resting energy expenditure (REE): amount of energy needed to consume over 24-hour
period for the body to maintain internal working activities while at rest.
o Nutrients: energy necessary for the normal function of numerous body processes.
o Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury,
infection, activity level, and thyroid function affect energy requirements.
o Factors that affect metabolism include illness, pregnancy, lactation, and activity level.
o Factors that influence nutrition: environmental factors, developmental factors,
sociological, cultural, religious, ethical, psychological and emotional factors.
o Enteral tube feeding: provides nutrients into the GI tract; nasogastric, jejunal, or gastric
tubes; surgical or endoscopic placement; patient is unable to ingest food but can still
digest and absorb nutrients; at risk for aspiration.
o If aspiration occurs: (1) stop feedings (2) administer metoclopramide (Reglan) if ordered
(3) monitor for nausea, vomiting, cramping, and diarrhea and tube occlusion (4) increase
rate per order.
o Parenteral nutrition: nutrients are provided intravenously; patients are unable to digest
or absorb enteral nutrition or are in highly stressed physiological states (sepsis, head
injury, or burns); via peripheral or central line.

Discuss the role of nutrition in maintenance of health and the healing process:
o Optimum nutrition is the stepping-stone of good health and the cutting edge to
prevent illness.
o The foods we eat and nutrition we absorb are influencing factors on our growth,
development, functional abilities, and health.
 o Education in nutrition can help prevent diseases such as heart disease, CA, and
CVAs/TIAs.
o Our lifestyle choices such as proper nutrition, health habit discipline, and exercise
will help decrease future medical expenses

Identify therapeutic diets based on client diagnoses, nutritional needs, and

cultural preferences:
o Types of diets:
o High fiber: veggies, bran, oatmeal, dried fruit.
o Low sodium: 4g, 2g, 1g.
o Low cholesterol: 300 mg/day.
o Diabetic: usually 1800 cal/day. Regular: no restrictions.
o GI diseases: Peptic ulcer: Etiology: H. pylori, stress, acid overproductions. Treatments:
avoid caffeine, avoid spicy foods, avoid aspirin, nonsteroidal anti-inflammatory drugs
(NSAIDs), consume small frequent meals.
o Inflammatory bowel disease: Etiology: Crohn’s, idiopathic ulcerative colitis. Treatments:
elemental diets (formula with the nutrients in their simplest for ready to absorb) or PN
when symptoms such as diarrhea and weight loss are prevalent, vitamins and iron
supplements to correct/prevent anemia, increase fiber, reduce fat, avoiding large meals,
avoiding lactose or sorbitol containing foods.
o Malabsorption: Etiology: celiac disease. Treatments: gluten-free diet.
o Diverticulitis: Etiology: inflammation of the diverticula. Treatment: moderate or low
residue diet; after prescribing high-fiber diet.
o Diabetes mellitus: Type 1: insulin and dietary restrictions. Type 2: exercise and diet
therapy initially *Monitoring carbohydrate consumption is a key strategy for both type 1
and 2, limit saturated fats to less than 7% of total calories and cholesterol intake to less
than 200 mg/day; should consume usual amounts of protein.
o Cardiovascular diseases: AHA dietary guidelines: Balance caloric intake and exercise;
maintain a healthy body weight; eat a diet rich in fruits, veggies, and complex carbs; eat
fish twice a week; limit foods and beverages high in sugar and salt; limit trans-saturated
fats to less than 1%.
o Cancer and cancer treatment: Malignant cells compete with normal cells for nutrients;
patients often experience anorexia, nausea, vomiting, and taste distortion. The goal of
nutrition therapy is to meet the increased metabolic needs of a patient. Nutrition
management: maximizing intake of nutrients and fluids.
o HIV/AIDS: Patients with these diseased typically experience body wasting and severe
weight loss r/t anorexia, stomatitis, oral thrush infection, nausea, or recurrent vomiting;
all resulting in adequate intake.
o Factors associated with weight loss and malnutrition include diarrhea, GI malabsorption,
and altered metabolism of nutrients.
o Restorative care: maximize kilocalories and nutrients; encourage small frequent,
nutrient-dense meals with fluid in between
Utilize the nursing process to plan care for individuals experiencing fluid and
electrolyte imbalance and alterations in nutrition:
o ND: Deficient fluid volume r/t increased output of GI fluids N/V.
o Goal: patient achieves normal hydration status at discharge.
o Expected outcomes: HR and BP are normal w/in 24 hrs, urine color becomes light w/in
and patient is educated.
o Nursing interventions/rational: Provide favorite fluids at preferred temp patients
centered care/ Provide glass of H2O at bedside easy access. Administer IV as prescribed,
monitor for complications at IV site.

Utilize the nursing process to plan care for individuals receiving enteral
feedings:
o ND: Risk for aspiration r/t enteral tube feeding.
o Goal: Prevent patient from aspirating.
o Expected outcome: Patient will maintain patent airway and clear lung sounds.
Nursing interventions/rational: Position patient with HOB elevated a minimum of 30
degrees decreases risk for aspiration. Check tube placement every 4-6 hours
improperly positioned tube increases the risk for aspiration. Check gastric residual
volume every 4 hours indicated whether gastric emptying is delayed; gastric
emptying increases the risk for aspiration.
o ENTERAL TUBE FEEDING: Before starting, flush the line with water so the tube is
clear. Reduces sepsis, minimize hypermetabolic response to trauma, decrease
hospital mortality, and maintain intestinal structure and function.
o ENTERAL ACCESS TUBES: When patients can’t ingest food but can digest and absorb
nutrients.
o Procedure: Start at full strength. Slow rate. Increase every 8-12 hours as ordered.
Assess for signs of intolerance: High gastric residuals, nausea, cramping, vomiting
and diarrhea. Assess for complications: Aspiration, Diarrhea, Bacterial
contamination, Tube occlusion, delayed gastric emptying

Identify the role of monitoring, measuring, and documenting intake and output:
o Intake all oral liquid, semi-liquids, enteral feedings, parenteral fluids (IV); any fluid that
leaves the body (vomit, any drains).
o Dysphagia: difficulty swallowing. Risk for Aspiration r/t impaired swallowing.
o Outcome: Patient will maintain patent airway and clear lung sounds.
o Nursing Interventions. Monitor for s/s of difficultyin swallowing. Cough during eating;
change in voice tone or quality after swallowing; abnormal movements of the mouth,
tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag,
delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal
pooling, delayed or absent trigger or swallow, and inability to speak consistently.
o Nursing Diagnosis: Monitor Respiratory rate, depth, and effort, Auscultate lung sounds q
4 hrs, Monitor bowel sounds q 4 hrs, Take VS q 4 hrs, esp. Temp, Feed slowly with small
 bites and allow time for chewing and swallowing, Place food on strong side of mouth,
Have patient sit upright when eating and keep HOB 30-45 degrees for an hour after
eating, Encourage patient to use chin tuck when swallowing, Provide rest periods,
Consult HCP for speech consult for swallow study.
o NGT FEEDING: Nursing Diagnosis. Risk for Aspiration r/t NGT feeding.
o Outcome: Patient will maintain patent airway and clear lung sounds.
o Nursing Interventions: Determine if patient is at high risk for aspiration: coughing, hx of
GERD, nasotracheal suction,an artificial airway, decreased LOC, and lying flat. Keep HOB
up to 30-45 degrees at all times. Measure gastric residual volumes every 4-6 hrs. 250 ml
or more on 2 consecutive assessments: delayed gastric emptying or if 500 ml on
assessment. Discuss follow up with HCP. Stop feedings if aspiration occurs. Administer
metoclopramide (Reglan) if ordered. Monitor for nausea, vomiting, cramping and
diarrhea and tube occlusion. Increase rate per order.
o PARENTARAL NUTRITION: Nutrients are provided intravenously. Patients unable to
digest or absorb enteral nutrition or are in highly stressed physiological states.
Peripheral or central line. Initiating parenteral nutrition. Preventing complications. If
using a CVC that has multiple lumens, use a port that is exclusively dedicated for the
TPN. Label it! Verify the HCP’s order. Inspect the solution for particulate matter. Always
use an infusion pump. First 24-48 hrs: delivers 50% of estimated needs and then rate
has will be increased
o Catheter-related Problems: Pneumonthorax: Sudden sharp chest pain, dyspnea, and
coughing. Monitor for 24 hrs. Air embolus: Occurs during insertion of the catheter or
when changing the tubing or cap. Turn pt to left side and have pt perform a Valsalva
maneuver (hold breath and bear down during catheter insertion to help prevent air
embolus. Keep IV system closed.
o Catheter occlusion: If sluggish or no flow, stop infusion and flush with NS or heparin
(per protocol). Attempt to aspirate clot or follow protocol for thrombolytic agent
(urokinase).
o Sepsis: Fever, chills, or glucose intolerance and positive blood culture. Change tubing q
24 hrs. Hang bag for only 24 hr; lipids 12 hrs. Check to see if solution needs a filter.
o Metabolic alterations: Electrolyte and mineral imbalances:
o Hyperglycemia: Thirst, HA, lethargy, increased urination. Monitor BS q 6 hrs. Give
insulin.
o Hypoglycemia: Diaphoresis, shakiness, confusion, loss of consciousness. Do not abruptly
discontinue TPN. Taper rate. Give IV bolus of dextrose.
o Dehydration: Do no try to catch up: decrease gradually during a 60 to 90 minute
duration. Pneumothorax results from a puncture insult to the pulmonary system and
involves the accumulation of air in the pleural cavity with subsequent collapse of the
lung and impaired breathing. An air embolus possibly occurs during insertion of the
catheter or when changing the tubing or cap. Catheter occlusion is present when there
is sluggish or no flow through the catheter. Suspect catheter sepsis if a patient develops
fever, chills, or glucose intolerance and has a positive blood culture.
Utilize the nursing process to plan care for individuals experiencing alterations in
elimination:
o ND: stress urinary incontinence r/t weak pelvis muscle.
o Goal: will have reduced episodes of urine leakage b/n voiding within 6-8 weeks. Improve
urinary elimination within 2 months.
o Expected outcome: urinary continence, patient reports less than 2 episodes of daily
incontinence following the start of kegels, patient remains free of UTI and is able to
resist urge to void for 15+ mins without leaking.
o Nursing interventions/ rational: Pelvic muscle exercise is effective in curing stress
urinary incontinence. Bladder re-training, teach how to inhibit strong sensations of
urinary urgency by taking deep breaths and relaxing offer as a first line treatment for
stress, mixed and urge incontinence. Avoid heavy lifting by teaching supportive
measures reduces intra-abdominal and bladder pressure.

Describe common laboratory studies used to assess the function of

the metabolic system:
o BMP (basic metabolic panel): gives info about your body’s metabolism; gives snapshot
of the health of your kidneys, blood sugar levels, levels of electrolytes; measures 8
things in your blood. calcium: plays a role in keeping your cells working the way they
should; also helps clotting. Carbon dioxide: can be a measure of how well your kidneys
and lungs are functioning. Chloride: measures relation to how your body is managing
fluid. Creatinine: it is a byproduct from kidneys Fx is. Glucose: (blood sugar) key source
of energy for your body; but too much or too litter is a problem. Potassium: plays
leading role in cell health. Sodium: plays key role in cell health. B.U.N: by product of
kidneys to see their Fx. CMS (comprehensive metabolic panel). BMP (basic metabolic
panel) less lab work, more specific to electrolytes.
o BOWEL ELIMINATION PROBLEMS:
o Constipation: A symptom, not a disease; infrequent stool and/or hard, dry, small stools
that are difficult to eliminate. infrequent bowel movements (less often than every 3
days), difficulty passing stools, excessive straining, inability to defecate at will hard
feces. (Risk for) Constipation R/T. Opiate containing meds, Decreased fiber intake,
Decreased fluid intake, Recent anesthesia, Stress, Inactivity (immobility), Eating a large
amount of dairy products, AEB no stool in 3 days. Outcome: Pt will have a soft, formed
stool in 24 hours.
o Assess for s/s of constipation: Decrease in frequency of bowel movements,
Consistency of stool, Anorexia, Abdominal distention and pain, Feeling of fullness
or pressure in rectum, Straining during defecation, Assess bowel sounds.
o Interventions: Encourage fluid intake of at least 1500 ml/24hr, Encourage
activity: walk pt in hallway 4 times a day, Encourage to defect whenever urge is
felt Assist to BR, BSC or bedpan (put pt in high Fowlers), Provide for privacy,
 Encourage to drink hot liquids in AM, Administer laxatives or enemas as ordered.
Consult with HCP to check for impaction.
o Teaching: Teach to increase intake of foods high in fiber, Teach importance
of activity, Teach reasons for changing opioid medication to a non-opioid
medication.
o Impaction: Digital removal of stool. Results from unrelieved constipation; a collection of
hardened feces wedged in the rectum that a person cannot expel. A health care
provider’s order is necessary to remove an impaction. Digital removal of stool. Use if
enemas fail to remove an impaction. This is the last resort for constipation.
A health care provider’s order is necessary to remove an impaction.
o Diarrhea: an increase in the number of stools and the passage of liquid, unformed feces.
Risk for impaired skin integrity, Risk for Electrolyte imbalance, Risk for imbalanced fluid
volume, Risk for falls.
o Incontinence: Inability to control passage of feces and gas to the anus. Common causes
of fecal incontinence include diarrhea, constipation,
and muscle or nerve damage. Spinal cord injury, Multiple Sclerosis, Stroke, Intestinal
obstruction, Seizures.
o Nursing Diagnosis: Impaired Body Image. Impaired Social Interaction.
o Flatulence: Accumulation of gas in the intestines causing the walls to stretch. Causes :
swallowed air, foods and beverages, medicines of nutritional supplements, bowel
obstruction.
o Nursing Diagnosis: Pain, impaired body image.
o Hemorrhoids: dilated, engorged veins in the lining of the rectum.
o Causes: Diarrhea, Constipation, Pregnancy, Prolong sitting and standing Cirrhosis
of the Liver.
o Nursing Diagnosis: Pain.
o Nutritional considerations: Consume low fiber for the first weeks. Eat slowly and
chew food completely. Drink 10 to 12 glasses of water daily. Patient may choose
to avoid gassy foods.
o Nursing Diagnosis: Disturbed body image.
o Health promotion: Promotion of normal defecation. Establish a routine an hour
after a meal, or maintain the patient’s routine. Sitting position, Privacy,
Positioning on bedpan.
o Physical assessment: Mouth, abdomen, and rectum.
o Laboratory tests: Fecal characteristics, Fecal specimens.
o Diagnostic examinations: Radiologic imaging, with or without contrast,
Endoscopy, Ultrasound, Computed tomography (CT) or magnetic resonance
imaging (MRI).
o Evaluation: Do you use medications such as laxatives or enemas to help you
defecate? What barriers are preventing you from eating a diet high in fiber and
participating in regular exercise? How much fluid do you drink in a typical day?
What types of fluids do you normally drink? What challenges do you encounter
when you change your ostomy pouch?
o Urinary Retention is the inability to partially or completely empty the bladder.
o Signs and symptoms: Feelings of pressure, Discomfort/pain, Tenderness over the
symphysis pubis, Restlessness, Diaphoresis.
o Treatment: Residual urine Bladder scan. I & O catheter. Escherichia coli is the
most common bacteria.
o Risk for UTI: Indwelling catheter, Urinary Retention, Urinary and fecal
incontinence, Poor perineal hygiene practices.
o Signs and symptoms: Pain or burning during urination (dysuria), Fever, chills,
nausea, vomiting, and malaise, Frequent and urgent sensation of need to void,
Blood-tinged urine (hematuria).
o Treatment: Medication.
o Upper UTI: can be serious.
o Pyelonephritis: Fever, chills, Diaphoresis, Flank pain. Life-threatening
bloodstream infection (bacteremia or urosepsis). Treated with antibiotics.
o Lower UTI: Burning or pain on urination (dysuria), Irritation of the bladder
(cystitis, Incontinence, Suprapubic tenderness Foul-smelling urine, Mental status
change: delirium, Blood in urine (Hematuria).
o Overflow UI: Involuntary loss of urine caused by an overdistended bladder often related
to bladder outlet obstruction or poor bladder emptying because of weak or absent
bladder contractions.
o Stress UI: Involuntary leakage of small volumes of urine associated with increased
intraabdominal pressure related to either urethral hypermobility or an incompetent
urinary sphincter (e.g., weak pelvic floor muscles, trauma after childbirth, radical
prostatectomy). Result of weakness or injury to the urinary sphincter or pelvic floor
muscles. Underlying result: urethra cannot stay closed as pressure increases in the
bladder as a result of increased abdominal pressure (e.g., a sneeze or cough).
o Urgency UI: Involuntary passage of urine often associated with strong sense of urgency
related to an overactive bladder caused by neurological problems, bladder
inflammation, or bladder outlet obstruction. In many cases bladder overactivity is
idiopathic; cause is not known. Caused by involuntary contractions of the bladder
associated with an urge to void that causes leakage of urine.
o Nursing Diagnosis: Impaired Social Interaction r/t Loss of independence: clothing
becomes wet with urine and odor. Impaired body image r/t incontinent of urine.
Risk for impaired skin integrity. Impaired urinary elimination. Self-care deficit:
toileting
o ASSESS URINE: Intake and output (I&O).
o Characteristics of urine.
o Color: Pale-straw to amber color. Clarity: Transparent unless pathology is
present. Odor: Ammonia in nature. Urine testing: Specimen collection.
o IMPLEMENT: Maintaining Elimination Habits, Maintaining Adequate Fluid intake,
Promoting Complete Bladder Emptying, Preventing Infection.
o Closed drainage system: Maintain closed system, Hang bag on frame of bed not
allowing back into Touch for. Never hand bag on bed rails, Urinary drainage system
 patent. Check for kinks or bends in the tube, Avoid positioning to patient on the tube.
Never position bag higher than bladder level.
o 7 reasons for insertion of a Foley Catheter: Urinary retention, To relieve urinary
obstruction, Accurate I&O in critical patients, Bladder decompression for surgery,
Urinary incontinence with stage 3 – 4 pressure ulcers, Comfort for terminal patient,
Urological procedures.
o RESTORATIVE CARE: Strengthening pelvic floor muscles, Bladder retraining, Habit
training, Self-catheterization, Maintenance of skin integrity Promotion of comfort.